HANDBOUND
AT THE
L'NI\ FRs-ITN- np
Medical record
A Weekly yournal of Medicine and Surgery
EDITED BY
GEORGE F. SHRADY, A.M., M.D.
URGEON TO ST. FRANCIS HOSPITAL, NEW YORK ; CONSULTING SURGEON TO THE NEW YORK CANCER HOSPITAL, TO THE COLUMBUS
HOSPITAL, NEW YORK, TO THE NEW YORK RED CROSS HOSPITAL, AND CONSULTING PHYSICIAN-IN-CHIEF
TO THE HOSPITALS OF THE HEALTH DEPARTMENT OF THE CITY OF NEW YORK
JULY 4, 1896— DECEMBER 26, 1896
Ay
NEW YORK
WILLIAM WOOD AND COMPANY
1896
.-n
The PiBLisHERs' Printing Compan-y,
132, IJ4, ijb IVesl i4lh Si..
New York.
LIST OF CONTRIBUTORS TO VOL. L.
Abrahams, Dr. R., New York.
Acer, Dr. Louis C, Brooklyn,
N. Y.
Alexander, Dr. L. S., St. Augus-
tine, Fla.
Alexander, Dr. Samuel, New
York.
Allen, Dr. Charles W., New York.
Allen, Dr. F. H., Staples, Minn.
Andre, Dr. Orrin C, Waverly, O.
Ash-mead, Dr. Albert S., New
York.
Ayers, Dr. Edward A., New York.
Babcock, Dr. Warren L., Ogdens-
biirg, N. Y.
Baginsky, Dr. Adolph, Berlin, Ger-
many.
Bailey, Dr. Pearce, New York.
Baldwin, Dr. J. P., Columbus, O.
Ball, Dr. A. Brayton, New V irk.
Barton, Dr. Joshua Lindley, New
York.
Baruch, Dr. Herman B., New
York.
Beal, Dr. F. E., Papillion, Neb.
Beck, Dr. Carl, New York.
Bertrand, Dr. Leon, Antwerp,
Belgium.
Bleythinu, Dr. George D., New
York.
Bond, Dr. A. K., Baltimore, Md.
Booth, Dr. Carlos C, Youngs-
town, O.
Booth, Dr. J. Arthur, New York.
Bottom e, Dr. F. A., New York.
Boyer, Dr. Arthur Irving, New
Haven, Conn.
Bremer, Dr. Ludwig, St. Louis,
Mo.
Brettauer, Dr. Joseph, New York.
Brothers, Dr. Samuel, New York.
Bryan, Dr. Alonzo, Detroit, Mich.
Burt, Dr. Frank L., Boston, Mass.
CAnwALi.ADER, Dr. R., Fall River
Mills, Cal.
Carstens, Dr. J. H., Detroit, Mich.
Chamberlin, Dr. E. Crosby, New
York.
Chapin. Dr. Henry Dwight, New-
York.
Cheatham, Dr. \Yillia.m, Louis-
ville, Ky.
Chilgren, Dr. G. A., St. Peter,
Minn.
Clark, Dr. L. Pierce, Sonyea,
N. Y.
CoRDiRR, Dr. A. H., Kansas Citv,
Mo.
Corish, Dr. John L., Brooklvn,
N. Y.
Corning, Dr. J. Leonard, New-
York.
Craig, Dr. Charles F., Danbury,
Conn.
Crutch ER, Dr. Howard, Chicago,
III.
Darnall, Dr. William Edgar, At-
lantic City, N. J.
Davis, Dr. Theo. G., Bridgeton,
N.J.
Davis, Dr. \\ eslev, Worcester,
Mass.
Denison, Dr. Charles, Denver, Col.
Dessau, Dr. S. Henry, New York.
DiLLER, Dr. Theodore, Pittsburg,
Pa.
Drake, Dr. E. L., Philadelphia, Pa.
Drescher, Mr. August, Newark,
N.J.
Drew, Dr. C. A., Medfield, Mass.
Dunn, Dr. James H., Minneapolis,
Minn.
Dunwodv, Dr. J. A., Cripple Creek,
Col.
Earle, Dr. Samuel T., Baltimore,
Md.
Eddy, Dr. Mary Pierson, Sidon,
Syria.
Edgar, Dr. J. Clifton, New York.
Elliott, Dr. Hiram, \\'oodhaven,
N. Y.
Erdt.mann, Dr. Paul W., New York.
Eshner, Dr. Augustus A., Phila-
delphia, Pa.
Evans, Dr. D. W., Dell Rapids,
So. Dak.
Ferguson, Dr. E. D., Troy, N. Y.
FiNLEY, Dr. Mary Jordan, Mans-
field, O.
Fischer, Dr. Louis, New York.
FiscHLowiTZ, Dr. G. G., New York.
Fisher, Dr. W. A., Chicago, 111.
FYagg, Dr. Cora H., Boston, Mass.
Fleming, Dr. Luke, Tarrvtown,
N. Y.
Flower, Dr. Sidney, Chicago, 111.
Forker, Dr. F. L., Binghamton,
N. Y.
Fowler, Dr. George R., Brooklvn,
N. Y.
Frank, Dr. J., Chicago, 111.
Frankenburger, Dr. j. M., Edith,
Col.
Freudenthal, Dr. W., New York.
Frothingham, Dr. Richard, New-
York.
Frye, Dr. Maude J., Buffalo, N. Y.
FuRMAN, Dr. F. S., Shreveport, La.
Gage, Dr. W. V., McCook, Neb.
Gallant, Dr. Ernest, New York.
Gardner, Dr. H. M., Athol, Mass.
Gates, Dr. H. A., Delhi, N. Y.
Geiser, Dr. Mary L., Fort Madi-
son, Iowa.
Giles, Dr. J. Edward, New York.
Gillette, Dr. Willard, Roseboon,
N. Y.
Gilliam, Dr. D. Tod, Columbus, O.
Gladmon, Dr. Edwin, Washington,
D. C.
Goelet, Dr. Augustin H., New
York,
GoldEn, Dr. William ^^'., Elkins,
W. Y'a.
Goldenburg, Dr. Hermann, New^
York.
Gordon, Dr. Bernard, New York.
Gould, Dr. Orissa W., Nellore,
India.
GouLEY, Dr. W. S., New York.
Greene, Dr. Charles Lyman, St.
Paul, Minn.
Griffin, Dr. E. Harrison, New-
York.
Guiteras, Dr. Ramon, New York.
Hadra, Dr. B. F., San Antonio,
Te.x.
Hall, Dr. A. Llewellyn, Fair
Haven, N. Y.
Hall, Dr. J. N., Denver, Col.
H.\lton, Dr. Frederick J., Brook-
lyn, N. Y.
Harrison, Mr. Reginald, London,
England.
Haslam, Dr. George, Fremont, Neb.
Hatchett, Dr. B., Fort Smith, Ark.
Hauptmann, Dr. J. H., Erie, Pa.
Hays, Dr. Harry C, Toledo. O.
Hegeman, Dr. Tho.mas B., Brook-
lyn, N. Y.
Heiman, Dr. Henry, New- York.
Heineman, Dr. H. Newton, New
York.
Henderson, Dr. A. H., Mon^,
South Shan States.
Hillis, Dr. Thomas J., New York.
HoLDEN, Dr. Ward A., New York.
Hollowbush, Dr. J. R., Rock
Island, 111.
Holmes, Dr. A. M., Denver, Col.
Hunter, Dr. John, Toronto, Can-
ada.
Irwell, Mr. Lawrence, Buffalo,
N. Y.
Irwin, Dr. S. Nelson, New York.
Kales, Dr. J. W., Franklinville,
N. Y.
Keiller, Dr. William. Gaheston,
Tex.
Kellogg, Dr. Theodore H., New-
York.
Kemp, Dr, Robert Coleman, New
\oik.
Kenefick, Dr. Thomas A., New-
port, R. I,
Kennedy, Dr. James C, Brooklvn,
N. Y.
Kilbourne, Dr. H. S., U. S. Army.
Kiliani, Dr. Otto G. T., New York.
Knapp, Dr. Mark L, New York.
Knopf, Dr. S. A., New York.
Koles, Dr. Henry M., New York.
Roller, Dr. Carl, New York.
Lambert, Dr. Adelaide, New
Haven, Conn.
Leviseur, Dr. Frederick J., New-
York.
Lewis, Dr. F. Park, Biift'alo, N. Y.
Lindley, Dr. Walter, Los An-
geles, Cal.
Loftus, Dr. LuciEN, Atlanta, Ga.
L0HR.STORFER, Dr. F,, Port Huron,
Mich.
LoRAND, Dr. Arnold, Karlsbad,
Germany.
Lord, Dr. John Prentiss, Omaha,
Neb. .
Luther. Dr. Calista V., Newark,
N.J.
MacArtney, Dr. W. N., Fort Co-
\ington, N. Y.
McCassy, Dr. J. H., Dayton. O,
McClanahan, Dr. H. M., Omaha,
Neb.
IV
CONTRIBUTORS TO VOL. XLIX.
McCoNNEL, Dr. H. S., New Brigh-
ton, Pa.
McCreery, JJr. Forbes R., New
York.
MAcEvrrr, Dr. J<jh.n' C, Brooklyn,
N. Y.
McGuire, Dr. J. C, Washington,
D. C.
-Mcl.v.vis, Dr. H. L., Edmonton,
Canada.
McKay, Dr. A. F., Chicago, 111.
•McKee, Dr. E. S., Cincinnati, O.
McNair, Dr. Robert H., New
Haven, Conn.
Martin, Dr. E. H., Green Grove,
Miss.
Mau.s, Dr. L. M., C. S. .\rmv.
Mecray, Dr. P. M., Camden, N. J.
Merriit, Dr. Frank D., Brooklyn,
N. Y.
.Mettler, Dr. L. Harrison, Chi-
cago, 111.
Miller, Dr. J. Estill, Pittsfield,
111.
Miller, Dr. W. H. F., Baltimore,
Md.
MiLLiGAN, Dr. J. D., Pittsburg, Pa.
.MiLLiKEN, Dr. Samuel E., New
York.
.Moore, Dr. Ja.mes E., Minneapolis,
Minn.
-MoRcAN, Dr. Francis P., Washing-
ton, D. C.
Morris, Dr. Rorert T., .New York.
.Morton, Dr. William J., New
York.
MosER, Dr. W., Brooklyn, N. Y.
MuNDi^:, Dr. Palm. F., New York.
Mi'rrav, Dr. H. G.. Baltimore, Md.
MvKKs, Dr. R. p., Honohilu, H. I.
Nam.mack, Dr. Charles E., New
York.
.Nam MACK, Dr. William H., New-
York.
Newion, Dr. Richard C, Mont-
clair, N. J.
Nichols, Dr. J. B., Washington,
D. C.
.Northrtp, Dr. William P., New
York.
O'Dwyer, Dr. Joseph, New York.
Overton, Dr. F'rank, Patchogue,
N. Y.
Palmer, Dr. John O., Auburn,
N. Y.
Parsons, Dr. Ralph Lyman, New
York.
Peet, Dr. Edward W., New Yor!:.
Perkins, Dr. G. W., Ogden, Utah.
PiiRRV, Dr. Middleton L., Morris
Plains, N. J.
Peterson, Dr. Frederick, .New-
York.
PiKFARD, Dr. Henry G., New York.
TooLEV, Dr. Thomas R., .New ^'ork.
Potsdam KR, Dr. Joseph B., Phila-
delphia, Pa.
Prentis-S, Dr. 1). W.. Washington,
D. C.
Preston, Dr. S. P.. Lvnchburg. Va.
I'RErrvMAN, Dr. J. S.,'Milford. Del.
Pryor, Dr. W. R., New York.
Raffertv, Dr. T. N., Robinson, 111.
Raymond, Dr. James Harvey, Wai-
luku, H. I.
Robinson, Dr. A. R., New York.
Robinson, Dr. Byron, Chicago, 111.
Robinson, Dr. Daniel S., New
Haven, Conn.
Robinson, Dr. William J., New
York.
Rosenberg, Dr. L., New York.
RosENWASsER, Dr. Louis, New-
York.
Rosewater, Dr. Charles, Omaha,
Neb.
Rupp, Dr. Adolph, New York.
Rvfkogel, Dr. H. A. L., San Fran-
cisco, Cal.
Santway, Dr. F. L., Theresa, N. Y.
Savidoe, Dr. Eugene Coleman,
New York.
Saxl, Dr. Joseph, New York.
Schadle, Dr. J. E., St. Paul, Minn.
ScHEPPEGRELL. Dr. W., New Or-
leans, La.
Semeleder, Dr. F., Cordoba, Mex-
ico.
Shelley, Dr. Henry A., New \'ork.
Shrady, Dr. George F., New ^"olk.
Skeel, Dr. Frank D., New York.
Skinner, Dr. W. W., Lucerne,
Switzerland.
Sloan, Dr. W. Harper, Philadel-
phia, Pa.
Small, Dr. Sidney I., Saginaw,
Mich.
Smith, Dr. Andrew H., New York.
Smith, Dr. J. H., Plattsburg, N. Y.
Smith, Dr. L. B., Fremont, Neb.
Smith, Dr. Wm. T., Hanover, N. H.
Spra<;ue, Dr. Geor(,e P., Danvers,
Mass.
Spruill, Dr. Joseph L., Baltimore,
Md.
Stearns, Dr. Henry S., New York.
Stedman, Dr. Thomas L., New
York.
Stein, Dr. Alexander W., New
York.
Stinson, Dr. J. Copi.in, San Fran-
cisco, Cal.
Stone, Dr. R. M., Oin.iha, Neb.
Stoner, Dr. A. P., Cainesville. Mo.
Studley, Dr. F". C, Milwaukee,
Wis.
Surri>N, Dr. R. Siansburv, Pitts-
burg, Pa.
Sy.monds, Dr. Brandreth, New
York.
Tait, Dr. Law-son, Birmingham,
England.
Taylor, Dr. Basil M., Greensburg,
Ky.
Thlstle, Dr. W. B., Toronto, Can-
ada.
Tho.mas, Dr. T. Gaillard, New-
York.
Thomas, Dr. Allen M., New- York.
TiMBALs, Dr. F. B., Detroit, Mich.
Tomi.in.son, Dr. H. A., St. Peter,
.Minn.
Toms, Dr. S. ^V. S., Bellport, N. Y.
Torren.s, Dr. Benjamin, New York.
TowNSEND, Dr. Willia.m Warren,
Rutland, Yt.
Tyson, Dr. James, Philadelphia, Pa.
Valentine, Dr. Ferd. C, New
York.
\'andoren, Dr. S. H., Saybrook,
111.
Van Santvoord, Dr. R., New York.
ViNEBERG, Dr. Hiram N., New
York.
ViNKE, Dr. H. H., St. Charles, Mo.
Waiss, Dr. A. S., New Orleans, La.
Walsh, Dr. J. J., Philadelphia, Pa.
Warden, Dr. Carl C, Ishpeming,
Mich.
Washbur.v, Dr. W., New York.
Weir, Dr. James, Jr., Owensboro,
Ky.
Weller, Dr. W. M., Ithaca, Mich.
Welsh, Dr. W. J., Bailey, Mo.
Wendt, Dr. Edmund C, New York.
Whit.man, Dr. Royal, New York.
WiGGiN, Dr. Frederick Hol.me,
New York.
VVilkins, Dr. Theoda, Pomona, Cal.
Williams, Dr. Edw-ard H., Fish-
kill Landing, N. Y.
Wood, Dr. Albert, Worcester,
Mass.
Woodman, Dr. John, New York.
Societies of 7vJiiih Reports have been
published.
American Association of Obste-
tricians AND Gynecologists.
American Dermatological So-
ciety.
American Laryngological Asso-
ciation.
.American Medico-Psychological
Association.
American Neurol6gical Associa-
tion.
American Orthopaedic Associa-
tion.
American Public Health Asso-
ciation.
British Medical Association.
F"rench Congress of Alienlsts
AND Neurologists.
French Medical Congress.
Illinois State Medical Society.
International Congress of Gyne-
cology AND Obstetrics.
Medical and Chirurgical Fac-
ulty OF Maryland.
Medical Society of Delaware.
Medical Society of the County
of New York.
Medical Society of New Jersey.
Mississippi Valley Medical As-
sociation.
New York Academy ok Medicine.
New York County Medical As-
sociation.
New York Neurological Society.
New- York Pathological Society.
New York State Medical As.so-
ciation.
Pan-.American Medical Congress.
Practitioners' Society of New
York.
Southern Surgical and Gyneco-
logical Association.
Medical Record
A JVeekly Journal of Medicine and Surgery
Vol. 50, No. I.
Whole No. 1339,
New York, July 4, 1S96.
$5.00 Per Annum.
Single Copies, loc.
©vioinrtt |irticlcs.
THE REPORT OF THE AMERICAN PEDI-
ATRIC SOCIETY'S COLLECTIVE INVES-
TIGATION INTO THE USE OF ANTITOX-
IN IN THE TREATMENT OF DIPHTHERIA
IN PRIVATE PRACTICE.'
This subject was chosen by the officers of the societj-
for its eighth annual meeting, witli the belief that a
large amount of valuable experience not otherwise
available might in this way be reached and collated.
It was also believed that a more trustworthy estimate
of the value of the serum treatment of diphtheria
might thus be obtained than by statistics taken from
hospital practice. There are very few hospitals in
America that receive diphtheria patients, and the con-
ditions under which patients are admitted to hospitals
and the surroundings while there are so different from
those of private practice, that the measure of success
in hospital cases cannot be taken as an index of the
results which have been obtained upon this side of
the Atlantic with the new treatment.
In order, therefore, to obtain an expression of opin-
ion from American physicians as to the serum treat-
ment, after what had been, with most of them, their
first year's experience, a circular letter was prepared
and issued by the committee early in April. This
was distributed through the members of the society
as widely as could be done during the time allowed.
An attempt was made to reach as many physicians as
possible who had had experience with the remedy.
The first surprise of the committee was in learning
how very w^idely the serum treatment had been em-
ployed, especially in the Eastern and mid-Western
States. A\'ith more time the number of cases col-
lected might easily have been doubled and perhaps
trebled; but enough reports have come in to enable
one to see what opinion was held on May i, 1896, by
American physicians who have used this remedy.
The circular letter asked for information upon the
following points: Age; previous condition; duration
of disease when the first injection was made; the
number of injections; the extent of the membrane —
tonsils, nose, pharynx, and larynx; whether or not the
diagnosis was confirmed by culture; complications or
sequelae, viz., pneumonia, nephritis, sepsis, paralysis;
the result; and remarks, including other treatment
employed, the preparation of antitoxin used, and gen-
eral impression drawn from the cases.
Reports were returned from six hundred and fifteen
different physicians, with thirty-six hundred and
twenty-eight cases. Of these, two hundred and forty-
four cases have been excluded from our statistical ta-
bles. These were cases in which the disease was
said to have been confined to the tonsils and the diag-
nosis not confirmed by culture, and therefore open to
question. A few cases were reported in such doubt-
ful terms as to leave the diagnosis uncertain. The
figures herewith given are therefore made up from
' Reported at the Eighth .\nnual Meeting, held at Montreal,
Canada, May 26, 1896.
cases in which the diagnosis was confirmed bv culture
(embracing about two-thirds of the whole number)
and others giving pretty clear evidence of diphtheria,
either in the fact that they had been contracted from
other undoubted cases, or where the membrane had
invaded other parts besides the tonsils, such as the
palate, pharynx, nose, or lar}-nx. It is possible that
among the latter we have admitted some streptococcus
cases, but the number of such is certainly very small.
There are left, then, of these cases, thirty-three hun-
dred and eighty-four for analysis. These have been
observed in the practice of six hundred and thirteen
physicians from one hundred and fourteen cities and
towns, in fifteen different States, the District of Co-
lumbia, and the Dominion of Canada.
In the general opinion of the reporters the tvpe of
diphtheria during the past year has not dift'ered mate-
rially from that seen in previous years, so that it has
been average diphtheria which has been treated. If
there is any difference in the severity of the cases in-
cluded in these reports from those of average diphthe-
ria, it is that they embrace a rather larger proportion of
very bad cases than are usually brought together in sta-
tistics. The cases, according to the extent of the mem-
brane, are grouped as follows: In five hundred and
ninet5--three the tonsils alone were involved. In thir-
teen hundred and ninety-seven the tonsils and phar-
}Tix, the tonsils and nose, the pharynx and nose, or all
three were affected. In twelve hundred and fifty-six
cases the larynx was affected either alone or with the
tonsils, pharynx, and nose, one or all. In many in-
stances the statement is made by the reporters that the
serum was resorted to only when the condition of the
patient had become alarmingly worse under ordinary
methods of treatment. This is shown by the unusu-
ally large number of cases in which injections were
made late in the disease. Again, many physicians,
being as yet in some dread of the unfavorable effects
of the serum, have hesitated to use it in mild cases,
and have given it only in those which from the onset
gave evidence of being of a severe type. The expense
of the serum has unquestionably deterred many from
employing it in mild cases. These facts, it is be-
lieved, will more than outweigh the bias of any anti-
toxin enthusiasts by includTng many mild cases which
would have recovered under any treatment. It will,
however, be remembered that tonsillar cases not con-
firmed by culture have not been included.
Only two reports embracing a series of over one
hundred cases have been received, most of the observ-
ers having sent in from five to twenty cases, although
there are many reports of single cases, particularly of
single fatal ones.
In addition to this material which has come in re-
ponse to the circular, there have been placed at the
disposal of the committee, by the courtesy of Dr. H.
M. Biggs, nine hundred and forty-two cases treated in
their homes in the tenements of New York. Of these,
eight hundred and fifty-six were injected by the corps
of inspectors of the New York health board, upon the
request of the attending physician, and eighty-six oth-
ers were treated by physicians receiving free antitoxin
from the health board. In the first group the diagno-
sis of diphtheria was confirmed by culture in every
MEDICAL RECORD.
[July 4, 1896
case, and in all of the latter except twenty-six; in
these the diagnosis rested upon extensive membranous
deposits or laryngeal invasion. The cases of the New
York health board were of a more than ordinarily se-
vere type, four hundred and eighty-live, or more than
fifty per cent., of these being reported as being in bad
condition at the time of injection; to mild cases the
inspectors were not often called. Further, an unusu-
ally large number of them (Ihirty-eight per cent.) were
injected on or after the fourth day of the disease. In
one hundred and eighty-two of these cases only the
tonsils were afTected ; in four hundred and sixty-six
the tonsils with the pharynx or nose, the pharynx and
nose, or all three; in two hundred and ninety-four the
larynx was invaded either with or without disease of
the tonsils, nose, or pharynx.
Through the courtesy of Dr. Biggs, the committee
is able to include also a partial report upon fourteen
hundred and sixty-eight cases from Chicago, treated
in their liomes in that city by a corps of insiJectors of
the health de|)artment. It was the custom in Chicago
to send an inspector to every tenement-house case re-
ported, and to administer the serum unless it was re-
fused by the parents. These cases were therefore
treated much earlier and the results were correspond-
ingly better than were obtained in New York, although
the serum used was the same in both cities, viz., that
of the New York health board.
The Result as Influenced by the Time of Injec-
tion. -In 'J'ablc I. are given the results obtained in
these three different groups of cases, classified accord-
ing to the day on which they received the first injec-
tion of serum antitoxin.
and does not differ materially from ordinarj- diphthe-
ria statistics. Our figures emphasize the statement so
often made, that relatively little benefit is seen from
antitoxin after three days: however, it must be said
that striking improvement has in some cases been seen
even when the serum has been injected as late as the
fifth or sixth day. The duration of the disease, there-
fore, is no contraindication to its use.
The Influence of Bacteriological Diagnosis upon
the Statistics. — This is shown in Table II.
Table II. — Di.\gn'osis Confirmed nv Bacteriologic.vi. E.\-
AMINATION.
^ ^ - T^..^.u.- Mortality,
Case;,. Deaths. p„ ^ent.
Committee's reports 2,453 3<^~ '2.3
New York board of health gi6 160 16.9
Chicago board of health 1,468 94 6.4
Totals 4.837 556 II. 4
E.xcluding 145 cases which were moribund or
which died in twenty-four hours 8.7
Diagnosis from Clinical Evidence Only.
Cases. Deaths. ^^^'^
Committee's reports 931 14S 15.7
New York board of health 26 g 34.6
Totals • 957 157 16.3
Excluding 72 cases either moribund or dying in
twenty-four hours. 9.6
In the cases in which the diagnosis was not con-
firmed by a bacteriological examination the mortality
is thus five per cent, higher than in the bacteriological
cases. This difference is to be explained by two facts:
t.\i;le I.— day oi" injection and result.
Injected o.n
First Day.
Injected on
Second Day.
Injected on
Third Day.
Injected on
Fourth Day.
Injected on
OR .\ftek
Fifth Day.
Day of
Injection
Unknown.
Totals.
0
764
126
106
996
i
s
a
38
II
0
7,
J
S
Q
si
0
ir.
A
336
153
269
l_
77
32
38
1
1
a
St:
J
So,
0
1
Committee's report
New York health board . . .
Chicago health board
4.9
8.7
0
1,065
815
336
89
26
5
8.3
12.0
1.5
620
228
660
79
37
18
12.7
16.6
2.7
22.9
20.9
14. 1
390
203
97
152
59
33
3S.9
29.0
34-0
215
17
0
15
4
0
7.0
23.5
0
3,384
942
1,46.'
450
169
94
13.0
17.8
6.4
Total
4.9
1,616
120
7-4
1,508
134
8.8
20.7
690
244
35-3
232
19
8.2
5,794
713
12.3
Tile grand total gives fifty-,seven hundred and nine-
ty-four cases with seven hundred and thirteen deaths,
or a mortality of 12.3 per cent., including every case
returned ; but the reports show that two hundred and
eighteen cases were moribund at the time of injection
or died within twenty-four hours of the first injection.
Should these be excluded there would remain rifty-fi\c
hundred and .seventy-six cases (in which the serum
may be said to have had a chance), with a mortal it v
of 8.8 per cent.
Of the forty-one hundred and twenty cases injected
during the first three days there were three hundred
and three deaths — a mortality of 7.3 per cent., includ-
ing every case returned. If from these we deduct the
cases which were moribund at the time of injection,
or which died within twenty-four hours, we have four
thousand and thirteen cases, with a mortality of 4.8
per cent. Kehring's original claim, that if cases were
injected on the first or second day the mortality would
not be five i)er cent., is more than substantiated by these
figures. Tiie good results obtained in third-day injec-
tions were a great surprise to your committee. I^ut
after three days have passed the mortality rises rapidly,
first, as already stated, that we have excluded from our
reports all tonsillar cases (and hence most of the very
mild ones) not confirmed by bacteriological examina-
tions; and secondly, by the fact that this group of
cases comprises those treated in the country, where
physicians have hesitated to use antitoxin unless the
type of the disease was a grave one, and where also a
large proportion of the injections were made later than
in the cities. However, should we leave out the mori-
bund cases, the mortality is but 9.6 per cent., which
differs but slightly from the cases confirmed by bacte-
riological diagnosis.
In our subsequent statistics we shall consider to-
gether all the cases bacteriologically confirmed and
otherwise, as the statistics are not materially altered
by this grouping.
The Results as Modified by the Age of the Pa-
tients.— Unfortunately, the ages have not been fur-
nished in the report of the Chicago cases, and we have
therefore only the cases reported to the committee and
those from the New York board of health for analysis.
In Table III. is shown the mortality of the different
ages grouped separately.
July 4, 1896]
MEDICAL RECORD.
TABLE III.— AGE AND RESULT OF TREATMENT.
0 TO 2 Years.
2 TO 5 Years.
5 TO 10 Years.
10 TO 15 Years.
IS TO 20 Years.
2o Years and
Over.
J
1
■i
s
0
0
St
0
Mortality,
Per Cent.
0
SO
1
Q
II
Committee's report
New \'ork health board . . .
631
236
137
65
21.7
27-5
1,276
466
175
83
13-7
17.8
883
178
108
21
12.2
II. 2
276
29
19
0
6.8
0
112
11
4
0
3.6
0
214
22
9
0
4.2
0
Totals
867
43
202
23-3
1.742
59
25S
14-7
i,o6i
59
129
12.1
305
9
19
6.2
123
0
4
3.2
236
. 4
9
Moribund
3-i>
Mortality, excluding mori-
bund cases.
19.2
13.3
8.7
3-3
3.2
2,t
The highest mortality is seen as in all reports to be
in the cases under two years, but including all those
returned, even those that were moribund when injected,
the death rate was but 23.3 per cent. (21.7 per cent, of
the committee's cases), while, if we exclude cases mori-
bund when injected or dying within the first twenty-
four hours, it falls to 19.2 per cent.
After the second year there is noticed a steady de-
cline in mortality up to adult life. In many of the
reports previously published the statement has been
made that no striking improvement in results was ob-
sen-ed in adult cases treated by the serum. Our fig-
ures strongly contradict this opinion. • Of three hun-
dred and fifty-nine cases over fifteen years old which
were returned, there were but thirteen deaths. That
the reader may judge for himself how far antitoxin is
to be held responsible for the result, a brief summary
of these thirteen cases is appended:
Case I. — -Fifteen years old; injected on the fourth
day; membrane covering tonsils and pharynx; pro-
foundly septic, sinking rapidly when injected; died
in two hours. " My only death in seventeen cases"
(Jones, Gloucester, Mass.).
Case II. — Forty-four years old; injected on the
fourth day; membrane on the tonsils and pharynx; in
bad condition; died three hours after injection. The
tonsils had been previously incised, the early diagnosis
having been quinsy.
Case III. — Thirty-one years old; injected on the
sixth day; membrane on the tonsils, nose, pharynx,
and larynx; intubation; sepsis; in bad condition;
lived eight hours after injection.
Case IV.— Thirty-five years old; injected on the
fifth day; membrane on the pharj'nx and nose (?);
in bad condition; septic; died in twelve hours.
Case V. — Si.xty years old; in bad condition; had
serious mitral regurgitation; injected on the fourth
day; membrane covering tonsils, pharynx, and larynx;
died from heart failure on following day.
Case VI. — Si.xty years old; "kidney trouble for
years;" injected on the third day; very extensive
membrane, covering tonsils, pharj-nx, and nose; pro-
found sepsis; in bad condition ; died suddenly on the
day after injection.
Case VII. — Seventeen years old ; in bad condition ;
convalescing from measles; enormous adenopathy;
profound sepsis; e.xceedingly high temperature; mem-
brane covering tonsils and nose; injected at the end
of forty-eight hours; three injections, temporary
improvement after each one; duration of life not
given.
Case VIII. — Fifteen years old; in bad condition :
injected on the ninth day; membrane covering tonsils,
nose, pharynx, and larynx; no operation; enormous
infiltration of the tissues of the neck: nephritis; sep-
sis; lived four days and died of sepsis.
Case IX.— Twenty years old; injected on the third
day; membrane upon the tonsils, nose, pharynx, and
larynx. " A stubborn patient, who got up before he
was allowed, and died suddenly after it."
Case X. — Twenty-five years old; injected on the
fifth day; membrane covering both tonsils, entire
pharynx, and completely occluding nose; nephritis
and sepsis; throat cleared off entirely; died suddenly
on the fourteenth day from cardiac paralysis.
Case XI. — Nineteen years old; injected on the fifth
day; membrane upon the tonsils and pharynx; pro-
found sepsis; duration of life unknown.
Case XII. — Twenty-two years old; injected on the
fourth day; membrane on the tonsils and gums; sep-
sis; died on the sixth day.
Case XIII. — The well-known Brooklyn case, re-
ported in 1895. Girl, sixteen years old, who died
suddenly ten minutes after injection.
Such are the adult cases which antitoxin failed to
cure. Four of them were moribund at the time of in-
jection, no one of them living over twelve hours.
Two, both sixty years old, were already crippled by
previous organic disease, one of the heart and the
other of the kidneys. In the measles case there was
undoubed evidence of streptococcus septicemia. Only
two of the cases were injected as early as the third
day, three of them on the fifth day, and one on the
ninth day. Omitting the four moribund cases, the
mortality of three hundred and fifty-five adult cases
treated with the serum is 2.5 per cent.
Paralysis — Reliable data upon this point and
those hereafter to be mentioned are to be had only
from the thirty-three hundred and eighty-four reports
returned to the committee. Of these, 'paralytic se-
quela appeared in three hundred and twenty-eight
cases, 9.7 per cent. Of the twenty-nine hundred and
thirty-four cases which recovered, paralysis was pres-
ent in two hundred and seventy-six, or 9.4 per cent.
Of the four hundred and fifty cases which died, paral-
ysis was noted in fifty-two, or 11.4 per cent.
Observations of some of the individual cases are in-
teresting, particularly those of cardiac paralysis. It
is twice stated that the child had gotten up and walked
out of the house, where it was found dead. Twice
death occurred after sitting up suddenly; once, on
jumping from one bed to another. One patient of
twenty years got up contrary to orders and died soon
afterward. Another patient was apparently well until
he indulged in a large quantity of cake and candy,
soon after which cardiac symptoms developed, and he
died shortly. One case was that of a woman sixty
years old, who had serious organic cardiac disease.
It is difficult from these statistics to state what pro-
tective power the serum may have over the ner\-e cells
and fibres. Apparently this is not great unless the
injections are made early in the di.sease, and even then
in severe cases the amount of damage done to these
tissues in twenty-four hours may be very great, even
MEDICAL RECORD.
[July 4, 1896
irreparable. Time is not the only element in estimat-
ing the effect of the diphtlieria toxins.
Great discrepancy exists in the statements made re-
garding the frequency of paralytic sequela after diph-
theria. In a series of one thousand cases reported by
Lennox Browne, paralytic sequela; were present in
fourteen per cent. In twenty-four hundred and forty-
eight cases by Sanne', paralysis was noted in eleven
per cent. In the series of cases here reported, the
difference is slightly in favor of the antitoxin treat-
ment, but paralysis is certainly frequent enough to
show how extremely susceptible the nen'ous elements
are to the diphtheria toxins. One thing is quite strik-
ing from a study of these cases, and that is the pro-
portion that have died from late cardiac paralysis.
That very many of them would undoubtedly have suc-
cumbed earlier in the disease from suffocation (lar\n-
gea.1 cases) or diphtheritic toxaimia, had the serum not
been employed, is beyond question. Although the se-
rum is able to rescue even many such desperate cases,
it cannot overcome the effects of the toxins upon the
cells which have occurred before it was injected.
The variety of the paralysis and the date of injec-
tion is shown in the following table:
Table IV.
-Variety of Paralysis and the Day of
Injection.
Recovery C.\ses.
Paralysis mentioned (variety not specified). [ ' 132
Throat only (aphonia, nasal voice, or re- 11 14
gurgitation) .
Extremities 14
Ocular II
General (multiple neuritis) 4
Sterno-mastoid I
Fatal Cases.
Paralysis mentioned (variety not specified).
Cardiac, late after throat clear (in four of
them throat also).'
Throat only
General late
Muscles of respiration
Totals 328
Day of Injection.
_.k
28 73 76 43 49 5S
Sepsis. — Sepsis is stated to have been present in
three hundred and sixty -two of the thirty-three hundred
and eighty-four cases, or 10.7 percent. It was pres-
ent in one hundred and forty-five, or thirty-three per
cent., of the fatal cases. Some explanation is neces-
sary for a correct appreciation of these figures. The
majority of the reporters, it is plain from their re-
marks, have not distinguished between diphtheritic
toxaemia and streptococcus sepsis. The former is cer-
tainly meant in the great majority of the cases. There
is a very small proportion in which there is evidence
of streptococcus sepsis. The six cases complicating
measles, and the five complicating scarlet fever, how-
ever, should possibly be included in this list.
Nephritis. — The statements on this point are quite
unsatisfactory. The reports state that nephritis was
present three hundred and fifty times, or in ten per
cent, of the cases. On the one hand, it must be stated
that the diagnosis of nephritis rests in many cases
simply upon the presence of albumin in the urine;
but, on the other hand, it is true that in a large num-
ber of the cases, more than half, no examination of the
urine is recorded as having been made, so that it is
impossible to state, with ajnything like approximate
accuracy, the frequency of nephritis in these cases.
' Cases of heart failure occurring at the height of the disease
have not been included here. .-Uthough they are mentioned
among the cases of cardiac paralysis in the table of fatal cases.
Of the four hundred and fifty fatal cases, the presence
of nephritis is mentioned without qualification or ex-
planation in thirty-nine cases: these being usually
put down also as septic, dying in the acute stage of
the disease. There are fifteen fatal cases, however, in
which the renal disease was stated as the cause of
death. In no less than nine the nephritis occurred late
in the disease, usually during the second or third week.
In these fifteen cases the evidence of severe nephritis
was conclusive, such symptoms being present as drop-
sy, suppression of urine, with coma or convulsions.
Broncho - Pneumonia. — Lroncho - pneumonia is
stated to have been present in one hundred and nine-
ty-three of the thirty-three hundred and eighty-four
cases, or 5.9 per cent., a remarkably small proportion
when compared with hospital statistics. Among the
patients that recovered, broncho-pneumonia was noted
one hundred and fourteen times, or in 3.8 per cent.;
among the fatal cases seventy-nine times, or in 17.5
per cent., but in only about half of these was the
pneumonia the cause of death. Of these, thirty-seven
were larvngeal cases operated upon late, ten were sep-
tic cases, and the pulmonary disease was coincident
with the height of the diphtheritic process. In seven
pneumonia was independent of both the above condi-
tions, occurring late in the disease in all but two.
Laryngeal Cases. — Of the thirty-three hundred and
eighty-four cases reported to the committee, tlie larynx
is stated to have been involved in twelve hundred and
fifty-six cases, or 37.5 per cent. This proportion is
somewhat higher than is usual, and is partly explained
by the fact that several physicians have sent in the
reports only of their laryngeal cases. These laryn-
geal cases occurred in the practice of three hundred
and seventy-nine physicians.
In si-x hundred and ninety-one, or a little more than
one-half the number, no operation was done, and in
this group there were one hundred and twenty-eight
deaths. In forty-eight of them laryngeal obstruction
was responsible for the fatal issue, operation being re-
fused by the parents, or no reason for its being neg-
lected having been given. In the eighty remaining
fatal cases the patients died of other complications,
and not from the larj'ngeal disease.
In the five hundred and sixty -three cases, therefore,
or 16.9 per cent, of the whole number, there was clini-
cal evidence that the larynx was involved, and yet re-
covery took place without operation. In many of these
cases the symptoms of stenosis were severe, and yet
disappeared after injection without intubation. No
one feature of the cases of diphtheria treated by anti-
toxin has e.xcited more surprise among the physicians
who have reported them than the prompt arrest, by the
timely administration of the serum, of membrane
which was rapidly spreading downward below the
larynx. Such expressions abound in the reports as
"wonderful," '• man-el lous," "prepared to do intuba-
tion, but at my next visit the patient was so much bel-
ter it was unnecessary," '" in all my experience with
diphtheria have never seen anything like it before,"
''no unprejudiced mind could see such effects and not
be convinced of the value of the serum," etc.
In establishing the value of the serunL, nothing has
been so convincing as the ability of antitoxin, prop-
erly administered, to check the rapid spreading of
membrane downward in the respiratory tract, as is at-
tested by the observations of more than three hundred
and fifty physicians who have sent in reports.
Turning now to the operative cases, we find the
same remarkable effects of the antitoxin noticeable.
Operations were done in five hundred and sixty-five
cases, or in 16.7 per cent, of the entire number re-
ported. Intubation was performed five hundred and
thirty-three times, with one hundred and thirty-eight
deaths, or a mortality of 25.9 per cent. In the above
July 4, 1S96]
MEDICAL RECORD.
are included nine cases in which a secondary tracliu-
otomy was done, with seven deaths. In thirty-two
tracheotomy only was done, with twelve deaths, a mor-
tality of 37.4 per cent. Of the five hundred and si.xty-
five operative cases, si.\ty-six were either moribund at
the time of operation or died within twenty-four hours
after injection. Should these be deducted, there re-
main four hundred and ninety-nine cases operated
upon by intubation or tracheotomy, with eighty-four
deaths, a mortality of 16.9 per cent.
Of the twenty-eight hundred and nineteen cases not
operated upon, there were three hundred and twelve
deaths, a mortality of 11.3 percent. Deducting the
moribund cases or those dying within twenty-four
hours after injection, the total mortality of all non-
operative cases was 9.12 per cent.
Let us compare the results of intubation in cases in
which the serum was used with those obtained with
this operation before the serum was introduced. Of
fifty-five hundred and forty-six intubation cases in the
practice of two hundred and forty-two physicians, col-
lected by McNaughton and Maddren (1892), the mor-
tality was 69.5 per cent. Since that time statistics
have improved materially by the general use (in and
about New York, at least) of calomel fumigations.
With this addition, the best results published (those
of Brown) showed in two hundred and seventy-nine
cases a mortality of 51.6 per cent.
Let us put beside the cases of McNaughton and
Maddren the five hundred and thirty-three intubations
with antitoxin, with 25.9 per cent, mortality. With
Brown's personal cases let us compare those of the
fourteen observers who have reported to the committee
ten or more intubation operations in cases injected
with serum. These comprise two hundred and eightv
cases with sixty-five deaths, a mortality of 23.2 per
cent. In both comparisons the mortality without the
serum is more than twice as great as in the cases in
which serum was used.
The reports of some individual observers concerning
intubation with the serum are interesting:
Neff, New York: Twenty-seven operations, with
t\venty-seven recoveries.
Rosenthal, Philadelphia: Eighteen operations, with
sixteen recoveries.
Booker, Baltimore : Seventeen operations, with sev-
enteen recoveries, including one aged ten months, and
one seven and one-half months.
Seward, New York: Eight operations, with eight re-
coveries.
McNaughton, Brooklyn : " In mv last seventy-two
operations without serum, mortality 66.6 per cent. : in
my first seventy-two operations with serum, mortality
33.3 per cent."
O'Dwyer, New York : '• In my last one hundred in-
tubations, first seventy without serum, mortality sev-
enty-three per cent.; last thirty with serum, mortality
33.3 per cent.''
But even these figures do not adequately express the
benefit of antitoxin in laryngeal cases. Witness the
fact that over one-half the laryngeal cases did not re-
quire operation at all. Formerly, ten per cent, of re-
coveries was the record for laryngeal cases not ope-
rated upon. Surely, if it does nothing else, the serum
saves at least double the number of cases of laryngeal
diphtheria that has been saved by any other method of
treatment.
The great preponderance of intubation over trache-
otomy operations shows how much more highly the
profession in this country esteems the former opera-
tion.
A Study of the Fatal Cases. — Of the four hun-
dred and fifty fatal cases in the committee's report,
two hundred and twenty-nine, or one-half, received
their first injection of the serum on or after the fourth
day of the disease, and one hundred and fifty-two, or
over one-third of these, on or after the fifth day.
There were fifty-eight cases in which it was stated
that the child was moribund at the time of injection,
the serum being administered without the slightest
expectation of benefit, but at the earnest solicitation
of the parents.
There remain three hundred and fifty cases in which
the cause of death could be pretty accurately deter-
mined by the reports. These died from the following
causes, the most important cause being placed first:
Sepsis (including diphtheritic toxaemia) was the
cause of death in one hundred and five cases : of
which sixteen had nephritis, four were intubated or
tracheotomized, two were lar}-ngeal cases not operated
upon, four had paralysis, one had pneumonia, and in
one the fatal sepsis was attributed to a traumatic con-
dition of the left knee.
Cardiac paralysis was the cause of death in fifty-
three cases. Under this head are included cases of
sudden heart failure occurring at the height of the dis-
ease (twenty-one in number), as well as those more
commonly designated as heart paralysis, where death
occurred suddenly after the throat cleared off. Of the
latter there were thirty-two examples; four of these
cases had throat paralysis, nineteen were septic, eight
had nephritis, five were intubated, and one trache-
otomized.
Broncho-pneumonia was put down as the cause of
death in fifty-four cases. In thirty-seven of these it
followed laryngeal diphtheria; of these, tw-enty-two
were intubated and four tracheotomized; two had ne-
phritis; nine were septic. Broncho-pneumonia and
sepsis was the cause of death in ten cases, of which
three had nephritis and one general paralysis. Bron-
cho-pneumonia caused death in seven cases, apart from
sepsis or laryngeal diphtheria; of these, only one had
nephritis; one died from heart failure; and in five
pneumonia came on late in the disease.
Laryngeal diphtheria without operation caused death
in forty-eight cases. In some of these the operation
was refused by the parents, in others it was neglected
by the physician, the patients dying of asphyxia: three
of these cases had nephritis, four were septic, two had
pneumonia, and one had sepsis and nephritis.
Diphtheritic tracheitis or bronchitis caused death in
eleven cases ; all of these were intubated, and in two
there was evidence of the existence of membrane in
the bronchi before operation. There were thirty-three
other cases in which death followed laryngeal diph-
theria without the supervention of pneumonia. It is
highly probable that in some of these death was due to
membranous tracheitis or bronchitis. All of them
were operated upon ; ten were septic, two had paraly-
sis, and one had nephritis.
Sudden obstruction of the intubation tube was the
cause of death in three other laryngeal cases.
The tube was coughed up in three cases, fatal as-
phyxia ocurring before the physician could be sum-
moned.
Died on the .table during tracheotomy, one case.
Nephritis was the cause of death in fifteen cases;
seven of these were septic and three had been intu-
bated.
General paralysis was the cause of death in five
cases; in all probably the pneumogastric was involved.
Paralysis of the respirator}- muscles produced death
in one case, one of laryngeal diphtheria, which was
intubated and was complicated by broncho-pneumonia.
Measles associated with diphtheria produced death
in six cases; five of these were laryngeal and were in-
tubated: in two there was pneumonia and in two sep-
sis. Diphtheria developed during the height of the
measles or immediately followed it.
Scarlet fever with diphtheria was the cause of death.
MEDICAL RECORD.
[July 4, 1896
in six cases; in three of these there was broncho-
pneumonia, nephritis, and sepsis; in two scarlet fever
preceded diphtheria, and in one of these there was
sepsis with gangrene of the tonsils. In the sixth case
the patient died of scarlet fever, which developed dur-
ing convalescence from the diphtheria.
Gangrene of the cervical glands or cellular tissue of
the neck was the cause of death in two cases associ-
ated with profound general sepsis.
Endocarditis cau.sed death in one case, nineteen
days after the diphtheria.
Diphtheritic inflammation of the tracheal wound
with sepsis caused death in one case.
General tuberculosis, five weeks after diphtheria,
was assigned as the cause of death in one case.
Exhaustion was the cause of death in three cases,
one a protracted case; another complicated by pneu-
monia and sepsis; one by nephritis.
Convulsions was the cause of death in three cases
apart from disease of the kidneys. In one, the well-
known Brooklyn case, the girl died ten minutes after
the injection, in another twenty-four hours after injec-
tion, in the third the particulars were not given.
Meningitis was assigned as the cause of death in
one case
The Kind of Antitoxin Used. — They are given in
the order of frequency with which they have been used.
First, the serum prepared by the New York board of
health; second, Behring's; tliird, Gibier's; ' fourth,
Mulford's; fifth, Aronson's; sixth, Roux's. In addi-
tion, a large number of cases are reported as having
been treated by the serum prepared by the health
boards of different cities — Brooklyn, Newark, Roches-
ter, Pittsburg, etc. The largest number of cases have
been treated by the serum prepared by the New York
health board, a very large number by Behring's serum,
all others being relatively in small numbers.
Dosage and Number of Injections. — In the great
majority of cases but one injection is reported. In
very severe ones two and three have been given. The
largest amount is in a case by Weimer (Chicago) who
gave eighteen injections of Behring's serum to a laryn-
geal case in a child thirteen years old. Another in-
stance of ten injections is reported with no unfavor-
able symptoms.
As a rule the dosage has been smaller in antitoxin
units than is now considered advisable, particularly
in many of the laryngeal cases and others injected
later than the second day.
Cases Injected Reasonably Early (During the
First Three Days) in which Antitoxin is Said to
have Produced no Effect, the Disease Ending Fatally.
— These cases are nineteen in number, lirief reports
are introduced that the reader may judge to what de-
gree they may be regarded as a test of the serum treat-
ment. In our statistical tables all of them have been
included among tlie fatal cases.
In Cases I. and II. the cultures were reported nega-
tive.
Case I., by Gallagher, New York: Child eighteen
months old; septic; although no eruption was present,
the reporter was " inclined on reflection to regard this
case as one of scarlatinal sore throat."
Case II., by Potter, Buffalo: Male, fourteen months
old; two cultures made, but no Loeffler bacilli found;
membrane in the nose and pharynx. Injected on the
third day, one dose of Behring's serum No. 1. No im-
provement ; death from sepsis. " Probably pseudo-
diphtheria" (I. H. P.).
' It is worthy of note that in the tests made by the State Board
of Health of Massachusetts, published under' date of April 6,
1S96, this serum w.is found far below the standard .as labelled
upon the bottle ; thus, a package marked to contain twenty-five
hundred units, by test was found to contain less than seven hun-
dred. All the other varieties of serum tested were found essen-
tially up to the standard.
In Cases III, to IX. no cultures were made.
Case III., by Tefft, New Rochelle: Seven years
old; injected after eighteen hours' illness; two injec-
tions of Behring's No. 2 serum; membrane on the
tonsils, pharynx, and nose ; no effect observed froin
injections, patient dying on the third day.
Case l\'., by Telft: Male, four years old; mem-
brane on the tonsils and pharynx; injected after
thirty-six hours' illness with Behring's No. 2; died
on the third day; no noticeable effect from the injec-
tion.
Case V., by Tefft: Six years old; membrane on the
tonsils, nose, and pharynx; septic; injected after
thirtj'-six hours' illness; three injections of Behring's
No. 2. " Saw no effect from the injections, the dis-
ease going steadily on to a fatal termination."
Case VI., by Cameron, Montreal : Two and a half
years old; fifty hours ill: membrane on the tonsils,
nose, and pharj-nx; septic; no improvement noticed,
and child died twenty hours after injection.
Case VII., by Baker, Newtonville, Mass.: Three
years old; laryngeal diphtheria; injected on the third
day ten cubic centimetres Roux's serum: cyanosis; in-
tubation; temperature 103° F., and continued high
until death in eighteen hours after operation ; injec-
tions had no effect.
Case VIII., by Anderson, New York: Three years
old; injected after three hours' illness; membrane on
the tonsils, nose, and pharynx; one injection of New
York health board antitoxin. "A case of malignant
diphtheria, full duration twenty-four hours."
Case IX., by McLain, Washington: Four years old;
twelve hours sick; membrane on the pharynx and
larynx; two injections; no operation; first injection
early in the morning, the other early in the afternoon;
died the same day; no change in the condition; anti-
toxin had no apparent effect.
In Cases X. to XIII, diphtheria complicated mea-
sles, all reported by W. T, Alexander, New York.
Disease confined to the larynx in all ; in three the
stenosis developed during measles, and in one while
the patient was convalescing from measles; diagnosis
confirmed by culture in every case, and in all intu-
bation performed. Antitoxin seemed to have no effect,
the cases going on to a fatal termination; all received
their injections within twenty-four hours after the
laryngeal symptoms appeared.
In three cases — XIV. to XVI. — the type of the dis-
ease was malignant from the outset.
Case XIV., by Lloyd, Philadelphia: P'ifteen months
old; injected after thirty-six hours' illness; diagnosis
confirmed by culture; membrane covered the tonsils,
phar}-nx, nose, and larynx; intubation; sepsis; death
on the fifth day. Although antitoxin was used as
promptly as possible no perceptible effect was noticed.
One injection, Behring's No. 3, was given.
Case X\'., by Wert, Mount Vernon, N. Y. : Eigh
teen months old; injected on the third day ; diagnosis
confirmed by culture; membrane on the tonsils and
pharynx, " Very intense type of the disease," Anti-
toxin could not be procured before the third day;
Gibier's serum used, "Died suddenly in apparent
convulsions about ten hours after injection; urine not
examined; very little passed."
Case XVI., by Ingraliam : Six years old; membrane
covered the tonsils, pharynx, and larynx; diagnosis
confirmed by culture; pneumonia present; condition
very bad; injected after two and a half days' illness;
three injections of Behring's serum ; no benefit
noticed.
Case XVII., by Johnson, Buffalo: Three years old;
twelve hours ill; case septic from the start; membrane
on the tonsils, pharynx, and lar}'nx; diagnosis con-
firmed by culture. " .Antitoxin apparently had very
little effect."
July 4, 1S96]
MEDICAL RECORD.
Case XVIII., by Baker, Newtonville, Mass.: Two
and a half years old; twenty hours ill; disease con-
fined to laryn.x; diagnosis confirmed by culture; one
injection of Gibier's serum; intubation. " Was doing
well a few minutes before death, when child got up in
its crib, changed color, and died almost immediately."
Death attributed to "sudden heart failure; found no
obstruction of the tube.'"
Case XIX., by Story, Washington: Five years old;
in fair condition ; thirty-six hours ill; diagnosis con-
firmed by culture: membrane on the tonsils, pharyn.x
and larynx; one injection of United States Marine
Hospital antitoxin ; injection produced no effect.
Cases in which Unfavorable Symptoms Were,
Might Have Been, or Were Believed to Have Been,
Due to Antitoxin Injections. — Only three cases re-
ported to the committe could by any possibility be
placed in this category. All of the details furnished
by the reporters are reproduced :
Case I., by Kortright, Brooklyn : Sudden death in
convulsions ten minutes after injection. This case is
the already well-known \'alentine case, occurring in
Brooklyn in the spring of 1895. The principal points
were as follows: A girl sixteen years old; in good
condition; tonsillar diphtheria; diagnosis confirmed
by culture; injected on the first day with ten cubic
centimetres of Behring's serum; died in convulsions
ten minutes later.
Case II., by Kerley, New York: Fairly healthy boy,
two and one-half years old; membrane on tonsils,
pharynx, and in nose. Diagnosis confirmed by cul-
ture ; injected on the morning of the fourth day with ten
cubic centimetres (1,000 units) New York health board
serum; temperature at time of injection 100.4° F- ; no
sepsis, and child apparently not ver}' sick; urine free
from albumin. Distinctly worse after injection; in ten
hours temperature rose to 103° F. ; urine albuminous;
throat cleared off rapidly, but marked prostration and
great anaemia, with irregular fluctuating temperature,
continued, and death followed from exhaustion with
heart failure four days after the use of the serum.
Case III., by Eynon, New York: Male, three and
one-half years old ; diagnosis confirmed by culture ;
two days ill; membrane on tonsils and in nose; two
injections New York health board serum. " A rapid
nephritis developed after the second injection, causing
coma, convulsions, and death twenty hours after the sec-
ond injection." In response to an inquirj' for further
particulars the following was received: "The case
seemed a mild one, but the injection was given one
afternoon and repeated the following afternoon, about
1,500 units in all. The urine up to that time had
not been examined. About fourteen or sixteen hours
after the second injection unfavorable symptoms began
to develop, pointing to infection of the kidneys. The
urine was found to be loaded with albumin. My im-
pression at the time was that the antitoxin either pro-
duced, hastened, or intensified nephritis, thereby
causing the fatal termination."
In regard to the three fatal cases just cited. Case I.
is wholly unexplained. In Case II. the query arises,
did this sudden change hinge upon the injection of the
serum, or was it one of those unexplained abrupt
changes for the worse in a case apparently progress-
ing favorably, so often observed in diphtheria? As
regards Case III., it will be seen from the letter that
the evidence is not at all conclusive. All details
available are given, and the reader may draw his own
conclusions.
Clinical Comments. — The following are selected
from hundreds which have been received, and may
be taken fairly to represent the sentiments of the phy-
sicians who have sent in reports:
Dr. Douglas H. Stewart, New York, sends reports
of four cases, all desperate ones, and all " presumably
fatal under any other form of treatment." Very ex-
tensive membrane in all: larynx involved in three; in
one neglected case in a child three years old, injected
upon the fifth day, the membrane covered the tonsils,
nose, pharynx, and larynx. Broncho-pnuemonia,
nephritis, and sepsis all present. Temperature 107° F.
at the time of the first injection. Prostration so great
that he dared not attempt intubation. Believes that
this case would certainly have been fatal in a few
hours without antitoxin. Perfect recovery-.
In another case, three years old, membrane first dis-
covered in the left ear; ne.xt morning seen upon the
tonsils; spread in a few- hours over the pharynx into
the larynx and trachea. Intubation necessary in a few
hours; had never seen membrane spread so rapidly as
in this child. Urine albuminous; membrane subse-
quently expelled from larynx and trachea in large
casts, with profuse blood}' expectoration. Complete
recovery on the ninth day. The physician describes
this as "the very worst case of diphtheria that has
ever come under my notice." Fifty-four hundred
antitoxin units were given in four injections. He
remarks : " My experiences in the past have been
so very unfortunate that the advocates of antiseptics
or therapeusis were a constant surprise to me. It has
been my fate to have the most desperate cases un-
loaded upon my shoulders. I have been forced into
the belief that the profession was absolutely powerless
in the presence of true diphtheria ; have lost case after
case with tube in the larynx and calomel fumigations
at work. Previous to antitoxin my only hope had
become centred in nature and stimulants. In two
years I have not lost a single case, and surely I may be
pardoned if I suffer from diphtheria-phobia in a sub-
acute form, and use antitoxin sometimes unneces-
sarily."
Dr. L. L. Danforth, New York, states that during
his twenty-two years of practice in New York he had
seen many fatal cases of diphtheria, had used all
kinds of remedies, mainly those of the homeopathic
school, and while he had as much confidence in the
latter as in anything else, he had seen so many deaths
during the year past that he '" hailed with delight the
advent of antitoxin, and determined to use it." Re-
ports five cases, all of a severe type. '" The result in
every case has been marvellous. I would not dare to
treat a case now without antitoxin."
Dr. H. \\'. Berg, New York, reporting fourteen cases,
says: "I have not yet ceased to be surprised at the
recovery of some of these cases, which, in the light of
my former experience with diphtheria treated without
antitoxin, seemed to be irretrievably lost."
Dr. George McNaughton, Brooklyn, reports seventy-
two laryngeal cases, with twenty-four deaths; sixty-
seven of these were intubated, with twenty-one deaths.
He states that he has kept no records of cases other
than laryngeal ones, as these seemed the best test of
the serum treatment. He believes that if the serum
is used early, very many cases will not need operation
for the relief of stenosis. "I would urge the use of
antitoxin in all cases of croup in any patient who has
had an exudation upon the pharynx; would not wait
for bacteriological confirmation of diagnosis, for in so
doing valuable time is lost." Has noticed that the
tube is coughed up more frequently in injected cases,
and believes this due to the fact that the swelling of
the tissues subsides at an earlier date.
Dr. D. C. Moriarta, Saratoga, reporting four cases,
says that the first was a malignant one, and '" I only
used the remedy because I am health officer and was
urged to do so, as the t\'pe of the disease was that form
which I have seen recover but once in eleven years."
Boy five years old, four days ill when injected;
great prostration, rapid breathing, and he was " prac-
tically gone." Nares filled and tonsils and phaiyn.x
8
MEDICAL RECORD.
[July 4, 1896
covered; severe nasal hemorrhage; cervical glands
greatly swollen; heart's action very frequent and
feeble; child unable to lie down. Behring's seram,
twenty cubic centimetres injected; in six hours evi-
dently more comfortable: in eighteen hours decidedly
improved; in twenty-four hours sitting up and feeling
much better; in forty-eight hours all urgent symptoms
gone and membrane loosening. Subsequently had
nephritis, which lasted si.x weeks, and multiple neuritis,
which persisted for three months, but ultimately re-
covered perfectly. '' I send this report because it con-
verted me. No unbiassed person familiar with diph-
theria could see such results as this and not feel there
must be good in it."
Dr. F. M. Crandall, New York, sends report of a
child seven years old. Membrane on the tonsils and
in larj-nx, with croup for forty hours when antitoxin
w-as injected and intubation done. Progress of the
disease had been rapid; semi-stupor and eyes half
open; very feeble rapid pulse; intense toxaemia; gen-
eral cyanosis. Both cyanosis and dyspnoea persisted
after intubation, showing clearly the presence of mem-
brane below the tube. Case regarded as " absolutely
hopeless." The first change was seen in the disap-
pearance of toxaemia, with improvement in the pulse,
clearness of the mind, etc. ; later a change in the local
condition; large masses of membrane were expelled
from the larynx and trachea, necessitating frequent
removals of the tube. Tube finally removed in a week
with complete recovery.
Dr. Reynolds, Baltimore, mentions a case showing
the danger of relying too implicitly upon the bacterio-
logical diagnosis. Male, three years. Culture re-
ported only staphylococcus and streptococcus, conse-
quently injection 'delayed until the fifth day, when
membrane covered tonsils, nose, and pharynx. Child
died two days later. A sister subsequently contracted
the disease, received antitoxin on the tliird day, and
recovered. The reporter would not wholly rely upon
the culture test for diagnosis.
Summary. — (i) The report includes returns from
six hundred and fifteen physicians. Of this number
more than six hundred have pronounced themselves as
strongly in favor of the serum treatment, the great ma-
jority being enthusiastic in its advocacy.
(2) The cases included have been drawn from
localities widely separated from each other, so that
any peculiarity of local conditions to which might be
ascribed the favorable reports must be excluded.
{3) The report includes the record of every case re-
turned except those in which the evidence of diph-
theria was clearly questionable. It will be noted that
doubtful cases which recovered have been excluded,
while doubtful cases which were fatal have been in-
cluded.
(4) No new cases of sudden death immediately
after injection have been returned.
(5) The number of cases injected reasonably early
in which the serum appeared not to influence the pro-
gress of the disease was but nineteen, these being
made up of nine cases of somewhat doubtful diagnosis :
four cases of diphtheria complicating measles, and
three malignant cases in which the progress was so
rapid that the cases had passed beyond any reasonable
prospect of recovery before the serum was used. In
two of these the serum was of uncertain strength and
of doubtful value.
(6) The number of cases in which the patients ap-
peared to have been made worse by serum were three,
and among these there is only one new case in which
the result may fairly be attributed to the injection.
(7) The general mortality in the fifty-seven hun-
dred and ninety-four cases reported was 12.3 per cent. :
excluding the cases moribund at the time of injection
or dying within twenty-four hours, it was S.8 per cent.
(8) The most striking improvement was seen in the
cases injected during the first three days. Of forty-
one hundred and tw'enty such cases the mortality was
7.3 per cent.; excluding cases moribund at the time
of injection or dying within twenty-four hours, it was
4.8 per cent.
(9) The mortality of fourteen hundred and forty-
eight cases injected on or after the fourth day was 27
per cent.
(10) The most convincing argument, and to the
minds of the committee an absolutelv unanswerable
one, in favor of serum therapy is found in the results
obtained in the twelve hundred and fifty-six laryn-
geal cases (membranous croup). In one-half of these
recover}' took place without operation, in a large
proportion of which the symptoms of stenosis were se-
vere. Of the five hundred and thirty-three cases in
which intubation was performed the mortality was
25.9 per cent., or less than half as great as has ever
been reported by any other method of treatment.
(11) The proportion of cases of broncho-pneumonia
— 5.9 per cent. — is very small and in striking contrast
to results published from hospital sources.
(12) As against the two or three instances in which
the serum is believed to have acted unfavorably upon
the heart, might be cited a large number in which there
was a distinct improvement in the heart's action after
the serum was injected.
(13) There is very little, if any, evidence to show
that nephritis was caused in any case by the injection
of serum. The number of cases of genuine nephritis
is remarkably small, the deaths from that source num-
bering but fifteen.
(14) The effect of the serum on the nervous system
is less marked than upon any other part of the body,
paralytic .sequelx* being recorded in 9.7 per cent, of
the cases, the reports going to show that the protection
afforded Isy the serum is not great unless injections
are made very early.
The conimitte feels that this has been such a re-
sponsible task that it has thought best to state the
principle which has guided it in making up the returns.
While it has endeavored to present the favorable re-
sults with judicial fairness, it has also tried to give
equal or even greater prominence to cases unfavorable
to antitoxin.
In conclusion the committee desires in behalf of
the society to express its thanks to members of the
profession who have co-operated so actively in this in-
vestigation, and to Dr. A. R. Guerard for the prepa-
ration of the statistical tables.
[Signed]
L. Kmmett Holt, M.D.,
VV. P. NORTHRUP, M.D.,
Joseph O'Dwver, M.D.,
Samuel S. Adams, M.D.,
- Committee.
The Action of the Society upon the Report
At the close of its presentation, the society voted to
accept the report of the committee, and after a full
discussion it was decided to embody its conclusions in
the following resolutions:
(i) Dosage. For a child over two years old, the
dosage of antitoxin should be in all laryngeal cases
with stenosis, and in all other severe cases, fifteen
himdred to two thousand units for the first injection,
to be repeated in from eighteen to twenty-four hours
if there is no improvement; a third dose after a simi-
lar interval if necessary. For severe cases in children
under two years, and for mild cases over that age the
initial dose should be one thousand units, to be re-
peated as above if necessary ; a second dose is not
usually required. The dosage should always be esti-
mated in antitoxin units and not of the amount of
July 4, 1S96]
MEDICAL RECORD.
(2) Quality of antitoxin. The most concentrated
strengtli of an absolutely reliable preparation.
(3) Time of administration. Antitoxin should be
administered as early as possible on a clinical diag-
nosis, not waiting for a bacteriological culture. How-
ever late the first observation is made, an injection
should be given unless the progress of the case is
favorable and satisfactory.
The committee was appointed to continue its work
for another year and was requested to issue another
circular asking for the further co-operation of the pro-
fession, this circular to be sent out as soon as possible
in order that physicians may record their cases as
they occur through the coming year.
THE '-X" RAY AND SOME OF ITS APPLI-
CATIONS IN MEDICINE — DEMONSTRA-
TIONS OF APPARATUS AT WORK AND
EXHIBITION OF STEREOPTICON VIEWS."
By WILLIAM J. MORTON, M.D.,
NEW YORK.
Physicians, from time immemorial, have ever had a
keen desire to explore the interior of the animal body.
Hence arose dissection, and later on vivisection, and
still later on the revelations of the microscope. Put
none of these methods fully satisfy the wnsh to know
what is actually taking place within the animal or-
ganism during life, particularly when the processes of
life pursue a morbid course. Hence sprang up further
methods of exploration, some of them optical, and
some auditor}', and many tactile.
These methods we need scarcely enumerate; fa-
miliar examples are the ophthalmoscope, the cysto-
scope, the instruments and methods for transillumina-
tion and for auscultation and percussion, the probe,
simple and electrical. The standard resources of phys-
ical science have ever been applied by the physician
to this aim, namely, exploration ; each discovery as it
is announced is eagerly scanned to see if it mav not
have some practical application toward this same end.
And in reality it is a noble strife, for it represents not
alone the practical desire of the physician to solve the
problem of life and disease and death, but also that
instinctive desire of the intelligent part of the human
race to get closer to and learn more of the mystery of
its own existence and thus to form some conception of
immortality.
No wonder then that the '" X" ray with its marvellous
revelations of the hitherto unseen has excited a uni-
versal interest. Thus far its greatest promise of use-
fulness is to medicine and surgery. It behooves us,
then, as physicians to familiarize ourselves with the
new method of exploration, and, now that the first
glare of its announcement and of its workings has
subsided, to judicially and conservatively turn our at-
tention to its relations to medical and surgical prac-
tice.
Even as yet, in the undeveloped stage of Roentgen's
discovery, there can be little doubt that no more valu-
able means of diagnosis has ever been afforded to
medicine.
Historical. — It is not here the place or time to re-
view the purely physical steps which led in direct
succession up to Professor Roentgen's discovery.
The nature of the " X" ray is not known. The very word
ray and the idea of a radiation are as yet hypothetical,
and meanwhile the entire scientific world is bending
its energies to the solution of the problem. Happy
the discoverer.
■ Address at a stated meeting of the Medical Societj' of ihe
County of New V'ork. .\pril 27, 1896.
The view that the effects, which we may term
Roentgen effects, are due to a stream of electrified
particles moving at a high rate of speed is easy of
conception. The contending view, that we have to
deal with disturbance of the ether, either transversal
or longitudinal, falls into line with the beliefs and the
kindred demonstrations of some of the greatest of
modern thinkers. We of the medical profession may
well leave this battle royal of the scientists to them-
selves, and while awaiting its issue turn our attention
to the practical applications of the " X" ray.
Discarding theory, it is enough to state that from
a high vacuum tube, commonly called a " Crookes"
tube, emanates a " radiation"' which passes through
substance in direct ratio to the density of the sub-
stance, and is capable of recording its impact upon a
fluorescent screen or upon a photographic sensitized
plate or film. The picture is therefore a record of
variations in density or, what is the same thing, a
record of opacity of the various fonns of matter sub-
mitted to the ■■ X" ray. That, for this reason, the bones
are outlined within the flesh is now a familiar story.
But, in my own experience, an examination of my
negatives proves that the differentiation of tissue by
relative density is capable of being carried to a much
greater refinement. In one and the same negative to-
night I shall be able to show you at the same moment
a picture of the medullary and cancellous cavities of
the bones of the leg, of the tendons, of the muscles,
and of the skin.
We will now examine
I. Apparatus and outfit. 4.
II. Demonstrate its workings.
III. Exhibit products of its work (lantern slides).
I. [Here followed a description of the Ruhmkorff
coil and Crookes tubes and an exhibition of the meth-
ods of using them.]
II. The record made by the " X" ray after its passage
through substances of varying density may be ob-
tained in two ways: the one the fluoroscopic, the other
the radiographic.
((/) Fluoroscopy. — Roentgen himself pointed out
the eilfect of the '" X" ray upon fluorescent screens. Its
development into its present practical form is due
largely to the efforts of Mr. Edison, who early aban-
doned the photographic method in favor of the fluoro-
scopic and devoted himself to finding, first a highly
sensitive fluorescent material and, second, a practical
method of employing it. As is well known, Mr. Edi-
son believes that the fluoroscopic method may be made
of great practical value to medicine, and has devised
a specially constructed apparatus for physicians' use.
The essential features of his plan I hope to be able to
demonstrate to you to-night through Mr. Edison's cour-
tesy in extending every aid in his power to us, and
through the courtesy of Messrs. Aylesworth and Jack-
son, who have put at my disposal this large screen of
tungstate of calcium. To Mr. Tesla also the medical
profession owes a debt of gratitude for his develop-
ment of the new art, photographic and fluoroscopic.
He reports that he has clearly seen the interior organs
of the human body, and even detected the rays after
their passage through three men standing near to-
gether.
The world cannot be too grateful to men like Edi-
son and Tesla, who unselfishly devote their entire in-
dividual energies and the great resources of their
laboratories and of their experience to the solution of
scientific problems like the " X"' ray and its practical
applications. [At this point a large portion of the
audience filed by the fluoroscopic screen and viewed
the bones of their hands in the fluoroscope. Also the
lights in the hall were turned out and the bones of
the forearm and other objects were exhibited to the
entire audience upon a large fluoroscopic screen.]
lO
MEDICAL RECORD.
[July 4, 1896
(/') Photography [Here followed an exhibition of
taking an "X" ray picture. The patient, brought by
Dr. Saxl, was-believed to have a piece of a needle in her
hand. An eight minutes' exposure produced the ac-
companying picture, which was immediately devel-
oped and the negative passed about the audience.']
III. [The sjoeaker showed various lantern slides,
explained their working, and then continued:]
We are now in a position to draw some deductions
as to the applications
of the "X" ray in
medicine and Bur-
ger}'.
Bones and Osseous
Formations. — The
most obvious appli-
cation of the " X" ray
is to present to the
eye a picture of the
bones of the body,
individually and in
their relations to
each other and to
otlier tissues. B y
this means it is pos-
sible to detect and to
diagnosticate irreg-
ularities, deformi-
ties, malformations,
congenital or other-
wise, of bones, and
likewise to detect the
existence of fractures
and dislocations, the
coexistence of both
or the existence of
one to the exclusion
of the other. Disea-
ses of the bones
which vary their
density, either by
increasing or dimin-
ishing it, like exos-
toses, tuberculosis,
and sarcoma, are
clearly located. The
various stages of the
union of fractures are
outlined. One of the
radiographs I have
presented depicts the
slight malposition
and a change in the
marrow cavity at the
ends of the fractured
extremities in a case
of an ununited frac-
ture of the radius.
Another locates what
is presumed to be
tuberculous disease,
and is certainly some
form of disease of
bones of the wrist, in
a case which has thus far for five years defied diagno-
sis and treatment. An operation, soon to be made,
and not justifiable for mere ordinary exploration, will
soon decide upon the nature of this disease.
The further possibilities of bone pictures alone
are very great. By their aid the obstetrician may de-
termine the position of the foetus in its latest stages
' Photographic prints of all my negatives, noiv a fairly large
collection, may be obtained of Mr. E. 15. Meyrowitz, 104 Kast
Twenty-Third Street. A descriptive catalogue will be furnished
upon application to him.
of development within the uterus. Already I have
taken one radiograph which plainly shows the child's
head and the mother's vertebra;. I only await a favor-
able opportunity to repeat this with a result which will
be satisfactory to any obser\-er. Even now the fcetus
may be plainly seen by aid of the fluoroscope and it re-
quires no prophetic vision to state that the time is not
far distant when the child may be as easily viewed
within the womb as the coins within a purse, even to
the extent of its sex.
Another promising
field of research is
the detection of cal-
careous infiltrations
involving, for in-
stance, the arteries,
or occurring in the
lungs and other tis-
sues. Calculi in the
kidneys, in the blad-
der, in the salivary
ducts have already
been successfully
located.
The stages of ossi-
fication and the epi-
physeal relations of
the osseous structure
in children may be
pictured, as is de-
monstrated in the pic-
ture of the entire
skeleton of an infant
five months of age,
shown here to-night.
The radiograph here
exhibited shows
plainly that it will be
possible to detect spi-
nal disease either in
children or in adults.
In Dentistry. — Al-
ready I have had the
pleasure of demon-
strating before the
Odontological So-
ciety that the " X" ray
locates the hidden
fangs of teeth, the
presence of foreign
bodies about the
roots, the existence
and extent of unsus-
pected fillings, the
size of the pulp cham-
ber of the tooth, the
presence of teeth not
yet erupted, and the
existence of localities
of disease at the
roots.
Comparative Anat-
omy. ^ — -Akin to the
interest to the sur-
geon and to the dentist as relates to osseous tissue
is the interest to the comparative anatomist of an
opportunity to study the bony structure of animals,
the higher as well as tlie lower. The radiograph of
the fish shown to-night is most accurate and fascinat-
ing in its almost lacework outline of bony structure.
Foreign Bodies. — The detection of foreign bodies,
particularly those of a metallic nature, is already an
established fact. Bullets and shot are often embetided
in bone or situated close to it, but the " X" ray detects
them. The same is true of needles and other pieces
July 4, 1S96]
MEDICAL RECORD.
1 1
of steel. Glass, though partially permeable by the ray,
affords a reliable picture of its location.
Germicidal. — I am inclined to dismiss this much
vaunted claim made for the " X" ray with the remark
that if two animal organisms exist side by side, one a
bacterium, the other an animal cell, then what affects
one affects the other; the '" X"' ray, if germicidal, is
also homicidal.
Soft Tissues. — One of the most une.xpected and as
)"et a most undeveloped, but obviously one of the most
useful, applications of the " X" ray, is to locate the posi-
tion of soft tissues, and not alone to indicate that they
are the subject of disease but to locate even the area
over which the disease extends.
In the radiograph of the infant the liver is plainly
shown in outline, the heart is shown and mapped out
in relation to the usual landmarks. Organs distended
with gas, such as the stomach and intestines, allow the
" X" ray to pass freely, and thus the record of their lo-
cation and size is made.
These findings in relation to the soft tissues upon
a radiograph are but the beginnings of a new art of
diagnosis. In delineating and demarcating the organs
and tissues, we shall soon arrive at refinements of
method and of technique in relation to tirne of ex-
posure, posturing, etc., which resemble the skill of the
practised photographer, for an exposure may be so
timed as to depict clearly the soft tissues and their in-
terrelations. An overexposure, for instance, effaces
every record upon the plate except that of the bones
and may even easily efface that, while an underex-
posure gives a negative which is full of delicate
ghost-like and yet clearly defined outlines of skin,
muscle, tendon, veins, and arteries. Negatives of the
latter t}'pe are far stranger and more startling to the
investigator than the mere crude outlines of bones.
The mind walks in among the tissues themselves. It
is their ghost or their astral form that stands de-
picted.
But stranger still are the revelations of looking
through the living fleshly body by aid of the fluoro-
scope. First are seen the vertebrae, the greater bones,
the ribs, and then to the astonished gaze, in dark out-
line but moving, may be seen the beating of the
heart, the rise and fall of the ribs in respiration, and
the movements and rhythmical displacement of organs.
I have seen these organs plainly outlined and noted
changes in their density due to disease.
We need not become imaginative or speculative in
a presentation of this subject, particularly as it is
not yet possible to demonstrate to a large audience all
that the experimenter himself has seen in the stillness
and favorable circumstances of his own laborator}-.
But, gentlemen, in conclusion it may be said, that
if the practical development of this new art of what
may be called inside-seeing or esography progresses
yet another month at the rate it is now progressing,
you will see with your own eyes and easily, not alone
the skeleton construction of your neighbor or your pa-
tient, but also the location of his organs, the shape of
his muscles and tendons and veins and arteries, nay,
more, the variations in density of structure of these
parts, and therefore the seat and area of their dis-
eases.
'■ Many things that are hidden shall now be re-
vealed."
Castration and Urination. — Power to void the urine
naturally is usually one of the first results of castra-
tion. It is not always permanent. Atrophic changes
in the gland begin after a few days. The explana-
tion, therefore, is that ligation of the spermatic plexus
produces active stimulation, tonic spasm of the mus-
cles, etc. — MouLLi.x.
WANDERING PHLEBITIS (PERIPHLEBITIC
LYMPHANGITIS).'
Bv WILLI.\M P. NORTHRUP, M.D.,
NEW YORK.
The purpose of this paper is to raise the question
whether much of the so-called phlebitis complicating
typhoid fever, influenza, and other infectious diseases,
may not be in reality periphlebitic lymphangitis.
The following illustrative case is submitted in favor
of the view that it may be :
The patient was a woman seventy-two years old,
well presened, cheerful, energetic — one of whom it
was said she was always " happy and interested in
everything about her."
Her father and brother had frequent hemorrhages
from the nose, which seem to have been moderate; an-
other brother and a sister died of hemorrhage of the
lungs; the patient herself had from childhood been
subject to frequent profuse nose bleedings and hem-
orrhage from piles. She had several miscarriages be-
fore the birth of her one living child, after which birth
she suffered from milk leg. Apart from the above,
there was no significant family or personal history;
no gout, no rheumatism. The patient herself had
never suffered any serious illness.
One personal peculiarity of the patient was the con-
spicuousness of her veins in all parts of the body.
From early adult life she had been unable to wear a
low-necked dress because of this, and at the time of
her illness, at the age of seventy -two, the veins were
showing in her delicate skin in a manner most rare ; the
dark purplish color in contrast with the fair skin made
one think of veins painted on a manikin by a rather
clumsy amateur. This pecularityis mentioned not be-
cause it suggests anything in the etiological line, but
because it by chance afforded an excellent opportunity
for observing any changes in superficial veins.
The history of the illness now described began with
ill-defined feelings of not being in usual good health for
one to two weeks, during the last two days of which
time she experienced pain in the region of her left
hip. It was afterward recalled that the patient, con-
trary to her habit or temperament, was very much de-
pressed in spirits. To improve her general condition
her daughter took her to drive and sought to entertain
her by a visit to a loan art exhibition. While there
the patient, to use her daughter's words, '" seemed to
give out altogether," and wished to go away. Think-
ing a little drive would do the patient good, they
turned into the park. Presently the patient became
"dazed," stupid, could not see, talked incoherently,
became ghastly pale, could not answer questions, and
appeared to be dying. The daughter hurried the pa-
tient home and to bed. When undressing her it was
observed that the whole left leg was swollen and the
left thigh looked bruised. Very soon after this I ex-
amined the patient, finding the left limb considerably
swollen, normal in color, warm, and pitting a little on
pressure, with something to attract attention in the left
groin. There was diffuse bogginess over the whole
region. On pressure in Scarpa's space, an irregular,
slightly nodular induration and moderate deep tender-
ness was observed. The tenderness was not so severe
as to preclude a thorough examination, but the boggi-
ness rendered it difficult to determine definitely the con-
dition of the underlying parts. The point which gave
rise to the most anxiety of all in the examination was
the fact that no pulsation could be felt in the femoral
artery. On the other side it could be distinctly and
easily felt, and subsequent examinations proved that
there was no abnormality in the collocation of parts on
the affected side.
' Read by title before the Association of American Physicians,
Washington, May 2, 1S96.
12
MEDICAL RECORD.
[July 4, 1896
The case stood for the time, then, as follows : Sud-
den prostration; absence of femoral pulsation in left
Scarpa's space, swollen limb; color of limb normal;
temperature not sensibly different from that of its
fellow. Body temperature, 103' F. ; stupor, alternating
with moderate delirium.
At this point in the history Dr. H. F. Walker
saw the patient in consultation. His diagnosis was
■" lymphadenitis" and consequent diffuse oedema. The
swelling in a confined space and ctdema about it, caused
the artery pulsations to become imperceptible. This
diagnosis seemed at that moment to explain all the
symptoms. Dr. Walker had seen similar cases.
On the following day about six inches of the internal
saphenous vein became hard, with a whipcord feel,
and very sensitive, finger- wide redness gradually devel-
oping along its course and later a wide irregular oedema,
the whole linear area being e.xquisitely sensitive.
After lasting four days the oedema began to subside,
then the redness. The vein could easily be seen and
appeared to the sight to be normal. The whipcord
feel, however, still remained and the parts continued
too sensitive to be handled. At this point it was
noted that the adema of the leg had not increased —
had perhaps grown less. The patient gradually be-
came more comfortable, the fever subsided, and gen-
eral improvement was marked.
About a week from the first obser\'ation and when
the whipcord feel was the only remaming evidence of
inrtammation about the saphenous, the outer aspect of
the thigh in the upper half became tender and diffusely
red with a wide area, having a brawny feel. It became
apparent that this advance had taken in a loop of com-
municating veins wliich were whipcord-like and in a
condition similar to that of the internal saphenous.
The invasion of this new and extensive region was at-
tended with constitutional symptoms, chilliness, eleva-
tion of temperature (loi F.), rapid pulse (125), pallor,
sighing, restlessness, marked irritability, and depres-
sion of spirits, with petulance and weeping, stupor, and
mild delirium. The constitutional disturbance lasted
one or two days; the redness began to disappear on
the fourth day, cedema was gone at the end of eight
days, the whipcord feel and tenderness alone remain-
ing.
At this time it was interesting to speculate whether
the lesion was in the vein wall, a thrombo-phlebitis:
if it should prove to be such, being a plainly visible
vein, it would be interesting to observe what further
use the patient would have of the affected veins, ag-
gregating now about eighteen inches in length. After
a few days of rest there was another event of interest —
another pain, chill (chilly sensations), moderate rise
of temperature, whipcord condition of another si.x
inches of vein, finger-wide redness, bordering cedema,
exquisite sensitiveness, this time reappearing about
the internal saphenous vein, continuous with that of
the first attacked. Now it was observed that all signs
about the early affected veins had disappeared ; there
was, furthermore, an indication that the lesion was not
of the intima with thrombosis, but that the lesion was
extra-venous.
The walls of the veins were apparently entirelv nor-
mal; blood could be easily stripped out of them, the
current creeping back in plain view.
In this manner the process continued. .After inter-
vals of repose of from three to seven days, the affection
at each recurrence measuring off six-inch lengths upon
the vein, there were the same characteristic manifesta-
tions of chill, febrile reaction, whipcord feel, finger-
wide redness, cedema, sensitiveness, subsidence of all
symptoms, and then a complete return of the vein to
normal condition.
The process followed the line of the internal saphe-
nous vein to the lower third of the leg and there ceased.
Hope was entertained in the houshold that " it would
pass off at the toes," as suggested by the patient.
After the lapse of from ten days to two weeks another
chill with febrile reaction visited the patient, no vis-
ible vein being affected : then after another few days
a second febrile reaction, similar to the four or five
previously experienced, and still no visible vein was
affected. While we were speculating as to where the
inflammation would next appear, there came a third
similar attack, and the internal saphenous in the oppo-
site groin became a whipcord with accompanying
cedema. From this point the process intermittingly
measured off its lengths up the superficial epigastric
vein to the breast and there ceased. Still another
rest, chill, and fever, and the same process entered upon
its march along the course of the internal saphenous.
It hitched along one six-inch length downward, halted,
made a detour along the loop of external saphenous
veins on the external aspect of the thigh exactly as it
did on the other side; ceased in this region, in ex-
actly the same way; measured oft' more and more
lengths down the internal saphenous to the lower third
of the leg, and ceased at the same level that it did on
the first. When the inflammation made its appearance
in the second leg all the lesion about the veins of the
first affected leg had disappeared; the perivascular
tissues of the superior epigastric and the upper portion
of the internal saphenous had become quite normal.
When the process ceased ?t the right ankle and the
lesion had disappeared, the patient was well. She
has since been well, a period of more than two years.
Whether perivascular lymphatics of the superior
epigastric vein of the left side were inflamed iDefore
the patient came under observation can be only conjec-
tured. There are reasons for thinking they had been,
for the patient had complained of pain in the left hip
and had been ill some days before she collapsed in the
art gallery. If, then, the inflammation behaved sym-
metrically in this respect as in all others, about two
yards of superficial vein were involved first and last.
The only hidden lymphatics affected, so far as known,
were those of the pelvis, along which the process ad-
vanced from the left side to the right in the interval of
its ceasing at the left ankle and appearing at the right
groin. As will be remembered, this progression was
marked by two chills and two febrile reactions of
the same degree of severity and of the same general
character as those in the other steps of progression.
The treatment of the case consisted in rest in bed,
elevation of the swollen limb (the second affected did
not swell), fluid diet, general regulation of tlie func-
tions of stomach and bowels. Local applications of
various kinds were tried. Cotton pads vere employed
for protection; hot and cold, wet and dry applications,
with and without pressure, for relief of pain and ten-
derness, but no specific treatment was attempted. No
alkaline treatment was directed toward dissolving any
intravenous clot, neither was any scarification at-
tempted to limit the advance of the lymph-channel in-
fection. Bichloride wet applications were attempted,
but caused irritation and were not continued systemati-
cally.
Quiet, rest in bed, fluid food, relief of symptoms,
general good hygiene was the only aim in the later
stages. None of the various plans of treatment tried
at the outset seemed to modify the course, and the
patient begged only to be left undisturbed.
It seems to the writer that periphlebitic lymphan-
gitis is the correct name for the lesion in the present
case. In the writer's experience the behavior of the
tissues about superficial veins in typhoid fever has
been practically the same. There has been the same
whipcord feel, tenderness, ctdema, and final subsi-
dence of all evidences of previous inflammation.
Furthermore, this inflamed tissue is located quite
July 4, 1S96]
MEDICAL RECORD.
often upon limited lengths of vein, in continuity,
spreading a little or not at all and disappearing, hav-
ing apparently let loose no accidental emboli and hav-
ing left no thrombosis. The masterful way in which so-
called thrombo-phlebitis has been cured and veins re-
stored thrombus-free, suggests that the veins in such
cases may have had a perivascular inflammation. A
coat-sleeved infiltration, the perivascular spaces being
crowded with lymphocytes, could easily give the cord-
like feel, while vet the intimal coat and calibre re-
mained practically undisturbed.
The writer cannot, at this point, refrain from e.\-
pressing his opinion that infectious thrombo-phlebitis
rarely, if ever, disappears completely, leaving a per-
vious vein. Upon this point discussion is invited.
As to etiology of this variety of lymphangitis the
explanation must await the results of animal e.^peri-
mentation or of chance autopsies. Bleeding piles, in
the present case, would suggest themselves as a portal
for entering infection. The infective process having
appeared in the groin, its subsequent migration was
along continuous ways, limiting itself to similar tis-
sues. Why it confined itself for the most part to the
lymphatics about the superficial veins, apparently se-
lecting those of the internal saphenous and refusing
those of the femoral, selecting those of the superficial
epigastric and refusing those of the deep, is not easily
explained. I have it on the authority of Prof. Geo.
Huntington that the superficial veins are better sup-
plied with surrounding lymphatics than the deep.
Erysipelas has analogous characteristics and very
similar features of appearance and behavior, i.e., in
cutaneous and subcutanous tissues and surfaces.
Briefly to summarize: An aged patient, without pre-
vious illness, suffered a migrating lymphangitis which
followed for the most part the course of superficial
veins. There was no evidence that there was in any
part a thrombosis, and the vein was ultimately left in
an apparently normal condition.
Its infectious origin, intermitting advances, topo-
graphical limitations, suggest a process analogous to
that of erysipelas.
Again, the question arises just here as to the pos-
sibility and probabilit}" of an infectious venous tlirom-
bosis ever clearing up, leaving the vein quite normal.
The reason for calling attention to this case is the
fact that the migration was so extensive, and, further,
that it seems to the writer that this lesion has been
often set down by clinicians as phlebitis. Anatomists
maintain that the perivascular lymph spaces are not
an essential part of the vein wall. There may be no
objection to the term '' periphlebitis," but periphlebitic
lymphangitis would seem to describe the lesion more
completely.
57 East Seventy-Ninth Street.
Abnormal Labor Pains. — Dr. Schaeflfer, of Heidel-
berg, makes a division in labor pains, those that are
purely atonic and those which are partially spasmodic.
The most frequent cause of the partially tetanic pains
is endometritis of the cervix, which results in a slowed
first stage and consequently increased suffering; an-
other cause is the frequent examinations made and ir-
ritation which they produce ; abnormal position of the
uterus may also produce them. In this condition it is
not necessary to rupture the membranes, for they usu-
ally rupture without special delay. Treatment consists
in placing the patient in favorable posture, use of warm
baths, and hot vaginal douches. For weak pains, when
simple atony of the uterus is present, small hypoder-
matic injections of ergotin are found useful, produc-
ing an effect in about eight minutes after administra-
tion.— Cciitralblatt fiir Gjndio/ogie, Xo. 4, 1896.
IMPROVED TRACHELORRHAPHY.
Bv AUGUSTIN H. GOELET, M.D.,
PROFESSOR OF GYNECOLOGY IN THE NEW YORK SCHOOL OF CLINICAL MEDI-
CINE, ETC.
The benefit afforded by properly performed trache-
lorrhaphy in appropriate cases is very generally ad-
mitted, and though the operation may be applied un-
necessarily by some and may be performed incorrectly
by others, upon the whole it has perhaps been pro-
ductive of more good than any other operation in gyne-
cological surgery. The difficulty in those cases which,
do not yield satisfactory results lies usually in not
removing a sufficient amount of the diseased tissue
of the cervix, or in removing too much on the outer
or vaginal margin and not enough on the inner mar-
gin or that next the canal, thus leaving a wedge of
tissue which prevents proper coaptation of the flaps,
and puts too much strain on the sutures. This is
partly because the denudation is done with scissors,
which can seldom be made to cut through such dense
tissue where it is desired to cut. They invariably
slip, and considerable trimming is necessary after-
ward to get the flaps in proper condition for the ap-
plication of the sutures. This consumes a great deal
of time and is a serious disadvantage, as well as the
fact that the scissors will frequently cut where it is
not desired to cut and too much tissue is removed.
Another serious objection to the ordinary trache-
lorrhaphy is the great difficulty of inserting the su-
tures, because of the density of the tissue and the
awkward position for the operator of the parts to be
united. I venture to assert that any operator would
infinitely prefer to do an abdominal section than one
of these tedious and fatiguing cervix operations. It
is, therefore, because I believe I have simplified the
operation and made it quicker and easier, that I have
been encouraged to describe the method that I have
employed with so much satisfaction.
In the first place, the denudation is done with a
knife especially designed for the purpose, which con-
sists of a short two-edged blade set at an obtuse angle
to the shaft and handle (see Fig. i). I am well
aware that several knives have been designed and used
for this purpose before, but, so far as I know, none
have been made upon the principle of this one, and
they have not proven satisfactory, else they would be
more used. These knives are made in two sizes and
lengths, so as to be useful in all cases, since the cer-
vix in some instances is thick and the flaps deep,
and in others tliin by comparison. The method of
using the knife is to seize one angle of the laceration
with a tenaculum, transfix it with the knife, which is
then drawn forward, making a clean cut and denuding
the flap out to the lower margin of the cervix with one
stroke. It is then inserted again on the other side
and the opposite flap denuded in the same manner.
If now the tissue which is to be removed remains at-
tached at the angle, a reverse movement of the knife
severs it with its other cutting-edge. Besides the
greater ease of denuding with the knife, there is an-
other advantage, viz., it can be inserted and held in
such manner as to avoid leaving a wedge of tissue on
the inner edge of the wound. ,
In the next place, a special needle is employed for
inserting the sutures. I have abandoned the straight
needles and the straight needles with slight bend
near the point, and use a nearly half-curved, round
needle, much smaller in diameter than the needles
usually employed in this operation, with a flattened
spear point. These needles can be inserted into the
hardest cervix with the greatest ease. I have never
yet broken one of these needles, and find that they can
be inserted with ver)' much less force than any other
needle which I have used.
M
MEDICAL RECORD.
[July 4, 1896
Next I use for suture material silkworm gut -which
has been especially prepared so as to render it pli-
able and easily tied. I do not think catgut, silk, or
any suture which is not impervious should be used in
plastic work upon the cervix. The silkworm gut is
prepared in this manner: Each strand is carefully
wiped off with gauze or cotton saturated with ether,
and a number of strands are put into a glass tube of
suitable length, the ends being stoppered with rubber
corks. The tube is filled with a two-per-cent. solu-
FlG. I.
tion of lysol, one end is left uncorked, and it is placed
in a sterilizer in which the solution in the tube can boil
for half an hour. The lysol solution makes the silk-
worm gut very pliable, so it can be tied as easily
as catgut, and in addition it renders it thoroughly
aseptic.
The operation is further facilitated by placing the
patient in the lithotomy position.
Technique of the Operation. — It is of the greatest
importance that the patient be carefully prepared for
the operation. For two weeks, every second day a
Fig. =.
tampon of prepared wool soaked in glycerin is placed
against the cervi.x to deplete and soften it. This is
removed after twenty-four hours and a copious douche
of hot water is projected against the cer\-ix and
vaginal vault by means of a syringe giving an inter-
rupted flow. At each sitting for the introduction of
the glycerin tampon any cysts of the Nabothian
glands detected on the cervix are punctured and
emptied.
Two days previous to the operation the patient is
given a calomel-and-soda purge and she is placed
upon a restricted diet. The morning of the operation
she is given a saline cathartic, the vulva is shaved
and washed in a one-per-cent. solution of lysol, and
she is given a vaginal douche of lysol solution also.
When anaesthetized, she is placed upon the operat-
ing-table in the lithotomy position, a speculum is in-
serted, and the vagina is thoroughly scrubbed with a
one-per-cent. solution of lysol and afterward irrigated
with a solution of bichloride, i to 2,000. A ligature
is then passed through each lip of the cen-ix and tied
with a long loop, which is held by an assistant, usually
the nurse, who also holds the speculum and who stands
at the left of the operator. The cer\-ix at the angle
on one side (tlie left first) is seized with a tenaculum
and the knife (as shown in Fig. i ) is made to transfix
the cervix on one side of the angle. This done, the
tenaculum is loosened and reinserted in the lip near
the lower border near where the line of denudation is
Fig. 3.
to terminate on that side (see Fig. 2), and the knife
is drawn forward, making the denudation with one
stroke. The knife is again inserted at the angle on
the same side of the cervi.x, but on the opposite flap,
and it is denuded in the same manner. If the tissue
to be removed remains attached at the angle, a few
strokes upward with the other cutting edge of the
knife severs it so it can be removed. The same thing
is repeated on the other side (see Fig. 3).
In making the denudation the knife is held at such
an angle that rather more tissue is taken from the
inner than from the outer surface, so as to remove the
Fig.
ridge along the margin of the new canal of the cervix,
which if left would prevent satisfactory coaptation of
the flaps. In denuding with scissors this nearly al-
ways remains and must be carefully trimmed ofl^ after-
ward, considerable time being consumed in doing so.
The sutures of silkworm gut are inserted by means
July 4, 1S96]
MEDICAL RECORD.
15
of the special curved needles described above, being
threaded with a carrying-thread (see Fig. 4). It is
preferable to insert the outer or lower suture first, so
as to get perfect coaptation of the edges of the flaps
where the new external os is to be formed. It will
not be difficult to insert the other sutures if the loop
of this first one is left long, so as not to draw the flaps
together. The sutures are, of course, inserted on the
vaginal margin of the flap and brought out on the
margin of the new canal upon the mucous surface and
not upon the denuded surface. As each suture is
passed it is clamped by pressure forceps and handed
to an assistant to hold. All the sutures on both sides
(three on each side being usually sufficient) are in-
serted before any are tied. Then' the flaps are sepa-
rated, and they are thoroughly irrigated with a solution
of bichloride, i to 2.000. The sutures are tied from
without inward, or from below upward, tying that at
the angle last. The ends are cut about half an inch
from the knot, the vagina is washed out, and the pa-
tient is removed from the operating-table to the bed.
No dressing is applied to the cervi.x or vagina.
351 West Fifty-Seventh Street.
(Clinical §epartmcut
DISLOCATION OF THE FOURTH CERVICAL
VERTEBRA— REDUCTION— RECOVERY.
By WILLIAM H. NAMMACK, M.D.,
NEW VOEK.
George W , aged twenty-one, on September 2,
1895, while bathing at Far Rockaway, L. I., dived
into shallow water and struck his head against the
bottom. The forcible flexion of his head resulted
in a dislocation. He became unconscious and re-
mained so for about an hour as a result of the concus-
sion of the brain, but this condition responded readily
to the usual remedies.
On examination by Dr. Thomas J. Keamev and
myself a marked deformity was apparent. We felt
the vertebra prominens, and the sixth and the fifth
vertebrae were also found in their normal position.
Above these, however, the spine was bent forward, and
a wide gap posteriorly was easily felt and was even
visible. The head was completely immobile and the
malposition of the parts was peculiarly characteristic.
There was no paralysis either of motion or of sensa-
tion, severe pain, of which the patient complained,
being the only pressure symptom. Deglutition of
liquids was difficult and painful, that of solids im-
possible.
By placing the finger in the posterior part of the
mouth, the projection forward of the displaced verte-
bra was easily felt, so that we believed that the artic-
ulation between the two vertebn-e, the fifth and the
fourth, was torn open, that the supraspinous and the
infraspinous ligaments, the ligamentum subflava. and
posterior common ligament were torn through, while the
the ligamentum nucha; remained intact, drawing the
occiput downward toward the vertebra prominens and
so increasing the deformity.
Upon consultation it was decided to endeavor to
reduce the dislocation, and the dangers incident to
such a step were explained to the familv, who left the
treatment entirely to our discretion. Drs. Bums and
Bumster, whom I called upon for assistance, acqui-
esced in the following plan of treatment:
The patient was placed prone upon the table with
his head and neck extending beyond its end, and sup-
ported in that position during the administration of
ether. As soon as the anaesthetic had produced com-
plete relaxation, e.xtension was made from in front
with counterextension at the shoulders, the greatest
care being taken that no sudden movement should be
made. There was an immediate and gratifying re-
sponse to these efi'orts, respiration was not at all
affected, and we could then distinctly feel the spinous
process of the fourth cer\ical vertebra in line with
those below, while there was complete disappearance
of the deformity. Having thus reduced the disloca-
tion, the next problem was to retain the bones in their
proper position. The solution decided upon was a
plaster-of-Paris cast, which was applied so as to ex-
tend from the occiput and the thyroid cartilage above
to the first dorsal vertebra and the' sternum below, care
being taken to allow sufficient room for the neck. The
patient was then placed in bed and watched carefully
for three hours, during which time his condition re-
mained satisfactory. He was allowed to go about in
a week, the plaster was removed in three weeks, its
place being taken by roller bandages, and he was dis-
charged cured in five weeks from the date of the in-
jury. Since then he has been attending to his work
as a compositor, and he is apparently none the worse
for the accident.
271 East Broauway.
HYDATIDIFORM MOLE.
By WILLARD GILLETTE, M.D.,
ROSEBOON, N. V,
A M.ARRiED lady, eighteen years of age, and the
mother of a child twenty-two months old, was regu-
lar in her menstrual periods until September ist last
and noticed nothing again until October 2sth, when
she began to have uterine hemorrhage, at times pro-
fuse. November 7th I was consulted in regard to this
flow and, regarding it as simple menorrhagia, gave her
a three-grain pill of ergotin three times dailv, to
check hemorrhage, which it did to some extent. This
treatment was continued until November 24th, when I
saw the patient for the second time and made an ex-
amination of the abdomen. I found the uterus about
the size of a child's head and tense and I diagnosed
the case as one of pregnancy. This the patient
strongly denied and said she had never noticed any
enlargement until then. November 28th, about eleven
o'clock at night, I was called to see her and foimd her
in considerable pain and having some hemorrhage; I
gave her an anodyne. I made a vaginal examination
and found the uterus reaching to the umbilicus. I
was very much surprised to find this rapid increase in
size in this short time, for, as before stated, the uterus
was just above the pelvis and about the size of a
child's head on November 24th, only four days before,
but now it reached the umbilicus. I found the uterus
ver)' low and distended, of a doughy feeling, and the
OS so far displaced toward the sacrum that I could
scarcely reach it and also slightly dilated.
To say that I was astonished at this state of things
is putting it mildly. However, I decided to await de-
velopments. In the morning I found the patient in a
chair, with no pain and no hemorrhage. About noon
I saw her again when she was ha\ing some hemor-
rhage. Vaginal examination revealed the os more
dilated. I used a tampon and gave one drachm of
ergot, fluid extract, followed once in two hours by a
three-grain pill of ergotin. The pain continued.
About 5 P.M. expulsive pains began and after a lit-
tle time the patient said the child was born. Upon
examination I found a mass of hydatids or hydatid
cysts resembling white currants, and then for the first
time in the history of the case did I find that I had to
deal with "a molar pregnancy," the first one in my
experience. These cysts continued to be expelled
i6
MEDICAL RECORD.
[July 4, 1896
until between three and four quarts were taken, and
among them .a foetus of perhaps two months. The
hemorrhage ceased immediately. I gave ergotin pills
at four-hour intervals during the night. I saw the
patient December 2, 1S95, and found her doing nicely.
^^rogrcss of J^cdical J'Cicncc.
A New Form of Incontinence of Urine. — Dr.
Abarran calls attention to a new form of incontinence
of urine in young girls, which is due to a defect in the
development of the internal genital organs (A'e?^' York
Medical Jotinial). He relates the case of a patient
who had been troubled with incontinence for si.x years.
It had appeared when menstruation was established,
and all treatment had failed to bring about a cure.
The patient was thin, badly-developed, and ner\-ous.
The external genital organs were normal, but an exam-
ination revealed the absence of the anterior cul-de-
sac of the vagina; the vaginal wall was tense, and it
was inserted directly on the anterior lip of the cervix
uteri; the posterior cul-de-sac was well developed;
the uterus was small and conoid; the left ovary was
in its proper place, but the right ovary was nearer
than normal to the anterior vaginal wall. The blad-
der and the urethra were normal, but a malformation
of the internal genital organs existed, which consisted
of an abnormal adhesion of the posterior wall of the
bladder to the anterior surface of the uterus. This ex-
plained the cause of the incontinence. When the pa-
tient lay down the uterus became displaced backward
and dragged with it the posterior wall of the bladder,
■which adhered to its anterior surface; when the pa-
tient stood up the uterus became displaced forward
and pressed heavily on the posterior wall of the blad-
der, thus causing the vesico-urethral sphincter to re-
main open. An incision was made in the anterior
wall of the vagina, extending from the neck of the
uterus almost to the urethra. The uterus was de-
tached from the bladder, and the inter-utero-vesical
space was packed with iodoform gauze. At the end
of fifteen days the faradic current was applied to the
neck of the uterus three times. This treatment, says
the author, resulted in a complete cure.
Trional in Epilepsy — Dr. H. P. Boyer reports his
observations in regard to the clinical use of this drug
by Dr. S. Weir Mitchell, as the results obtained from
this treament were such, he says, that it was thought
advisable to publish them. In most instances where
trional was used the patients were in some way bene-
fited {Nc7o York Mcdiiiil Journal). Either the num-
ber of attacks was diminished, their severity lessened,
or the general physical condition of the patient im-
proved. Early in 1894, says Dr. Boyer, Dr. Mitchell,
pleased with the results of this treatment in his pri-
vate practice, began to use it in his out-patient ser-
vice. The results of its use and the drawbacks are
stated in an account of thirteen cases. Others, savs
Dr. Boyer, might be added to the list, but the patients
neglected to report at the hospital, and the results
could not be carefully watched. Others, again, suf-
fered so much from drowsiness and vertigo, and de-
rived so little benefit in regard to the diminutioH of
the number of attacks, that the treatment was not kept
up for more than two or three weeks. Of the thirteen
cases referred to, in ten there was a marked decrease
in the number of attacks during the treatment, and the
physical symptoms also were singularly improved. In
five of the cases the number of attacks was less under
the trional treatment than under the bromide treat-
ment: in two others, however, the bromides gave more
satisfactory results. Dr. Mitchell believes, says Dr.
Boyer, that trional may often prove an efficient sub-
stitute for the bromides, and he states that he has seen
no ill effects follow its continuous use for many weeks.
It is well, he says, at times to give the bromides in
the daytime and trional at night.
Gunshot Wounds of the Abdominal Viscera. — Dr.
Randolf Winslow {Bulletin of the Maryland University
Hospital, vol. i., No. i) summarizes his views as fol-
lows: I. In view of the almost uniformly fatal result
of gunshot wounds of the abdominal viscera, when
treated conservatively — that is with opium, rest, and
star\-ation — it is the bounden duty of surgeons to sub-
ject such cases to laparotomy, and to repair, so far as
possible, such injuries as may have been inflicted. 2.
Operate at once, and do not wait for symptoms of per-
foration of the intestines to occur — that is, for the de-
velopment of peritonitis — or the golden opportunit)'
will be lost and the operation will be too late. 3.
The condition of shock in abdominal injuries usually
means hemorrhage, and it is best not to wait for reac-
tion; otherwise the only possible chance of saving life
may be lost. 4. The exploration of the abdomen
should be thorough, and for this purpose a ver)- free
incision may be necessary. 5. All bleeding vessels
must be secured, and all intestinal wounds must be
sutured. 6. It is generally best to open the abdomen
in the linea alba, but in some cases it may be prefer-
able to operate at the site of the wound. 7. Operate
as speedily as possible, but do not hurry.
Indications for the Induction of Abortion. — Dr.
Jeffe [Medicinische Aeuif^l'citen, Xo. 45, 1894) after a
study of the literature of the last ten years fixes the
indication for inducing abortion as follows: Absolute
indications — i. Uncontrollable vomiting of pregnancy.
2. Incarceration of the gravid uterus. 3. Obstruction
of the pelvic outlet by tumors or exudates. 4. Pro-
gressive and pernicious anaemia. 5. Grave chorea.
Relative indications — i. Great contraction of the pel-
vis with the conjugata vera below five centimetres.
2. Pulmonary emphysema with signs of degeneration
of the heart. 3. Nephritis, especially with eclampsia.
4. Chronic heart disease. 5. Other general diseases
of the mother which would jeopardize her life at that
time of delivery. The author holds that a conjugate
vera of six centimetres and advanced pulmonar)- tu-
berculosis should not be regarded as indications for
abortion, as it is not just to sacrifice a future life for
one that is " certainly lost."
Syphilis and the Etiology of Atheroma. — Dr.
\^'eber (Ameriean Journal of the Medical Sciences,
May, 1896) concludes: i. That atheroma of the aorta,
though often preceded or accompanied by inflamma-
tion, is itself a merely degenerative process; that
syphilitic or other inflammation may locally predis-
pose to atheroma. 2. That aneurism of the aorta is
induced more often by the yielding of a portion of its
wall affected by syphilitic or other inflammation than
of a portion aft"ected by simple atheroma.
Dislocations of the Hip. — In a monograph on this
subject, to which was awarded the Samuel D. Gross
prize for 1896, Dr. Oscar H. All is discussed the follow-
ing points: I. The capsule is the most important agent
against traumatic dislocations of the femur. 2. For
the laceration of the capsule and dislodgment of the
head of the femur the femur is employed as a lever.
3. Every lever has a fulcrum; the fulcra required in
dislocations of the femur are bony and ligamentous.
4. Dislocation by thrust, if possible, is infrequent.
5. Reduction by circumduction is the simplest, the
most brilliant, and the most hazardous of all modes of
replacement. 6. Method suggested for reduction of
dislocation of the head of the femur when associated
with fracture of the shaft.
July 4, 1896]
MEDICAL RECORD.
17
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, July 4, 1896.
THE ANTITOXIN QUESTION.
At the present time, when the antito.xin treatment for
diphtheria is so much under discussion, the report of
the American Pediatric Society will be read with
much interest. It is only by such thorough work in
the collection of statistics from widely different sources,
and the fair and careful estimation of all possible
controlling influences, that valuable and impartial
facts can be obtained. Under such circumstances
only can fair opinions be formed and proper conclu-
sions drawn. Too much praise cannot be given to the
committee having the matter in charge for the pains-
taking manner in which the work has been done.
Never before has a similar investigation been made
in which more vital interests have been at stake and
in which it was more necessary that some general
principles should be established upon which proper
conclusions could be founded. It is fair to say that
upon the question whether or not antito.xin is valuable
in diphtheria rests the whole theory of the serum treat-
ment of infectious diseases. Too much care cannot
be taken in properly sifting all the facts /n? or con.
bearing upon the important point at issue. The con-
viction cannot be resisted that the great preponder-
ance of professional opinion is strongly in favor of
the method. This is abundantly proved, thus far at
least, by the widespread use of the remedy and the
growing conviction that it has a marked and striking
effect in reducing mortality. Notwithstanding, how-
ever, the large number of statistics already collected,
we are not yet prepared for final conclusions. There
is no denying the fact that bacteriology pure and
simple has appropriated more than its just share of
credit in the present aspect of the question, nor is
there any doubt of a desire among the very active
workers in this now promising field of investigation
to still more magnify the importance of their re-
searches at the expense of clinical experience, upon
which, after all said and done, the practical use of
every therapeutic measure must finally rest. Thus the
tendency has very naturally shown itself to found the
diagnosis absolutely on the bacteriological examina-
tion, with the result of greatly enlarging the number
of cases and proportionately reducing the rate of mor-
tality. Not every throat containing the Loeffler bacil-
lus is necessarily a malignant case. In times past
there was noway of deciding between a malignant and
a benign case save by the different constitutional dis-
turbances that were manifest. In a great many of these
cases the local lesions were apparently the same.
Bacteriology has made great advances in clearing up
many cases of reasonable doubt, but the broad gener-
alizations regarding the true significance of a given
microbe are not yet so firmly established as to be be-
yond the possibility of doubt or above the right of
challenge.
The Pediatric Society has shown a very proper
spirit in its efforts to eliminate these sources of error,
and in this respect more particularly has shown the
example for future investigation along very promis-
ing lines. The truth will eventually be found in the
middle ground between the extreme views. The so-
ciety has made the most of its opportunities, which
have been quite extraordinary, in raising the discus-
sion to such a level, and in this respect has set the
pace for all similar inquiries.
The conditions of the inquiry have been fair and
reasonable, and need only to be carefully studied to be
properly appreciated. It was eminently proper that
the test of the remedy should be made on children
previously well nourished, such, for instance, as could
be seen in private practice ; that the number should
be widely distributed, and be sufficiently large, includ-
ing all cases reported, to reduce errors of calculation
to a minimum and establish a proper estimation of
percentages. A crucial test has been made on the
basis of mortality of the severer cases which required
intubation. It can be seen that so far the favorable
figures are on the side of antitoxin. Still, as before
intimated, we are just beginning to study this ques-
tion from the proper standpoints, and while the great
majority of the profession may very properly continue
the use of antitoxin, we are very much in need of
many more facts before we can silence absolutely
such as still need to be convinced of its efficacy. The
case is still being very successfully argued on the
side of antitoxin, but the great, silent, careful, power-
ful jury of the profession is not yet ready with its
final verdict.
THE TREATMENT OF PRURITUS.
In a recent issue of the British Medical Journal, a dis-
cussion on the pathology and treatment of pruritus is
published, in which a number of prominent dermatol-
ogists took part. The discussion was limited in the
main to the consideration of pruritus not associated
with any distinct skin eruption, although an able dis-
cussion of the relation of this symptom to skin disease
is given by Dr. Brooke. It is interesting to read over
simply the list of the causes which lead to persistent
and obstinate itching of the skin. Pruritus occurs in
old people, and seems to be merely one of the symp-
toms of an involution of the epidermis. It attacks
some persons in the winter time, because a lower tem-
perature is enough to bring out the symptoms in those
with a predisposition to the trouble. There are curious
types of pruritus, which have been called by some
" brain itch" and by others " pruritus mentis." In this
the itch is a pure hallucination, the locality being not
in the skin but in the cortex of the brain. There is a
i8
MEDICAL RECORD.
[July 4, 1896
pruritus that ccimes on after people take strong tea or
strong coffee, and another kind which develops after
eating badly cooked oatmeal or indigestible starchy
food. General pruritus has been known to be caused
by tapeworms, and there is a popular belief that itch-
ing of the tip of the nose is a reflex pruritus from pin-
worms in the rectum. One of the speakers in the dis-
cussion stated that he had seen in recent years many
cases of pruritus ani from bicycling and polo playing.
Pruritus, however, in its commoner manifestations is
probably most often seen in connection with a gouty
diathesis or with diabetes, in which cases there is often
some eczema associated with it.
The foregoing are some of the facts, sufficiently fa-
miliar, but presented anew by the speakers in the dis-
cussion referred to.
The subject of treatment was touched upon by half
a dozen of the gentlemen, most of them referring to
measures which they had found useful in some partic-
ular form of the trouble. Dr. Garrett Anderson rec-
ommends for the pruritus of neurotic women and
" men of feminine habits" — whatever she may mean by
that — rest before meals, increase of food, silk under-
clothing, and cod-liver oil. Dr. Myrtle reconunended,
in vulvar and anal cases, the free use of an ointment
composed of fifteen to forty grains of potassa fusa to
one ounce of lard. Two physicians, Dr. Waldo and
Dr. F. H. Barendt, advised the use of mustard leaves
over the spinal cord or of blisters over the same area.
Dr. Barendt also recommended strongly, as a local ap-
plication, hot olive oil containing two per cent, of car-
bolic acid for five minutes night and morning. We
find nothing specially new in the line of drugs for in-
ternal use. Dr. Anderson has had the best results
from the administration of atropine or of one of the
coal-tar derivatives, and by using electricity. Atro-
pine is given subcutaneously, in doses of one-one-hun-
dredth of a grain, gradually increased. Of the coal-
tar derivatives, antipyrin is the best, but it is to be
given in large doses. Mention is, of course, made of
the -ordinary precautions as regards diet and bathing,
things which all physicians would naturally take into
consideration.
say opening into the air passages, he had better stick
to the English. It is quite expressive and fairly well
understood in this country.
AN IMPOSSIBLE WORD.
We have received a reprint of an article entitled
" Aeroporotomy," written by a medical practitioner
in Cleveland who has a laudable desire to better
our medical nomenclature. Our heart sank as we
read the title, for the obvious meaning of the word
would be cutting up an aeronaut. These poor crea-
tures run enough risks through collapse of their para-
chutes, and it did seem too bad that any of them
should have come under the knife of a Cleveland
surgeon. We were somewhat relieved, however, to
find that the dreadful word was only one which the
author proposed as a general term to express any or
all of the various methods for letting air into the air
passages. .\s such, the attempted coinage is not a
success. We do not think the need of any such in-
clusive term is very strongly felt, but if one wants to
BtnxJs of the imcck.
A Hospital Quarrel in Australia. — The members
of the attending staff of the Adelaide Public Hospi-
tal, of Adelaide, South Australia, have resigned in a
body on account of some disagreement with the au-
thorities, the nature of which is not stated in the
dispatches. The government is stubborn, and has
sent to England to secure a full staff of physicians
and surgeons to serve on a salary. The local profes-
sion is unanimous in support of the resigning staff,
and those who may take their places on the invitation
of the government will not receive a verj' cordial wel-
come from their confreres. This will doubtless, how-
ever, not interfere with the success of the govern-
ment's scheme, and indeed one well-known London
man. Dr. Leith Napier, has already accepted the invi-
tation, and his example will probably soon be imitated.
Dr. Hans von Hebra, the son of the " Father of
Dermatology," formerly privat-docent, has now re-
ceived the appointment of professor at the University
of Vienna.
A New Greek Medical Journal. — We have re-
ceived the first number of Iut/h/.Ti llponSd'i (Afft/iVd/
Progress), a monthly journal published in Syros, undec
the editorial management of Dr. John A. Phoustanos.
Each number is to consist of twenty-eight quarto pagc-s,
with a supplement containing a serial treatise on the
" New Remedies" by the editor. The first two num-
bers contain several interesting articles on varioiis
.subjects.
Resignation at the Woman's Hospital of Phila-
delphia.— Dr. Anna M. Fullerton, physician-in-charge
of the Woman's Hospital for the past ten years, has
resigned her position in that institution. The mana-
gers have not yet appointed her successor.
New York Medical Licenses no Longer Accepted
in Pennsylvania — The Pennsylvania State Mediciil
Council has rescinded its rule accepting licenses from
the New York State Board of Medical Examiners, in
retaliation for the refusal of the New York examiners
to accept the licenses issued by the Pennsylvania
board.
The University of Utrecht has just celebrated the
two hundred and sixtieth anniversary of its foundation
on June 2 2d.
Professor Virchow has had a narrow escape, having
been thrown down in the streets of Berlin by a bicy-
cle. Fortunately he suffered no severe injury.
Dr. Joseph McFarland, demon.strator of patholog-
ical histology and lecturer on bacteriology in the Uni-
versity of Pennsylvania, has been elected professor of
pathology in the Medico-Chirurgical College, in suc-
cession to Dr. E. B. Sangree, recently elected to a
similar chair in Vanderbilt University.
July 4- 1896] MEDICAL
Medico-Chirurgical College of Philadelphia Dr.
Isaac Ott, professor of physiolog}', lias been elected
dean of the Medico-Chirurgical College, vice Dr. Er-
nest Laplace, resigned.
College of Physicians of Philadelphia At the
stated meeting of the College of Physicians of Phila-
delphia, held on June 3d, Dr. Joseph Leidy read a
"Note on Infantile Scurvy," reporting two of nine
cases that had come under his observation. Dr. Os-
car H. Allis read a paper entitled '"The Mechanism
of Dislocations of the Shoulder and Hip Deduced
from their Accidental Restoration," and presented
specimens as follows: (i) Impacted fracture of the
neck of the femur; (2) fracture of the neck of the fe-
mur, partly intracapsular, partly extracapsular, with
transfixion of the capsule, and accompanied with flex-
ion of the femur at the hip. Dr. Robert G. Le Conte
reported the case of a man who had received a bullet
wound of the neck, in which the missile could not be
found upon examination by the ordinary means, but
which after some time was located by means of sko-
tography. After extended search the bullet was found
in front of one of the lower cervinal vertebrae, be-
tween which and the cesophagus in front an abscess
had formed. This is an instance of the saving of life
which is to be credited to the new light. The follow-
ing were elected to fellowship : Drs. T. C. Ely, H. D.
Beyea, A. H. Cleveland, L. S. Smith, J. C. Da Costa,
W. M. Angney; and the following to associate fellow-
ship: Sir George Murray Humphrey, Bart., of Cam-
bridge, England; Dr. George M. Sternberg, U. S. A.,
of Washington, D. C. ; Dr. Phineas S. Conner, of Cin-
cinnati, O. ; Dr. T. McLane Tiffany, of Baltimore,
Md. ; and Dr. William T. Lusk, of New York City.
The Lepra Bacillus has been found in the blood, as
well as in the tissues, by Dr. Boufte, of Paris.
Vital Statistics of Philadelphia.— For the week
ending June 20th there were reported to the Philadel-
phia board of health 414 deaths, of which 174 occurred
in children under five years of age. Among the most
important causes of death were: Pulmonary tubercu-
losis, 46; cholera infantum, 32; heart disease, 30;
pneumonia, 28; marasmus, 26; convulsions, 22. The
following figures sliow the morbidity and mortality of
diphtheria, scarlet fever, and typhoid fever for the
weeks ending June 13th and 20th respectively:
, — June 13. — , , — June 20. — s
Cases. Deaths. Cases. Deaths.
Diphtheria 46 8 40 II
Scarlet fever 16 . . 13 i
Typhoid fever 39 9 30 3
State Medical Examinations. — At the Pennsylva-
nia State Medical examinations, held at Harrisburg
on June i6th, there were three hundred regular appli-
cants, about seventy homoeopathic, and several eclec-
tic. It was discovered that one of the applicants
had in advance obtained a copy of the examina-
tion questions, and was disposing of his informa-
tion at the rate of $25 to all who wished it. The
discovery was made in time to change the questions,
and the confession of the offender was followed by his
RECORD.
19
proscription from the practice of medicine in the State
of Pennsylvania. The examination of applicants for
a license to practise medicine in Delaware was held
on June i6th, 17th, and i8th. The examination of
graduates in regular medicine was held at I)o\er;
those of graduates of homoeopathic schools at Wil-
mington.
Philadelphia County Medical Society.— At the
stated meeting of the Philadelphia County Medical
Society, held on June loth. Dr. B. Meade Bolton, di-
rector of the bacteriological division of the board of
health, read a paper entitled " The Examination of
Cultures from Cases of Suspected Diphtheria.'' The
data were abstracted from the first annual report of
the bacteriological laboratory of the bureau of health,
and were summarized in the Mkdical Record of
March 7th, p. 347. Dr. Edward Jackson read a com-
munication entitled "The Profession, the Opticians,
and the Public," in which he made a strong plea for
greater care and attention on the part of ophthalmolo-
gists in the correction of refractive errors of the eye.
He condemned the practice, now happily declining,
of prescribers of glasses accepting commissions or
other form of compensation from oculists. Dr. Er-
nest Laplace read a paper on " The Surgical Treat-
ment of Insanity," reporting several cases presenting
symptoms of mental aberration, in which relief was
afforded by trephining, separation of dural adhesions,
removal of old blood clots, etc. Dr. J. P. Crozer
Griffith reported " A Case of Varicella Gangra-nosa,"
in which, following an attack of croupous pneumonia,
diphtheria, rubeola, and varicella occurred synchro-
nously in a child twenty-two months old. Large bulla:
formed in various parts of the body, the breaking down
of whose walls and the evacuation of their contents
were followed by ulceration and gangrene. Upon
post-mortem examination the trachea was found oc-
cluded by diphtheritic membrane, although the larynx
was free.
" A Medical Jack the Ripper " is what the gen-
tlemanly premier of South Australia called the former
head of the gynecological staff of the Adelaide Hos-
pital, who had resigned with his colleagues rather
than submit to be ruled by a board, one of whose
members was a practitioner who had been expelled
from the local branch of the British Medical Associ-
ation.
Obituary Notes — Dr. George C. Shatiuck
Choate, of Pleasantville, Westchester County, died
suddenly in this city on June 28th. He was born in
Salem, Mass., in 1826. He was the oldest son of Dr.
George Choate, of Salem, and a brother of Joseph H.
Choate and William G. Choate, of this city. Dr.
Choate was graduated from Harvard College in 1846
and from the Harvard Medical School in 1849. He
was for ten years superintendent of the Massachusetts
State Asylum for the Insane at Taunton. Thirty-six
years ago he established a sanatorium near Pleasant-
ville, and it was there that Horace Greeley died on
November 29, 1872. — Dk. Josei'H Bauer, of St. Louis,
20
MEDICAL RECORD.
[July 4, 1896
a son of Dr. Louis Bauer, died on May 2 2d of Bright's
disease, at the age of forty-two years. He was a na-
tive of Brooklyn, N. Y., and was graduated in medi-
cine from the Missouri Medical College. — Dr. C. H.
Bahl, a graduate of the University of Pennsylvania
in 1864, died in Philadelphia on June 14th.
Measles in Costa Rica. — The American Practi-
tioiiiT and News says that a fearful epidemic of mea-
sles and mumps is reported by private letters to be
raging in Costa Rica. More than ten thousand chil-
dren are estimated to have died from these maladies
during a period of three weeks. All official reports
are rigorously suppressed for commercial reasons.
Li Hung Chang's Bullet Found by the Roentgen
Rays. — During the stay of Li Hung Chang in Berlin
he visited the Charlottenburg Polytechnic and sub-
mitted himself to a Roentgen-ray examination, which
revealed the location of the bullet fired by the would-
be assassin of the Chinese statesman at Shimonoseki,
Japan, when the treaty between China and Japan was
being arranged. The bullet entered the left cheek
and buried itself in the tissues slightly below, where
it is now encysted.
Cholera in Egypt. — The official cholera statistics
show that during the week ending June 27th there
were 1,383 new cases of the disea.se reported and 1,091
deaths.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the U. S. Navy for the week ending June 27,
1S96: June 23d. — Assistant Surgeon S. B. Palmer,
detached from the New York Laboratory, June 29th.
June 26th. — Passed Assistant Surgeon George Roth-
ganger, detached from the Independence, July isth, and
ordered to the Oregon.
The New Jersey State Medical Society, at its
annual meeting which closed at Asbury Park on June
24th, elected the following officers: Fresideiit, Dr. F.
|. Smith, Bridgeton : lurst Vice-President, Dr. D. C.
Knglish, New Brunswick; Second Vice-President, Dr.
('. R. P. Fisher, Bound Brook; Third Vice-President,
Dr. Luther M. Halsey, Newark; Correspondi?tg Secre-
fiiry. Dr. E. L. B. Godfrey, Camden ; Recordijig Secre-
tary, Dr. William Pierson, Orange; Treasurer, Dr.
Archibald Mercer, Newark; Prize Essayist for 1897,
Dr. Harris. The subject for the fellows' prize essay
for the coming year is the " Antitoxin Treatment of
Tetanus." The next annual meeting will be held in
Atlantic City in June, 1897.
The Fourth of July in Berlin. — The American
physicians and dentists resident in Berlin propose to
celebrate the Fourth by holding a picnic at Grunau
after attending the official reception which is to be
given by United States Ambassador Uhl.
Professor Edwin Klebs has been elected to the chair
of pathology in Rush Medical College.
Rush Medical College of Chicago This college
has recently been recognized by the examining board
of the Royal College of Physicians and the Royal
College of Surgeons of London, England. This recog-
nition entitles its alumni to all the privileges accorded
to the graduates of other institutions recognized by
that board.
Medical Association of Baltimore and Ohio Rail-
way Surgeons. — The semi-annual meeting of the
Medical Association of Baltimore and Ohio Railway
Surgeons was held at Philadelphia on June 23d and
24th, Dr. J. M. Spear, of Cumberland, Md., presiding.
An address of welcome was delivered by Dr. W. W.
Weaver, chairman of the committee of arrangements.
Among the communications presented were the follow-
ing: "A Clinical Study of the Ophthalmic Symptoms
in a Case of Fracture of the Anterior Base of the
Skull," by Dr. Charles A. Oliver; "Fracture of the
Elbow-Joint," by Dr. B. J. Byrne, of Ellicott City,
Md. ; '■ Legal Surgery," by Dr. S. S. Good, of Myers-
dale; '-Fractures," by Dr. W. E. Stothers, of Wheel-
ing, W. Va.; "Color Blindness," by Dr. Charles A.
Oliver; "The Best Form of Amputation for Stumps,"
by Dr. J. M. Thome, of McKeesport; "Fracture of
the Thigh," by Dr. J. F. Reger, of Littleton, W. Va. ;
'■ The Railway Surgeon," by Dr. J. W. Wright, of
Columbus. A demonstration of making tablets and
an address on their use were given by Dr. J. J.
Hamilton, of La Paz, Ind. It was decided to hold
the next meeting at Chicago in December, 1896.
American Dermatological Association. — The next
annual meeting of this association will be held at the
Hot Springs of Virginia September 8, 9 and 10, 1896.
Several papers on interesting subjects have been
already promised. Dr. White, of Boston, will open a
general discussion on the subject, '' What Effect do
Diet and Alcohol have upon the Causation and Course
of the Eczematous Affections and Psoriasis?" The
secretary of the association is Dr. Charles W. .Allen,
126 East 60th Street, New York City.
(Dbitxuu'ij.
EDWIN D. RAMSDELL, M.D.,
NEW VORK.
Dr. Edwin D. Ramsdell died at his home in this
city on Friday morning, June 12th, from pneumonia,
after an illness of only three days. Dr. Ramsdell
was born in Belleville, Jefferson County, N. V., March
19, 1830. He received his education in the piililic
schools of Watertown. When but sixteen years old
he became a teacher and continued in this work for
four years, and then came to New York, where he en-
tered the Medical School of the University of the City
of New York. He was graduated in 1855, and at once
began practice in this city.
Dr. Ramsdell was a member of the Medical Society
of the County of New York. He leaves a widow and
four children, a daughter and three sons, one of the
latter a physician in this city.
All who knew him revered him for his honestj' of
purpose, his simple life, his fidelity to all trusts, and
his charity toward the poor. He never strove for hon-
ors or preferments or riches, but strove ever to do his
duty to all. and he received his reward in the devoted
love of his patients.
July 4, 1S96]
MEDICAL RECORD.
21
Jiociety Reports.
AMERICAN ORTHOP.-EDIC ASSOCIATION.
Tenth Annual Meeting, Held in Buffalo, May ig, 20,
and 21, iSg6.
RovAL Whit.max, M.D., of New York, President.
First Day — May igth.
The Rationale of Gymnastic Exercise and Pressure
Correction in the Treatment of Scoliosis.— Dr. L.
A. Weigel, of Rochester, read a paper with this title,
and summarized his viev.s as follows: (i) Gymnastic
exercise as an exclusive method of treatment must be
limited to the very early stages and to deformities
which are postural, pure and simple; (2) exercises of
all kinds are insufficient, even in comparatively mild
cases; (3) treatment by mobilizing tiie spine should
precede any attempt to develop the muscles; (4) re-
moval of the superincumbent weight is the important
part of the treatment and is of great value in sustain-
ing the effects of exercise; (5) overdevelopment is to
be avoided; and (6j empiricism should have no part
in the treatment of scoliosis.
The Rapid Cure of Rotary Lateral Curvature of
the Spine and Other Postural Deformities, by
Means of Thorough Development and Corrective
Exercises with Heavy Weights. — Dr. Jacob Tesch-
NER, of New York, present by invitation, read a paper
on this subject and gave a demonstration of the meth-
od of carrying out these exercises. According to liis
view of lateral curvature, it was due to general muscu-
lar weakness and habitual faulty position, and hence
the whole muscular system shoukl be developed. At
each visit the patient is put to his individual limit,
and it is found tliat this usually increases at each visit.
He claimed that by this method he had succeeded in
curing cases of lateral curvature in which there were
bony and ligamentous changes and marked rotation
present. In tlie milder cases improvement was quite
noticeable within two weeks, and a cure would often
be effected in three months. He said that out of
twenty-one cases treated by him according to this
method, nineteen had been cured, and two had been
very much improved at the time the treatment had
been discontinued. The advantages claimed for the
treatment were: (i) The improvement in the general
health and in the muscular development ; (2) a marked
increase in the lung capacity; (3) a slower and more
forcible heart action; and (4) that long after the ces-
sation of the treatment an improvement was noted in
the muscular system and in the general health.
Dr. S. Ketch, of New York, in opening the discus-
sion on the foregoing papers, said he agreed with Dr.
Weigel, except that he would attribute some benefit to
will power. Regarding Dr. Teschner's paper, he would
say that he was not yet convinced that it was neces-
sary or even advisable to subject children and adoles-
cents to such a severe course of gymnastics — indeed,
he believed that the cases cured by this method could
be treated with equal success by other and safer
means. It was not difficult to secure an improvement
in cases of lateral curvature by correcting the postural
cur\-es, but the only test of marked benefit or of cure
was the amelioration of the element of rotation. In
his opinion it was important to increase and to main-
tain the lateral flexibility of the spine, and hence he
would look upon the best method of treating lateral
curvature of the spine as that one which combined the
use of mild gymnastics and the application of retentive
apparatus.
Dr. John Ridlox, of Chicago, said that he had tried
these heavy exercises on only one patient, a girl of six-
teen. This girl became greatly fatigued after making
ten or fifteen movements with dumbbells weighing
one and one-half pounds, and it was impossible to get
her to put up a five-pound bell more than five times.
As there was no visible improvement after four or five
weeks of this e-xercise, he had abandoned further
trial of the method.
The speaker then proceeded to criticise the incom-
plete and inaccurate photographic records presented by
Dr. Teschner, objecting particularly to the absence of
photographs of cured cases and also of the best position
the patient could be made to assume prior to the treat-
ment. Without these, he said, it was impossible to
judge of the merits of the method.
Dr. Reginald H. Savre, of New York, said that
he could not accept the statement that development of
one part of the muscular system must necessarily be
at the expense of the remaining portion. In his opin-
ion there were many cases of lateral curvature which
could not be well treated without mechanical appli-
ances. If it were a fact that bone changes could be
made to disappear by muscular exercise alone, it was
certainly a novel and wonderful scientific fact. Until
indisputable evidence to this fact were forthcoming, he
could not but be in doubt regarding the kind of cure
meant. Nor could he accept the statement that the
improvement in muscular development continued after
cessation of the exercises, for this was at variance with
general principles.
Dr. a. J. Steele, of St. Louis, said that he thought
there was enough in Dr. Teschner's method to justify
him in continuing his work along this line. He could
not agree with Dr. Weigel that the spine could not be
rendered flexible by means of jackets and similar ap-
pliances.
Dr. Harry M. SHER^LAN, of San Fran isco, said
that while he agreed with those who considered the su-
perincumbent weight the chief etiological factor, he
could not but wonder why any bone in the body should
be abnormally weak, unless, possibly, as a result of
rickets in early life. He endorsed the use of mirrors
as an aid to the proper performance of gymnastic ex-
ercises.
Dr. a. E. Hoadley, of Chicago, said he considered
the prime etiological factor to be "cellular tension'' or
debility. Such a condition, when present in the inter-
vertebral cartilages, may result in marked shortening
of the stature. He had know'n this to amount to as
much as one and one-eighth inches between the time
of rising and going to bed at night. When such short-
ening exceeded half an inch deformity was invited.
Dr. W. E. Wirt, of Cleveland, said that he agreed
with Dr. Teschner regarding the increased flexibility
of the spine produced by these heavy exercises, but he
thought it was a mistake to pin one's faith on one
method of treatment exclusively.
Dr. Hanxa, of Oberlin College, said that in the
treatment of cases of lateral curvature he preferred
massage to forcible manipulation, together with the use
of the hot and cold douche.
Dr. Weigel said that he did not believe that the
disadvantages of mechanical supports were as great as
had been claimed. He could not believe, as Dr.
Teschner had stated, that the muscular strength was
increased from visit to visit by the heavy gymnastics.
Dr. Teschner, in closing the discussion, said he
admitted the inaccuracies of his records, as of all
known methods of recording such cases, but they were
the best obtainable under the circumstances. He had
made no attempt to pose his patients for their photo-
graphs.
Spontaneous Dislocation of the Hip. — Dr. Wil-
liam J. Taylor, of Philadelphia, reported a case of
spontaneous dislocation which had evidently occurred
about six months after a fall. The historv clearlv in-
22
MEDICAL RECORD.
[July 4, 1896
dicated that it was not a case in \vhicli the dislocation
had been produced by tlie injury and had been merely
overlooked. -As the dislocation had existed for fifteen
years before coming under his observation, no attempt
had been made to dislodge the head of the femur from
its position on the dorsum of the ilium.
Drs. R. H. Sayre, Goldthw.'^it, and Ridlon re-
ported similar cases.
The Anterior Transverse Arch of the Foot. —
Dr. Joel E. Goi.dthwait, of Boston, said that the
cases of abnormality of the anterior transverse arch of
the foot might be divided into two groups, viz. : (i)
The rela.xed form ; and (2) the rigid type with distinct
bony change. A patient having stated that the foot was
becoming wider, an examination showed a callosity
under the head of the second, third, or fourth metatar-
sal bone. The speaker thought that improper shoeing
was largely responsible for the condition.
In the treatment of the rela.\ed form, it was most im-
portant to strengthen the front part of the foot by ap-
propriate balancing exercises, and to relieve the strain
on the ligaments and muscles by the application of a
snugly-fitting bandage just behind the head of the first
metatarsal bone. Immediate relief would follow the
application of a pad of felt so as to make pressure just
back of the heads of the second and third metatarsal
bones.
Dr. Ketch referred to a case in which the gouty
diathesis rather than bad shoeing had caused the con-
dition.
Dr. E. H. Bradford said that by means of the rub-
ber bandage and felt pads he had relieved many cases.
He had seen no case of true metatarsalgia in which
the second metatarsal bone was depressed; this con-
dition was confined to cases in which the trouble was in
the fourth metatarsal bone.
Dr. J. E. Moore, of Minneapolis, said that he had
met with this condition most connnonly among nurses.
His treatment had been successfully carried out along
the lines recommended in the paper.
Dr. Kerr, of Washington, D. C, said he also had
found metatarsalgia associated with depression of the
fourth metatarsal bone, and had relieved the pain and
disability by excision of the metatarsal joint and
sometimes also of the nerve.
The President called attention to the fact that a
proper shoe should be made so that the toes do not
point upward, as they did in the ordinary shoe.
Dr. Goldthwait, in closing, said that undoubtedly
the chief cause was bad shoeing. In some cases there
had been pain at the head of the fourth metatarsal
bone, and in others between the second and third meta-
tarsals.
The President's Address. — The subject of this
address was '" The Definition and Scope of Orthopedic
Surgery." Dr. Whitman suggested the following
definition: " Orthopadic surgery is that division of
surgery which treats of disabilities and diseases of the
locomotive apparatus and of the prevention and treat-
ment of the deformities of the framework of the body.''
Investigations on Flat Foot Dr. E. H. Brad-
ford, of Boston, by means of lantern slides, showed
the development and causation of flat foot. These
photographs compared the weak feet of shoe-wearing
people with the strong feet of those who were accus-
tomed to go about without shoes.
Dr. Whitman commented upon the evident advance
that had been made in the last decade in the knowl-
edge and therapeutics of this subject.
Second Day — Alay 20th.
The Treatment of Abscess in High Dorsal Ca-
ries.— Dr. E. H. Bradi'ord, of Boston, in a paper with
this title, advocated operation and drainage of the ab-
scess. This operation should be begun, he said, by
cutting down upon the tip of the transverse process and
resecting a portion of rib, after the manner of an op-
eration for empyema. There was less danger to the
heart and large blood-vessels if the incision were made
on the right side.
Dr. R. H. Sayre said that Dr. Schafer, of Chicago,
in some cases of this kind, had passed in a probe and
cut down upon it, and had then established through
drainage from one side to the other.
Dr. Sherman said that he had performed the oper-
ation in a case in which the abscess had perforated an
intercostal space and produced an accumulation under
the skin. The diagnosis was comparatively easy if
the way were made plain by the burrowing of the ab-
scess between the ribs.
Dr. Ketch referred to a case of very sudden death
of a child suffering from disease of the second and
third cervical vertebra. Although no autopsy could
be obtained, it seemed fairly certain that death had
been due to the direct pressure upon the respiratory
centre.
Dr. Goldthwait said he had seen the suddenly fatal
case which had formed the text for Dr. Bradford's re-
marks. The cause of the sudden death remained un-
explained, for the autopsy showed that the abscess had
not ruptured, and there was no evidence of pressure on
the spinal cord.
Dr. Bradford, in closing the discussion, said that
when there was disease of the axis and atlas there was
danger of direct pressure upon the respiratory centre,
but when the disease was lower down and was asso-
ciated with suftocative symptoms, it w as fair to conclude
that an abscess is present. The operation which he
had advocated was certainly a grave one, but it was in-
tended to meet a grave emergency.
Suppuration in Joint and Spinal Disease, and
Its Relation to Tuberculous Meningitis. — Dr. Sam-
uel Ketch read a paper with this title.
Dr. J. E. Moore said he thought it might be safely
concluded that the formation of tuberculous abscesses
did not play a very important part in the development
of tuberculous meningitis. The evidence in the paper
would also seem to point to the fact that operative
measures were much less likely to cause tuberculous
meningitis or general tuberculosis tlian had been sup-
posed.
Dr. a. M. Phelps said that he did not think it was
possible for true suppuration to produce a tuberculous
lesion.
Dr. Goldthwait said that his cases of tuberculous
meningitis had given only the clinical evidence of this
disease, but in every instance the autopsy had dis-
closed an acute general miliary tuberculosis.
A Clinical Study of Iodoform Glycerin in Tuber-
culous Osteomyelitis — Dr. Harry M. Sherman, of
San Francisco, read a paper on this subject, based on
a carefully recorded experience in twenty cases. Fif-
teen of these were cases of hip disease, two of knee-
joint and two of ankle-joint disease, and one of dis-
ease of the elbow. In all, one hundred and sixty-four
injections were made. About half of those were in-
tra-articular and the other half were intra-osseous in-
jections of a ten-per-cent. solution of iodoform in gly-
cerin. In no case was there any iodoform poisoning
nor was the injection the cause of suppuration in any.
The action of the injections was in most instances
disappointing. In no case was the orthopsedic treat-
ment interrupted.
Dr. Roswell Park, of Buffalo, said that he had
made an extensive trial of the intra-articular injec-
tions of iodoform, but had not seen much benefit from
their use. In two cases coming to excision the iodo-
form was found packed into a mass, w-hich acted as a
foreign body. He had made some culture experiments
July 4, 1896]
MEDICAL RECORD.
23
with iodoform, and these had demonstrated that the
germicidal power of iodoform was very feeble.
Dr. J. E. Moore said that he, too, had met with
nothing but disappointment from the iodoform injec-
tions, except in the treatment of psoas abscesses.
With these he thought they had been of some benefit.
Dr. Henry Lixi; Taylor, of New York, said that
although iodoform had proved disappointing when in-
jected into diseased joints, he thought a solution of
iodoform in ether was a valuable injection for sinuses.
Dr. Park said that as the germicidal action of iodo-
form was claimed to be due to the liberation of free
iodine, he proposed to study the effects of injections
of iodine and glycerin.
Dr. John Ridlon said that a sharp distinction
should be made between cases treated by protective
apparatus in conjunction with iodoform injections and
those in which only the injections were used. He had
treated about thirty cases by the intra-articular injec-
tions. About one-third had shown improvement;
another third had remained stationary; and the others
appeared to have been made worse by the treatment.
Dr. a. M. Phelps, of New York, said that he had
used the injections of iodoform with negative results.
Iodoform and glycerin were useful in tuberculous ab-
scesses, partly because of the hygroscopic nature of
the glycerin.
Further obser\-ations on the use of hydrochloric acid
in bone necrosis of tuberculous origin, with report of
cases were made by other speakers.
Dr. Jerome Hilton \VATERMAN,.of Buffalo, reported
his experience in the treatment of tuberculous bone ne-
crosis by means of injections of strong hydrochloric
acid. The injections were usually made twice a week.
His experience was, on the whole, favorable to the
method.
Dr. W. R. Townsend said that he had observed
good results from this treatment, particularly where
the necrosis was superficial.
Dr. a. E. Hoadley, of Chicago, said that the appli-
cation of a five-per-cent. solution of hydrochloric acid
was sufficient to quickly decalcify the bone without
destroying other tissues.
Dr. Sherm.\n said that as the chief seat of disease
was the granulation tissue in the bone, it would seem
to him that the use of the sharp spoon would be more
effective.
Dr. Waterii.an, in closing, said that the treatment
was at times quite slow. He would advise the use of
a local anaesthetic in conjunction with the acid appli-
cations.
The Use of Dry Heat in the Treatment of Chronic
Joint Affections — Dr. \\'illl\m E. Wirt, of Cleve-
land, described the apparatus which he employed. It
consists of a copper drum twelve inches long and nine
inches in diameter, fitted at each end with a wooden
ring and a hood of thick rubber. Having protected
the back of the knee with cotton, it is enclosed in the
apparatus and heat applied to the outside by means of
a Bunsen burner. ^lost patients would tolerate a tem-
perature between 250^ and 300° F., provided three
holes were made in the drum to secure proper ventila-
tion and so keep the air dry. This treatment gives an
immediate relief to pain and increases temporarily the
mobility of the joint.
Division of the Hamstring Tendons by the Open
Method for Correcting Malposition and Securing
Rest in Tuberlous Disease of the Knee Dr. Ber-
nard Bartow, of Buffalo, in a paper with this title,
contended that division of the hamstrings gave quick-
er relief and secured better rest than did mechanical
appliances, and that it cut short the inflammator)- pro-
cess. The operation should be done by open incision.
Dr. Wirt thought it was rare that mechanical means
would fail to straighten these cases.
Dr. R. H. Savre said that the operation might be
occasionally demanded, but whenever possible the
straightening should be accomplished by mechanical
treatment alone.
Dr. B. E. McKenzie, of Toronto, said that he con-
sidered the method unjustifiable until after mechanical
treatment had failed, and in his experience mechanical
means had never failed under such circumstances.
He thought that the patients just exhibited should not
be allowed to go around without better protection of
the joint.
Dr. John Ridlon, of Chicago, was ver\- positive
that any joint still diseases could be straightened with-
out operation. He was accustomed to use some form
of a Thomas brace. In cases in which the greater part
of the rigidity appeared to be due to fibrous adhesions
and muscular shortening, without evidence of acute
inflammation, he would straighten the limb by manual
force applied under anesthesia.
Dr. W. E. Wirt, as an example of what could be
accomplished by mechanical means alone, referred to
a recent case which had been pronounced by several
surgeons to be one of bony ankylosis, yet he had suc-
ceeded by mechanical measures alone in straighten-
ing the limb in two months.
Dr. Bartow, in closing, said that to insure safety
and thoroughness the operation of dividing the ham-
strings should be done through an open incision. In
the cases that he had treated by the method described
in the paper he knew- of no other alternative than ex-
cision; hence he considered the division of the ham-
strings jDerfectly justifiable. The method was in-
tended as only one means of accomplishing an end.
A Theory of the Ultimate Etiology of Deformity,
and its Practical Application. — Dr. Royal Whit.man
said that in the process of evolution the erect posture
had been comparatively acquired, and that it was an
attitude difficult of acquirement and difficult to main-
tain. The ordinary' so-called postural deformities
were then explained. The flexion and contraction de-
formity, he said, was of special interest to the ortho-
pedic surgeon. If one accepted the morphological
theory of its etiology, it would be evident that as the
erect posture was a newly-acquired attitude, so also
the uses by the limbs proper to that posture were
newly acquired. Complete extension of the limb in
the support of this posture required not only the great-
est expenditure of nervous energy but also the greatest
strain upon the joint surfaces, and when the ability to
assume this attitude became impaired the affected
member became fle.\ed; in other words, it involunta-
rily assumed an attitude common to the lower or quad-
rupedal form of locomotion. Flexion was an evidence
of unbalanced nenous influence and of preponderance
of power of the lower or reflex centres. In joint dis-
ease the cause was local irritation and consequent
muscular spasm ; in the second, the inhibitor)- influence
of the higher centre was impaired or removed. The
erect posture was an evidence of the higher position of
man in the scale of evolution. U'hen the controlling
force of the higher centre w-as directly or indirectly
impaired, the more difficult and newly-acquired atti-
tudes were disused, and the affected part fell backward
toward the type from which it had been differentiated.
Further Observations on the Cause of the Limp
of Hip-Joint Disease. — Dr. Harry M. Sherman, of
San Francisco, read a paper with this title. He said
that tuberculous bone disease resulted in a wasting of
the osseous trabecule and the development of an area
of structural weakness, usually in the neck of the fe-
mur. In hip disease the effort is made to bring the
centre of gravity of the body as nearly as possible
over the head of the femur, so as to relieve the strain
put upon the structurally weak spot. This theory as-
sumes that there is a '-bone sense," comparable to
24
MEDICAL RECORD.
[July 4, 1896
the muscle sense. The speaker then went on to de-
scribe by the aid of blackboard diagrams his mechani-
cal theory of .the causation of the limp of hip-joint dis-
ease. He endeavored to show that the keynote to the
subject, from a mechanical point of view, was the fact
that the head and neck of the femur constitute a col-
umn and bracket, or what is known in mechanics as
a cantilever, and that these anatomical members
were, therefore, governed by the same mechanical laws
as control the operation of the cantilever.
Dr. Wirt said that he believed the author was in
the main correct in his theory, but he would remind
him that when running the femur supports the weight
of the body plus the momentum.
Dr. a. M. Phelps said that he was of the opinion
that the capsule of the joint was swollen with tubercu-
lous material, and that as a result, in order to relieve
intra-articular tension, the patient pulled the limb into
a partially fle.xed position.
Dr. Br.'^dford said that in some cases the lack of
free motion in the joint would account for part of the
limp. In cases of cured hip disease with the limb
much adducted, the limp was often due to the effort
of the patient to balance himself.
The President said that the weak point in the au-
thor's argument was the assumption of voluntary adap-
tation of the limb. If this were voluntary one would
certainly not e.xpect it to occur in very early infancy,
and yet it was known that the limb assumed such a
position in these patients.
Dr. Weigel said that he would like an explanation
of the fact that in the early stage there would be a
limp even though there had been no swelling of the
joint. Again, Dr. Judson had shown that patients who
had recovered from hip disease and who still limped,
could be trained until the limp was scarcely notice-
able.
Dr. Shermak said that in running the footprints
were very nearly in a straight line, thus bringing the
point of support nearer to the centre. This was not
a voluntary but a reflex act. He believed it was rare
for hip-joint disease to begin in the capsule. The re-
covered patients who walk without limp are those in
whom there is ankylosis between the bones.
Femoral Osteotomy for Correction of Hip Defor-
mity ia Adults. — Dr. A. R. Sh.^nds, of Washington,
D. C., read a paper in which he advocated Gaunt's in-
tratrochanteric osteotomy. He preferred to do this
operation with Gaunt's osteotome having a blade only
three-fourths of an inch wide. The only dressing was
sterilized gauze retained by adhesive plaster and a
plaster-of-Paris spica applied after a proper position
of the limb had been secured.
Dr. Phelps said that he would advise in a case of
double hip-joint disease with ankylosis the performance
of excision, care being taken to remove enough bone
to prevent ankylosis. He had recently adopted a nov-
el method of securing motion at the joint, viz., cutting
through just above the lesser trochanter, bringing down
the limb by force, culling off about three-fourths of an
inch of the femur, and then inserting a piece of fascia
between the ends of the bones.
Dr. Sherman said he would limit this subtrochan-
teric osteotomy to cases in which there was no motion
between the femur and pelvis.
Dr. W. R. Townsend referred to several adult pa-
tients coming under his observation, in whom an excel-
lent result had been obtained by operation for bony
ankylosis.
Dr. GoLr>THw.\iT also cited several adult cases, and
remarked that in these cases the limb had been put up
with ten or fifteen degrees of llexion, so as to make it
more comfortable for the patient when sitting down.
Dr. J. E. Moore said that while the result was not
so likely to be good in cases in which there was some
motion, he would not confine operation entirely to
those cases in which there was complete bony ankylo-
sis.
Osteo-Sarcoma of the Hip — Dr. Arthur J. Gil-
lette, of St. Paul, reported three cases illustrating the
difficulties in differential diagnosis when there was
osteo-sarcoma of the hip. Deformity might not occur
for months after the onset of the disease, and there
would be in all probability no fixation, very little atro-
phy, and little or no shortening.
Drs. R. H. Sayre, Sherman, and Moore also re-
ported similar cases.
Tuberculosis of the Wrist — Dr. James E. Moore,
of Minneapolis, read a paper on this subject. He
said that wrist-joint disease comprised about five
per cent, of all tuberculous joint diseases, and oc-
curred most commonly in persons between fifty and
sixty years of age. The disease was insidious in
its development, but the diagnosis could be easily
made by the swelling, atrophy, flexion, and the pecu-
liar position of the thumbs and fingers. The tendon
sheaths were often involved. Children often recover
from the joint affection, but rarely live to maturity;
in adults it almost invariably ends in phthisis. For
children, enforced rest of the joint by means of plas-
ter-of-Paris dressings is of service; but for adults it is
applicable to recent cases only, and should then be
combined with injections of iodoform emulsion.
When there were sinuses and evidence of suppura-
tion, the choice lay between complete excision and
amputation. .Amputation was often the most conser-
vative treatment. The author did not favor early exci-
sion, because the functional results were bad, and as
a life-saving measure it could not compare favorably
with amputation. When the disease was well marked
and progressing rapidly, when there was well marked
WTist-joint disease with incipient phthisis, and when
with the wrist-joint disease there was advanced pul-
monary tuberculosis, he would recommend amputation.
Dr. McKenzie said that he had had some very good
results in this class of cases from the use of injections
of iodoform and glycerin. He had not observed se-
vere reaction following this treatment; indeed, in
some instances the existing pyrexia had been observed
to diminish after the injections.
Dr. Sherman commended amputation as the best
treatment in cases of severe disease of the wrist.
Dr. Gilleite said that some of those who had
spoken had implied that these patients suffered much
pain. His own impression had always been that wrist-
joint disease was associated with very little pain.
Dr. Moore, in closing, said that occasionally pain
was prominent. In one case he had done an amputa-
tion because of the intense pain, and the result, both
as regards prolongation of life and increased comfort,
had justified the amputation.
The Mechanical Treatment of Ingrown Toe Nail.
— Dr. Hkxry Lino Taylor, of New York, read a pa-
per in which he recommended the following method,
modified from that devised by Mr. Masters, of Eng-
land: .A. flat strip of silver, one-one-hundredth of an
inch thick, and one-eighth of an inch wide, and one
inch long, is bent into the shape of a fishhook. The
toe having been cleansed with peroxide of hydrogen
and moistened with a solution of cocaine, the hook is
inserted under the lateral edge of the nail so that the
shank of the hook curves over the side of the toe and
lies close to it. The greater the ulceration the less
the pain in inserting the hook. It is retained in
place by adhesive plaster or a bandage. The hook
not only protects the flesh from the nail, but it exerts
a lifting action on the nail. .After a few hours the pa-
tient suffers no inconvenience from the hook, and in
a few days the swelling subsides and the granulations
become more healthv. It is well to wear the hook for
July 4, 1896]
MEDICAL RECORD.
25
several weeks after the tissues have healed, in order
that they may become sufficiently hardened. The
method, the speaker said, was applicable to tlie sever-
est cases.
Third Day — May 21st.
Mechanical Support for Flat Foot. — Dr. J- C.
ScHAPPs, of Brooklyn, described a method of making
steel soles for flat feet. On hammering out by hand a
steel sole to conform to the arch of a well-developed
adult foot, it would be observed that the anterior and
posterior halves were nearly alike. Having modified
the sole plate so as to make these the same, it was
found that the shape resembled that of a portion of
the convex surface of a cone, with the apex directed
toward the outer side of the sole and the base toward
the inner side of the foot. From this plate plaster
casts were made, and these casts served as models
from which iron dies were manufactured. With such
dies any mechanic could make steel plates, from which
soles were easily cut for right or left feet, high or low,
large or small feet A contour of the patient's foot is
taken on cardboard and trimmed to fit the sole of the
shoe in front, outer side, and back, and is made wide
enough to allow of it coming well up on the inner side
of the foot at the arch. This pattern is used to cor-
rect the rough outline of the foot taken on the plate
itself. The cur\'ed line representing the inner edge
of the arch of the plate should be located Just below
the scaphoid and the head of the astragalus. The in-
ner flange of the plate requires careful shaping; it
should be nearly vertical as the patient stands on the
plate. Having fitted the plate to the foot and to the
shoe, it should be covered with vulcanized rubber.
Apparatus for the Treatment of Pott's Disease
Dr. Schapps also presented a wheel cot which he had
found useful for the purpose of maintaining uninter-
rupted recumbency with regulated pressure in Pott's
disease. Traction could also be applied. He said
that the energy required to hold the spine rigid and
the lower limbs in a continuous state of elastic tension
to break the shock to the spinal column, exhausted the
general and local recuperative forces. It was inju-
rious, in his opinion, to interfere with the respiratory
movements of the chest and abdomen. The sternum
should be used as a base from which to make forward
pressure on a dorsal kyphos. It was also apparent
that both the posterior or spinal and the anterior or
sternal supports of the upper mass should be kept un-
der it, and lateral pressure on the chest avoided. For
the treatment of Pott's disease in the upright position
the author used a combination of the Taylor brace pos-
teriorly and anteriorly a rigid light support which
made pressure only on the parts which could convey
it to the spine without interfering at the same time
with respiration.
The Treatment of Pott's Paraplegia Dr. Le
Roy W. Huebard, of New York, in discussing this
subject and reporting two cases, asked if it were possi-
ble to reduce the period of paralysis. After reviewing
the history of the treatment of this very common com-
plication, and reading replies received from a circular
letter that he had sent to tJie members of the associa-
tion, he concluded that if immediate efficient mechani-
cal support were applied to the spine, absolute recum-
bency enforced until power returned, and a general
tonic plan of treatment were carried out, there would
be a complete cure in almost very instance, and in the
majority in a short time. Operative treatment was
very rarely called for.
Dr. Ketch said that his experience did not show a
natural tendency toward recovery in cases in which
the paraplegia affected the arms.
Dr. Weigel said that it had been his lot to deal
more especially with cases of adults, in whom the prog-
nosis was relatively less favorable. He did not think
any one could give even an approximate idea regarding
the average duration of Pott's paraplegia.
Dr. Ridlox said that his experience had been that
the cases in which the sphincters were involved gave
the worst prognosis. In one case in which the arms
had been affected recovery had been quite rapid.
Congenital Defects of the Long Bones Dr. B. E.
McKexzie, of Toronto, presented a number of speci-
mens and reported upon ten cases of such defects.
Congenital Club Hand.— Dr. C. E. Thomson, of
Scranton, present by invitation, reported a successful
operation on a case of this kind, occurring in a girl of
thirteen, who belonged to a rather remarkable family of
children with congenital deformities.
The Treatment of Club Foot.— Dr. A. M. Phelps,
of New York, said that the treatment of club foot by
manipulation and retentive dressings should be begun
at the earliest possible moment, and when after a rea-
sonable time the progress by this method became very
slight, all parts offering resistance to reduction of the
deformity should be cut and the limb put up in a super-
corrected position. Out of three hundred and forty-
three operations he had had only five per cent, of re-
lapses, and in the last series — one hundred and
eighty-two cases — there had been no mortality.
Dislocation of the Patella Treated by Operation.
— Dr. J(.)El E. Goldthwait, of Boston, presented a
report upon this subject.
Torticollis Due to Adenoid Vegetations and Chronic
Hjrpertrophy of the Tonsils. — Dr. Arthur J. Gil-
LETT, of St. Paul, reported three cases, two of them being
congenital. In one of the cases the removal of the
adenoid vegetations was sufficient, without any divi-
sion of the sterno-mastoid or other treatment, to effect
a prompt cure.
Dr. Samuel Ketch, of New York, was elected pres-
ident of the association for the ensuing year.
ILLINOIS STATE MEDICAL SOCIETY.
Abstract of the Proceedings of the Forty-Sixth Anniiai
Meeting, Held at Ottawa, May ig, 20, and 21,
i8g6.
The society met in the First Baptist Church, and was
called to order by the president. Dr. D. W. Graham,
of Chicago.
Dr. C. W. Hall, of Kewanee, offered the following
resolution, which was unanimously adopted:
" ll7ien-as, Resolutions concerning vivisection were
passed by the American Medical Association at At-
lanta; therefore be it
■' Resolved, That the resolutions mentioned and pub-
lished in Xht Journal of f/ic American Medical Associa-
tion express the sentiments of the Illinois State Medi-
cal Societ)', and that our secretary be requested to
send copies of these resolutions to the members of
Congress from our State."
The first paper read was by Dr. E. Fletcher Ix-
GALs, of Chicago, entitled
Orrhotherapy in Diphtheria. — The author stated,
at the outset, that as a result of the work of Pasteur
and the numerous investigations which have followed
in the same line, it is now generally believed by bac-
teriologists that many diseases, especially those which
seldom affect individuals more th^n once, are self-
limited by the formation within the blood of a product
capable of destroying the toxic material that excites
thedisease; hence called antitoxin. In such diseases,
if life be prolonged until a sufficient quantity of the
antitoxin has been developed, the toxic agent is de-
26
MEDICAL RECORD.
[July 4, 1896
stroyed and recover)- follows if no serious complica-
tions have arisen.
Coming to the question of diphtheria, he said that
the diphtheritic poison had been introduced into ani-
mals, preferably into the horse, until immunity to its
further effects had been obtained. The animal was
then bled, the blood allowed to separate, and the se-
rum preser\'ed under the name of antitoxin.
Attached to the paper was a table showing a large
percentage of complications after the antitoxin treat-
ment. By far the most frequent complication was a
rash, usually urticarial, sometimes er}thematous, or
having the appearance of scarlatina. A rash was ob-
served in 45.9 per cent, of all cases. This was accom-
panied by fever in many cases, amounting to 29.6 per
cent, of the patients presenting a rash. In some in-
stances the rash persisted for many days, but usually
it had run its course by the end of the third or fourth
day. There were a few instances of effusion into the
joints, and abscesses were found at the site of injec-
tion in 2.3 per cent, of the cases.
Dr. Ingals closed thus: "Until more definite infor-
mation is obtained conservative physicians may well
be e.xcused for declining to experiment with this reme-
dy upon their patients; however, the wide belief that
it does much good and the comparatively certain
knowledge that it does but little harm, suggests that
our duty to our patients demands that when diphtheria
exists we should administer the antitoxin if it is de-
sired, but that at the same time we should use such
other remedies as have been proven of most value in
combating this disease; but we should hesitate to
recommend it as a prophylactic measure. We believe
that experimentation in the treatment of diphtheria by
serum is in the right direction, and we hope that the
enthusiastic friends of orrhotherapy may be largely
vindicated; yet we cannot search far into the history
of medicine to find that very many of the remedies
now employed have in the beginning been lauded ex-
cessively, and that not a few of those that were for-
merly supposed to be extremely efficacious have been
found to be practically worthless.''
Treatment of Tuberculosis was the title of a paper
read by Dr. N. S. D.^vis, Jr., of Chicago, in which
he said that the establishment of serum antitoxin as a
successful remedy for diphtheria by the elaborate ex-
periments of Behring, Kitasato, and others, suggested
the employment of serum prepared by analogous meth-
ods for tuberculosis. Tuberculin and the products
derived from it had fallen into almost complete dis-
use. A few still employed them. Serum was em-
ployed as a cure for tuberculosis in 1890. Recently
serum from horses, made immune to tuberculosis by
inoculations successively with viruses of gradually
increasing virulence, has been prepared and tried in-
dependently in Italy, France, Austria, and in this
countrj'. Good results are reported with much uni-
formity from the employment of this serum in cases
that are not complicated by serious infection with
other microbes than the tubercle bacillus. The ordi-
nary dose is 2.5 cubic centimeters, administered hy-
podermatically daily or every second day. Much
larger doses have been employed, but not with propor-
tionately better results. The heart and arteries are not
affected by these injections. A leucocytosis follows
them. Increase in the number of red blood corpuscles
and haemoglobin occurs as general improvement takes
place. As a rule the urine is not materially modi-
fied. In a few instances albuminuria and peptonuria
have been provoked, but no serious lesion of the kid-
neys. Appetite is almost uniformly improved after the
first few injections, and increase in bodily weight
rapidly follows.
The author's experience with this treatment is lim-
ited to a single case now under observation, and from
it he says he cannot yet draw conclusions. The treat-
ment seems to be harmless and in suitably selected
cases to promise improvement. Much more time must
elapse before we can with confidence pronounce such
improvement a permanent cure.
Dr. James B. Herrick, of Chicago, read a paper
entitled
Therapeutic Uses of the Thyroid Extract. — He
reviewed at considerable length thyroid therapy and
presented the conclusions that one feels justified in
drawing from a study of the results already accom-
plished by the employment of this remedial agent
in various diseases. He drew the following deduc-
tions concerning thyroid extract:
1. It is curative in myxoedema (idiopathic, creti-
nism, operative).
2. Many cases of obesity are cured by it.
3. Simple hyperplastic struma, particularly in the
young, is frequently cured or improved.
4. In I, 2, or 3, the remedy has to be continued for
an indefinite time in order to prevent relapse.
5. It may prove of value in some cases of tetany.
6. In skin diseases it is of doubtful value, to say the
least.
7. The same is true of mental and nervous diseases.
8. In exophthalmic goitre it is contraindicated.
9. The results are practically the same whether fresh
glands, extracts, or dried glands are employed.
This is probably true also of the thyroidin of Bau-
mann.
Home Cure and Treatment of Epileptics. — This
paper was read by Dr. A. L. Warner, of Kankakee.
After giving an outline of epilepsy the author stated
that the percentage of complete recoveries from this
disease was small, owing to its obscure nature and to
the fact that only in a small number of cases does
treatment seem to have more than a palliative action.
In referring to the preventive treatment, he called
especial attention to the fact that even slight head in-
juries may sooner or later become active factors in the
causation of epilepsy, and such injuries should be
closely examined and receive proper treatment, not
only for the injury itself but to prevent the possibility
of a person becoming subject to epilepsy at a future
time.
The treatment of epilepsy resolves itself into: (i)
The treatment of convulsive seizure; (2) treatment —
medical, hygienic, and surgical — to prevent the recur-
rence of seizures; and (3) treatment of complications.
The surgical treatment has come more prominently
into use during the past two years. Under aseptic
conditions, trephining for the elevation or removal of
depressed bone has become common, and even exci-
sion of portions of the cortex of the brain have beert
made by some with the view of destroying the sup-
posed explosive centre. Ojserations for the removal
of diseased tissues and meningeal and brain tumors
have also been followed frequently with good results.
Finally, he said that it was to be regretted that the
progressive State of Illinois has not yet provided a
hospital for epileptics, where they would be cared for
and treated in a systematic manner by physicians and
nurses who make a specialty of this disease, and, in
the event of its being of an incurable nature, would have
a home provided by the State in which they may have
comforts and surroundings suited to their peculiar
needs.
Hystero-Epilepsy. — This paper was read by Dr.
Hugh T. Patrick, of Chicago, in which he first de-
fined hystero-epilepsy as not epilepsy in any sense
of the word, but hysteria pure and simple. He then
proceeded to describe a typical paroxysm of hys-
tero-epilepsy, an attack which he said is rarely seen,
but serves well as a basis for the description of the
incomplete or aberrant forms which are of frequent
July 4, 1S96]
MEDICAL RECORD.
27
occurrence. The different periods and substages
were accurately described and illustrated by a number
of well-executed drawings. He showed that in an at-
tack of hystero-epilepsy there is nothing after the first
or epileptoid period that in the least resembles epi-
lepsy. A patient who struggles, has to be held, who
makes exclamations, tears the bedding, or tries to bite
himself or others, is not an epileptic. A patient who
shows marked opisthotonos, rolls over and over, or
performs acrobatic feats, is not an epileptic. A pa-
tient who assumes striking postures or shows exalted
psychic action during the attack is not an epileptic.
An attack that lasts fifteen minutes or more is not epi-
lepsy.
Dr. Patrick then gave in detail the points in the
differential diagnosis between an hysterical attack
closely simulating epilepsy and true epileptic convul-
sions.
In conclusion, he insisted that hysterical convul-
sions are not confined to Paris and the Salpetriere,
but are of rather frequent occurrence in this country in
the small towns, as also in the large cities. He has
seen in the last few months a number of cases of
hysterical convulsions which had been thought to be
epilepsy and had been treated as such for various
lengths of time.
Dr. J. B. Maxwell, of Mt. Carmel, read a paper
entitled
Status of Epileptic Legislation. — Among the spe-
cial reasons for the establishment of a colony of epi-
leptics he gave :
1. For the welfare of the epileptics, whose numbers
justify the outlay.
2. For the welfare of the insane, who should not be
compelled to associate with them in the hospitals.
3. To diminish so far as possible the overcrowding
of hospitals for the insane.
4. To remove the epileptics from the almshouses,
where it is a hardship for many of them to be, as un-
der favorable circumstances they would be able to
work and might be restored to health.
The benefit that must accrue to epileptics in particu-
lar and to society in general would be very great, and
scores if not hundreds who now refuse to enter the dark
portals of the hospitals for the insane or the forbid-
ding gates of the institution for the feeble minded
would be glad to enter the home or colony for epileptics.
The speaker is convinced that too much time has al-
ready been lost, and he strenuously recommended im-
mediate legislation in behalf of epileptics.
The president. Dr. D. W. Graham, of Chicago, de-
livered the annual address. He selected for his sub-
ject the
Mutual Relations of the Medical Profession and
the Public. — He said that the reciprocal relations and
duties of the medical profession and the community
were a theme like an old jewel, which required an oc-
casional resetting to bring it into harmony with the
changes of time and circumstance. The medical
profession, as one of the constituent parts of the com-
munity, has intimate relations to ever)- other interest
and part of that community. Its work and the prin-
ciples which it represents are in their importance to
organized society second to no other. Through med-
ical science the profession has a twofold relation to
the community at large. First, that in which the phy-
sician lives for himself; second, that in which as a
benefactor he contributes to the welfare of others, in
which he is the exponent of all that medical science
means to men. By and through it he earns his living
as a citizen, discharges his first duty to himself and
others both in point of time and importance.
There were rewards other than pecuniary which were
due the physician from the community, and of which
he was sometimes deprived. It was due to the dignity
of his calling and in the interests of the highest use-
fulness of the profession to the public that all posi-
tions of honor, profit, or trust, whose chief functions
pertained to medical matters and required medical
knowledge for their administration, should be held by
physicians.
A confusion of values in the mind of the public and
to some extent in the mind of the profession, has aris-
en in these latter days with respect to remuneration.
This, Dr. Graham thought, was partly due to the ex-
uberant specialism which characterized modern medi-
cine. It was also partly due to the greater advance
and wider scope of operative surgery, and in part to
the relatively unimportant role which the internal
treatment of disease by drugs has assumed in compar-
ison with former times. There never was a time when
the drug treatment of disease could accomplish more
than to-day, when internal medication was more de-
finite in its results, though its limitations are better
recognized than before. While in former times it out-
ranked in importance all other means and methods, to-
day preventive medicine and operative surgery have
outstripped it in the general advance in demonstrable
results.
The medical profession has a standing grievance
against the community, in that the pretender, the un-
scrupulous, and the ignorant so often received the en-
couragement and the reward which rightly belonged to
the qualified, educated physician.
A government which spends eighty million of
money a year on its army and navy in times of peace,
one hundred and fifty million in pensions, sixty mil-
lion on its inland rivers and harbors, and many mil-
lion more to promote commerce and other material
interests of its people, ought to spend more than erne
or two hundred thousand dollars a year in the inter-
ests and in the name of the health of all the people.
This small pittance which is now expended in this di-
rection is spent in the name and for the sake of trade
and commerce by the marine hospital service for the
purposes of quarantine, one of the subordinate func-
tions of this department, which is itself a subordinate
department of the executive branch of the government.
Coming to the question of medical legislation, Dr.
Graham said that a sprinkling of intelligent medical
men might improve a legislature. It could not affect
it seriously otherwise. When medical men are willing
to take part in public affairs, instead of staying at
home and grumbling and writing jeremiads, medical
questions may be better treated in legislative assem-
blies.
Dr. Harold N. Mover, of Chicago, followed with
an address entitled
Needed Medical Legislation in Illinois — He said
that medical legislation in this State has been fairly
fruitful in the past. An examination of what has
been accomplished, shows that existing law, while
pregnant with promise for the future, is still far short
of what should be. To this State belonged the proud
distinction of having first placed upon its statute books
a law regulating the practice of medicine. This was
followed by our best piece of law making, the anato-
mical bill, which, as amended, is as nearly perfect as
could be wished. By it anatomical study has been
placed within the reach of students of medicine to a de-
gree and with a perfection that leaves nothing to be
desired.
The law regulating the admission of insane patients
to our hospitals, which has been in operation for the
past two years, was rendered much less effective than
it otherwise would have been by a stupid amendment
which has made its construction verj- difficult. .As it
was prepared by a committee of this society and sub-
mitted to the legislature, it was a symmetrical bill,
providing not only for a trial by jury but also for the
28
MEDICAL RECORD.
[July 4, 1896
appointment of a commission and for self-commit-
ment. Tliese were all separately described in the bill
and provision made for carrying them out.
Dr. Moyer then passed on to the consideration of
expert testimony, saying that it had been taken up
and considered at the last session of the legislature,
and a bill regulating this important branch of judicial
procedure narrowly missed enactment. In his judg-
ment this bill ought again to be brought forward and
an effort made to pass it. As at present proposed, the
law is restricted to expert testimony in criminal cases.
Finally, he said, the time for an examining board
has arrived. This being established, the various schools
could then meet on the common ground of anatomy,
chemistry, pathology, bacteriology, and, above all, a
thorough test of a candidate's knowledge of the Eng-
lish language and general scientific attainments.
Diagnosis of Typhoid Fever. — Dr. C. 11 Hor-
RELL, of Colchester, read a paper on this subject.
Two potent factors essential to success in a physician
are a good diagnostician and a good collector. The
speaker has not always found the diagnosis of typhoid
fever an easy task, not even in simple uncomplicated
cases. He insisted that without careful and exhaus-
tive physical examination of the patient and investi-
gation of his surroundings the physician was likely to
be placed under the embarrassment of a mistaken di-
agnosis.
The Treatment of Typhoid Fever was the title
of a paper by Dr. James P. Lvtle, of Princeton.
After dwelling at considerable length upon the various
treatments of typhoid fever, the author said that what-
ever may be our present or future treatment of this
disease, good judgment and common sense in its man-
agement would ever remain the chief elements of suc-
cess. The late Dujardin-Beaumetz recognized this,
for at the end of a busy life, full of years and good
works, he left this legacy as the result of his experi-
ence: "That the best treatment for typhoid fever is a
good physician."
Dr. John A. Prince, of Springfield, read a paper
entitled
Pelvic Abscess. — The author dwelt upon the surgi-
cal treatment, citing a few cases that had occurred in
his own practice. He believes that in nearly all cases
the infection is from the tubes, and tliat whether the
abscess is a true pyosalpinx, an ovarian abscess, or in-
dependent of the uterine adnexa, the tubes constitute
the channel of infection.
The surgical treatment resolves itself into the va-
rious methods of evacuating the pus. The various
methods might be classified as follows: (i) Laparot-
omy with extirpation of abscess mass. (2) Laparot-
omy with cleansing and drainage of abscess cavity.
(3) Drainage by vaginal hysterectomy. (4) Drainage
by vaginal incision. (5) Aspiration.
Laparotomy with complete extirpation of the patho-
logical tissues involved in the abscess is, he thinks,
the ideal method, and where practicable should be
employed.
Vaginal hysterectomy for the cure of pus cases was
of very recent origin, and as the speaker's experience
was limited to one case he was not prepared to speak
witii autiiority.
The Necessity of Close Inspection in Head In-
juries.— By Dr. R. H Lewis, of Macomb. The au-
thor emphasized the importance of investigating every
case which comes under observation. Sufficient time
has now elapsed since the inauguration of operative
procedures upon the cranium and brain for the cure
of various mental and physical defects to allow us to
judge somewhat correctly of their merits, and in look-
ing over the reports of cases with subsequent histories
in the hands of the most competent operators, the
speaker was astonished to find so small a percentage of
actual cures resulting from what at first seemed bril-
liant and promising methods. After relating an in-
teresting case of depressed fracture of the skull, which
the author had treated successfully, he drew the fol-
lowing conclusions:
1. All scalp wounds will bear close inspection.
2. The troubles resulting from pressure on the brain
should be removed so soon as manifest.
3. This work should be done by the general practi-
tioner in the rural districts, as well as by the skilled
surgeons in the city.
Craniotomy on the Dead Child.— Dr. Joseph B.
De Lee, of Chicago, read a paper with this title, in
which he gave the following indications for crani-
otomy :
1, All cases in which the child is dead give indi-
cation for the termination of labor. This operation
should be done instead of using the forceps, when the
maternal soft parts are unprepared for rapid delivery.
Such cases are eclampsia, placenta previa, premature
detachment of the normally implanted placenta, pro-
lapse of the cord, with danger to the mother from any
cause. In short, the forceps should not be applied on
a dead child. The only exception the speaker would
make to this rule was the case of a multipara, with the
head low down and the soft parts well prepared,
2, Cases of contracted pelvis when the conjugata
vera is not smaller than two and one-half inches. To
do a hard version extraction, or extraction by forceps,
or a Caisarean section, is not justifiable when the child
is dead,
3, In neglected transverse presentation embryotomy
should be done. The thought of a version should not
be entertained for a moment.
Cleanliness in Obstetrics. — Dr. Emm.\ B. Stand-
ley, of Alexis, contributed this paper. The first step
in cleanliness in obstetrics was for the physician to be
clean himself when called upon to attend a woman in
confinement. Her plan has always been to allow the
mother to rest for a little time after delivery until the
babe is attended to; then a bowl filled with warm wa-
ter is brought and a disinfectant added, and the pu-
dendum thoroughly cleansed, care being taken not to
expose the patient. Another help to cleanliness in
obstetrics was the rectal enema of warm water that the
bowels might be thoroughly moved. This has a re-
laxing effect upon the sphincter ani muscle and peri-
neum, and prepares the way for advance of the child
far better than if the physician has a loaded rectum to
contend with.
Hydrotherapy in the Management of High Tem-
perature in Typhoid Fever. — By Dr, Cteoroe G,
Cr.aii;, of Rock Island. He enumerated the methods
generally used for applying hydrotherapy in the treat-
ment of typhoid fever. As with any other remedy, judg-
ment must be exercised in the selection of the mode
and the manner of administering it in each individual
case, bearing in mind that statistics prove that the
nearer the exact teclinique of Brand is and has been
followed the better the results. In all cases the phy-
sician could not let his views be known, but in hos-
pital practice particularly, and in private practice
when possible, the author believes that we should
adopt hydrotherapy as a whole or in part.
Dr. O. B. Will, of Peoria, read a paper entitled
"Some Obser\-ations Respecting the Etiology of Ecto-
pic Pregnancy."'
Surgery of the Gasserian Ganglion. — Dr, J. B.
Murphy, of Chicago, followed with a demonstration
of the surgery of the Gasserian ganglion, and reported
cases. He confined himself almost exclusively to the
technique of the more recent operation, after review-
ing the results of previous operations for the removal
of the ganglion. Internal medication and anodynes
had absolutely failed to permanently relieve the intract-
July 4, 1S96]
MEDICAL RECORD.
29
able neuralgias of the face. Reference was made to
the methods advised and advocated by Rose, Horsley,
Andrews, and others, for the removal of the ganglion.
Dr. Murphy then described in detail and illustrated a
slightly modified technique of the Frank Hartley oper-
ation. He said there had been forty-seven cases col-
lected up to date, w ith only two deaths. One of the
patients died shortly after the operation from shock.
The other death was presumably due to the advanced
age of the patient.
Dr. Joseph B. Bacon, of Chicago, contributed an
interesting paper on
Dermoid Cysts as a Cause of Fistula in Ano
All of the cases were of blind internal fistulas that were
sent to his clinic for operation, the fistula being con-
nected with small cysts. The patients attributed their
ailment to chronic diarrhcea, ulcer of the bowel, or
piles, and could give only an indefinite history of re-
peated attacks of pain.
The first case was that of a practitioner of medicine
who came to the Post-Graduate Hospital, November,
1895, to be treated for painful ulcer of the anus. He
was a w«ll-deveIoped, muscular man ; weight, one hun-
dred and eighty pounds. He gave an indefinite history
of painful defecation, spasm of sphincter muscles, and
discharge of pus from bowel, that extended back over a
period of several years. After patient was anresthetized
and the sphincters divulsed, an anal ulcer with every
appearance of an ordinary mechanical tear of the mu-
cous membrane was noticed on the posterior median
line of the anal canal between the. internal and exter-
nal sphincters. The ulcer was covered by old granu-
lations. After removing the granulation tissue with a
curette, a fistulous tract was found leading into a
small sac, filled with granulation tissue, pus, and a
bunch of fine blond hair. The sac was found to lie
behind the anus and veiy near the skin. The external
sphincter w-as severed in the posterior median line and
the sac laid open and curetted and converted into an
open woimd. The wound was packed with iodoform
gauze and daily irrigated with boric-acid solutions
and repacked. The patient made a perfect recovery in
three weeks. The author reported three other cases,
and stated that he had done so because there was a
limited amount of literature upon the subject. The
cases were interesting in that they afforded a favora-
ble prognosis in a certain per cent, of fistula in ano,
a very important point for those interested in life in-
surance. The very large percentage of fistulas of a
tuberculous origin may prevent patients suft'ering
from fistulffi in ano receiving insurance. Yet a more
careful consideraton of each case and its history
would determine that possibly some of them are due
to dermoids, and thus all anxiety for the patient's gen-
eral infection from tuberculosis would be removed
from doubt.
Metatarsalgia, with a Report of Three Cases. —
This paper was read by Dr. A. E. H.\lste.\d, of Chi-
cago. After dealing with the subject in an exhaustive
manner, the author concludes:
T. That what is known as metatarsalgia is not in
the beginning a distinct pathologic entity, but rather
an early symptom of static flat foot. In cases of
long-standing irritation of the plantar nerves by pres-
sure from flattening of the transverse metatarsal arch
may cause an inflammation of the nerve, or even in
some cases the development of a neuro-fibroma.
2. That most of these cases can be permanently
cured by following the treatment usually employed in
beginning flat foot — e.g., systematic massage, gT,-mnas-
tics, and the use of properly fitted shoes, and in some
cases the application of a metallic brace to the sole of
the foot.
3. In cases of long standing, where there is well-
marked pathologic change in one or more of the
branches of the plantar nerves, resection of the nerve
should be performed. The more radical operations,
such as resection of the metatarso-phalangeal joint or
amputation of the toe, are not indicated.
Cholelithiasis : A Plea for Operative Treatment.
— By Dr. E. Mammer, of Bloomington.
All cases which are not promptly relieved by the
passage of small stones, or by therapeutic measures
effectively and judiciously employed, at once furnish
true indications for resort to cholecystenterostomy.
The operation can be safely done and will be success-
ful when calculi are in the gall bladder only; when
they are in the gall bladder and in the c\stic duct;
and when they are in the ductus communis choledo-
chus, and can be removed, or when, even if left there,
the bile will find a free passage by the new channel.
Indications for operation in such as the above may
be detemiined by carefully weighing all symptoms
and a thorough study of them in all their relations.
The author reported two cases in which he had
operated successfully.
Vaginal Section for the Cure of Retroversion of
the Uterus was the title of a paper read by Dr. Henry
T. ByFORn, of Chicago, in which the author described
the technique of the method which he had employed
as follows: The vulva and vagina are thoroughly
scrubbed with softsoap, then with strong alcohol and
with a I to 2,000 solution of bichloride of niercur}-.
The uterus is dilated and curetted, and disinfected
with mild or strong solutions, according to the require-
ments of the case. This preparation is necessar)' to
prevent the infection of the connective tissue and
buried ligatures.
A transverse incision, a trifle over an inch long, is
made in the vaginal wall just in front of the cervix
and the bladder separated' from the uterus by the fin-
ger as far up as the peritoneal reflection. Then a
longitudinal vaginal incision about two inches long is
made in the median line from the neck of the bladder
to the middle of the transverse incision. The bladder
is separated from the vagina for a short distance on
either side of the incision to give room for manipula-
tion. The peritoneum is then torn across between the
uterus and bladder, an intraperitoneal pelvic examina-
tion is made, adhesions are separated, and such parts
are treated or removed as may so require. The blad-
der peritoneum is then seized by forceps and drawn
down by successive grips until that which belongs be-
hind the pubes can be seen. Two chromicized catgut
threads are introduced about one inch apart through
this portion of the peritoneum and subperitoneal tis-
sue as high as possible. Then the anterior surface of
the uterus is grasped with tenaculum forceps and the
fundus pulled into the vaginal wound and attached to
the bladder by means of the above-mentioned catgut
threads. The finger is now hooked over the left round
ligament, which lies beside the vaginal wound: a loop
of the ligament is drawn into sight, grasped by forceps,
and pulled down until the inguinal end is taut. A
catgut suture is put through it as far from the uterine
end as possible and is made to attach it to the uterus
just above the normal uterine insertion, which is
easily exposed to view by the vaginal retractors. The
same is done to the right ligament. The entire vagi-
nal wound is closed with transverse sutures that reunite
the bladder to the vagina and also draw the ends of
the transverse incision together, leaving one row of
sutures in the median line. A few inches of a narrow
strip of gauze is placed in the connective tissue in
front of the cervix, to be removed in twenty-four hours
by pulling on the end, which projects between the su-
tures into the vagina.
Dr. Byford has operated upon ten patients in this
manner, and also upon one patient in whom he merely
sutured the fundus over the bladder. In each case the
MEDICAL RECORD.
[July 4, 1896
uterus has remained in a normal, mobile position, with-
out the aid of a pessary at any time. The comfort is
greater and the complaint much less than after Alex-
ander's operation. The uterus has no abnormal at-
tachments except the two points of peritoneal adhe-
sions to the bladder, and there can be nothing to fear
from subsequent pregnancy.
Iodoform Injection Treatment of Hip-Joint Dis-
ease.— By Dr. A. H. Ferguson, of Chicago. The
intra-articular medication of tuberculous joints is of
recent date and is not yet very widely employed. The
author had selected the hip-joint on account of the
frequency with which it is diseased, and because he
had found it more amenable to the iodofonn emulsion
injections than any other joint. Objections to the hith-
erto recognized methods of the treatment of hip-joint
disease were mentioned, after which the author out-
lined the manner of using these injections. He has
treated upward of twenty-five cases with the most
satisfactory results.
What Measures Best Restrict the Spread of Tu-
berculosis?— By Dr. E. \V. Zook, of Peoria. The
restriction of the spread of tuberculosis, while not a
new subject, was one that has not been given the at-
tention it deserves. The author believes that the time
is not far distant when a specific cure for tuberculosis
will be discovered, but until that time comes we will
have to rely upon preventive measures, and if these
can be uniformly enforced he thinks we will without
doubt be able to check the spread of this disease, but
in order to do so we will have to put forth our best
efforts.
Permanent Ambulatory Extension in Surgery. —
By Dr. .\lex. C. Wiener, of Chicago. He said that
in fractures of the shaft of the tibia or femur absolute
immobilization of the bones in the normal position,
either by compression bandages or by weight extension,
is indispensable, but is it absolutely necessary to have
the patient rest in bed all the long weeks until con-
solidation is perfect? The speaker replied in the
negative. The surgeon gives his patient a dressing
tightly fitting the outlines of the extremities, so as to
keep the fractured bone in a correct position and to
regulate the impaired circulation so that the injured
■can put his legs on the floor without pain. In order
to allow the patient free mobility he is supplied with
an apparatus which Dr. Wiener described, and which
seems to be very practical and useful in the treatment
■of the cases under consideration.
Functional Indigestion, Its Causes and Treatment.
— Dk. |. M. G. Carter, of \\'aukegan, in a paper
■on this subject stated that the term indigestion
referred to a condition, not a disease. This disturb-
ance, then, was always functional. The following in-
dications may be regarded as pointing out the course
of correct treatment in the class of cases considered in
■the paper, to be varied to meet the necessities of indi-
vidual patients: (i) Remove the cause; (2) check or
prevent the growth of bacteria ; (3) assist digestion,
and (4) repair damages done. These indications were
then dwelt upon at lergth.
The treatment requires, first, the removal of the
•cause; second, the checking or prevention of the
growth of bacteria; third, an effort to assist digestion,
and, fourth, the repair of damages to the stomach or
to the general system.
Dr. Fexton B. Turck, of Chicago, made some re-
marks upon the pathology of gastritis and demon-
strated his method of treating this affection on a pa-
tient. He went over substantially the same ground
as that covered in his previous contributions to med-
ical literature on this subject, and with which most of
the members of the profession are doubtless more or
less familiar.
The Differential Diagnosis of Neurasthenia and
Its Treatment. — Dr. E. S. Pettyjohn, of Alma,
Mich., read this paper, in which he said that ever
since Beard used the term neurasthenia, and Van
Dusen directed attention to a group of symptoms so
named, the profession has been struggling to map
out a definite set of symptoms to be thus classified,
and in his opinion we had as yet but poorly suc-
ceeded. Althaus, of London, protests against the
term, and Gowers says that nervousness covers the
conditions. There is one thing upon which authors
are agreed, namely, that this group of symptoms indi-
cates disease of some part, or every part, of the ner-
vous system ; that there is a marked defect in the nu-
trition of the cerebro-spinal axis, giving an almost
endless variety of symptoms difficult to classify. The
changes noted in the patient come on gradually.
These changes were described, and also those which
occur in cases of neurasthenia. The author believes
that neurasthenia as a distinct disease does not exist.
Under the head of treatment the author expatiated upon
elimination, food, and environment.
Cryptogenetic Sepsis. — Dr. J.ames T. Whittaker,
of Cincinnati, O., said that the terms pyoi'mia,
septicEemia, sepsis, septic pya;mia, are variously em-
ployed by different authors. There is no longer
support for the different terms. Pysemia was the
term first employed. It was a useful term because
it expressed a poisoning of the blood by pus and con-
nected this poisoning with a pus centre. So distinct
was this connection that the people understood it by
the common term '• blood poisoning." But the mere
presence of pus in the blood does not necessarily pro-
duce blood poisoning. In one sense there is always
pus in the blood; that is, there are white blood cor-
puscles, leucocytes, and these corpuscles accumulate
in leucocytosis to constitute a protective process.
I^yamia is now generally understood to mean infec-
tion of the blood as indicated by multiple metastases,
in the absence of any central depot of suppuration;
whereas, septicarmia is used to express the infection of
the blood in which there is a decided depot in the ab-
sence of demonstrable metastases. It is believed at
the present day that rheumatism is caused by micro-
organisms closely allied to if not identical with the
micro-organisms of pus.
Dr. Whittaker made the point that many of the
lighter forms of disease, which had been vaguely
described as rheumatism, malaria, incipient tuber-
culosis, la grippe, or a bad cold were cases of light in-
fection with septic matter in which the micro-organ-
isms of sepsis may be found in the blood, and that
individuals who are the frequent subjects of these dis-
eases are carr\-ing about in them manifest or more espe-
cially concealed depots or colonies of septic micro-
organisms.
The treatment may be dismissed in a few words.
The prophylaxis depends upon an increase in the
general habits of cleanliness, the greater frequency of
ablutions, and more care for higher sanitation.
Officers Elected. — The following officers were elected
for the ensuing year: President, Dr. A. C. Corr, Car-
linville; Vice-Presidents, Dr. J. M. G. Carter, Wau-
kegan, and Dr. T. J. Pitner, Jacksonville; Treasurer,
Dr. George N. Kreider, Springfield; Permanent Secre-
tary, Dr. John B. Hamilton, Chicago.
The next meeting will be held at East St. Louis,
third Tuesday in May, 1897.
Gonorrhoea. — Dr. Schwimmer used alumnol in in-
jections, irrigation, and instillations (0.5 to 5 per
cent.). Its effect in chronic cases seemed to be better
than in acute cases. In women tampons soaked in
the solution are used more or less successfully. —
Arch.f. Dertnat., No. 29.
July 4, 1896]
MEDICAL RECORD.
31
Jiuvoical J^u go est ions.
Intrathoracic Tumors. — i. The most frequent in-
trathoracic tumor is sarcoma. 2. The most frequent
point of origin is the anterior mediastinum, and in par-
ticular the remnant of the thymus gland. 3. Clini-
cally these growths may be grouped as those affecting
the anterior mediastinum in which physical signs are
prominent, those of the middle and posterior medias-
tinum in which the symptoms predominate over the
physical signs, and those beginning in the pleura in
■which both symptoms and physical signs predominate
from the first. — Pepper and Stengel.
Persistence of Pigmentation in Epidermic Grafts.
— Drs. Carnot and 1 )eliandre report to the Societe de
Biologie, February 15, i8g6, that a pigmented graft
transplanted upon a white skin in the Gilbert Labora-
tory preserved its color and extended rapidly at the
expense of the latter. In one case the central part
became more and more pigmented and the periphery
presented a zone of extension equalling about a milli-
metre, the color of which was intermediary. If a white
graft is transplanted upon a black epidermis, it fails
to take or disappears quickly, as though the pigmented
■cells attacked the unpigmented ones and replaced them.
The secondary epidermic products undergo analogous
transformations — the hairs which grow upon the black
graft are first mostly white, but become black as the
graft gets older. The epidermic pigmentation of
mammifera would then seem to be a cellular property
'largely independent of vascular and nervous influence.
This behavior of epidermic grafts is contrary to that
•which has hitherto been taught to prevail in man.
Hemorrhoids. — Dr. J. N. Baughnian {Ajuerican
J'ractitioner and News) recommends the following:
IJ Fl. ext. belladonna 3 i.
Fl. e.\t. horsechestnut 3 ij.
Tannic acid gr. x.
Vaseline 3 ij.
M. at fiat ungt. S. Apply to inflamed parts two or three
times in twenty-four hours.
Dr. Schmey recommends (^International Journal of
Surgery) painting the nodules once daily with a two-
per-cent. solution of nitrate of silver, which causes a
reduction in size without pain. In a large number of
cases the tumors entirely disappeared in the course of
■one or two weeks. When patients positively refuse
•operative treatment this new procedure may prove use-
ful.
Epididymitis. — Dr. J. William White, in the Mcili-
xal World, gives the following formula:
1} Sodii bromidi,
Acidi borici aa Bviij.
Tr. aconiti gtt. viij.
Tr. belladonna; 3 i.
Liq. cit. potassii q.s. ad | viij.
M. S. Tablespoonful three times a day.
Put the patient to bed with the scrotum elevated and
a pillow under the hips.
Chronic Pyelitis. — Dr. Robin prescribes the follow-
ing (Lc Progres Medical) when pain is present:
'S, Venice turpentine,
Powdered camphor aa 3 iss.
Extract of opium gr. v.
Extract of aconite root gr. iij.
Make into twenty pills. Take one every eight hours to-
gether with a small glassful of uva ursi sweetened.
Abscess of the Liver. — Dr. Fontan, of Toulon {Le
Progres Medical), adopts as rules for operating: (i)
A free incision eight or ten centimetres long as soon
as the abscess is recognized; (2) the final resection of
one or more costal cartilages to expose the abscess
freely; (3) the separate suturing of the peritoneum
and of the pleura to prevent the penetration of pus into
these serous cavities; (4) complete curetting of the
cavity of the abscess, as this method removes the dis-
eased tissue and does not predispose to hemorrhage.
M. Fontan reports eighty-six per cent, of cures due
to the operative technique and curetting. The best
statistics of incision or excision by the bistoury alone
give only thirty-six to fifty-one per cent, of cures.
Ulcers of the Leg are usually caused by a depraved
state of the local blood supply. The tortuosity of the
superficial and sometimes of the deep veins of the leg
favors venous stasis and interferes with the nutritive
forces of their localities. In order to effect a cure,
this condition must be rectified 'by relieving the veins
of their superabundance of blood and by aiding the
overdistended venous coats to resume their normal
proportions. This is done by bandaging. To be ef-
fective, the bandage should be carefully applied, so
that equal pressure is brought to bear throughout.
The bandage should reach from the toes to the knee.
— Dr. Edlen, N. y. Med. Jour., March 14, 1896.
Hemorrhoids. —
1} Gallic acid gr. x.
Extract of opium gr. iv.
Extract of belladonna gr. v.
Simple ointment 3 ss.
M. S. Apply locally morning and night.
— Hare.
Alopecia. — Dr. Samter, of Konigsberg, reports good
results from the use of a ten-per-cent. chrj'sarobin
ointment, whereas after using the faradic current for
weeks no results seem to have been achieved.
Prophylactically, strict antiseptic rules should be car-
ried out in barber shops.
A Novel Tractor — In the Rev. de T/ier., November,
1895, a piiysician describes the use of a stout cord as
an aid to traction in obstetrics. The patient is placed
in the usual position and the forceps adjusted. The
physician seats himself on a low chair in front. A
loop on one end of the cord, which should be about a
metre and a half in length and quite thick, is fastened
to the left handle of the forceps, then carried across
to the right handle and back again several times,
making a figure of eight. It is then passed from left
to right around the physician's back and fastened to
the right handle. In this way the physician can con-
trol the forceps with his body and he has free use of
his hands. In careless hands this device might do
damage, but properly used it is a great advantage.
Leucorrhoea. —
If Acidi tannici 3 ij.
Alcohol, pur.,
Creosoti aa 3 ss.
Aquas dest 3 viij.
M. S. Add a tablespoonful to a quart of warm water and
use three or four times a day as a vaginal injection.
• — LiROLA, Progres Meaical, No. 6, 1896.
Syphilis. — The Societe de Dermatologie {Progres
Medical, February 8th) has been considering the ques-
tion of mercurial injections. The conclusions seem to
be that their use should not be limited to severe cases,
but that they are beneficial in all, and that injection is
the best means of administering mercury, on account
of its reliability, rapidity, and the intensity of its action.
Le Pileur has treated six hundred cases with injections
of gray oil, which he especially recommends. Hallo-
peau and others prefer injections of calomel
MEDICAL RECORD.
[July 4, 1896
(Covrcspouclcuce.
OUR LONDON LETTER.
(From our Special Correspondent.)
DEATHS OF TWO VETERANS, SIR RUSSELL REYNOLDS
AND SIR GEORGE JOHNSON MEETING OF MEDICAL
COUNCIL A NURSING EXHIBITION- — MEDICO-CHIRUR-
GICAL SOCIETY REHABILITATION OF GUAIACUM — •
GENERAL MEDICAL COUNCIL'S SESSION THE EXAMI-
NATION SY'STEM — DUBLIN APOTHECARIES* HALL
PENAL CASES — MIDWIFERY INSTRUCTION — GUY'S HOS-
PITAL— PRINCE OF WALES AND HOSPITALS ROYAL
SOCIETY.
London, June 5, 1S96.
When I was writing my last week's letter Sir Russell
Reynolds still lingered in the hopeless condition to
which my previous statement pointed. Though not
appreciably different in the morning, he died the
same afternoon, too late to add to my letter the sad
but not unexpected news. His health had declined
for more than a year. Last summer he was a good
deal exhausted by the work entailed on him as presi-
dent of the British Medical Association. Early in Jan-
uary serious illness was manifested in a sudden attack
as he rose from the table at a dinner he had given to
his colleagues at the College of Physicians. A little
later he went to Hastings for a time, but did not gain
strength. On March 23d, on returning from a drive,
he slipped on his doorstep and sprained his ankle.
He was taken to his bed, which from that time he did
not leave, as pneumonia supervened. He survived the
immediate attack, but the remainder of his life may be
said to have been a gradual failure of strength.
John Russell Reynolds was born in 1S28. His
father was the Rev. John Reynolds. His grandfather
was a physician and F.R.S. His brother, the Rev.
H. Reynolds, D.D., principal of Cheshunt College, a
learned and greatly esteemed theologian, survives him.
The career of the late president of the College of Pliy-
sicians has been all along successful. He graduated
at the London University, carrying off gold medals
and the distinction of " university medical scholar."
He passed through the various stages at University
College, to which he eventually became professor of
medicine and physician to the hospital — positions he
occupied for many years, where his teaching was most
highly appreciated. His contributions to medical
literature began with his essay on "Vertigo" in 1S54,
and his other writings on "Neurology" are ver\' well
known. He edited a '" System of Medicine," by va-
rious writers, extending to five volumes, 1866-79. L'p
to the latter date this work is full and reliable, but so
great has been the progress of medicine since that the
"Twentieth Century" will probably push it aside as
largely obsolete. His work on neurologj' was greatly
appreciated abroad as well as at home. Several of his
writings were translated into foreign languages and
many learned societies delighted to enroll him among
their members. He was elected a fellow of the Royal
Society, served in most of the offices at the College
of Physicians, becoming president in 1893, after which
he was created a baronet, having been physician to the
Queen's household from 1878. He has died honored
of all his brethren for his sterling character and genu-
ine worth, and a large number of the leaders of the
profession were present at the funeral service on Tues-
day (2d inst).
Another veteran has also fallen. Sir George John-
son, F.R.S. , whose name will be familiar to your read-
ers, died on Wednesday afternoon (June yi\, after a
brief illness. He was in his usual health and spirits
until Monday, when, on returning from a drive, he was
seized with hemiplegia. He regained consciousness,
but gradually sank. He was in the seventy-eighth
year of his age, and occupied a considerable position
in the profession throughout a long and honorable
career. For many years he was physician to Kings
College Hospital and professor of clinical medicine,
and on retiring was made consulting physician and
emeritus professor. Vou will remember his views on
cholera, which at one time excited much controversy.
Only a few months ago he issued a volume on the sub-
ject, in which he reiterated his views with all his old
energy and conviction. His writings on kidnev dis-
eases were also well known, and he had just completed
a work on the " Pathology of the Contracted Granular
Kidney," which narrowly escaped being a posthumous
production, for I hear that the publishers only deliv-
ered copies on the day before he died. This work can-
not fail to interest those who opposed his views of this
subject as well as those who accepted them, as it will
be his latest utterance, and no doubt many new facts
will be weighed and his judgment pronounced in the
light of the most recent additions to our knowledge.
Sir George was physician e.\traordinar\- to the
Queen, a member of the senate of the London Univer-
sity, where he took his jSLD. as long ago as 1844. In
1850 he became a fellow of the College of Physicians,
where he passed through most of the official positions
and became vice-president in 1887. In 1864 he pub-
lished a couple of lectures he had delivered at the col-
lege on the laryngoscope, and he retained to the last
a certain interest in laryngeal diseases, and consented
to be president of the Second Laryngological Society
— though it is hard to see whj' the specialists could
not unite in a single society.
The General Medical Council met on Tuesday, when
the three new members took their seats and the presi-
dent was re-elected and delivered his address. Mr.
Teale brought forward a resolution respecting the ex-
aminations, which was partly discussed and then re-
ferred to the education committtee. The case of the
Dublin Apothecaries' Hall was taken up the next day,
but adjourned over yesterday, which was occupied
with questions of professional misconduct. This be-
ing so, I, too, will adjourn further notice of the pro-
ceedings which are so unfinished.
A nursing exhibition has been open all the week,
where various things are shown of more or less use to
the sick or injured. Music, the new photography, and
other attractions have been provided to induce those
to come who are not sufficiently interested in nursing.
Many prescribers value guaiacum and serpentaiy so-
little that they would not object to see them expunged
from the pharmacopeia. Sir Alfred Garrod believes
in the virtues of both, especially guaiacum. Accord-
ingly, he undertook its rehabilitation at the last meet-
ing of the Medical and Chirurgical Society, in which
somewhat skeptical atmosphere he claimed to have
been successful in establishing the following points:
(1) Guaiacum was innocuous and might be taken for
an indefinite period of time, and, looked upon as a con-
diment rather than as a drug, was as harmless as ginger
or any other condiment. (2) Guaiacum possessed a
considerable power, but less than colchicum, in di-
rectly relieving patients suffering from gouty inflam-
mation of any part; it might be given whenever there
was but little fever. (3) Guaiacum taken in the inter-
vals of gouty attacks had a considerable power of
averting their recurrence: in fact, it was a very power-
ful prophylactic. C4) Guaiacum did not appear to
lose its prophylactic power by long-continued use.
(5) There were a few persons who could not readily
continue the use of guaiacum; for such cases there
were other drugs whose action was in some respects
similar, and perhaps serpentary was one of the most
powerful of these. He had given it successfully in
July 4, 1S96]
MEDICAL RECORD.
gouty inflammation in tiie elderly subject, and as a
prophylactic doubted not that it was possessed of con-
siderable power. As to the origin of uric acid in the
animal economy, instead of supposing that it was
formed in the system by the metabolism of the nitro-
genized tissues and then thrown out by the kidneys,
he was of opinion that it was produced from urea and
other nitrogenized bodies in the blood by the direct
action of the kidney, and that when uric acid was con-
tained in the blood this arose from the absorption from
the kidney structures of the urate of ammonium, de-
pending on the want of sufficient throwing-oft powers
in these tissues. He did not think that guaiacum
affected the formation of uric acid, but that it acted
directly on the kidney itself as a stimulant and ena-
bled it to get rid of any accumulation in the tubules,
and thus prevented absorption from them into the blood.
In confirmation of this view, patients when taking
guaiacum often had unusual deposits of urates in their
urine.
Dr. Norman JNIoore had seen at least one hundred
instances post-mortem of persons displaying the fea-
tures in morbid anatomy which Sir Alfred B. Garrod
had first shown to belong to this disease. Colchicum
might be given for long periods with advantage and
some success in warding off the attacks.
Dr. Murrell said that he could support Sir A. B.
Garrod's conclusions as to the efficacy of guaiacum in
chronic gout. He had used it during the last si.x
years, not only for chronic gout, but for rheumatism,
tonsillitis, and chronic bronchitis associated with the
gouty taint. He favored a confection.
Dr. Haig agreed that guaiacum tended to ward off
gouty manifestations, but could not accept the expla-
nation offered as to the way in which the drug acted.
Iodide of potassium provoked diuresis and dilatation
of all the blood-vessels, with a fall of blood pressure.
Lithia and ammonia had a similar action, as also had
copaiba, tar, cannabis indica, certain salts of calcium,
and certain bitters, such as chiretta, gentian, and pos-
sibly serpentary. Copaiba contained a large quantity
of acid, and guaiacum agreed with it in this. He
believed that all these drugs diminished the excretion
of uric acid and kept the blood clear of it, and he had
explained fully elsewhere the method of action of some
of those drugs. He accepted the view that urate of
ammonia was not formed from urea in the kidneys,
but that the reverse took place. Much of the uric acid
met with in disease was not formed in the system, but
was introduced with animal food.
Dr. Ewart thought that the action of guaiacum upon
the capillaries was not limited to the kidney, but ex-
tended to the whole system, and in particular to the
capillaries of the muscles; indeed, the effect of guaia-
cum in relieving painful manifestations located in the
muscles was well known. It was easy to imagine that
any interference, however small, with the metabolism
of the muscles must have an appreciable efl^ect upon
the juices, and as to the glandular system guaiacum
acted in that way also, and was a recognized hepatic
stimulant. If the drug were used over a long period
in doses sufficient to cause a la.xative action, this would
influence gouty persons materially. He found tincture
of iodine very useful in combination with guaiacum.
The president. Dr. Dickinson, said that in rheuma-
tism guaiacum had been used at St. George's Hospital
for at least a century, and was certainly much more
successful than other remedies in use at the early part
of that time. The treatment of acute rheumatism
by guaiacum had been continued until twenty years
ago, and even now it was used for chronic rheuma-
tism. From his own experience he could speak very
strongly as to its value in some forms of acute rheu-
matism as well as in gout. With regard to the relation
of uric acid to gout, he placed himself in tiic position
of a disbeliever. There was no doubt of its presence,
but he preserved doubts as to its being the real cause.
Was it not what we might call a by-product? During
convalesence from scarlet fever, when nephritis was
present, it was not uncommon to find enormous quan-
tities of uric acid passed, but that did not necessarily
lead to gout.
Sir A. B. Garrod, in reply, said that one never
missed finding urate of sodium deposited in the tissues
after the slightest attack of gouty inflammation. He
admitted the value of guaiacum in acute rheumatism,
but many cases formerly treated as acute rheumatism
were really instances of acute gout. He was con-
vinced, also, that guaiacum would relieve muscular
pains which were not gouty. Further, there could be
no gouty symptom without the presence of urate of
sodium in the blood, and this had no relation to the
amount thrown out by the kidneys. Guaiacum might
act by increasing the amount excreted, causing visible
deposit, to which the patient would call attention.
London, June 12, 1896.
The most important subject discussed in the session
of the General Medical Council which concluded on
Tuesday was that brought forward by Mr. Teale in a
resolution which is a very serious indictment of our
examination system. The subject has for some time
been forced on teachers by a very unpleasant experi-
ence, while students have groaned under the continu-
ally increasing demands upon them. Examinations
have been multiplied and the ratio of rejections has
increased at every step, so that Mr. Teale calculated
that if every student took his share of plucks he would
be rejected twice in his career. Of course, such aver-
ages are mere indications, and if not used carefully
may mislead ; but there is yet a more serious aspect
of this question, viz., the continuous rise in the per-
centage of plucks. The more we multiply examina-
tions the more fatal does each become, so that there is
obviously good reason for the alarm that has been
raised. Mr. Teale regarded the examinations as faulty
on account of the element of chance which is almost
inseparable from them, and also from avoidable cir-
cumstances, viz., the hurry with which some of them
are conducted and the absurd ciuestions which are too
often set. This latter point he illustrated by a series
of examples of the misguided energy of examiners.
The council is undoubtedly responsible for the
manner of regulating the examinations which has re-
sulted in a bitter cry from teachers and students, and it
should lead to much searching of hearts by councillors
and examiners. These last must be subjected to con-
trol. Every examiner exalts his own subject until the
only plan of meeting his requirements is systematic
cramming, to the neglect of clinical work. Thus we
have sent up for examination men who can give parrot
replies to questions framed from certain te.xt-books,
but who are at a loss as to how to put their knowledge
to use by the bedside. Facts and rules are insisted on
and are therefore accumulated by rote, while the more
important part of true training is rendered impossible
of attainment.
Mr. Teale would maintain the standard on subjects
which it is essential for a practitioner to know and
" retain the knowledge of," but would withdraw from
public examinations those subjects which he should
" know about," and let the schools teach and certify
them. There is certainly some danger if this sugges-
tion were adopted that the competition of the schools,
which is too keen now, might lead to the perfunctory
certification in these subjects of all who had attended
the lectures, or, which is almost the same, paid the
fees. Surely the qualifying body should not be re-
lieved of its responsibility. Let us set up no school
34
MEDICAL RECORD.
[July 4, 1896
examinations to worry the students more, but insist
that the teaching is sufficient for a young man of aver-
age intelligence and increase the preliminary educa-
tion so as to ensure the fitness of every student to en-
ter on the curriculum prepared for his work.
The council, "without committing itself in any way
to the views'" brought forward, referred the matter to
the education committee for consideration and report.
The Dublin Apothecaries' Hall made the proposal
suggested by the privy council for the appointment of
examiners by the medical council. This was dis-
cussed with the same acrimony that has marked the
eflfort to shut up the hall in the interest of the Irish
College of Physicians. No doubt the hall is useless.
We have too many licensing bodies, and this ought not
to have been one. But, having attained a legal status
and being unwilling to commit the '" happy despatch,"
the effort to get rid of it by a side-wind is mean. If
the council is satisfied that its examinations deserve
such condemnation, the acts provide a method of ter-
minating its career in a straightforward manner.
Eventually the council deferred any expression of
opinion and directed communications to be made to
the hall and to the College of Surgeons, with a view of
bringing about a conjoint board. No doubt the hall
will be ready enough to unite again; but will the col-
lege?
Three days were devoted to penal cases. Three
names were ordered to be removed from the register
for infamous conduct, of which the council, having
heard the defence and deliberated /// cameni, found
them guilty. Another case terminated in the an-
nouncement that the charge was not proved. A den-
tal offender was found guilty and judgment postponed.
The council is a very expensive court for the trial of
these cases. Moreover, its proceedings are often des-
titute of all appearance of judicial dignity. It is to
be hoped some more appropriate tribunal may be en-
trusted with the trial of these cases. A body appointed
by the council might, perhaps, be authorized by the
next medical act. Lawyers make short work with any
black sheep that gets into their ranks. Why should
not doctors be provided with an equally efficient
metiiod ?
The council resolved that in future the alternative
of three months' attendance on the indoor practice of
a lying-in hospital should be attendance on twenty
labors, of which not less than five should be conducted
throughout (including the whole puerperium), under
the direct supervision of a registered practitioner.
A statement by Mr. Muir Mackenzie, as standing
counsel, was made to the eft"ect that he is not satisfied
that it is necessary or advisable to seek to amend the
penal clause of the act.
On Wednesday the Prince of Wales again raised his
voice on behalf of hospitals — a cau.se he has often
pleaded before. This time it was for Guy's Hospital,
the income of which has been so reduced by the fall
in the value of land that the governors are compelled
to appeal to the public. The endowment provided by
Thomas Guy for the maintenance of this hospital was,
in accordance with his will, entirely invested in land.
The rents proved sufficient until some fifteen years ago,
when the depression began to be seriously felt. When
all economies failed, even the closing of wards,
^100,000 was raised by subscription to tide over what
was hoped was only a temporary difficulty. But the
fall in prices has increased until now, and an effort is
being made to raise a fund to bring in ^^i 5,000 a year.
To help toward this, a festival dinner and reception
was arranged to be held at the Imperial Institute. It
came off on Wednesday, when the prince presided with
his usual grace and geniality, pleaded the cause of the
hospital in a powerful speech, and accepted the office
of president. The response was unprecedented, and
this festival will be memorable for the amount an-
nounced at it — a total of _;^i67,S28.
Of course, a great proportion of this sum had pre-
viously been sent forward or promised, but the amounts
subscribed in the course of the festival were worthy of
the occasion. The reception after dinner was at-
tended by a great throng of fashionable society — sa
great that, as the weather was wet and the gardens ac-
cordingly deserted, there was quite a crush in some
parts of the spacious buildings, especially about the
staircases and some of more contracted parts. Still,
on the whole, the thousands of ladies and gentlemen-
present met with very little inconvenience, and seemed
thoroughly to enjoy the great reception, which did not
disperse till long after midnight.
The previous day (Tuesday) the prince had accom-
panied his wife to Hackney, where Her Royal High-
ness opened a bazaar on behalf of the Band of Hope.
On this occasion the prince expressed for himself and
the Princess the pleasure it gave them to assist in this-
good work, and declared they had been delighted with
their reception along the route and in the hall. Hav-
ing gone round the stalls and made purchases, the royal'
visitors were entertained with a gymnastic performance
by some of the children, and left amid loud plaudits,,
which were redoubled outside all along the route.
On Monday the prince attended a meeting of the
council of the Hospital Sunday Fund, of which he is
a vice-president. There he presented to Mr. Burdett
an album containing the portraits of the council, and
which, with an address they had voted him, was offered
in commemoration of his successful efforts in increas-
ing the fund. Mr. Burdett was naturally gratified that
the prince should have come on this occasion.
With all this, I may safely say the prince has done
some good work this week and emphasized his well-
known interest in all efforts on behalf of the sick poor.
The Royal Society's cotiversazionc — the "ladies'
night," as it is familiarly called — was held on Wed-
nesday and well attended, notwithstanding the counter-
attraction mentioned above. The " X" rays and other
exhibits were as attractive as usual.
Dr. Thomas Barlow has been appointed, in succes-
sion to the late Sir R. Reynolds, physician-in-ordinary
to Her Majesty's household.
PORKIGN PRACTITIONERS IN FRANCE.
To TirK Editor of the Medical Record.
Sir: In my number of your journal just received
(May 9, 1896, p. 684) you refer to the " Rampant Pro-
tectionism for French Physicians," and the question
is asked, " How many of the interlopers are Ameri-
can?"
Thinking this would interest your readers, I venture
to give some details of the question.
All the F'rench medical journals are full of what
they call the invasion of the foreigners (doctors who
come to France to practise medicine). This, although
these foreigners are made to pass all the medical ex-
aminations that l''renchmen pass.
A late writer says : " These people come here to
take advantage of the foolish public, who are attracted
by anything tiiat comes from afar oft and that has a
barbarous name. Most of these stranger doctors are
Russians and Jews, who fly from their native soil to
divide our bread with them, as they are tired of black
bread."
Two new articles are proposed to the medical lawsr
I St. All foreigners can enter the F'rench faculties of
medicine, but the diploma given will not entitle them-
to practise in France.
2d. No foreigner can practise medicine in France
unless he has been naturalized French, has done his.
July 4, 1896]
MEDICAL RECORD.
military service, and has passed the examinations for
bachelier, like Master of Arts.
It is therefore evident that great difficulties will be
put in the way of any foreigner who wants to practise
in France.
Up to the present the foreign Master of Arts degrees
or similar ones have been accepted as suflficient for
entrance in French faculties, and some allowance oft'
has been made to holders of good medical diplomas.
In late years, however, foreign medical men have
barely been allowed to enter the French schools and
have been compelled to pass all the examinations
(eleven in all). The medical examinations are called
five, but are each divided in two, making ten, which,
with the printed thesis examination, make eleven ex-
aminations in all.
The writer came in under this last ruling.
The " invasion'' is mostly a Russian one and is the
fault of the French themselves. In late years they
have encouraged and shouted for everything Russian.
Any student of a Russian school was admitted to the
Paris faculties (males and females). This has led to
the present overwhelming of tlie French doctors.
The Russians are poor men and women who do not
care to return to their own inhospitable land, and stay
to practise in France and with and upon French peo-
ple. They speak excellent French as well as verj-
often English and German, and practise among the
French as well as the English or any others.
It is a very different matter with the English-speak-
ing (English and American) doctors who practise in
France. The better-class English and Americans
travel much in France and pass seasons in its winter
and summer health resorts, and they demand a physi-
cian of their own country and language when ill.
This has caused a certain number of English and
American doctors to settle in France, and they prac-
tise only with their own country people, never accept-
ing a French patient.
They have all had to pass the full examinations of
the French faculty the same as the French students,
and have as well a diploma from their own medical
schools, thus having had a double education.
As the question is asked, perhaps it would be well
for you to give the full list of all the American physi-
cians now practising in France, as follows:
Aix-les-Bains: Dr. Thomas Linn (in summer).
Nice: Dr. Thomas Linn (in winter).
Paris: Drs. Austin, A.Clarke, B. F. Dearing, Pike,
R. R. Good, G. Halsted-Boyland, Chamberlain, M. F.
Hein, Magnin, Reiss, Afrs. Klumpe-Dejerine (wife of
Professor Deje'rine), Whitman.
Thus, twelve are in Paris, and one, Dr. Linn, at
Nice and Aix-les-Bains and the rest of France.
The English doctors are about twelve also in Paris,
eight in Nice, si.x in Cannes, five in Monte Carlo, six
in Mentone, one in Beaulieu, and two in Hyeres.
There are about, then, a dozen Americans in all
France, and some twenty-eight English in south France
and twelve in Paris; thus, forty of the latter in all
France.
This surely is not a great " invasion" when the thou-
sands of English and American invalids are considered.
The French doctors need to be told that the only
competition they have is from the Russians, whom they
have brought to France themselves, while, so far as
the American and English doctors are concerned, they
never practise among the French, and it is because
they reside there that many English and American in-
valids make a stay in French resorts. Americus.
Contagious Diseases — Weekly Statement Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending June 27, 1896:
Deaths.
Quinine is distinctly contraindicated in inflamma-
tion of the middle ear, of the skin, meninges, and the
urinary and alimentary tracts.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
.Small-po.N.
Mosquitoes and Malaria. — Dr. Manson believes
that malaria may be and often is propagated through
the agency of the mosquito. We quote his views from
The Lancet of March 21, 1896, as follows: '" I think I
have advanced many cogent reasons for believing that
the Plasmodium malariaj on leaving man, and as a
normal step in its life historj', becomes parasitic in
the mosquito, and that in this insect it enters some
cell — as any gregarine or coccidium would do — and
probably develops into its reproductive sporulating
form just as it does in the blood corpuscles of man.
\\'hat then ? How can its spores get out of the mos-
quito so as to increase and multiply and preserve its
species from extinction when in the course of nature
the mosquito dies? How, too, does it spread over the
land, and how does it get back to man again? Be-
fore attempting to answer these questions, I must first
describe very briefly a passage in the life of the mos-
quito. The female mosquito, after she has filled her-
self with blood — the male insect is not a bloodsucker
— seeks out some dark and sheltered spot near stag-
nant water. At the end of about si.x da\'s she quits
her shelter, and, alighting on the surface of the water,
deposits her eggs thereon. She then dies, and as a
rule falls into the water beside her eggs. The eggs
float about for a time and then in due course each
gives birth to a tiny swimming larva. These lar\ae,
in virtue of a voracious appetite, grow apace, casting
their skins several times to admit of growth. Later
they pass into the nympha stage, during which, after
a time, they float on the surface of the water. Finally,
the shell of the nympha cracks along its dorsal sur-
face and a young mosquito emerges. Standing, as
on a raft, on the empty pelt the young mosquito floats
on the surface of the water while its wings are dr}-ing
and acquiring rigidity. When this is complete it flies
away. The young mosquito larva, to satisfy their
prodigious appetites, devour everything eatable they
come across; and one of the first things they eat if
they get the chance is the dead body of their parent,
now soft and sodden from decomposition and long
immersion. They even devour their own cast-off
skins. In examining mosquito lar\'£E one often comes
across specimens whose alimentary canals are stuffed
with the scales, fragments of limbs, and other remains
of the parental insect. As we have seen that the
mosquito larva devours its own and its neighbor's ex-
uvia;, we can readily understand how, once gregarines
have been introduced into a pool of water, the larval
mosquitoes in that particular pool become infected by
the parasite. But as the mature mosquito when she
quits her nympha husk also contains numerous gre-
garines, we can also understand how she, too, carries
the infection with her, scattering it about the countr)'
in her fxces or conveying it to any other pool where
Her body is
she may lay her eggs and afterward die.
36
MEDICAL RECORD.
[July 4, 1896
then devoured by her progeny or by any other mos-
quito larva that already chance to be in the pool.
Along with her body, of course, the larvje swallow any
gregarine germs it may contain if they have not al-
ready been picked up by the larvae when feeding on
the mud at the bottom of the pool. Does not this
little story of the gregarine indicate the way, or a way,
in which that other mosquito sporozoon— the Plasmo-
dium malaria;— multiples? Does it not indicate how
this parasite, in which man is so much interested,
passes from mosquito to larva, from larva to mosquito,
in never-ending series? Does it not indicate how the
Plasmodium disease of mosquitoes spreads from pool
to pool and is scattered broadcast about the country,
and does it not indicate how it may get back to man
again? We can readily understand how the mosquito-
bred Plasmodium may be swallowed by man in water,
as so many disease germs are, and we can readily un-
derstand how it may be inhaled in dust. Mosquito-
haunted pools dry up. The plasmodia in the larv;E
and those that have been scattered about in the water,
finding themselves stranded by the drought and so
placed in a condition unfavorable for development,
pass into a resting stage, just as they do when by qui-
nine or other means man is rendered temporarily
unsuited for their active life. The dried specimen
of the pool, blown about by winds and currents of air,
is inhaled by man, and so the plasmodium may find
its way back again to the host from whom its ancestors
had, perhaps, started generations back. I would con-
jecture that on entering man and on entering the lar-
val mosquito it develops into a flagellated spore sim-
ilar to the flagellated spore into which it_ develops in
the mosquito's stomach. In this way it would be
enabled to penetrate the mucous surfaces and get into
the human blood cell. Many mosquitoes die without
getting to water; all male mosquitoes die without
seeking water. They may die far from water, blown
away, as we know mosquitoes are, by high winds.
The bodies of such mosquitoes fall in time on the
soil and decompose. The parasites they contained
pass into the resting stage, and in this form they also
may be carried into the air by currents, or be blown
about as dust, or be shaken out by man when he dis-
turbs the soil. In this way the plasmodium may find
a route back to man again. In this way, too, we may
explain the occurrence of those cases of malaria
which apparently, though not really, are unconnected
with swamp or stagnant water. Such is my view of
the life history of the malaria parasite, and the role
of the mosquito with regard to it, and of the process
by which man becomes infected."
Bacteriology of Air Passages.— In an article read
before the Academy of Medicine, .\pril 7th, by Dr.
W. H. Thomson, he' quotes from Dr. St. Clair Thom-
son and Dr. R. T. Hewlett, of the Bacteriological De-
partment of the British Institute of Preventive Med-
icine, to the section on pathology at the last annual
meeting of the British .Medical Association, which led
to special research as to the fate of micro-organisms
in inspired air. They calculate that the lowest esti-
mate of org.rnisms inhaled every hour would be fifteen
hundred, but in London atmosphere it must be com-
mon for fourteen thousand organisms to pass into the
nasal cavities during one hour's tranquil breathing.
Beginning with the trachea, they found that the mucus
derived from the trachea of all animals recently killed
in the laboratory was always sterile. The mucous mem-
brane of a healthy nose only exceptionally shows any
micro-organisms whatever. The interior of the great
majority of normal nasal cavities is perfectly £.septic.
The vestibule of the nares, the vibrissse lining them,
and all crusts forming there are generally swarming
with bacteria. The vibrissa: seem to act as a filter,
and a large number of microbes meet their fate in the
moist meshes of the hair which fringes the vestibule.
This arrangement not only arrests the ingress of germs,
but by the action of cilated epithelium those which
have penetrated into the nose are rapidly ejected.
Sanatorium Treatment of Phthisis. — Dr. Otis
{jVao York Mdi'ual Journal, June 3, 1896I writes as
follows: ■■ It seems to me that it is to be deplored that
the main object of all sanatorium treatment — namely,
the hygienic — should in any way be obscured in these
laudable attempts to establish special institutions for
the treatment of consumption by the more specious
claims of special methods of treatment or specifics.
It is well to again repeat that up to the present time
there has been discovered no specific which will cure
consumption, and the best results have been, and are
now, obtained by the hygienic, open-air treatment, as
illustrated in the best-equipped and best-conducted
sanatoriums. The extraordinary and une.xpecled, like
the 'X' rays, may at any time happen in the discover)- of
the devoutly desired specific or immunizing serum ; but
when it does come, if ever, there will still be as great
a need of sanatoriums as at present, where the dam-
age left in the wake of the dislodged and routed ba-
cillus and his confreres can be repaired, and the bat-
tered body gently and skilfully restored for further
service."
Fractures of the Cranial Vault. — Dr. Senn says
that operative interference is absolutely indicated
under the following circumstances: i. All open frac-
tures, including gunshot and punctured fractures. 2.
Depressed fractures attended by well-defined symp-
toms caused either by the depression or intracranial
complications. 3. Rupture of the middle meningeal
artery with or without fracture of the skull.
While the Medic.\L Record is pleased to receive all tiew publi-
cations which may be sent to it, and an acknowledgment will be
promptly made of their receifl under this heading, it must be 'u-ith
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it -cohich in the judgment of its editor will not be
of interest to its readers.
Tr.\nsactions of the American Orthop.€dic Association.
Ninth Session. Vol. VIII. 8vo. 335 pp. Illustrated.
Dame Fortune Smiled : A Doctor's Story. By Willis
Barnes. 8vo, 335 pp. Arena Publishing Co. , Boston, Mass.
The Methodical E.x.\mination of the Eve. By William
Lang, F. R.C.S. i2inQ, 96 pp. lUustcated. Longmans, Green
& Co. Kew York.
Text-Book of Comparative Anatomy. By Dr. .Vrnold
Lang, translated by Henr\- M. Bernard and Matilda Bernard.
Part II. Svo, 6iS'pp. illustrated. Macmillan & Co. New
York.
ANLEITENUE VoRLESINGEN FCR den OrERATIONS-ClRSrS
an DER Leiche. Von Prof. E. von Bergmann und Dr. II. Koch,
l2mo, 2S6 pages. Illustrated. August Hirschwald, Berlin,
Germany.
The Treatment OF Phthisis. By Arthur Ransome, M.D.
Svo, 237 pages. Smith, Elder & Co., London.
Occasional Papers ON Medical Subjects, 1S55-1896. By
W. Howship Dickinson, M.D. Longmans, Green i: Co. New
York.
The Stomach. Its Disorders, and How to Cure Them.
By J. H. Kellogg, M.D. 1 2mo, 368 pages. Illustrated. Mod-
ern -Medicine Publishing Company, Battle Creek, Mich.
Obstetric .\ccidents, Emergencies, and Operations. By
S. Ch. Boisliniere, M.D. i2mo, 3S1 pages. Illustrated.
W. B. Saunders, Philadelphia, Pa. Price, $2.00.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 50, No. 2.
Whole No. 1340.
New York, July ii, 1S96.
$5.00 Per Annum.
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©vigiual ^iiiidcs.
A METHOD OF EXAMINING THE PELVIC
CONTENTS WHICH RENDERS EXPLORA-
TORY LAPAROTOMY UNNECESSARY IN
INFLAMMATORY CONDITIONS OF THE
ADNEXA UTERI, AND IN CERTAIN OTH-
ER DISEASED STATES OF THE PELVIC
VISCERA.
By \V. R. PRYOR. M.D.,
l-KOFESSOR OF GYNECOLOGY, NEW YORK POLYCLINIC.
Up to two years ago the writer performed abdominal
section upon certain patients who presented local and
general symptoms strongly resembling pyosalpinx.
Upon opening the abdomen, either a hydrosalpinx or
broad-ligament cyst, or large cystic ovary, matted by
recent lymph to an occluded tube, was found. Meet-
ing such conditions, no method of treating them other
than removal appeared safe. Again, other cases were
encountered which were very obscure, and in which
persistent pelvic pain with tenderness at the sides of
the uterus demanded a clearing up of the diagnosis by
abdominal section. In other words, we were forced in
our fallibility to do a grave operation, in order to
make a diagnosis.
The very uncertainty attaching to our diagnoses lead
some to shamefully abuse the operation, using as an
excuse the necessity for a clear diagnosis, and the
words '■ exploratory laparotomy" became the attractive
cloak behind which ignorance worked. The laparot-
omist, having once gotten in the belly, must have a
token of his prowess, and absolutely normal organs
were removed. It was in the consciousness, then, of
the mistakes inherent in his specialty that the writer
sought to develop a method of approaching the adnexa
uteri in obscure cases which would be a radical de-
parture from old procedures, and which would both
clear up doubtful cases and stay the hand of the lapa-
rotomist. This operation will assuredly clearly draw
the distinction between those who can and those who
cannot do this sort of work. For, while the new ope-
ration is simple, yet is the space limited. There is
no such gate to throw open as exists between the
xiphoid and pubis. In front of the vaginal incision
lie the uterus, uterine arteries, ureters, and bladder,
behind it lies the rectum, and above are the coils of
small intestine. The regional anatomy is intricate
but fairly constant. I have this to congratulate myself
upon, that experience as an apprentice is demanded
to do this operation and a good deal of manual dexter-
it)'. Having these, the operation is easily performed,
and is devoid of risk. Without them, none should
try it.
Operation. — For two days before the operation the
vagina is kept filled with a gauze dressing, soaking
wet with bichloride solution, i to 5,000. At the sec-
ond renewal of this dressing, twenty-four hours before
the operation, the patient is shaved. This wet anti-
septic dressing is applied for the purpose of loosen-
ing the superficial layers of vaginal epithelium, and it
should be ample enough to spread out the vaginal
rugoe. The patient is placed in the lithotomy posture.
At the time of operating the external genitalia are
scrubbed with a one-per-cent. solution of lysol, fol-
lowed by Thiersch's solution. The vagina is cleansed
with the same solution, using for this purpose the
hair brush which jewellers employ to clean watches.
The uterus is curetted, irrigated with a boiled one-
per-cent. solution of salt, and its cavity swabbed out
with iodoform gauze to remove de'bris. All instru-
ments employed in this procedure are cast aside and
(u'-.
■M)
y
Fig. I. — The cut-de-sac incision is made with scissors from .v-y-.v. Blunt tear-
ing with the fingers is made out to the lateral Yaginal walls to A-A. The
level of the uterine arteries is much above this line of incision, approxi-
mately at l(.
the vagina is again flushed out with Thiersch's solution.
With stout, blunt traction forceps the uterus is pulled
down, and the point at which the vagina is reflected
from the cervix is demonstrated by moving the cervix
up and down in the vaginal vault. This point of re-
flection is shown by a crescentic fold which appears
just behind the cervix when the cervix is shoved up.
Picking up this fold in the middle with strong
mouse-tooth forceps, the operator cuts through the
vaginal mucous membrane at y (Fig. 1). This inci-
FlG. 2.— The uterus (^ is held up behind the symphysis (.?) with the bladder
(5) by the trowel (A'), while the rectum {R) and posterior vaginal wall are
pulled down by the retractor ( }').
sion is extended to each side to x-x, making a cut
about an inch long, or a little less, usually, than the di-
ameter of the cervix of a parous woman. The scissors
cut through the vaginal mucosa only. The posterior
riap is now grasped at its centre by stout forceps, and
38
MEDICAL RECORD.
[July 1 1, 1896
while making down-traction upon the uterus and this
flap the operator pushes his finger into the cul-de-sac
up to the level of the internal os. If the finger has
not already perforated the peritoneum, the cavit}' is
wiped dry and the peritoneum picked up with forceps
and cut with scissors. A digital examination of the
pelvic contents is now made, still keeping up down-
traction on the uterus. Having satisfied himself that
an ocular inspection is necessary, the operator intro-
duces two fingers into the opening in the cul-de-sac,
and, separating them laterally, he tears the vaginal
mucous membrane and peritoneum out to the points
A, A (Fig. I ). Very rarely will the vaginal mucosa
be found so stout that he cannot do this. Should it
Fig. 3. — The cul-de-sai: 1- 1 iMied. 1 1 ■, > .^.Lal wM is held down by tbe retractor, while with the trowel the
uterus is shoved up aKainst the Liiaudt-i. i iic ^jjacc obtained is estimated by comparing the length of the operator's
index finger with the distance between the bladesof the retractors. In this case it was 2^ inches.
be SO, he will lightly touch it with a scalpel in the di-
rection in which he wishes the tissues to separate.
The medium blade of the long Pean retractor is intro-
duced into the pelvic cavity, the forceps on the pos-
terior flap are removed, and the cer\-i.x is freed from the
traction forceps. The Tcan-Pryor trowel is now in-
serted into the pelvis and the uterus forced up behind
the symphysis (Fig. 2). This will widely open up
the pelvic cavity. Into this opening a gauze pad, to
which is attached a stout string, is inserted to prevent
descent of the intestines and to catch any sero-san-
guinolent fluid.
The patient, still on the back and with legs bent
upon the trunk, is thrown into Trendelenburg's posi-
tion (Fig. 3). By gentle manipulation with small
gauze pads held by Hunter's forceps, the intestines
and omentum are made to enter the abdominal cavity.
When it is found that the intestines are adherent, they
are gently freed. Should the digital examination have
demonstrated the probable existence of pus foci, to
which the intestines are attached, these latter should
be separated before putting the table into Trendelen-
burg's position, in order to prevent escape of pus into
the abdominal cavity.
The intestines having been freed in such cases, a
complete diaphragm of gauze pads is put between the
pus foci and the intestines above, and the Trendelen-
burg position secured. But in those cases in which
the purulent accumulation is extensive enough to cause
any degree of adhesions, '" exploratory incision" is not
often necessar}'; for the diagnosis is generally suffi-
ciently clear to indicate the proper form of radical
operation. It is in the doubtful cases — cases of pos-
s i b 1 e hydrosalpinx,
broad- ligament cyst, or
large ovary with ad-
herent inflamed tube,
that we find the indica-
tion for this, as for the
abdominal exploratory
incision.
Tubal pregnancy, hy-
drosalpinx, broad-lig-
ament cyst, ovarian
cystoma, occluded
tubes, pelvic adhesions,
pyosalpinx, uterine
fibroid — in fact, all the
various lesions of the
peritoneal face of the
uterus and of its ad-
nexa, I have found and
demonstrated by this
procedure.
To grasp the ovaries
and tubes with Luer's
forceps and sever their
adhesions is easy.
Cysts of the ovary
may be punctured, and
so can blood clots in
the ovarian stroma.
The clear sterile fluid
of a hydrosalpinx or
broad-ligament cyst
can be evacuated. Ad-
hesions between an oc-
cluded tube and the
ovary can be readily
broken. In fact, by
this means of explor-
ing the pelvis, we can
apply conse r v a t i v e
measures to a class of
cases which would be
subjected to great risk were conservatism attempted
from above.
I have also succeeded in showing that a supposed
cancerous involvement of the rectum was nothing but
a mass of lymph about a diseased ovary and tube. In
five cases I have demonstrated to spectators the ver-
miform appendix.
Absolutely and without mutilation can we make a
positive diagnosis of the pelvic contents from the pel-
vic brim to the vagina. In a discussion of my opera-
tions later on, I will bring out certain other points
relating to treatment.
Having satisfactorily examined the pelvis, all fluid
is wiped away, the uterus again swabbed out, and now
packed full of iodoform gauze. The gauze pads are
now removed and a loose plug of iodoform gauze is
inserted just within the edges of the vaginal rent; but
it must fill tlie opening to prevent protrusion of small
intestine. The uterus and this plug are replaced en
July I I, 1896]
MEDICAL RECORD.
39
masse, and the vagina is filled with gauze. A self-re-
taining rubber catheter is inserted into the bladder,
and tlie sphincter ani dilated. No morpiiine is given.
The bowels are moved by salines in twenty-four hours,
when light diet is begun. After two days the bladder
is irrigated with boric-acid solution and tlie catheter
removed. On the third day the patient is put in Sims'
position and the uterine packing removed without ir-
rigation. Whatever vaginal gauze has been taken out
to do this is replaced by fresh dressing. I leave the
cul-de-sac plug in for from .seven to ten days, accord-
ing to the character of the case. It is removed and
replaced under a short chloroform narcosis. In doing
this the patient is in Sims' position. The operatcr
Fig. 4. — 1, Pean-Pr>'or irowei ; 2, Pean retractor ; 3, Luer's pile forceps; 4,
Hunter's sponge holder ; 5, Pryor's traction forceps ; 6, self-retaining cath-
eter.
must be careful to support the cervi.x anteriorly with
the trowel, so as not to disturb the lymph behind the
uterus. A second dressing is made a week later,
without pain, and repeated until the opening closes.
I let the patient sit up in bed after the first dressing,
get out of bed in two weeks, and become an office case
between two and three weeks.
These incisions produce no ill results whatever.
The lymph which fomis behind the cervix is exceed-
ingly evanescent. I would call the attention of the
reader to the difference between the amount and char-
acter of the lymph which is thrown out about an anti-
septic absorbent dressing and that which is the ex-
ponent of a pathogenic invasion. Even in cases of
puerperal infection subjected to this operation the
uterus its entirely movable in two months.
The cul-de-sac closes rapidly, and leaves a scar
which is with difficulty found after a few months have
passed.
The amount of room which I secure is amply suffi-
cient for purposes of inspection. I enter the cul-de-
sac in from one to five minutes. There are two
layers anatomically — vaginal mucosa and peritoneum.
One small vessel is severed, the azygos artery of the
vagina. It is so insignificant that I have always found
the few minutes' crushing with the heavy forceps
•while opening the peritoneum to be sufficient to con-
trol it. No ner\es of sensation are severed. My inci-
sion is made below the line of the broad ligaments and
uterine arteries with the accompanying ureters. The
blunt tearing of the vagina is made parallel with the
branches of the vaginal artery, and they are never
wounded. Six instruments are needed for this opera-
tion and one assistant.
Roughly described, the distances from the cul-de-
sac to the vulva and to the anterior abdominal skin are
the same. When I open the cul-de-sac and attempt to
separate the blades of my retractors, I find I get but
little space unless I throw the woman into Trendelen-
burg's position. This is because complete relaxation
of the pelvic muscles does not occur until they cease
to feel the necessity for supporting the intra-abdomi-
nal pressure.
Even in an old nullipara with rigid muscles, I get
from one and one-half to two and one-half inches be-
tween the blades of my retractors. My belief is that
there no longer exists an indication for cceliotomy as
an exploratory procedure, or for purposes of treating
adhesions, adherent retropositions, occluded tubes,
cystic ovaries, hydrosalpinx, or broad-ligament cyst.
The application of the procedure to adherent retro-
positions has been previously described.'
Should a vaginal hysterectomy be indicated, the
exploratory vaginal incision completes the first step
of the radical operation. In case the operator deems
it wise to open the abdomen, the vaginal opening made
for exploration furnishes the rational drainage space.
In other words, where exploration alone is demanded,
and in certain cases now subjected to cttliotomy, the
vaginal operation above described is a complete pro-
cedure; and in other cases in which radical work is
indicated my operation is but preliminary to what is
to follow.
The Results of the Conservative Vaginal Section
and of Vaginal Hysterectomy, in Inflammatory
Lesions of the Adnexa Uteri. — In order that opera-
tors may see how the above-described method of ex-
amining the pelvic contents modifies our work, I will
tabulate the last fifty-three cases I have operated upon.
Tiie position of the patient in these cases occupies the
same important relation to the operation that Tren-
delenburg's position does to suprapubic ablation of the
uterus.
So long as the vaginal operation was the blind,
bloody work which we first saw, it scarcely appealed
to those of us who were used to the suprapubic opera-
tion. But now the operator can see every step of his
dissection if he pleases to do so.
FIFTY-THREE CONSECUTIVE CASES OF CON-
SERVATIVE AND RADICAL OPERATWDNS UPON
THE ADNEXA UTERI, THROUGH THE VAGINA.
'^
Initials.
Si
<
Lesions.
Operation.
Result.
I
R. 11.
33
Retroversion with ad-
hesions.
Cul-de-sac opened,
uterus released and
replaced.
Cured.
2
M. U
35
do.
do.
do._
3
C. K.
21
Retroversion with ad-
hesions; occluded
tubes.
do.
D e I i V e red at
full term,
May, 1896.
4
M. G.
do.
do.
Expects to be
c 0 n fi n e d
June, 1896.
5
C. S.
Retroversion with ad-
hesions.
do.
Cured.
6
M. W.
19
do.
dn.
do.
7
M. W.
39
Retroversion with ad-
hesions; diffuse pel-
vic peritonitis.
do.
Improved.
8
F. de W.
20
Large cystic ovaries,
retroversion with ad-
hesions.
do.
Cured.
9
N. E.
21
Adherent retroversion.
do.
do.
10
-. L.
35
do.
do.
do.
11
B. W.
28
do.
do.
do.
12
M. Ch.
19
Left hydrosalpinx . . , ,
Cul-de-sac incision,
evacuation.
do.
13
H. M'F.
22
Laparotomy two years
ago, right adnexa re-
moved; general pel-
vic peritonitis; left
salpingitis and ova-
Cul-de-sac opened,
uterus released; oc-
cluded tube opened,
replacement.
do.
ritis; tube occluded;
retroversion with ad-
hesions.
M
M. M.
40
One hydrosalpinx, one
Cul-de-sac opened^ all
S y m p 1 0 matl-
pyosalpinx; acute
fluid accumulations
cally cured.
pelvic peritonitis,
evacuated; pelvic
specific; acute alco-
Mikulicz.
holism.
15
M. O'H.
21
Left gonorrhceic sal-
pingitis; acute pelvic
peritonitis.
Cul-de-sac opened, all
adherent structures
released; pelvic
Mikulicz.
Cured.
16
N. o'n.
=5
Acute pelvic peritoni-
tis; bilateral salpin-
gitis following in-
duced abortion.
Cul-de-sac opened,
adherent tissues
separated; pelvic
Mikulicz.
do.
17
A. G.
22
Acute puerperal infec-
t ion ; retroflexion;
diffuse pelvic perito-
nitis; septica;mia.
Cul-de-sac opened.
large hydrosalpinx
and broad -ligament
cysts evacuated;
pelvic Mikulicz.
do.
18
M. P.
24
Retroflexion; diffuse
pelvic peritonitis;
puerperal septicfe-
mia.
Cul-de-sac ope n ed ,
lymph planes broken
up; large pelvic
Mikulicz.
do.
19
K. H.
21
-Acute bilateral pyosal-
pinx, specific, and
peritonitis.
Cul-de-sac opened,
tubes widely split
open; pelvic .Mikulicz
Improved.
' N. V. .MeIjIC.vl RecuRU, July 20, 1895.
4°
MEDICAL RECORD.
[July I I, 1896
z
Initials.
u
<
Lesions.
Operation.
Result.
20
H. L.
Bilateral chronic sai
Cul-de-sac opened,
Sy m plomati-
pingitis.
tubes released; gauze
dresssing as in retro-
version cases.
cally cured.
21
M. L.
19
Diffuse pelvic suppura-
tion; puerperal sep-
ticemia.
Cul-de-sac opened,
all pus foci opened
large pelvic Mikulicz
do.
22
S. A.
39, Right pyosalpinx; left
Right salpingonabpho-
Cured.
salpingitis.
rectomy through cul-
de-sac; forceps.
'3
J. S.
'9
Bilateral pyosalpinx; Cul-de-sac opened.
S y m p tomati-
acute peritonitis,
tubes split open.
cally cured.
specific.
lymph planes sepa-
rated; pelvic Miku-
M
Mrs. Y.
21
Bilateral acute salpin- Cul-de-sac opened,
gitis and pelvic peri-J tubes released,
tonitis; had been cu- lymph planes sepa-
retted. rated; pelvic Miku-
do.
25
M. H.
27
licz.
Puerperal septicemia. Cul-de-sac opened;
Cured.
repealed curettage,
etc.
Specific bilateral sal-
pelvic Mikulicz.
26
K. A.
22
Cul-de-sac opened,
do.
pingitis and perito-
etc.; pelvic Mikulicz.
nitis; retroversion.
27
E. K.
35
Large tumor in pelvis
on right side.
Cul-de-sac opened,
tumor found to be
an omental lipoma;
adhesions seve red;
gauze packing.
do.
28
F. N.
23
Left pyosalpinx. . . .
Left salpingo-oopho-
rectomy through
cul de-sac; forceps.
do.
29
L. S.
30
Bilateral salpingitis;
small fibroids.
Vaginal hysterectomy.
do.
30
M. F.
34
Bilateral tuberculous
salpingitis.
do.
do.
3'
L. W.
24
Abdominal sinus and
diffuse pelvic suppu-
ration about infected
ligatures left after
cccliotomy.
Va.ginal hysterectomy;
ligatures recovered.
do.
32
M. P.
21
Bilateral pyosalpinx;
diffuse pelvic sup-
puration; large chan-
croids on vulva.
Vaginal hysterectomy.
do.
33
L-J.
29
General pelvic perittv
nitis due to infected
ligatures after cccli-
Vaginal hysterectomy;
ligatures recovered.
do.
34
M. F.
■9
otomy.
Large ovarian apo-
plexy; acute salpin-
gitis.
Vaginal salpingo - oo-
phorectomy; forceps.
do.
35
M. B.
32
Bilateral salpingitis;
suppurative, specific.
Vaginal hysterectomy.
do.
36
M. W.
34
Bilateral pyosalpinx. . .
do.
do.
37
C. C.
27
Diffuse pelvic perito-
Cul-de-sac opened ,
do.
nitis; puerperal sep- lymph planes sepa-
ticamia. rated; pelvic Miku
licz.
38
H. H.
27
Old ruptured ectopic Cul-de-sac opened,
gestation; saprscmiaj putrid fluid and
profound. ; clotted blood evacu-
I ated.
do.
39
M. S.
40
Chronic bilateral sal- Vaginal hysterectomy,
pingitis; repeated at-
tacks.
do.
40
L. Z.
35
Bilateral pyosalpinx.. . do.
do.
41
A. H.
35
do. ... Vaginal hysterectomy
(broncho-pneumonia)
do.
42
A. C.
39
Diffuse pelvic suppu- Vaginal hysterectomy.
ration.
do.
43
T. P.
22
Ruptured ectopic ges- Vaginal hysterectomy
do.
t a t i 0 n ; salpingitis
(broncho-pneumonia)
on other side.
44
H. H.
(?)
Bilateral pyosalpinx. . .
Vaginal hysterectomy;
secondary hemor-
rhage from left ova-
rian artery; lapa-
rotomy.
Vaginal hysterectomy.
do.
43
M. F. *
s8
Left pyosalpinx and
do.
diffuse pelvic -perito-
nitis; laparotomy a
year before for right
pus tube.
46
0. H.
21
Bilateral pyosalpinx. . .
do.
do.
47
S. H.
28
Unruptured tubal
pregnancy of right
side, chronic salpin-
gitis of left.
do.
do.
48
S. A.
(See case
39
Left pyosalpinx
do.
do.
49
46
Old ectopic, which had
do.
,1.,.
ruptured into right
broad ligament; dif-
fuse pelvic suppura-
tion.
50
M.S.
44
Bilateral pyosalpinx...
do.
do.
5"
J. K.
23
Bilateral suppurative
salpingitis.
do.
do.
52
L. G.
46
Bilateral pyosalpinx
and diffuse pelvic
suppuration.
do.
do.
53
B. W.
28
Bilateral chronic sal-
pingitis; general pel-
vic adhesions; many
previous minor oper-
ations, etc.
do.
do.
Number of
Hysterecton
Vaginal sal|
Retroversio
Acute puer]
2asts
lies
53
ingo-ouphorectomies
1 with adhesions
3
eral infections
'.'".'.]'.'. c
Ectopic gestation, \
'
PyosaJpinx, ( Evacuation; )
Hydrosalpinx, f pelvic ^Iikubcz, )
Broad ligature cyst, )
Died
0
The operation of breaking up adhesions thirough the
cul-de-sac and replacing the uterus without suture I
have previously described. My persistent use of this
operation is due to the fact that I have al\va\s suc-
ceeded in relieving my patients. After the cul-de-sac
closes, I employ such plastic work on the vagina as
may be necessar\-. The operation supplants the hys-
terorrhaphy entirely. Two of the women I have deliv-
ered. The scar showed no tendency to break, and
during gestation neither attempted to abort. I have
not been able to trace all the cases, and others may
have become pregnant.
I have always considered hydrosalpinx and broad-
ligament cysts as perfectly innocent affairs. The cul-
de-sac method furnishes a safe way of dealing with
them without removal.
All infections do not result in pyosalpin.x, but often
nothing is left but firmly adherent and closed tubes.
These women suffer a great deal at times from spas-
modic pain. Not the gross lesions as found by e.xam-
ination, but the subjective symptom, pain, brings them
to the operating table. Cceliotomy appears too se-
vere an operation for dealing with merely occluded
and adherent tubes. The cul-de-sac operation ena-
bles the surgeon to sever all adhesions and to open
these agglutinated fimbria;.
We are approaching the position in this work which
calls for a halt and review of what we have previously
done. There can be no question that it is much more
satisfactory to the surgeon to make a clean radical
operation of every case of pus in the pelvis which he
meets. But, viewed from the standpoint of the
woman, the sudden artificial menopause is about as
distressing as the pus tubes. This is especially true
when young women, who have never had children,
are spayed. In such cases, then, I believe our surgery
must be modified by extraneous circumstances very
largely, and if we can afTord that measure of relief
which will enable these women to be up and about
and still menstruate, we have done our full duty to
them. Cure them symptomatically and leave them
physiological, partially at least!
The cases numbered 13, 14, 15, 16, 19, 20, 22, 23,
24, and 26 were all treated by the conservative vagi-
nal section, no structures being removed. ■ This meth-
od must not be confounded with the trocar puncture.
I always make a very wide incision in the cul-de-sac,
and split open the pus sacs so that they can be packed
with gauze.
When nature effects a cure of repeated inflamma-
tions, it is by means of a fibrosis of the tissues. We
see such tissues in old whores who have had many
attacks of gonorrhea and many applications of curette
and caustic. Now, in this cul-de-sac work on pus
tubes we attempt to secure an obliteration of the
affected tube.
I have designated my gauze packing a pelvic Miku-
licz, as the best descriptive term. The gauze is packed
tightly into the pelvis, to act not as a drain, but as an
occluding dressing.
Eight months after the cul-de-sac operation I did a
suprapubic hysterectomy upon Case. XXIII. I found
both tubes practically masses of fibrous tissue. The
right ovary was attached high at the pelvic brim to
a diseased appendix vermiformis. It was the abdo-
minal rather than the pelvic lesion which indicated the
radical operation.
Pyosalpinx of one side I have treated through the
vagina, removing the tube between forceps. I do not
like the operation. I had opportunity to see the result
of this work also. In Case XXII. I carried my con-
servatism too far in my attempt to save the left tube.
The patient subsequently, months afterward, developed
a pyosalpinx on the left side. When the hysterectomy
was done, I found the area of first interference per-
July T I, 1896]
MEDICAL RECORD.
41
fectly smooth and no evidence of recent lymph about
the right stump. 1 do not like to put forceps in among
the intestines, even though they be surrounded by
gauze. Should they touch the intestines, slough
would probably result within a few hours. As for
ligatures, we cannot apply these sufficiently close to
the cornu to be safely effective.
If we dissect the bladder away from the uterus, we
can get at the cornu from in front and tie off a pus
tube. But the traumatism here is more severe than
with cceliotomy. In the present state of our knowl-
edge, it is wiser to remove single pyosalpin.\ through
the abdomen'.
The exploratory cul-de-sac operation adds nothing
to the danger of the cceliotomy. It rather lessens it
by furnishing a perfect drainage space.
The fact that I have, in five of my cases, been en-
abled to demonstrate the vermiform appendix through
the cul-de-sac indicates a possible way to evacuate
appendiceal abscesses in women. These abscesses are
so usually associated viith pyosalpinx that the surgeon
in approaching them by the usual laparotomy incision,
does not empty the entire pus formation. He could
do this from the cul-de-sac without difficulty.
There have been a number of cases of pus tubes
which I have subjected to suprapubic operation, hav-
ing shown through the cul-de-sac that the lesions were
abdominal in their importance because of important
intestinal complications.'
The vaginal hysterectomies werefor all the various
conditions of pus in the pelvis, except a pus tube
opening into the intestine. Since beginning my
vaginal work, I have not met with one of these.
Sometimes I split the uterus, but more often I leave
it entire, so that my intra-uterine traction forceps can
hold. I never make the Se'gond incision, as I believe
it displaces the uterine arteries, as well as the ureters.
I make my incision behind the base of the broad liga-
ments (Fig. i) and then carry it around the cervix.
Having separated the bladder above the level of the
ureters, I introduce the inde.x fingers of both hands
into the cul-de-sac and the middle fingers between the
bladder and uterus, and gradually separate the two
hands. In this way, I force the bladder and ureters
outward without disturbing the vascular supply of the
uterus.
But in diffuse pelvic suppuration, and in certain
other cases, the difficulties must be divided by split-
ting the uterus in two. Me can. in this way, deal with
each side separately.
My method of dressing these cases is radically
different from that employed in France. The French
surgeons use two narrow strips of gauze as drains.
When I have completed my operation, I make a
careful ocular inspection of the pelvis, the table being
in Trendelenburg's position. If there be no bleeding
points, I put in one piece of folded gauze between the
forceps of each side and the vagina. I then pack in
the gauze in squares, one end being up as high as the
tips of the forceps, and the other in the vagina. From
four to eight of these pieces are necessary to fill the
vagina and pelvis. But if vessels are found leaking,
small anastomotic branches other than the ovarian and
uterine trunks, I put the gauze in as follows:
Having protected the vagina against forceps pres-
sure, as before, I insert one square of gauze alongside
one pair of forceps and against the oozing points. I
then take the long Pe'an narrow retractor (it is good
for nothing else), and crowd this piece of gauze hard
against the forceps and side of the pelvis. Another
piece of gauze is put in, the retractor removed and
placed over this square of gauze, and it is also crowded
hard against the other piece. In this way, alternately
inserting the squares of gauze and pressing them
' The New York Polyclinic, February 15, iSq6.
together against the side of the pelvis, when we insert
the last piece and remove the retractor for the last
time, we have a column of dressing from one set of
forceps to the other, which e.xercises haemostatic pres-
sure from one lateral pelvic wall to the other. If one
likes, he can use enough pressure to control the iliac
arteries. The important point is to get the pressure
from side to side, rather than between the movable,
hollow viscera, bladder, and bowel. The uterine artery
could be perfectly controlled in this way.
I remove the forceps in two days. The first dress-
ing comes out under a chloroform narcosis of a few
minutes, on the eighth to fourteenth day. Each piece
of gauze is put in as a square, is four inches wide and
a yard long, so that when the eight pieces are inserted
there is an abundance of absorbant dressing to remain
over a week. The self-retaining catheter comes out
with the forceps, after washing the bladder.
In reviewing this work as a whole, the greatest satis-
faction is felt upon contemplating the five cases of
puerperal septicaemia and the cases of pus in the pelvis
conservatively treated. I am almost inclined to state
that a hysterectomy should not be done until this cul-
de-sac evacuation of pus and pelvic Mikulicz packing
have been tried and failed.
Not a case in tliis series would have been treated a
few years ago in any way other than by cceliotomy.
In many parts of Europe and, I regret to say, in cer-
tain American cities, very many of those cases would
have been subjected to hysterectomy, which I have
avoided. The two women who have borne children
would have been castrated if cceliotomy had been
done. Every one of the adherent retroposition cases
presented more or less marked tubal involvement.
They have all got their tubes and ovaries, except in
Case VII. in which the patient was subjected to a
necessary hysterectomy eight months later. But if the
reader considers me extreme in my conservatism, I
would like to offer him the following proposition; the
evacuation of purulent sacs in the pelvis with the use
of properly applied dressings, will symptomatically
cure eighty per cent, of such cases, and will preserve
the menstrual function to them all; the cases not so
cured are relieved of acute symptoms, and the radical
operation can be done at the elective time.
When I meet with a case of pus in the pelvis, I
always think that the man who first saw the patient
is to blame. The way to stop operations like hysterec-
tomy for pus is to prevent suppuration. When I have
to do a hysterectomy in a pus case, I must admit to a
sense of humiliation very often. The sooner we recog-
nize that pelvic inflammation is a surgical disease and
should be surgically treated, the better for women.
The application here of the great surgical truth, that
the way to check infection is by cutting oft" the original
source of infection and draining away its complica-
tions, is beautifully illustrated in half my cases.
And, given anything like a decent chance, the won-
derful reparative power of the pelvic viscera will
bring about a symptomatic cure, at least.
The day is passed when he who gives opium and
comforting words for peritonitis can be secure. The
responsibility is too great to assume.
Urination after Labor. — i. Urination after labor, in
the majority of cases, follows spontaneously. 2. Cath-
eterization is but exceptionally required; if it be nec-
essary, it should be deferred as long as possible. 3.
It is only indicated when the bladder assumes abnor-
mal proportions, or if retention occurs. 4. Catheter-
ization is liable to occasion two evils — cystitis, in
spite of all precautions, and dependence of the blad-
der for a time upon the catheter. — X. Recht, Hh:
Internationale dc Bihliosr. Med.
42
MEDICAL RECORD.
[July 1 1, 1S96
THE IDEATIVE FACULTIES AND SELF-CON-
SCIOUSNESS IN THE LOWER ANIMALS.
By JAMES WEIR, Jr., M.D.,
OWENSBORO, KY.
Without entering into a detailed e.xegesis of what
mind is, it may be safely affirmed that mind, in some
former other, exists not (as is erroneously believed by
the masses) in the brain alone, but throughout the en-
tire animal organism. It can be easily demonstrated
that muscle, even when separated from the body, has
memory and that it retains this function of the mind
until morbific, degenerative, lethal, or putrefactive
changes set in; likewise, it can be easily shown that
throughout the organism there are scattered many
brains (ganglia), which, in some of the lowest animals
at least, do not differ histologically from those that are
recognized as being true brains. Recent microscopic
investigations lead me to believe that certain of these
ganglia or pseudo-brains are the centres of senses not
possessed by man; for instance, the sense of direction
(homing instinct) and the sense of mute, though abso-
lutely intelligent, communication. It is not the pur-
pose of this paper, however, to enter at this time into
a description of the histological characteristics of these
ganglia, nor to detail the experiments made by myself
in my endeavors to locate sense centres. I wish rather
to call the reader's attention to some original observa-
tions in the psychologj- of the lower animals, by which
I propose to demonstrate the fact that animals exceed-
ingly low in the scale of life, as well as animals
high in that scale, give unmistakable evidences of
ideation, ratiocination, and even of abstract thought.
This last quality of the mind, abstract thought, has
been heretofore considered distinctly and distinctively
a possession of man alone of all created beings: but I
• hold and think it capable of demonstration that all
animals in which are to be found cerebra, cerebella,
optic thalami, and corpora striata, and in which the
phenomena of dreaming are noticeable, are able to en-
gage in abstract thought to a certain e.xtent. Some of
the higher animals are, in my opinion, in a measure
self-conscious — the degree of self-consciousness ap-
proximating that of an infant of two and one-half or
three years. The foregoing propositions will be dis-
cussed in their proper turns as they are brought out in
the progress of this paper.
Memory of locality, of route, is to be found in many
animals of exceedingly low organization. While en-
gaged in watching a water louse, I saw it swim to a
hydra, tear off one of its buds, and then swim some dis-
tance away to a small bit of mud, behind which it hid
until it had devoured its tender morsel. Again it
swam back to the hydra, and again plucked from it one
of its young; again it swam back to the little mud-
heap, behind which it once more ensconced itself until
through with its meal. When we remember that this
little creature was among entirely new surroundings
(for I had dipped it from a pond in a tablespoonful of
Avater which I had poured into a saucer), we will ap-
preciate the fact that the water louse evinced con-
scious determination and no little memory. It proba-
bly discovered the hydra accidentally; it then, as soon
as it had secured its prey, swam away, seeking some
spot where it could eat its food without molestation.
But when it sought the hydra again and then swam
back to its sheltering mudiieap, it showed that it re-
membered the route to and from its source of food sup-
ply and its temporary hiding-place.
H. J. Carter, F.R.S., says, in his "Annals of Natu-
ral History," that he once saw an actinophrj-s approach
a ruptured fungal cell from which starch grains were
escaping. It seized one of these starch grains and
went to some distance away, where it incepted it. It
then returned to the ruptured cell and obtained an-
other starch grain, which it carried oft in a like man-
ner. "All this," says he, "was repeated several
times, showing that the actinophrys instinctively knew
that those were nutritious grains, that they were con-
tained in this cell, and that, although each time after
incepting a grain it went away to some distance, //
kne2i' how to find its way back to the cell again which
fuinishcd this nutriment.'^ I have taken the liberty of
italicizing a portion of the above quotation, for it is
certainly a most wonderful instance of memory of route
in an animal of such minute size and low organization.
This entertaining writer and close observer also writes
as follows in the above-mentioned book: " On another
occasion I saw an actinophrys station itself close to a
ripe spore cell of pythium, which was situated upon a
filament of spirogyra crassa, and as the young ciliated
monadic germs issued forth, one after another, from
the dehiscent spore cell, the actinophrys remained by
it and caught ever)' one of them, even to the last, when
it retired to another part of the field, as if instinctively
conscious that there was nothing more to be got at the
old place."
At the base of the large terminal ganglion in the
neuro-cephalic system of the common garden snail, ly-
ing immediately below and between its two " horns,"
will be found, I am satisfied, the centre governing its
sense of direction. For, when this portion of this
ganglion is destroyed, the snail loses its ability of re-
turning to its home when carried only a short distance
away; otherwise, it can find its way back to its domi-
cile when taken what must be to it a very great dis-
tance away, indeed. Beneath the stone coping of a
brick wall surrounding the front of my lawn, and
which, on the side toward my residence, is almost flush
with the ground, many garden snails find a cool, moist,
and congenial home. Last summer I took six of these
snails, and after marking them with a paint of zinc
oxide and gum arable, set them free on the lawn. In
time, four of these marked snails returned to their
home beneath the stone coping; two of them were
probably destroyed by enemies. Again the same
number of snails were marked, after the base of the
above-mentioned ganglion had been destroyed, and
likewise set free. Although they lived and were to
be observed now and then on the trees and bushes of
the lawn, none of them ever returned to the place from
which they were taken beneath the stone coping. I
have performed this experiment repeatedly, always with
like results.
The ant has the sense of direction in a marked de-
gree, and, although I have not exactly located its cen-
tre, am convinced that it is to be found at the base of
the cephalic ganglia. It is very interesting to watch a
marked ant during her journey back to her nest, after
she has been carried away and placed among unfamil-
iar scenes and surroundings. At first, owing to her
fright, she will dash away helter-skelter: but soon re-
covering, she will head in the direction of home, and
moderate her pace until she creeps along at a very
cautious and circumspect gait indeed. Every now
and then she will climb a tall grass blade or weed and
take observations. After a while, she sees certain
landmarks, and her speed becomes faster: soon the
surrounding country becomes familiar, and she ceases
to climb blades of grass, etc.; now she is in the midst
of well-known scenes, and at last she fairly races into
her nest.
In this instance the ant is led at first by her sense
of direction alone; as soon, however, as she conies to
country which she has hunted over and with which she
is familiar, memory comes into play and the sense of
direction ceases to act, or, if it acts at all, it acts un-
consciously. Bees, wasps, and some of the beetles,
likewise, have the sense of direction highly developed,
as do most of the mammalia. The habit that some
July I I, 1S96]
MEDICAL RECORD.
43
animals have of returning to tiieir homes from great
distances is well known, and I do not propose, there-
fore, to enter into details concerning it; yet the follow-
ing instance is so unique that I cannot refrain from
mentioning it. In the fall of 1861, if I remember the
year correctl}-, a gentleman living in Vincennes, Ind.,
went to visit his father at Lebanon, Ky. When he
started back home his father gave him a yoke of steers,
which he drove to V'incennes via Louisville, Ky.
Shortly after his arrival home the steers escaped from
the field in which they were confined, made their way
to the Ohio River, which they swam at Owensboro,
Kv., one hundred and sixty miles below Louisville,
and in a week or so were discovered one morning at
the gate of their old home at Lebanon. Led by their
sense O direction alone, for they were young and had
never been off the farm at Lebanon until their owner
gave them to his son, they made their way home, sev-
eral hundreds of miles, over a route utterly unknown
to them.
It is a well-known ''act that many of the higher ani-
mals remember individuals for long periods of time,
when the}' are separated from such individuals for such
periods of time and are then again brought in contact
with them. It is not generally known, however, that
some of the lower animals likewise possess this psy-
chical trait, and yet they do.
For several months a large black hunting-spider
lived beneath a table in my room, and it was my cus-
tom to gi\e her, daily, crippled Hies and other insects.
She soon became very tame, would come out on the
table as soon as I entered the room, and would even
take tood from my fingers. She would come out, also,
when other persons entered the room, but would dart
beneath the table as soon as she discovered that it was
not I, thus showing that she recognized me as an indi-
vidual. I was absent from home for a week, but this
spider recognized me as soon as I came into the room
on my return, clearly indicating that she had remem-
bered my individuality for a week at least.
Again, a friend sent me two Floridian chameleons,
which dwelt in my desk and which in course of time
became very tame. My desk is a combination book-
case and writing-table, and these creatures passed most
of their time among the books, changing color so per-
fectly, especially when alarmed, that it took a very
sharp eye indeed to descry them when they were qui-
escent. When I sat at my desk writing they would
jump down on my head or shoulders and explore my
entire body, running here and there and everywhere
about me, sometimes tickling me with their sharp lit-
tle claws until I, too, was forced into making a voyage
of discovery, in order to bring them once more to the
light. But let a stranger enter the room, and, presto!
they were gone in the twinkling of an eye. I left
home on one occasion and was gone for two months.
When I came into my room and sat down at my desk,
I looked about for my little pets, but could not see
them. I had come to the conclusion that they had
either died or escaped from the room, when suddenly
I saw a tiny little head peep out from between two
books and as suddenly disapi^ear. I pulled out a writ-
ing-pad and went to work, keeping a watch, however,
for my shy little friends. They gradually became
bolder and bolder, until all at once they seemed to rec-
ognize me, first one and then the other leaping to my
shoulders. In a few moments they were making their
usual voyage over my person. In this instance these
lizards remembered me after an absence of at least
two months; it took them about two hours to fuUv re-
call my personality, yet they did it in the end. Some
insects have such good memories and are so amenable
to instruction that they can be taught to perform little
evolutions, draw miniature vehicles, feign death, etc.,
at the command or signal of their trainer. There are
many people alive to-day who witnessed the perform-
ances of a troupe of trained fleas, which was on exhi-
bition in the larger cities of the United States some
thirty or forty years ago. Great must be the intelli-
gence of a creature so minute to learn to do things so
utterly foreign to its nature, and greater still must be
the memory which could retain and remember such
instruction for days, weeks, and months!
Instinct is, in a certain sense, a process of ratioci-
nation, though its immediate operations may not be due
to reason. Instinct involves mental operations: if it
did not it would be simply reflex action. It is heredity
under a special name; the father transmits his mental
peculiarities as well as his corporeal individualities to
his offspring. The experiences of thousands of years
leave their imprint on the succeeding generations, un-
til deductions and conclusions drawn from these expe-
riences no longer require any special act of reason in
order to bring about certain results. These results,
which were at first the outcome of special acts of ratio-
cination, or accidental liappenings leading to the good
of the creature or creatures in which they occurred,
finally become hiibitual or instinctive.
These special acts of ratiocination are of daily, of
hourly occurrence in the lives of countless myriads of
the lower animals, and which escape our observation
because of the obtuseness of our senses. Every now
and then, however, the observer is able to chronicle
such an act of reason, and thus adduce the proposition
that if the creature or creatures were continually
placed in surroundings requiring a like act of reason,
that act would eventually become habitual and instinc-
tive on the part of that creature or those creatures. I
have witnessed hundreds of acts of intelligent ratio-
cination in the lower animals that were not called forth
by experience and which had not a single factor of he-
redity. For instance, several years ago I noticed that
one of the combs in a beehive, owing to the extreme
heat, had became melted at the top and was in great
danger of falling to the floor. The bees had noticed
this impending calamity long before I had, and had
already set about averting it. They rapidly threw out
a buttress or supporting pillar from the comb next to
the one in danger, and joined it firmly to it, thus
shoring it up and preventing its fall in a most effec-
tual manner. When they had made everything strong
and secure, they went to the top of the comb and re-
attached it to the ceiling of the hive. After this had
been done to their satisfaction, they removed the
shoring pillar and used the wax elsewhere. In this
instance, there was an immediate adaptation of them-
selves to surrounding circumstances, in which they
averted and prevented an utterly unforeseen and un-
heard-of catastrophe by means as eft'ectual as they were
intelligent. Could man do more or reason better?
Here was an experience which had not happened to
them in hundreds and hundreds of generations perhaps ;
which perhaps had never happened to them before,
and yet when it did happen their quick intelligence
readily grasped the situation and they at once set
about remedying the evil.
The higher animals, such as the dog, the cat, the
horse, the monkey, etc., are continually giving evi-
dences of acts of special ratio ination, in which in-
stinct plays no part. They are of such common oc-
currence that '■ he who runs may read;" therefore, I
will here give only one, an instance of intelligent ra-
tiocination in a dog, whereby the animal saved its
life. The following is from a letter that I received
from a friend: "The dog, a water spaniei, had gone
after a stick flung upon the ice of a pond about twenty
feet distant from shore. The water was about hve
feet deep. The ice gave way. The dog went under
the water several times in swimming about the en-
larged space made by attempting to regain the surface
44
MEDICAL RECORD.
[Jul
VII,
1S96
of the ice, which gave way under his weight. He be-
came thoroughly chilled by much confused swimming
about in a circle, seeking some point at which the ice
would bear his weight. I reached a limb to him, and
calling him by name shortly got his attention. He
placed his paws upon the ice and seemed to listen in-
tently as I extended the limb toward him, the ice,
meanwhile, sinking under his weight as he looked at
me. He caught the limb between his teeth and I as-
sisted him by pulling him toward me upon the thicker
ice inshore. Finally, the ice became strong enough
about fifteen feet from shore to sustain his weight.
So, still with his teeth locked on the stick, I pulled
him on the thicker ice and across the surface to the
shore." I learned from my friend that the dog was
completely exhausted when he reached shore and re-
mained prone upon the ground for quite a while. He
would have been drowned unquestionably had he not
recognized and seized the only available means for
saving his life.
It will be exceedingly difficult, if not altogether im-
possible, to demonstrate positively and absolutely that
animals lower than man possess the faculty of abstract
thought, yet analogically and inferentially the proposi-
tion is of easy demonstration. Man possesses two
kinds of consciousness — an active, vigilant, co-ordinat-
ing consciousness, the seat of which is in the cortical
portion of the brain ; and a passive, pseudo-dor-
mant, and, to a certain extent, incoherent and non-
co-ordinating consciousness, whose seat is in the great
ganglia at the base of the brain, viz., the optic thalami
and corpora striata, and in other ganglia situated in
the spinal cord and elsewhere in the body. We can
readily prove the truth of this by obser\-ing certain
phenomena which are to be noticed daily among our-
selves. A man falls into a "brown study," loses
himself in abstract thought, and if gently approached
without being startled he may be asked questions
which he will answer intelligently without any con-
scious act on his part. His ganglionic consciousness
for the time being holds him beneath its sway, yet his
active consciousness is not so much obtunded but that
he can answer questions intelligently. My fox terrier
has a brain which in all essential particulars does not
differ from that of man ; my observation teaches me
that his mind, so far as memory and the emotions are
concerned, is the same in kind though not in degree
as that of man. I am also convinced by actual exper-
imentation that he falls into "'brown studies'' just as
man does; therefore, why deny him the possession in
some degree of the faculty of abstract thought ? I do
not mean to say that my dog can commune with him-
self in regard to ethics and a-sthetics; his power of
abstract thought is in its embryonic state, for I am
more than convinced that it has passed through its
germ state.
Again, when active consciousness is stilled in slum-
ber, subconsciousness or ganglionic consciousness
sometimes remains awake and makes itself evident in
dreams. The lack of rational thought co-ordination in
subconsciousness is shown by the more or less extrav-
agance and incoherence of dreams. Everything, no
matter how unnatural and extravagant, occurring to the
dreamer is accepted by him as being natural and con-
sistent; when, however, his active consciousness is
aroused, he at once recognizes the incoherence of his
dreams. I hold emphatically that all dreams, when
closely studied, will show extravagance and incohe-
rence; a dream may seem at first glance to be entirely
coherent, but if the remembrance of the dream be per-
fect and it be closely studied, numerous incoherences
will always be discovered.
Many of the higher animals dream, notably the mon-
key, the cat. and the dog. I have repeatedly obser\ed
my dog while he was under dream influence, and have
even been able to predicate the substance of his dream
from his actions. Like man, the dog is unable some-
times to differentiate between his waking and dream-
ing thoughts ; he confounds the one with the other, and
follows out ill his waking state the ideas suggested by
his dreams. This with man is always a momentary
delusion; with the dog, however, it may last for a
minute or two. Thus, I have seen my dog chase im-
aginary rats around my room after being aroused while
in the midst of a dream. His chagrin when he '" came
to himself and saw me laughing at him was always
strikingly apparent. Finally, I have seen my dog,
seemingly after giving the subject some thought, jump
up and rush out to the stables and engage in a hunt af-
ter rats. The cjuality of abstraction in such ideation
is not ver)' high, it is true; nevertheless, it is present
to a certain extent.
To prove that self -consciousness is present in some
of the higher animals is even more difficult than is the
demonstrating of abstract thought in such animals:
yet, inferentially and analogically, it can be done. In-
ference and analogy are powerful and legitimate iii-
stnimcnta logiconim, and should, therefore, carry with
them great weight.
Many of the higher animals recognize to a certain
extent the rights of property. For instance, in 1879,
two very intelligent chimpanzees were on exhibition
at Central Park. One of these animals claimed as
her property a particular blanket, and, notwithstanding
the fact that there were other blankets in the cage in
which they were confined, always covered herself with
this blanket. She would take it away from her com-
panion whenever she wished to use it. Again, two
turkeys on my place deposited their eggs in the same
nest. The hen which first built and used the nest re-
garded the spot as her individual home; therefore,
whenever she found the other hen's egg in the nest, she
would break it with her beak and then carry it some
distance away. This I have seen her do repeatedly.
Many dogs and cats regard certain rugs, cushions, etc.,
as their own property, and resent any interference with
them. It seems to me, that in all such instances these
animals regard themselves as individuals; that they
recognize the psychical as well as physical difference
between the ego and the /// part as soon as they begin
to regard things as property. I do not mean to say
that their self-consciousness reaches the exalted state
as that which is to be found in mature man. I do
mean to say, however, that it approximates that of in-
fants of two and one-half and three years. Anthro-
pologists hold that as soon as man began to recognize
property rights he took a gigantic mental stride, and
in proof of this proposition they cite the mental degra-
dation of those races which have not arrived at such
knowledge. From this analysis of mind as it is to be
observed in the lower animals, I deduce the conclusion
that it is the same in kind as that of man, though differ-
ing in degree.
Salaries of Medical Teachers in Vienna. — The Vi-
enna corres|X)ndent of The Lancet says that a bill has
been submitted to the Austrian legislature the object
of which is to increase the salaries of the professors
in the universities of the empire. Hitherto there have
been three scales — namely, $900 a year for the profes-
sors in Vienna, $830 for those in Prague, and $775 for
those in other towns, the professor also receiving fees
for his lectures. In Austria lectures are delivered five
times a week, and the fees are fixed at $2.50 a half-
year. Teachers have now the choice between the
above salaries with the fees for lectures and the aug-
mented salary with gratuitous lectures, which nas
been fixed at $1,330.51,500 and $1,685. "Extraor-
dinary" teachers will be paid S665 and the privat-
docents will be unpaid, as hitherto.
July 1 1, 1S96]
MEDICAL RECORD.
45
CEDEMA IN GRAVES' DISEASE— REPORT OF
A CASE OF CEDEMA OF THE EYELIDS—
THYROIDECTOMY.'
By J. ARTHUR BOOTH, M.I).,
NEW YOKK.
Besides the three diagnostic symptoms usually found
in Graves' disease, there are a number of others which,
added to this well-known triad, finally present a symp-
tomatology at once unique, mysterious, and of e.xtreme
interest. Although these other seemingly unimportant
symptoms have attracted less attention than those by
which the disease is sometimes designated — namely,
exophthalmic goitre — one of them, adema, is perhaps
worthy of further consideration.
These various forms of swelling may be described
as consisting of three varieties: (i) CEdemaof cardiac
origin. It may be due to mitral disease coexisting
with Graves'. (2) OEdema of nervous origin, as is
seen in slight swelling of the insteps and lower legs,
which does not tend to increase. Valvular lesions of
the heart are absent. (3) Transitory oedema. This
is the rarest class, the cedema here being limited to
various parts of the face, neck, arms, and hands. The
cheeks and eyelids are favorite positions, and some-
times both limbs of one side of the body may be
affected. In discussing this symptom it will be con-
venient to consider it (i) as commonly met with, and
(2) its occurrence in what I deem a r.nre locality, the
eyelids.
(i) It consists in a circumscribed swelling or pufifi-
ness, not pitting on pressure, not stationary, and in
most cases confined to the ankle, upper part of
the foot, or lower part of the thigh. Sometimes the
cedema may be general over the whole body, but gen-
erally it is circumscribed. Rendu saw it in the supra-
clavicular and Germain Se'e in the infraclavicular
hollows; Burton, Baumler, and O'Xeil in the ankles;
Millard and Benedikt upon the hands; Osier and
Reinhold on the face, neck, and hands. Slight swell-
ing of the ankles and feet has been obser\-ed in one-
third of the cases by Arthur Maude. Millard collected
ten cases. In one of these, a very severe form of
cedema of the lower part of the body suddenly ap-
peared, and after three weeks' duration passed away
simultaneously with the onset of an acute attack of di-
arrhoea. Marie noted its presence in the legs in two
cases, and in one the swelling reached to the umbili-
cus. Mobius calls attention to its occurrence in the
lower extremities. Besides those cited by the above
authorities, cases are reported by West, Stierlin,
O'Neil, Goix, and Buschan. In none of the cases did
examination show any evidences of varicose veins or
kidney disease.
Judging from the above data, it appears evident that
cedema is frequently present in Graves' disease, al-
though from a perusal of our own literature on this
subject one would be justified in forming an opposite
opinion. In twenty-seven cases seen by the writer,
this symptom was noted in only one, and in this pa-
tient the swelling consisted of a slight but distinct
pufliness of the dorsum of the hands.
Various reasons have been given and theories for-
mulated in explanation of these dropsies. According to
Marie, it is not to be explained by the existence of a
cardiac lesion ; it being sufficient to \\axe mte fatigiw
(hi uviir, or a tendency to dilatation, which is common
in Graves' disease. Bienfait and Debove ascribe this
symptom to asystole; Germain Se'e and Mobius to
peripheral vasomotor disturbance. Maude states that
these forms of localized cedema are evidently of neu-
ropathic origin, and are, in fact, manifestations of
' Read before the American Neurological Association, June ;,
1S96,
peripheral neuritis ; also to be compared to the condi-
tions described as hysterical neuritis. The compari-
son is also striking between the.se localized ctdemas
and those seen in beri-beri, which is clearly a peri- ■
pheral neuritis.
(2) I wish now to speak of the presence of this
symptom in the eyelids. Its occurrence in this local-
ity is rarely seen, and attention has been called to it
by only a few authorities. R. Vigouroux ' says that
false cedema of the eyelids is a frequent symptom, and
ascribes the swelling to a paresis of the orbicularis;
stating that when contraction of that muscle is affected
by an electric current the swelling disappears, driven
back by the pressure of the subcutaneous fascia. In
contradiction to this statement, I may add that in the
patient I am about to present repeated trials by elec-
tricity brought about no such result. Hector Mac-
kenzine ^ found the eyelids cedematous in five cases, all
of old standing. Gowers ^mentions the occurrence of
swelling of the eyelids in a patient after apparent re-
covery from other symptoms.
With this brief reference to the bibliography of the
subject, I take pleasure in presenting a patient in
whom this cedema of the eyelids is present to a marked
degree, although the exophthalmos is hardly notice-
able. The history is as follows:
Nellie C , aged seventeen ; single; seen Novem-
ber 5, 1S95. When six years old a sister, taking her in
her arms, made a pretence of throwing her out of the
window. She was very much frightened, and an attack
of what was called brain fever followed. She was con-
fined to the bed for several months, and during this
time had a number of convulsions, but finally made a
good recovery. She remained well until the appear-
ance of menstruation si.x years later; about this time,
when thirteen years old, a swelling of the upper lids
of both eyes was noticed, which has gradually in-
creased and now has become so noticeable as to at
once attract attention. This symptom is more marked
in winter than summer.
She now complains of frequent attacks of palpi-
tation of the heart, accompanied by throbbing in the
neck and profuse perspiration; also of general ner-
vousness and occasional headache. She has neves
' Progres Medical, 1SS7. * Lancet, 1S90.
' " Diseases of the Nervous System," vol. ii.
46
MEDICAL RECORD.
[July 1 1, 1896
noticed any prominence of eyes, enlargement of tlie
neck, or swelling of the hands or feet. On exam-
ination the patient presents the appearance of a case
*of Graves' disease. When we examine the eyes, liow-
ever, no exophthalmos is discovered, but, instead,
a very marked and peculiar cedema of both upper
lids, as is shown in the accompanying photograph.
It is not a true oidema; no pitting follows pressure
and it does not cause the closure of the lids, such as
is produced by ordinary cedema. Movements of the
eyes and lids are harmonious. On inspection there is
no decided prominence of the thyroid gland, but on
palpation swelling and a diffused hardness of botii
lobes is made out. The heart action is agitated and
pulse rate rapid, averaging 120 beats to the minute.
With the exception of loud hft-mic murmurs at the base,
the heart is normal. Face, neck, and both hands are
covered with beads of perspiration. There is a slight
tremor of the fingers.
One month later (December 5th) prominence of the
left eye appeared. Having been unable to do any
work for some time, even to the attending of minor
household duties, the patient willingly consented to
operative interference, and on December 15th she was
admitted to St. Luke's Hospital, where a few days
later the right lobe of the thyroid was removed by Dr.
B. F. Curtis. Her recovery from the effects of the
operation was rapid and the progress of the case up to
the present time has been entirely satisfactory. It is
now six months since the operation, and during this
time there has been a complete disappearance of all
nervousness; the throbbing and palpitation have
ceased, and with two exceptions the pulse has not
been above 90, most of the time varv-ing between 80
and 86. Although the improvement in the symptoms
just mentioned has been marked, the peculiar ctdenia-
tous swelling of the eyelids still persists, that of the
left being greater tlian before the operation.
Conclusions. — The following conclusions may be
legitimately drawn from this brief contribution: (i)
Slight degrees of oedema, situated in the extremities,
are of common occurrence in Graves' disease, but this
symptom limited to the eyelids is very seldom seen.
(2) In distinguishing these various forms of swelling,
it is necessary to be guided by the position and de-
gree. If situated only on the face and upper limbs,
or if unsymmetrical, it is entirely of nervous origin,
and it may be so if it affects the feet, but it is only
slight and temporary. (3) These dropsies are evi-
dently of vasomotor origin and are probably due to a
paralysis of the vasoconstrictor nerves, manifestations
of peripheral neuritis. (4) Limited to the eyelids, it
may be due to a paresis of the orbicularis. If this be
true, liowever, it is strange we do not meet with it in
other palsies of this muscle. (5) Thyroidectomy,
carefully performed and by one cognizant of the occa-
sional complications, is not such a dangerous operation
as is generally believed. (6) From operative interfer-
ence in Graves' disease we may expect an improvement
in the rapidity of the pulse, cessation of the disturbing
attacks of palpitation, and a cure of many of the sub-
jective phenomena.
Gold Combinations. — i. The chloride of gold and
sodium of commerce, so called, is not such in fact, but
merely chloride of gold mixed with chloride of so-
dium; therefore for any chemical purpose chloride of
gold only need be considered. 2. Chloride of gold is
an extremely unstable compound, its identity being
readily destroyed by light or air, while the addition of
the least amount of organic matter will almost instantly
convert it into albuminate, wliich upon contact with
the mucous membrane or skin surface (albumin being
thus formed) is extremely difficult of solution — T. H.
Stuck V.
ELIMINATION, ANTISEPSIS, AND STARVA-
TION IN THE TREATMENT OF TYPHOID
FEVER.'
By H. S. McCONNEL, M.D.,
NEW BRIGHTON, PA.
Th.at typhoid fever is a self-limited disease, that the
system having absorbed the poison the disease must
run its course through the different stages, I do not
believe, and the physician who now treats this disease
on the so-called rational or let-alone plan, is as crimi-
nally negligent as the surgeon who to-day in treating
wounds ignores asepsis. This may seem a bold and
unwarranted statement, yet if it is not true, all the
time, labor, and money spent in the bacteriological
study of typhoid fever have been in vain, our conclu-
sions erroneous, and the bacillus tpyhosus is a myth.
Accepting the micro-organism theor}-, believing that
the point of attack is in the alimentary canal, that the
characteristic symptoms are due to the absorption of
the toxin, and are the result of the local activity of
the specific bacilli, and that a case is grave or mild
dependent upon the quantity of said toxin in the
blood, are we not compelled to grant the truth of the
above ?
If Eberth's bacillus is the cause — the corrobo-
ration of Eisner's observations seems to place this
beyond doubt — and it is ably assisted by the bacillus
coli communis, a treatment based upon this pathology
and directed to the exclusion and annihilation of
these bacilli is certainly a rational one, and when
pathology and treatment go hand in hand with a di-
minished death rate, and at the same time the patients
are more comfortable than by any former methods, we
are certainly justified in the above statement.
To fulfil all the indications there are three essential
features that we must bear in mind.
First, the prevention of the introduction into the
digestive tract of any specific bacilli.
Second, expulsion and destruction of all bacilli in
the alimentary canal, and the elimination of the pro-
ducts of their labor.
Third, rend-ering the canal thoroughly aseptic, mak-
ing it sweet and clean, and keeping it, as nearly as
possible, in this condition.
The first is best accomplished by permitting noth-
ing but boiled water and the remedies to enter the
stomach, and by keeping the mouth, teeth, nostrils,
hands, finger nails, whiskers, and the excretory outlets
aseptic. The latter precaution is very important, and
these parts should be thoroughly washed after each
evacuation. The room must be cleared of all unneces-
sary articles of furniture and clothing, and all vessels
must be kept surgically clean. Milk or any kind of
food should remain in the room no longer than is re-
quired. The apartment should be well lighted and
the temperature not above 65.°
The second object can be accomplished by giving
three five-grain powders of calomel at hourly intervals,
followed with Rochelle salts until there is free cathar-
sis. The patient must have no less than two free pas-
sages every twenty-four hours during the fever. If the
salts and an occasional dose of calomel will not do
this, we must resort to some more active cathartic.
Though contrary to what we were all taught, and what
is still being taught, purgatives reduce to a minimum
the liability to hemorrhage or perforation. The ulcer-
ation of Peyer's patches is not typhoid fever. It is
caused by the direct irritation of the bacterial poison,
and, as Professor Tliistle has so ably demonstrated, the
extent of the ulceration is in proportion to the degree
of concentration and duration of contact. By purga-
tives we increase the quantity of the intestinal fluids,
' Read before the meeting of the Society of the State of
Pennsylvania, at Harrisburg, May 19, 1896.
July 1 1, 1S96]
MEDICAL RECORD.
47
dilute the toxin and expel it, and thereby decrease
the danger from its local action upon the glands; we
restrict blood contamination, reduce the number and
activity of the bacilli, and permit the restoration of
the disabled tissue.
The third indication is met by guaiacol, salol, or
any of the other intestinal antiseptics. For the first
few days I prefer salol, after that guaiacol. An enema
morning and evening, of a large quantity of salt and
cold water, must be given regardless of the condition
o; the bowels. All food, and this includes milk, must
be prohibited for three days. Recent investigations
prove that in typhoid fever verj' little, if any, hydro-
chloric acid or pepsin is secreted, and Professor
Thompson says the stomach is similar to that of a new
born babe's. Yet in the discussion of typhoid fever
a few weeks since before the Cleveland Aledical So-
ciet)-, one of its members said he endeavored to have
all his typhoid patients take nine pints of milk in
twenty-four hours, and in a large number of cases the
daily average was over eight pints. Jenner says that
a pint of milk is equal to a full-sized mutton chop.
Think of it! nine mutton chops to a fever patient in
one day. Is this not absurd? Is it not injurious?
Is it not malpractice? And, to make it worse, this is
forced upon a patient who, except in rare instances,
has no appetite, who even loathes the sight or taste of
food. If a strong, active, and healthy laborer was to
consult you about some uncomfortable feeling in his
stomach, and told you he ate nine iiiutton chops per
day, if you did not tell him he was a swine you would
think so. Recalling the fact that hydrochloric acid
is nature's preventive of putrefactive changes, and the
formation of dangerous ptomaines in the digestive
tract, we see that a fever patient stuffed in this
manner is surrounded with perils so great that the
danger from the bacillus r\-phosus sinks into utter in-
significance. The patient is weak from fever and tox-
aemia, not from want of food. Increased feeding does
not imply increased nourishment, but oftener dimin-
ishes it from overworking the already enfeebled stom-
ach.
Jenner years ago called attention to the injuiy from
overfeeding, and said he had often seen delirium,
fever, and restlessness subside after the expulsion of
large curds of undigested milk. It will be said this
is retrogression. The starvation plan was active a
centur}- hence. Well and good. If you will exclude
bleeding, tartar emetic, and salivation, the treatment
then was excellent. Over sixty years ago Eberle's
treatment was as follows: Plenty of bland drinks, no
food, and purgatives: the latter were given to free the
intestinal tract of all irritating and poisonous sub-
stances, and he preferred the neutral salts as a purga-
tive. That was good treatment then for typhoid fever,
and it is one of the elements of the best treatment
to-day.
Page upon page has been written upon the injurious
effects of the coal-tar antipyretics, and ver\' few upon
excessive feeding, yet the danger of the former is small
compared with the latter. It is this almost universal
habit of overfeeding, cramming the patient with large
quantities of concentrated nourishment, that makes
antipyretic measures so frequently necessar)'.
In the Medical Record of June 14, 1893, I called
the attention of the profession to the beneficial effects
in infantile intestinal diseases of withholding all food
for twenty-four hours or more, and the giving of hot
water ad libitum. The rapid improvement under this
method in most cases, the great comfort afforded the
little patients, induced me to tr}^ it in typhoid fever,
and I can assure you that I have no cause to regret it.
Lutton, of Rheims, in 1880, extolled the withhold-
ing of food and giving large quantities of water: he
would give no nourishment until the beginning of the
third week. He claimed that this prevented the in-
crease of typhoid germs. As I said above, all food
must be positively prohibited for three days. After
this it may be allowed when the patient is unmistak-
ably hungry. About the fourth day the patient may
interpret an empty feeling for hunger, but this is no
indication for food. I had one patient seventeen days
without food; temperature first week 104° F. in the
morning and 105' F. in the evening. This patient
had organic heart disease, required no alcoholic stimu-
lants, and made a good convalescence. Another was
for fifteen days without food, and thirty-two went from
seven to twelve days. They can have all the water
they desire, but it must be sterilized, and preferably
hot. It should be administered in definite quantities
and at regular intervals. The large quantity of water
attenuates the poison and assists the purgatives.
Having stated the indications, I shall tell how I
meet them. After free catharsis I order twelve
powders each consisting of phenacetin and salol, five
grains each, and calomel, one-eighth grain, and give
one powder every three hours. I do not administer
the phenacetin as an antipyretic, but experience has
taught me that no drug will relieve the headache and
muscular pains so promptly as this. I now give
guaiacol in from five to eight drops every three hours,
and continue it for some time after convalescence. I
order half a teacupful of hot water ever}' hour, and
to impress the importance of this I place a tablet of
bromide of potash in a tumbler of water and order a
a spoonful of this to be given in the hot water every
hour. When the temperature is under 102^ F. I have
the body sponged off with cold water every two or three
hours. When the temperature is above 102'^ F. I apply
guaiacol to the right iliac region, from five to thirty
drops every three hours. It is applied in the manner
directed by my friend. Dr. H. G. McCormack, of \\'i\-
liamsport. Pa. In only one case did this fail me, and
this one was a case of relapse. While I could not re-
duce the temperature below 105 F. for over twenty-four
hours, no one can tell how high it would have gone had
this not been used. Upon speaking to Dr. McCor-
mack of this he argued that it had not been properly
applied. Here he is in error, for the same verj' com-
petent trained nurse had controlled the temperature
with this remedy throughout the primary attack, and
at the time above mentioned was applying as before
and afterward with good results. \A'e applied it hourly
for a while and thirty drops each time. It could not
have been due to the impurity of the drug, for we used
the original package from a thoroughly reliable manu-
facturer.
When heart sounds are weak I give str)-chnine ni-
trate, and in one case I gave one-sixtieth of a grain
ever)' hour for six days. After this I gave it ever)' two
hours, alternating with whiskey. In two cases with
diarrhoea I did not try to stop it. The greatest trouble
I have is in keeping the bowels sufficiently open.
When the appetite returns anv time after the third
day I give milk, two tablespoonfuls of milk in two
tablespoonfuls of water every three hours: then gradu-
ally I allow fruit juice, mashed potatoes, soft-boiled
eggs. If for any reason the diluted milk is distasteful
I give malted milk. I never order beef tea or any of
the so-called extracts, as I believe them harmful in
this disease.
In a series of thirty-four cases treated as above I
have had one death. This was of a lady of .seventy
years, who, one very cold day jumped out of bed
and sat upon the tioor. Lobar pneumonia developed
next day and she died on the fifth day. One pa-
tient had two relapses, three had each a relapse, and
one had a hemorrhage. The average duration of the
disease was 18.3 days. This treatment faithfully car-
ried out will materially shorten the duration of the
48
MEDICAL RECORD.
[July 1 1, 1896
disease, ^vill give the patient the greatest comfort pos-
sible, he will have no tympanites, the tongue will be
moist, and there will be very little restlessness or de-
lirium. When convalescence is established he will
have a stomach that, from its long rest, will be ca-
pable of easily and thoroughly digesting food.
I have avoided saying anything about the Brandt
method for two reasons. First, I have had no practi-
cal experience with it; second, it is impractical in a
country p'ractice. I have faith in it, and believe all
that its friends claim for it.
I desire to acknowledge my indebtedness to Prof.
W. B. Thistle, of Toronto, who has so earnestly and
ably advocated the eliminative method; also to Dr. C.
E. Page, of Boston, who gave me the courage of my
convictions in withholding food and using hot water
systematically ; and to Dr. McCormack, who has
taught us all how and when to use this valuable drug,
guaiacol.
SARCOMA OF THE ANTERIOR MEDIAS-
TI>fUM, WITH REPORT OF A CASE PRE-
SENTING A RARE COMPLICATION."
By JOSEPH M. POTSDA.MER, .V.M., M.D.,
PHILADELPHIA.
The rarity of this affection, the difficulty of arriving
at a diagnosis, and the unusual symptom met with in
the case I recently had under treatment, are the rea-
sons for introducing this subject for discussion this
evening.
The total number of cases of mediastinal sarcomas
on record is one hundred and seven, of which forty
occurred in the anterior mediastinum, ten in the pos-
terior, one in the anterior and middle, three in the
anterior and posterior, eight in the entire, three in the
middle, and one in the whole thorax. The reports of
the other cases were not complete enough for classifi-
cation.
Hare, in his study of mediastinal tumors, reveals the
fact that out of ninety-eight cases, thirty-one were pri-
mary, five secondary ; the others were not stated.
From the metastatic nature of sarcoma, one would be
led to believe that it would be found as a secondary
growth in this region, but all observers report to the
contrar3\ In the cases in which other parts of the
body were involved, the mediastinum escaped.
Se.x is a predisposing cause, three males being at-
tacked to one female. Age has some influence, the
largest number of males falling victims between the
ages of thirty and thirty-five, females between thirty-
five and forty.
Sarcoma is the most frequent form of rnalignant dis-
ease found in this region. Pepper and Stengel, in an
elaborate paper on mediastinal tumors, published in
the Transactions of the Association of American Phy-
sicians, vol. x., demonstrate that cases of cancer pre-
dominated prior to the time of accurate histological
study; but since then sarcomas are far more numer-
ous. The same authorities assert that it is not always
possible to distinctly differentiate between lymphade-
nomatous and sarcomatous growths.
The metastasis of sarcoma is through the blood-ves-
sels, excepting the small-round-celled varietv, which
may spread through the lymphatics, this being the
usual channel of lymphadenomas.
The lympho-sarcomas are found most frequently;
next the round-celled sarcoma: and, lastly, the spin-
dle-celled.
A sarcomatous growth may find its origin in any of
the following tissues, named in the order of fre-
quency: thymus gland, pericardium, periosteum of the
' Read before the James Aitken Meigs Medical Association,
November 21, 1895.
Sternum, mediastinal connective tissue, and thyroid
body. Virchow has pointed out that a sarcoma with
a regular outline grows from the thvmus gland.
The symptoms of a case of this kind may be nega-
tive for a long time. The patient may ne\er present
the appearance of a cachexia.
Dyspncta may be constant, intermittent, or absent.
If the tumor is in the posterior mediastinum it is the
former; if in the anterior chamber it is apt to be ab-
sent, or, if present, to be intermittent, changing with
the position of the patient. Pressure symptoms, such
as palpitation, faintness, or irregular action of the
heart, are never as marked as in cases of aneurism,
and are frequently absent. The symptoms are depen-
dent on the seat and size of the growth, and may de-
velop as the case progresss.
Cough is an early symptom in tumors of the poste-
rior mediastinum, but may be absent if the growth is
in the anterior. It is usually dry and ineffectual.
Occasionally there is a frothy expectoration tinged
with blood. Should there be any expectoration it
should be subjected to microscopic examination, with
a view of establishing the diagnosis. Free hamopty-
sis may occur. Pain is not frequently met with, as the
tumor rarely causes erosion of the sternum and it
moulds itself to the other organs, thus avoiding pres-
sure. Fever is never present, unless there is an in-
flammatory complication of the lungs or pleura. Dys-
phagia is not to be considered in tumors of the ante-
rior mediastinum.
Physical signs may be negative. The veins of the
face and neck may appear turgid, but then the growth
will be found of considerable size. The contour of
the chest may be altered, one side being larger than
the other. The sternum may be prominent. Trans-
mitted aortic pulsation is rarely noticeable.
Percussion is of assistance only in growths of con-
siderable size; otherwise it is impossible to distin-
guish cardiac and sternal dulness from that of a growth.
On auscultation we are apt to find the heart sounds
muffled and distant.
The duration of the disease depends upon the symp-
toms. Death may occur as early as the second month.
As long as the local symptoms are in abeyance, the
patient may live a long time.
L. A. N , aged forty-three, married, Bohemian ,
height, five feet nine inches; weight, two hundred and
ten pounds; father of five children, consulted me for
the first time on June 14, 1S95. I have been his fam-
ily physician for five years, during which time he
never was sick. During the past year I noticed that
he experienced difficulty in breathing on slight exer-
tion, but he attributed it to his obesity. He was of
regular habits and was a moderate beer drinker. Five
months prior to the beginning of this illness, Dr.
George Roessler examined him for life insurance.
The doctor informed me that the urine was normal
but of low specific gravity, and that the heart sounds
were slightly mul¥led, as if the organ was fatty. Oth-
erwise he found the applicant normal.
On my first visit I elicited the following history:
Both parents living, old and in perfect health; broth-
ers and sisters all living and well. Patient's last ill-
ness began on June«5, 1895. He had pain in the left
chest and hypochondriac region and shortness of
breath, for which symptoms he consulted a doctor who
happened to be in his store. The physician diagnosed
pleurisy, and assured the patient that he would be
well in a few days, as he was free from fever. The
doctor saw Mr. N every other day, and finding the
temperature normal made light of the case. During
this time the dyspnoea was increasing and I was called
in. On examination I found the patient sitting on
the edge of the bed, gasping for breath. Face flushed,
expression anxious. Pulse, 100; temperature, 98.6'
July 1 1, 1S96]
MEDICAL RECORD.
49
F. ; resDiration, 44. No ctdema in any part of the
body. Heart sounds normal, but muffled and distant.
No apparent increase in cardiac dulness. Marked
dulness on percussion over tlie left side of the chest as
high as the fourth rib. No respirator}- murmurs or
rales below this line. No rales or friction sounds in
any part of the chest. Left lung showed signs of com-
pression. Occasional dry cough. Radial pulses
equal.
Diagnosis: Mediastinal tumor of unknown origin
with pleural effusion.
Treatment: Liquor ammonii acetatis, two drachms,
every hour until copious perspiration set in ; then
every two hours.
June 15th, A.M. — Patient perspired freely during the
night, and decided improvement in breathing followed.
Temperature, normal; pulse, 100; respiration, 32.
I ordered large doses of acetate of potassium and in-
fusion of digitalis and a saline purge. That evening
condition unchanged.
June i6th. — Temperature, normal; pulse, 104; re-
spiration, 40. Patient passed large quantities of urine
and bowels moved freely. Breathing very much em-
barrassed. No change at the evening visit. Dr. Der-
cum met me in consultation, and on aspiration we drew
ofT one hundred ounces of bloody serum, which was
followed by immediate relief. The doctor agreed to
the diagnosis.
June 17th. — Temperature, 98.6' F. ; pulse, 100;
respiration, 20. Patient passed the first good night
since he was taken sick. Breathing not at all embar-
rassed. Careful e.xamination of the chest did not re-
veal any friction or other abnomial sound. The pa-
tient continued to improve until June 25th, when he
appeared well but weak. During this time the breath-
ing was normal.
June 22d. — Dr. Dercum re-examined the patient and
agreed to the absence of any visible cause for the effu-
sion.
June 25th, A..M. — Examination of the patient's chest
showed left lung in normal position and no effusion.
About 5 P.M. Mr. N arose to allow his bed to be
arranged, when suddenly he had a return of the dysp-
noea. I saw him one hour later. Pulse, 104; tem-
perature, 100.4° F. ; respiration, 40. Dyspnoea very
bad. Percussion and auscultation revealed the left
pleural cavity full of fluid At 10 p.m., with the assis-
tance of Dr. Strittmatter, one hundred ounces of fluid
were withdrawn from the cavity.
June 26th, A.M. — Patient felt well but weak. Pulse,
too; temperature, 100.4° F- ; respiration, 24. Dysp-
ncEa returned about i p.m., and by 5 p.m. was as bad
as ever. On aspiration I withdrew seventy ounces.
From this time until his admission to the Jewish
Hospital on June 30th, the dyspnoea gradually in-
creased. The tappings were made between the sev-
enth and eighth ribs, to the left of a line midway
between the axillary and nipple lines. Repeated ex-
aminations of the urine were made, and it was always
found normal, even to the specific gravity.
Dr. Knipe, chief resident physician of the hospital,
has kindly furnished me with the history of the case
until the time of the patient's death. I will only
quote the following interesting facts:
July 3d. — Aspirated and withdrew one hundred and
twelve ounces.
July 4th. — Breathing labored. Inserted drainage
tube.
July 6th. — Two convulsions. In the afternoon re-
inserted a drainage-tube and witiidrew forty-eight
ounces of fluid.
July 8th.— Patient died.
A study of the temperature chart shows that the
morning temperature was normal except on four occa-
sions, it twice being 100.4" F., once 97° F., and once
97.6' F. The evening temperature was above 100" F.
on eight different occasions.
Especial attention must be called to the fact of the
long interval that elapsed between the first aspiration
and the refilling of the cavity, a period of nine days,
during w-hich time the patient never suft'ered from
even a slight attack of dyspnoea. Again, we must note
the sudden and overwhelming effusion.
A post-mortem examination was made twenty-four
hours after death. All the organs were normal in ap-
pearance and size. The pleura was healthy and did
not exhibit any evidence of a pleurisy or a deposit of
sarcomatous tissue. On .turning back the sternum a
large mass was seen overlying the heart, which ap-
peared as a mass of fat. Careful enucleation of it
revealed a tumor of regular outlines, apparently not
attached to any of the surrounding tissues. Micro-
scopical examination showed it to be a round-celled
sarcoma. From these facts we concluded that it had
its origin in the thymus gland. The tumor weighed
two and three-fourth pounds. The heart was not dis-
placed.
From the nature of the fluid we should suspect ma-
lignant disease, but the acute onset of all the symp-
toms, together with the perfect health and good ph)-si-
cal condition of the patient and the absence of any
cachexia, would lead us to exclude that view.
A number of the cases on record were attended by
pleural eft'usions, but they were all caused by some in-
volvement of the pleura or lung tissue, or both, and in
none was there sudden effusion. In not any of the
cases was the effusion so marked as to be the cause
for seeking relief. In searching the literature I
found but one case that might be a parallel one. In
the early part of the eighteenth centur}- Boerhaave re-
ported " a case of sudden and terrible death." On
post-mortem examination a saponaceous tumor was
found in the anterior mediastinum, and there was con-
siderable effusion in the right pleural cavity.
As the post-mortem examination in my case did not
reveal any cause for the effusion, I hope the discus-
sion will bring forth some plausible explanation. My
opinion is that the sudden change of position dis-
turbed the relation of the tumor to the large vessels,
causing the calibre of one or more of them to become
diminished or obliterated for a time, thus giving rise
to the effusion.
1333 Franklin- Street, Philadelphia.
Advances in Skiagraphy. — Dr. Arthur \\'. Good-
speed, of the University of Pennsylvania, has suc-
ceeded in obtaining a skiagraph of the upper portion
of the trunk of his own body, as well as the lower part,
showing the entire pelvis, the hip-joints, and a por-
tion of the thigh bones, after an exposure of forty-
five minutes. The result indicates that less time
would have sufficed for the purpose. The tube used
by Dr. Goodspeed is of his own design, and consists
of a four-inch bulb with a branch on either side
through which are introduced the electrodes, each of
which is covered with blue enamel. One electrode
consists of an aluminium disc, which is placed at one
end of the tube, and the other terminates in a platinum
disc, about one inch in diameter, which is placed at
the centre of the tube and at an angle of forty-five de-
grees to the first disc. The tube is exhausted to about
one-millionth of an atmosphere. A Ruhmkorff" coil,
with a ten-incli spark, is used, the primar}- current
being broken two thousand times a minute by a motor.
Dr. Goodspeed has undertaken to produce a series of
pictures that shall show the normal condition of the
bones of the human body in a state of health, and that
shall sen-e as a means of comparison with abnormal
or diseased conditions.
50
MEDICAL RECORD.
[July 1 1, 1896
CCUnical department
LOCAL APPLICATION OF TERCHLORIDE OF
ANTIMONY IN A CASE OF EPITHELIOMA
OF THE FACE.
By JOHN" O. PALMER, M.I).,
ALBUK.N, N. V.
On November 26, 1895, the writer found himself con-
fronted by an epithelioma covering an irregular oval
space about t%vo and a half inches by three and a half
inches, extending from the tragus of the left ear to the
outer canthus of the corresponding eye.
The edges of this ulcer were verj- much elevated
and angry in appearance, and the whole surface was
discharging an offensive purulent secretion, and at
times bleeding freely.
In view of the extreme age of my patient (a mar-
ried lady, eighty-one years of age, and the mother of
a large family) and her enfeebled condition, the knife
seemed to be out of the question. I therefore decided
to give the case such benefit as might accrue from
some form of escharotic.
Having seen excellent results in the hands of Dr.
Carter S. Cole, of New York City, in similar cases by
the use of the terchloride of antimony, I began its use
on the above date.
After thoroughly cleansing the entire surface of its
secretion and washing it with bichloride of mercurj-,
I to 1,000, this powerful solution was applied over an
area of about one-half the sore, including that section
adjacent to the eye, as it seemed to be making most
rapid inroads at this point and involving the most im-
portant tissue. The application was thus limited, as
to have covered a larger surface would have invited
too severe a shock in so weak a subject.
The action of the escharotic on the diseased tissue
(which alone it attacks) formed a good crust, and the
reaction was as good as could be expected, although
the pain was considerable.
The subsequent secretion from the uncovered part
of the sore was very offensive, and, while it loosened
and carried away some of the crust, there was a fairly
good cover left on perhaps one-third of the ulcer.
The dressing following this and all subsequent ap-
plications was two-per-cent. carbolic acid on sterilized
gauze, and this was covered by rubber protective tissue.
Also one-quarter of a grain of morphine sulphate and
hot whiskey sling were exhibited.
On November 29th, third day, another application
of the antimony w^as made over sufficient space to
leave a good crust over the entire upper one-half.
The shock at this time was rather worse, and there
followed an extensive swelling. Salines and diuretics
reduced this in a few days and she rallied remarkably
well, so that on December 4th I was enabled to cover
the entire sore.
This time I stimulated thoroughly and applied a so-
lution of cocaine for ten minutes previous to the treat-
ment. The secretion loosened a little of the lower
part of the crust, and the swelling completely closed
her eyes and caused much distress and apprehension.
She also developed a temperature of loi^ F. and a
pulse of 115.
This condition yielded, however, to eliminative treat-
ment and quinine, and she went on to a good reaction.
The secretion loosened and brought away the crust
pretty freely, and by December 20th it was all off and
the sore began to look more auspicious, although the
ulcerous surface was but little more than half its orig-
inal size.
On December 2 2d after a hypodermic of morphine
sulphate, one-fourth grain, with atropine sulphate,
one-seventy-fifth grain, and free stimulation, the anti-
mony was again applied over the entire surface.
There followed no untoward symptom other than a
severe conjunctivitis, which was controlled bv cocaine
and boric acid in camphor water.
By the 28th the crust was all gone, the discharge
was ////, the pain had entirely disappeared, the disease
was conquered, and a healthy healing surface of about
one inch by one and a half inches was all that re-
mained to mark the site of the original epithelioma.
I regard this as a thoroughly satisfactory result of
this recently revived treatment of these malignant
affections of the face.
The writer desires to make acknowledgment to Dr.
Carter S. Cole, with whom he had correspondence dur-
ing the course of the treatment.
My apology for so full detail in this report is that
there was about as much to contend with as was pos-
sible to conceive, in the age and feeble condition of
the patient, together with the size and location of the
sore. If I may have encouraged the profession to
boldly attack this class of cases, I shall feel rewarded
for my efforts.
A CASE OF ELECTRICAL CHOREA."
By AUGUSTUS A. ESHXER, M.D.,
PROFESSOR OF CLI.N'ICAL MEDICINE IN' THE PH1L.\DELPHIA POLYCLINIC,
^'H^■SlCIAN TO THE PHILADELPHIA HOSPITAL.
The case of electrical chorea that I shall herewith re-
port does not belong to the type of disease described
by Dubini in 1846."
It represents rather a form of myoclonus in which
the contractions occur at irregular intervals and are
shock-like in character, resembling those induced by
the interrupted electric current. These peculiarities
seem to distinguish the affection from the ordinary
type of chorea, and there is nothing to suggest an
hysterical origin. Of the thirty-eight cases reported
by Dubini thirty-six proved fatal, but no appreciable
lesions were found after death. Treatment seemed to
be without avail. Young people between the ages of
seven and twenty years especially were affected.
Fright was believed to be the usual cause. Among
the premonitory svmptoms were sleeplessness, ano-
rexia, and prostration. The attack proper set in with
rhythmic, shock-like contractions, usually in a given
case of the same character throughout and involving
the same muscles. The movements ceased during
sleep. As the case progressed the involvement be-
came more extensive, and finally the parts affected
were paralyzed. The paroxysms lasted from four to
ten minutes each and were repeated several times
daily. The usual duration of the attack was from one
to five or six months.
The case that I have to report is in a patient under
observation at the Nervous Dispensary of Howard
Hospital, in the service of Dr. Lewis Brinton, to
whose kindness I am indebted for the privilege of
making this report. It occurs in a woman, twenty-
three years old, without special neurotic family his-
tory; though there is a marked history of tuberculosis
on the side of the fatiier. The patient herself has
been married, but does not live with her husband, and
has been delivered of a six-months dead-born child.
She has had the jerking movements which she pre-
sents since the age of seven years. These are of a
peculiar shock-like character and involve especially
the arms and forearms, though movements can also be
observed at times in the face. They are variable in
intensity, ceasing entirely during sleep and being less
' Report read before the Philadelphia Neurological Society,
.■\pril 27, l5f)6,
-Ann. Univ. di Med., cxvii., p. 5.
July I I, 1896]
MEDICAL RECORD.
51
pronounced when the patient is calm and cjuiet ; they
are also absent when the patient is walking, although
a jerk occurs with the first step. The patient can knit
and write w'ith facilit}', jerking very little in the per-
formance of these acts. She thinks the movements
may have been rather less pronounced during such at-
tacks of illness as she may ha\e suffered from. The
knee-jerks are exaggerated, and feeble ankle-clonus
can be elicited on the left. The onset of the move-
ments followed the fright of being locked in a ward-
robe. The heart and lungs present no abnormality.
I think this case may be safely called one of chorea,
though not of true Sydenham or of Dubini type.
There is reason to believe that chorea, as seen in its
various forms, is not a single affection and that all
cases do not have a uniform pathology. We are able
now to distinguish Sydenham, Huntington, Dubini,
hysterical, and post-hemiplegic varieties, and the fu-
ture may perhaps bring us knowledge of others. The
character of the symptoms suggests that the seat of the
disease is the cerebral cortex, and the clinical course
of cases would indicate that the disturbance may be
functional (habit - chorea), nutritional (Sydenham's
chorea, hysterical chorea), structural (Huntington's
chorea), or organic (post-hemiplegic chorea).
REPORT OF A CASE OF BURSITIS.
liV H. M. GARDNER, M.I).
ATHOL, MASS.
Mrs. R , fifty years of age; health good until
July, 1895, when her knee was injured by the break-
ing of a jackscrew. A physician was called, and
subsequently three others; but all treatment was of no
avail. The knee grew worse and pain was constant.
I was called to see the patient and found her unable
to move without crutches, which she had used tliree
months. Her leg was cedematous from the toes to the
trunk, and her general condition was poor. I applied
a rubber bandage the whole length of the limb, and
prescribed a tonic. This was Wednesday. Friday of
the same week I called again and found the leg one
mass of vesicles, with a marked diminution in the
swelling. I opened the vesicles, washed the leg anti-
septically, dusted with iodoform, and encased the
whole limb in a plaster bandage. I told the patient
I would return in ten days, but did not until eighteen
days had passed, when to my surprise my patient met
me at the door. She had removed the plaster the day
before and complete recovery had taken place. In a
case of eight months' standing this result may seem
remarkable, nevertheless it is true. I never treated
a similar case in this way, but shall any others that I
may have.
HORSE SERUM IN CONSUMPTION — RE-
PORT OF RECOVERIES AND IMPROVE-
MENTS.
r.v T. -\. DUNWODV, .M.I).,
CKIPPLE CREEK, COL.
I WILL begin with my own individual case.
Case I. — J. A. D , male, white, aged thirty.
On July 26, 1895, upon physical examination the
upper two-thirds of the left lung was found to be in-
filtrated; numerous moist rales could be heard through-
out this portion, and there was expectoration of a
muco-purulent character, about two ounces during the
twenty-four hours. Weight, one hundred and twenty-
five pounds. Microscopic examination showed tuber-
cle bacilli. Range of temperature was from 99' to
100° F., and this continued until August 2d, when I
•was attacked with acute pleurisy on the left side.
which confined me to my bed for ten days. The tem-
perature ranged then from 100° to 102.5° F- ior a
week, after which time it fell to 99° to 100° F., until
September i8th, when it became 98.5° F. The injec-
tions of serum were begun on July 26, 1895, ^^'ith '^^
millimetres and rapidly increased to forty-five milli-
metres, and were then reduced to thirty millimetres,
which quantity was maintained continuously, notwith-
standing the attack of pleurisy, until December 24,
1895, at which time a small abscess was produced, ow-
ing to the want of proper care by the physician giving
the injection. Weight at this time (December 24th)
had increased to one hundred and forty-three pounds;
the expectoration had nearly ceased, there not being
enough for microscopical examination. Physical ex-
amination revealed the absence of all rales; there was
clear vesicular respiration throughout the affected por-
tion of the lung, though somewhat weak in character.
The right lung was not affected at all. On March
24th I was attacked with la grippe, during which time
my weight was reduced to one hundred and thirty-four
pounds and cough returned for a short while, with loss
of appetite, etc. On April 13th I resumed the daily
injection of thirty millimetres of serum, with resulting
increase of weight of two pounds and cessation of
cough at this time, April 23d. I have used no other
treatment at all — the injections of serum alone. This
point in my case proves conclusively the great mistake
of stopping the use of the serum too soon, or before
the lung tissue has been restored to its full strength
and vitality.
Case II. — H. H , white, female, aged four years,
weight twenty-seven pounds. Date of examination,
January 3, 1896. Left lung almost completely con-
solidated; no vesicular respiration; bronchophony
quite distinct; cough quite distressing at times; range
of temperature, 99^ to 100^ F. in afternoon. I began
on January 3, 1896, with the injection of serum, four
millimetres, and rapidly increased to twelve milli-
metres daih'. The right lung showed no lesion. Dur-
ing the first six weeks of sero-therapy patient in-
creased in weight four and a half pounds, and has
maintained this weight (thirty-one and a half pounds)
until the present time. Upon physical examination on
April 8th, I find that there is some vesicular respira-
tion throughout the affected lung. Cough has almost
entirely ceased. During the last three weeks the in-
jections have been somewhat irregular, as the little
patient lives two miles away from my office, and has
had a mild attack of scarlet fever which has been
quite prevalent where she lives.
Case III. — Mr. S , white, male, aged forty-six;
weight, one hundred and thirty-five pounds. Date of
examination, March id, 1896. Left lung almost com-
pletely consolidated; no vesicular respiration, quite
dull and flat upon percussion; small tuberculous ulcer
upon the epiglottis and vocal cords, affecting the
voice; expectoration about four ounces daily. Patient
stated that he was first affected with tuberculosis in
October, 1894. A daily injection of thirty milli-
metres of serum was begun immediately. There was
considerable en,thema in this case, which gradually
disappeared, though the serum was given daily. On
examination .April 2i.st, I found that there had been
wonderful improvement in the condition of the lung;
there was already some slight vesicular respiration
throughout the lung. Expectoration had diminished
about one-half, or to two ounces in twenty-four hours.
He had increased four pounds in weight. When this
patient commenced the daily injections he could walk
only a short distance without extreme fatigue. Now
he states that he can walk at least half a mile without
any discomfort at all.
Case VI. — J. B , male, white, aged twenty one.
Date of examination, February 15, 1896. The patient
52
MEDICAL RECORD.
[July T I, 1S96
stated that he had had tuberculosis since the spring of
1893, and that his normal weight used to be one hun-
dred and forty-three pounds. The left lung at the
time of examination was in the same condition as in
the preceding case; no vesicular respiration, dull and
flat upon percussion. He weighed at that time one
hundred and fifteen pounds, and was much emaciated.
The patient is difficult to control, and comes only ir-
regularly for injections. He has not gained in weight.
There is evidence that he is addicted to masturbation.
Upon e.xamination on April 21st, I can find very little
or no improvement in this case, and there is very
little hope of his ever being relieved. (Such cases
cannot be e.xpected to recover by any mode of treat-
ment short of the miraculous.)
I have given here a history of these cases suffi-
ciently full, I trust, to enable the reader to form a judg-
ment. I am thoroughly convinced that sero-therapy
is in the line of right treatment, that will eventually
rid the dread disease (tuberculosis) of all its terrors
and its fatal record.
^roflrcss of I^^XetUcal s,cicncc.
Achillodynia. — From an editorial writer in the
Boston Mciliial and Surgical Journal we learn that
two years ago Albert described and named a condi-
tion of the foot characterized by pain on walking and
standing, located at the insertion of the tendo Achillis,
but disappearing in the sitting or lying positions.
In addition to this, a small swelling is to be noticed,
apparently due to the thickening at the insertion of
the tendo Achillis. The swelling, which is as hard as
the tendon, in some instances is slightly sensitive to
the touch. It appears as if the bone itself is enlarged.
Rossler reports nine cases of this affection, which he
is inclined to consider the result of the inflammation
of the bursa between the tendon at its insertion and
the projection of the os calcis. In one of these cases
only was there any evidence of presence of fluid in
the bursa on palpation, but an e.xperimental injection
of fluid into this bursa upon a cadaver did not give
clear evidence of fluctuation owing to the tenseness of
the structures. Schiiller found in two obstinate cases
of this aft'ection reddening and thickening of the walls
of the bursa and synovial fluid, which w'as manifest
on operation of the case. He demonstrated the exist-
ence of the bursa in a large number of cadavers. In
one hundred and forty cadavers he found twenty-five
bursa; and in twenty cases of new-born children,
synovial membrane was found in this region. In a
number of investigations upon cada\ers, Rossler found
frequently thickening of the cartilage and hyperostosis
of that portion of the os calcis which forms the anterior
wall of the bursa, constituting a bursitis deformans,
the result of chronic irritation similar in his opinion
to the formation of callus. VVeinlechner reports oper-
ating upon a case of this sort in a patient twenty-one
years of age ; the bursa was incised and curetted and
a bony prominence chiselled off. The same affection
has been described by Kirmisson as peritendinous
arthritis, and is mentioned by Heinecke in his work
on the " .Vnatomy and Pathology of the Tendon
Sheaths and Bursa;." The affection is apparently in
some instances induced by injury. Cases have been
cited where the origin is attributed to influenza and
to gonorrhoea. In one case apparently the affection
was rheumatic. Treatment can be operative or con-
servative; the latter includes the application of wet
sponges with compression and later massage: the for-
mer—incision into the bursa, curetting the bursal
wall, and removal of projecting bone. Under the
name of '" subtendinous exostosis," Dr. E. G. Brackett
reported a case of an affection similar to that described
by Rossler. A few of these cases had been observed
by Brackett independently of the work of the German
observers. In the one operated upon six months ago
and recently reported, the affection was considered by
the patient to have resulted from a sudden strain in
jumping, which was followed by a swelling on the out-
side of the tendo Achillis; this was tender to the touch
and caused pain in walking. The swelling was on
either side of and between the tendon, but was greater on
the outer than on the inner side ; and on account of the
resulting disability the patient was obliged to walk
upon crutches for a year and a half. Any attempt to
walk without crutches was followed by an increase in
the swelling and sensitiveness at the side of the inser-
tion of the tendon. A hard swelling was felt on the
back of the heel, with slight puffiness and fluctuation
on each side of the tendon. On cutting down upon
the swelling a hard bony growth was discovered on
the upper portion of the os calcis; the tendon was
split, and the growth was found to occupy the upper
portion of the exterior surface of the os calcis, and
presented a sharp projection under the tendon and
slightly above its insertion, in such a position that on
every step in walking the tendon would be stretched
over a sharp projection of bone. The tumor was re-
moved by a chisel; the patient made a complete re-
covery. A subsequent case has since been observed
by Dr. Goldthwait; and the probabilities are that the
affection is more common than has been supposed,
but has been overlooked from the fact that attention
has not been called to the subject.
Strapping the Chest in Phthisis. — Dr. Tidley
(British Mciliial Journal) suggests the following ad-
vantages: I. In early phthisis (catarrhal stage), to
give comparative rest and relaxation to the affected
lung tissue. 2. In the stage of consolidation, to se-
cure the same results, thereby limiting the risk of ex-
tension, and to promote elimination of the disease
products by improving the circulation in and about
the diseased area, and to facilitate expectoration. 3.
In the stage of cavitation, to promote closing of cavi-
ties by directing healthy lung to encroach on the dis-
eased area, instead of relying on natural processes of
cicatrization. 4. Diminished tendency to hemorrhage
by reduced tension on vessels and cicatricial traction
on vessel walls. 5. The ultimate object is to obtain
a smaller thoracic cavity filled with healthy lung, in-
stead of an enlarged thoracic cavity partly filled with
diseased lung.
Cold Baths in Delirium Tremens. — Dr. Letulle
speaks of the various drugs that have been used and
recommends cold baths, not a simple douche, but im-
mersion of the whole body in water at the temperature
of 64.4° F. The head should be cooled by large
waves of water. The bath should last eight, twelve,
or fifteen minutes according to the reaction of the pa-
tient. The baths may be repeated every two or three
hours. It is concluded that these baths possess a sed-
ative and calming action upon these cases. — La Frcssc
Jilcilii'alc, 1S96, Xo. 4, p. 20.
Whooping-Cough. — Dr. Fisher concludes from the
results he has obtained in the quinine treatment of
pertussis that it is the best remedy for whooping cough
at present known for the following reasons: (i) It di-
minishes the number of attacks essentially in five days
at the latest. (2) It reduces even the most vehement
whooping-cough to a mild bronchitis in from twelve to
fifteen da\'s. (3) It influences most favorably a ]30S-
sibly existing broncho-pneumonia. (4) It often stim-
ulates the appetite.
July 1 1, 1896]
MEDICAL RECORD.
53
Medical Record:
A Week/}' Jo7irnal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, July 11, 1896.
LATENT AND LARVAL TUBERCULOSIS.
As certain conditions are necessary for the lodgment
and propagation of the tubercle bacillus in the human
body, an intelligent prophylaxis will look to the main-
tenance of the normal mechanism by which such inva-
sion is ordinarily repelled and by which also the
process of spontaneous recovery from the developed
disease is brought about. From the same point of \iew,
it is obvious that success in the treatment of tubercu-
losis depends largely upon its early recognition.
Here, however, we encounter a serious difFicultv, as
the disease may develop without giving rise for a time
to appreciable manifestations, and these may not ap-
pear until the morbid process has made considerable
progress.
It is a well-known fact, long observed, that tuber-
culous lesions are often found after death when their ex-
istence during life had not attracted especial attention
or had even escaped observation. So well established
is this fact that the Germans have adopted an axiom that
every one ultimately becomes infected with tuberculo-
sis. The multiplication of the tubercle bacilli and the
generation of toxins occasion only local effects until
the intensity of the process has reached such a degree
that the resulting products gain entrance into the cir-
culation and thus give rise to constitutional manifes-
tations.
Maragliano,' in an address recently delivered, dis-
cusses the question of latent and larval tuberculosis
and offers a number of interesting and valuable con-
siderations bearing upon that subject. When tuber-
culosis is present without subjective or objective
symptoms, he goes on to say, the latency may pursue
one of three courses: (<?) It may persist indefinitely;
{h') it may be limited in duration; or (c) it maybe in-
termittent in occurrence. When the latency is persis-
tent the infection is beyond the range of certain
detection, the processes of auto-therapy or auto-serum-
therapy sufficing to control the advance of the disease.
Late in the history of the case there may be some im-
pairment of resonance, in consequence of the presence
of new-formed cicatricial connective tissue. When
the latency is limited in duration, the infection — for
a variable period not manifest —suddenly makes its
appearance. In this group belong cases in which
without previous symptoms ha^moptysis occurs; also
those in which manifestations of tuberculosis make
' Berliner klinische Wochenschrift. 1896. Nos. ly and 20.
their appearance in connection with some acute infec-
tious process. The duration of this limited latency is
variable and uncertain. The transition from latent
to manifest tuberculosis may be viewed as an evidence
of increased intensity of infection or of diminished
bodily resistance, or perhaps a combination of the
two. The developed disease may ((/) progress, (b)
remain stationary, or (c) subside, perhaps permanently,
perhaps to recur.
Larval tuberculosis is that in which typical mani-
festations of infiltration are wanting, although other
symptoms of the infection are present. This type of
the disease may appear in one of two forms: (i) dys-
trophic, (2) typhoid. The first is characterized by
progressive disturbance of nutrition. The patient
gradually fails, antemia develops, the heart becomes
enfeebled and the pulse rapid, the appetite is lost
and the digestion impaired, debility ensues and men-
tal depression results. As a rule, there is an absence
of fever, and physical signs may appear only late.
The typhoid form of larval tuberculosis is from the
beginning attended with fever, to which derangements
of innervation are early added. The fever is at first
intermittent, later becoming remittent or subcontinu-
ous. The general strength may be maintained. Ex-
acerbations closely resembling attacks of typhoid
fever are repeated from time to time. In some cases
both types of the disease may be present.
The manifestations of larval tuberculosis are to be
attributed to intoxication with the products of bac-
terial activity and vary as one or other poison pre-
dominates. The symptoms of tuberculosis may be
masked, whatever the localization of the lesion; but
this is most often the case when the lungs and the
lymphatic glands are involved.
The diagnosis of larval tuberculosis must be made
by exclusion, the greatest care in observation being
exercised. Tuberculosis of persistent latency is be-
yond recognition; if the latency is intermittent the
history of the case is of the utmost diagnostic signifi-
cance. In some cases in which doubt exists after the
exhaustion of all therapeutic resources, Maragliano
suggests a study of the toxicity of the blood-serum.
He has found that from three to five cubic centimetres
of blood-serum from a patient suffering from tuber-
culous toxemia for each kilogram of body weight is
sufficient to cause death in rabbits. The best means,
however, of detecting the existence of latent tubercu-
losis is the intelligent use of tuberculin injected be-
neath the skin. Some individuals will react to injec-
tions usually from one to three milligrams and never
exceeding ten milligrams, with fever and physical
signs such as rales at an apex, with harsh breathing.
etc. Others will not react to this dosage, but after an
injection of twenty-five milligrams will present swell-
ing of lymphatic glands and localized signs in the
lungs or other organ.
The existence of tuberculosis being thus estab-
lished, the treatment will be general or general and
specific. The first includes all measures capable of
improving the general nutrition and increasing the
bodily resistance. The last includes the judicious
use of tuberculin or antitoxic serum.
54
MEDICAL RECORD.
[July 1 1, 1896
ANTI-VIVISECTION EXTREMISM.
The pernicious influence that may result from the ut-
terances of certain well-meaning but misguided indi-
viduals, including medical men, is admirably illus-
trated by a circular recently issued by the American
Anti-vivisection Sociey. In this remarkable commu-
nication an appeal is made to the public not to circu-
late stories about " alleged mad dogs, and the terrible
results to human beings bitten by them. Such ac-
counts frighten people into nervous disorders and
cause brutal treatment of animals suspected of mad-
ness; and yet there is upon record a great mass of
testimony from physicians asserting the extreme rarity
of hydrophobia even in the dog, while many medical
men of wide experience are of the opinion that if it
develops in human beings at all, it is only on rare
occasions. The condition of hysterical excitement
described as ' hydrophobia ' is merely a series of symp-
toms due usually to a dread of the disease, such dread
being caused by realistic reports acting upon the
imaginations of persons scratched or bitten by animals
suspected of rabies." To this statement are added
the opinions of a number of medical men, most of
whom are not known as investigators or clinicians of
wide modern experience, who contend for the non-
existence of hydrophobia, because the disease has
never been recognized by them. There are still some
medical men who are unwilling to admit that hysteria
is a genuine disease, apart from simulation, but if
there is any great clinical truth that has of late re-
ceived general professional acceptance it is that hys-
teria is a reality, just as much as typhoid fever or
pneumonia. Those who deny that there is such a dis-
order as hydrophobia may as w-ell deny that there is
such a disease as hysteria. Perhaps, however, the
scientific world is wrong and the dissenters are right.
No doubt the anti-vivisectionists are as nearly right as
they usually are. To a judicial mind it must seem the
supremest folly to base a conclusion solely upon nega-
tive evidence and to deny the existence of that which
has not come under one's personal observation. .So
long as there are some who oppose the bacillary doc-
trine of disease, so long will there be .some who deny
the existence of hydrophobia in man and rabies in
animals. Conser\'ative anti-vivisection is a legitimate
agitation and will receive the support of all right-
minded people, but a blind fanaticism will defeat its
own ends. No cau.se can fail in the end that is based
upon truth and none succeed promulgated upon error.
THE PATHOGENESIS OF ABDOMINAL FAT
NECROSIS.
0.\E of the most obscure conditions with which the
clinician has to deal is that known as fat necrosis,
many years ago observed by Ponfick in bone marrow
and later described by his assistant Balser as occur-
ring in the pancreas. The condition has since been
frequently noted in association with pancreatic dis-
ease, especially hemorrhage, although it may occur
independently. The white necrotic areas, of varying
size, have been shown by Langerhans to contain lime
in combination with fatty acids.
Of the cause and mode of origin of this condition
there is as yet little definite knowledge. It has been
induced in the dog by injecting pancreatic extract
into the fatty tissue, and in cats by ligation of the
pancreas or its vessels and by transplantation of pan-
creatic tissue. In two cases Welch found the bacillus
coli communis. Stockton in two cases found bacilli
of varying size, .some with square and some with
rounded extremities.
The latest contribution to the pathology of tliis in-
teresting subject is made by Fontick,' who has suc-
ceeded in isolating from the fluid obtained from an
area of subperitoneal hemorrhagic infiltration upon
the posterior wall of the abdomen, in a fatal case of
fat necrosis, a bacillus morjihologically resembling
both the bacterium coli commune and the typhoid
bacillus, but differing from both of these in culture
and in pathogenic properties. The organism is de-
scribed as a fairly large bacillus, with rounded ex-
tremities, about two or three times as long as it is
thick, and possessing pathogenic activity toward white
mice and rabbits. It is capable of independent move-
ment, stains readily with aniline colors, and does not
liquefy gelatin. In cultures it proved to be a facul-
tative anaerobe. The patient was a corpulent man,
forty-three years old, who died in the cour.se of a few
days with symptoms of intestinal obstruction.
Bi-^uis of the ^xEccfe.
Obituary Notes. — Dr. J. P. Taylor died on June
1 6th, at San Angelo, Tex. Some weeks ago he was
thrown from his horse and received a compound frac-
ture of the arm, from which septicemia developed.
Dr. Taylor was born in New York fifty years ago, and
practised here until he was obliged to remove to Texas
on account of his health. — Dr. Augustus S. Kidder
died in .this city on July 5th, of pulmonary tuberculo-
sis. He was born in New Hampshire in 1840, was
graduated from Dartmouth College in i860, and later
from the Philadelphia Dental College. Immediately
upon graduation he came to this city, where he prac-
tised dentistry to within a short time before his death.
— Dr. James D. Browder died on his plantation at
Gallion, Hale County, .-Via., on June 27th. He was a
graduate of Jefferson Medical College and engaged for
a time in the practice of medicine in Philadelphia.
The Third International Congress of Dermatol-
ogy.— At this congress, which, as already announced,
will be held in London, from August 4th to 8th, there
will be a museum of drawings, casts, models, naked-
eye preparations, microscopic specimens, works, and
atlases pertaining to diseases of the skin. There will
also be an exhibition of clinical cases and demonstra-
tions of the same, at 9 a.m. and 2 p.m. of August sth,
6th, and 7th, and at 9 a.m. of August 8th. Any one
having anything to contribute to this department is re-
quested to address Dr. James Galloway, 21 Queen
' Berliner klinische Wochenschrift, 1896, Xo. 17. p. |C)5.
July
1 1, I
S96]
MEDICAL RECORD.
55
Anne Street, Cavendish Square, W., London There
will also be an exhibition of cultures and microscopical
preparations of organisms connected with the skin and
its diseases. Any communications in regard to this de-
partment should be addressed to H. G. I'limmer, Esq.,
Wunderbau, Sydenham, London. The social side of
the congress will be: ist, an informal reception at the
International Hall, Piccadilly Circus, on August 3d,
from 9 to 12 P.M.; 2d, a reception by the lord mayor
and lady mayoress, at the Mansion House, on August
5th, from 9 to 1 1 P.M.; 3d, a dinner to the foreign
members, at the Hotel Cecil, on August 7th. It is
advised that foreigners should arrive in London not
later than Sunday, August 2d, as Monday, August 3d,
is a public holiday.
Dr. George E. de Schweinitz has been elected
professor of ophthalmology in Jefferson Medical Col-
lege, in succession to Dr. William Thomson, resigned;
Drs. D. Braden Kyle and William S. Jones, clinical
professors of laryngology; and Dr. H. F. Harris, as-
sistant professor of pathology and bacteriology.
The Chalfont Epileptic Colony. — A home for
twenty women has been added to the epileptic colony
at Chalfont, England, where formerly there has been
provision for men only.
The Marine Hospital, at New Orleans, has re-
cently been sold by the federal government to the city
for $25,700. It was built many years ago at a cost,
including the purchase of the ground, of between
$600,000 and $700,000, and was never occupied.
Robbed and then Imprisoned. — A physician in
this city suffered recently from the depredations of an
office thief, and in the kindness of his heart called
upon his colleagues in the neighborhood to warn them.
One of the latter, so far from being grateful for the
warning, took the doctor himself for a thief, and had
him arrested as a suspicious character.
The French Surgical Association will hold its
tenth annual meeting in Paris during the week ending
October 24, 1896, under the presidency of Professor
Terrier. The tw-o subjects for set discussion are " The
Surgical Treatment of Clubfoot," to be opened by M.
Forgue, of Montpelier, and "The Treatment of Pro-
lapse of the Genital Organs," to be opened by M.
Bouilly, of Paris. The secretary-general of the asso-
ciation is M. Lucien Picque, No. 8 Rue de ITsly,
Paris.
Lepers in Paris. — Dr. Hallopeau, writing to the
Matin, says that there are over one hundred lepers liv-
ing in Paris without any attempt at isolation, most of
them having come from other countries for medical
treatment. Recently one was found on the street and
taken to the Hopital St. Louis, where there are now
twelve under treatment.
To Drive Away Flies Dr. H. S. Baketel, of
Derry, N. H., writes: " Many practitioners of medicine
among the poorer classes are greatly annoyed by flies
in the sick-room. The annoyance to the patient is
doubly great. Such, at least, was my e.Kperience not
long since on New York's great east side. An excel-
lent safeguard against these pests is the sweet-pea
flower. The Lathyriis maritimus, the purple variety,
grows near the seacoast from New Jeresy around to
Oregon, and beside the coasts of the Great Lakes.
The Lathjrits ochrokuais \sio\m6. on the hillsides from
New England to Minnesota, and even further West.
It is distinguished by its small, yellowish-white
flower. Either of these varieties can be grown in the
sick-room, and the sweet odor emanated seems verj-
offensive to the ordinary house fly."
Pathological Society of Philadelphia.— A stated
meeting of the Pathological Society of Philadelphia
was held on the evening of June nth, the president,
Dr. J. H.-Musser, in the chair. Dr. J. Dutton Steele
presented specimens of verrucose mitral endocarditis,
aneurism of the abdominal aorta, right-sided sclerotic
endocarditis, and a greatly dilated heart, giving rise
during life to symptoms suggestive of both aneurism
of the arch of the aorta and mediastinal tumor, such
as dilatation of the veins of the chest: adema, at first
unilateral, but later becoming bilateral: and inequal-
ity of the pulses. Dr. F. A. Packard presented two
specimens of right-sided endocarditis. Dr. D. Ries-
man exhibited a specimen of fibrous pericarditis, with
hypertrophy and dilatation of the heart and partially
patulous ductus arteriosus, from a girl with a history
of rheumatism followed by chorea. Dr. Joseph Sailer
showed the heart of an infant a few days old, exhib-
iting right-sided malignant endocarditis, and made a
report of three cases of chronic endocarditis in asso-
ciation with pulmonary tuberculosis. Dr. Alfred
Stengel presented a series of stomachs from cases of
pernicious anemia and exhibiting atrophy of the gas-
tric tubules, one of which was an extremely small vis-
cus, not so large as an ordinary fist and with greatly
thickened walls, from an adult woman. Dr. Stengel
also showed intensely anthracotic lungs from the body
of a coal-miner. Dr. A. O. J. Kelly presented a spec-
imen of carcinoma of the stomach.
Methodist Hospital of Philadelphia. — Dr. Joseph
P. Tunis has been elected visiting surgeon to the
Methodist Hospital of Philadelphia, succeeding Dr.
H. R. Wharton, who has resigned.
Dr. A. C. Abbott, hitherto first assistant, has been
elected professor of hygiene in the University of Penn-
sylvania, in succession to Dr. John S. Billings, re-
signed.
The National Conference of State Boards of
Health, recently held at Chicago, elected the follow-
ing officers : President, Dr. C. A. Ruggles, of Stock-
ton, Cal. ; Vice-President, Dr. Benjamin Lee, of Phila-
delphia; Secretary and Treasurer, Dr. C. O. Probst, of
Columbus, O.
Spanish Army Surgeons. — The Spanish govern-
ment has raised the age limit for those desiring to
enter the army medical service from thirty to forty
years, on condition that those so admitted shall serve
in Cuba until the close of the war.
56
MEDICAL RECORD.
[July 1 1, 1896
American iPhysicians Honored in China. — Dr.
Eli Barr Landis, ex-resident pliysician of the Lan-
caster County Hosptial and Insane Asylum, has re-
cently received the Order of the Double Dragon from
the Emperor of China in recognition of services ren-
dered by him during the war between China and Japan.
The same distinction had already been bestowed on
another American medical missionary, Dr. B. C. Atter-
bury, for work in connection with the Red Cross
Society in the late war.
The Second International Congress of Gynecol-
ogy and Obstetrics will be held in Geneva, Switzer-
land, from August 31st to September 5th inclusive.
The sessions of the congress will be held in the grand
hall of the university. The following are the'subjects
for the set discussions and the names of those who
will open the same:
Gynecology: i. "Treatment of Pelvic Suppura-
tions." Referees. — Drs. Bouilly, Paris; Kelly, Balti-
more; Zweifel, Leipzig. 2. ''Surgical Treatment of
Uterine Retro-Deviations." Referees. — Drs. Kiistner,
Breslau; Pozzi, Paris; Polk, New York. 3. "What
Method of Closing the Abdomen Presents the Best
Guarantee against Abscesses, Eventrations, and Her-
nias?" Referee. — Dr. Granville-Bantock, London.
Obstetrics: i. " Relative Frequency and Most Com-
mon Forms of Pelvic Contractions in Different Races,
Groups of Countries, or Continents." Referees. — Drs.
F. Barnes, London; Dohrn, Konigsberg; Fochier,
Lyons; Kufferath, Brussels; Jentzer, Geneva; Lusk,
New York; Rein, St. Petersburg; Pawlik, Prague;
Pestalozza, Pavia; Treub, Leyden. 2. "Treatment
of Eclampsia." Referees. — Drs. Charles, Brussels;
Charpentier, Paris; Halbertsma, Utrecht; Lohlein,
Giessen; Mangiagalli, Milan-Pavia; Parvin, Phila-
delphia; Smyly, Dublin.
The official languages of the congress will be Eng-
lish, French, and German. An exposition of gyneco-
logical and obstetrical instruments and appliances will
be held during the congress week. As the national
exposition of Switzerland will be held at the same
time as the congress, those intending to be present are
advised to secure hotel accommodations in advance.
Further information may be obtained by addressing
the secretary-general for North America, Dr. Fernand
Henrotin, 353 La .Salle Avenue, (^hicago, 111.
International Congress of Criminal Anthropology.
— The fourth International Congress of Criminal An-
thropology will be held at Geneva on August 24th to
29th. M. Adrien Lachenal, president of the Swiss
Confederation, is honorary president of the congress.
Dr. Paul Ladame is president of the organizing com-
mittee.
The Right to Practise in England on an Ameri-
can Diploma. — .\n English court has recently de-
cided that an American physician with a genuine di-
ploma from a recognized medical school is at liberty
to practise medicine in Great Britain, but must not
assume any titles implying that he is a registered Brit-
ish practitioner. The case was that of an American
who appended to his name the letters, " M.D., U. S.
A.," and the court held that there was no attempt to
claim qualifications other than those implied. The
Medical Defence Union, which undertook the prosecu-
tion, was condemned to pay costs amounting to about
^:8oo.
Unwelcome Newspaper Notoriety. — Dr. Warren L.
Babcock, of the St. Lawrence State Hospital, writes:
" The undersigned desires to disclaim any responsi-
bility for the sensational reports which have been go-
ing the rounds of the New York newspapers during
the past week regarding an alleged insanity cure.
The article in the Sunday Journal oi July 5th espe-
cially merits repudiation and condemnation. No in-
terview was granted the reporter, the affixing of my sig-
nature at the end of the alleged interview was a bold
forgery, and no original discovery has been made or
new treatment adopted. The illustrations are wholly
imaginary in every particular, instead of being repro-
ductions from photographs. The work to which the
sensational article crudely refers will be published in
its proper place — a medical journal — as soon as the
results of investigation will warrant."
Fees from Clergymen The question of accepting
or demanding a fee for medical services rendered a
clergyman has reached the .stage of open discussion
in Scotland. Dr. D. Campbell Black, of (ilasgow, re-
cently read a paper on the subject before a local med-
ical society, in which he said that, while he believed
that poverty and suffering would never appeal in vain
to the worthy disciple of Hippocrates, he distinctly
failed to see why, " because a man is a clergyman, he
is entitled to sponge, particularly on a young and poor
practitioner of medicine."
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical corps
of the United States navy for the week ending July 4,
1896 : June 29th. — Surgeon I. G. Heneberger, detached
from the marine rendezvous, New York, and ordered
to the hospital. Widow's Island; Passed Assistant Sur-
geon E. S. Bogert, ordered to the New York Navy
Yard, July 2d; Passed Assistant Surgeon T. C. Craig,
detached from the New York navy yard, July 2d, and
ordered to the marine rendezvous, New York. July
2d. — Passed Assistant Surgeon W. F. Arnold, detached
from special duty in China and Japan and ordered to
return home; .Assistant Surgeon H. F. Parrish, ordered
to the naval laboratory. New York City.
An Income Tax on Physicians. — Louisville, Ky.,
has imposed a license tax upon physicians, graded ac-
cording to their income. In case the income is less
than $2,000 the annual license shall be $10; $2,000
and over and less than $5,000, the license will be $20;
where the annual income is as much as $5,000 but
less than $10,000, the license is $40; all whose yearly
business amounts to $10,000 or over, shall pay a li-
cense of Si 00. The Louis-rille Medical Alonthly iz.ys
that the medical societies of Louisville have appointed
committees to confer with each other and take steps
to test the legality of the law. A test case will be
submitted to the court, and until this is done all phy-
sicians are requested to resist payment of the license.
July I I, 1S96]
MEDICAL RECORD.
57
J^ocictui Reports.
MEDICAL SOCIETY OF NEW JERSEY.
Oiw Hundred and Thirtieth Annual Meeting,
at Asbiiry Park, June 2J and 24, i8g6.
Held
William Elmer, M.I)., of Trextox, Presidext.
Report of Committee on Arrangements.— Dr. Hex-
KV Mitchell, in presenting tliis report, stated that
Asbury Park was free from certain noises wliicli were
such a nuisance in other cities. By ordinance ped-
dlers and hucksters were not allowed to cr)- their
wares in the streets. An ordinance had also been
recently passed, requiring that all milkmen obtain a
license, which they could do only on showing that
the milk was pure, clean, from healthy cows properly
kept. (Before their departure the delegates became
convinced that this ordinance had not yet been fully
complied with.) Another interesting feature of As-
bury Park was that it kept a record book of all hotels
and houses receiving summer visitors, giving all the
facts relating to their sanitary condition — cellar area,
ventilation, water supply, diseases which had occurred
in them, etc. All interested could avail themselves of
this information. The society was extended a warm
welcome to this healthful seaside resort.
Permanent Delegates All of the permanent dele-
gates proposed by the district societies were elected.
Dr. Alfred ]Mercer read his report as treasurer,
which showed a balance of over thirty-five hundred
dollars.
Dr. E. L. B. Godfrey, corresponding secretary, in
his report read some communications, one from Dp.
Sterxberg, relating to vivisection, and Dr. Daxiel
Storck offered a resolution against the vivisection bill
before Congress relating to the District of Columbia.
The resolution passed through the hands of a com-
mittee and was then adopted unanimously.
Honorary Members — Dr. A. Jacobi, of New York,
and Dr. Y. M. I). Marcy, of Cape May, were elected
honorary members.
Purulent Conjunctivitis Dr. W. B. Johxsox, in
the absence of the chairman of the committee, Dr.
Kipp, read the report of the committee appointed last
year to inquire whether the methods for the prevention
of conjunctivitis of the new-born in hospitals accom-
plished what was claimed for them by their respective
authors, and if so, to recommend that which, in their
opinion, was best adapted for use in private practice.
Personal observation, interview with physicians in
large lying-in hospitals, and study of the literature of
the subject had forced upon them the conviction that
the development of purulent conjunctivitis of the new-
born could be prevented by disinfection of the eye,
and that the method recommended for this purpose by
Professor Crede', of Leipsic, accomplished all that
was claimed for it by its distinguished author. It was
suggested that the society request the State board of
health to publish Crede's method in the form of a cir-
cular and distribute it freely, and that the State board
of medical examiners do not grant a license to practise
midwifery to persons not familiar with this method.
The Crede method consisted in carefully dropping
upon the cornea one or two drops of a two-per-cent.
solution of nitrate of silver. It should be applied in
all cases just after or before cleansing the child.
Dr. P. A. Harris made some remarks on the reso-
lution to adopt the report, which was done.
Bovine Tuberculosis. — In the absence of Dr. Stick-
ler, chairman of the committee. Dr. Youxg presented
a brief report, stating that the subject had not been
brought before the committee of the last legislature,
which was adverse, but the prospect for the future was
more hopeful. The committee was continued.
Health of New Jersey. — Dr. H. W. Elmer, chair-
man of the standing committee, read a summary of
reports from physicians throughout the State on the
health of their respective sections. The State had
been comparatively free from epidemics, but there had
been considerable grippe.
In discussing the report. Dr. E. L. B. Godfrey
called attention to the diminished mortality rate from
typhoid fever in Cooper Hospital, Camden, since the
introduction of the Brandt bath treatment. The aver-
age stay of the patients in the hospital had been re-
duced from fifty-two to thirty-three days. On the
average, the patients were out of danger by the fif-
teenth day.
Clinical Observations on Auto-Intoxication of
Gastro-Intestinal Origin. — Dr. Philip Marvel, of
Atlantic City, in a paper of some length on the subject
of auto-into.xication, acknowledged our indebtedness
to Bouchardt, gave a definition of auto-intoxication,
spoke of the toxicity of the urine, bile, and other se-
cretions, dwelt more especially upon the influence of
overeating, and related several interesting cases of
acute and subacute or chronic nature.
AMience the origin of these poisons? All toxic sub-
stances existing in the excretions must be produced by
decomposition of animal or vegetable food received
within the body, by fermentative action of bacteria,
and disintegration and restoration of cell life within
the body itself. In the maintenance of life there was
constant repetition of the processes of building up
and breaking down.
Atlantic City, being a pleasure resort, gave many
examples of the effects of overeating. Among symp-
toms of acute auto-infection from undigested food were
tympanites, burning sensation, eructation of gases,
acid vomiting, diarrhoea, increased formation of sul-
phuretted hydrogen, stools of greenish color, cramps,
vertigo, headache, lightness of head, etc. There
might be cramps, coma, and death. In one of his
acute cases the patient died the second day, and con-
genital absence of one kidney was found, but the one
present was healthv.
Demonstration of Bassini's Operation. — Dr. S. E.
MiLLiKEX, of New York, demonstrated this method by
drawings. He was first to describe it in this country,
in a paper published in the Medical Record some
years ago. Those who opposed it then had since
adopted it, and to-day it was the operation almost uni-
versally performed. He used kangaroo tendon, bury-
ing the sutures, and found non-suppuration essential
to success. The patient was kept abed three weeks;
no truss was worn subsequently.
Dr. Daxiel Storck, of Camden, had had no fail-
ures with the Bassini method, while Dr. Milliken ad-
mitted that he had.
Dr. Bexj.^mix and Dr. P. A. Harris also made
some remarks on the paper.
The Relations of Physicians and Pharmacists.
— At the last annual meeting a committee, co-operat-
ing with a committee from the New Jersey State Phar-
maceutical Association, proposed a code of ethics for
the guidance of physicians and pharmacists in their
relations to one another. This proposed code had
been sent out in circular form to the physicians of
the State for suggestions, preparatory to action at this
meeting. Although it had been adopted by the State
Pharmaceutical Association, evidently it did not meet
w ith the approval of the majority of physicians, for as
soon as it had been read it was voted, before debate
could take place upon its merits, that action be in-
definitely postponed. Dr. Shephard remarked that
we could not regulate the conduct of pharmacists.
Later a resolution was adopted, assuring Dr. Henry
■58
MEDICAL RECORD.
[July 1 1, 1896
Coit, chaiiman of the committee, and its other mem-
bers and the pharmacists, that no discourtesy had
■been meant by this action.
Revision of By-Laws. — Dk. Henry Mitchell,
chairman of the committee on the revision of by-laws,
read the report, and with a few exceptions it was
adopted as read. The proposition to require the nom-
inating committee to report three names instead of one
for third vice-president (who is always advanced to
president) was rejected through fear the election
•should too often fall to Essex County, in which New-
ark is situated.
Annual Address of the President. — Dr. William
Elmer, Jr., (if Trenton, chose for his address " The
Relation of the Physician to Sanitary Science." The
subject was treated in a scholarly and instructive
-way, and the necessity for sanitary observance was im-
pressed from a moral, social, and economic, as well as
physical point of view. He said the education of the
■masses was the real groundwork of the national health.
Disease was directly antagonistic to their interests as
wage earners, and tended to the degeneration of the
race.
■' Statistics of our large cities show that about one-
half of all deaths occurring are in children under five
years of age, and a large percentage of these deaths
takes place during the heated term, being attributed to
cholera infantum. This waste of life in its early pe-
riod is unnatural, and it should be inquired into, and
as far as practicable removed. Crowded, badly venti-
lated, and poorly drained apartments, vitiated food,
milk supply, hereditary diseases, and want of maternal
care are the principal factors in the death rate of the
slums of cities. The law compelling vaccination
should be rigidly enforced and a school record of it
should be kept. The teachers should know the early
symptoms of communicable diseases and take suitable
measures for protection. School authorities, in con-
nection with local boards of health, can do much
toward decreasing the spread of contagious diseases.
''Educate the people,' is the watchword of sanitary sci-
■ence, and the schoolroom is the place for its begin-
ning. Filtration of the water supply of our large
cities is a matter of importance that cannot be over-
estimated. Filtration is of greater importance than the
purity of the source. The process of filtration is now
being planned for Cincinnati. That the result will
greatly diminish the prevalence of typhoid fever and
acute intestinal diseases is unquestioned, as is shown
by the statistics of certain PLuropean cities.
" According to Rochard, the economic value of an
individual is what he has cost his family, the com-
numity, or the State, for his living, development, and
education until he reaches the age when he can restore
it by his own labor. This valuation has been vari-
ously estimated by different investigators. Chad-
wick, of England, considers a laborer equal to a per-
manent deposit of about S980. Farr gives about S780
as the average of value of each human life. F. F.
.Smith places the loss to a community by a death from
typhoid fever at $2,000, and, with this as a basis. Pro-
fessor Mason, of Rensselaer Polytechnic Institute of
Troy, in a recently issued book, estimates the yearly
loss to a city of one thousand inhabitants, where there
are seventy-five deaths from typhoid fever (estimating
ten cases to one death) as nearly $200,000." A pure
water supply would prevent all this.
Among other things referred to as evidence of ad-
vance in medical science. Dr. Elmer mentioned regu-
lations regarding tuberculosis, quarantine against chol-
era and other infectious diseases, etc.
A vote of thanks was extended to the president for
his able address.
Fibroid Tumors of the Uterus Obstructing La-
bor ; Their Subsequent Disappearance Dr. George
H. Balleray read a paper, giving the histories of
three cases of large fibroids of the uterus which had
disappeared after labor. They had caused marked ob-
struction during labor. Other cases were cited in
which such tumors had disappeard during or after
pregnancy, the reason for w-hich was not known. He
would try to deliver by version, but should elytrotomy
or Caesarean section be demanded, he would certainly
choose the latter.
Drs. W. B. Johnson, Benjamin, J. W. S. Gouley,
P. A. Harris, A. M. Cooper, and Curt discussed the
paper. Dr. Gouley would explain the disappearance
of such tumors after or during pregnancy on the be-
lief that they were niyomata, not fibromata ; that they
were composed of tissue like the uterine muscle, and
with these underwent involution after labor, or became
merged with them and flattened out during growth of
pregnancy.
Princeton Laboratory and Bacteriological Diag-
nosis.— Dr. M. Ravenel, of Princeton Laboratory,
spoke of the work being done in the bacteriological
and microscopical lines in that laboratory, and showed
cultures of bacilli of diphtheria, tuberculosis, etc., and
microsopical slides. Last winter the legislature
passed a bill providing for a State appropriation to
enable this laboratory to make examinations of cul-
tures and specimens sent them by physicians free, but
it was vetoed by the governor for economical reasons.
The society adopted resolutions requesting that such
a bill be made the law, and a committee of three was
appointed to appear before the committee of the legis-
lature.
Medical Directory. — Dr. H. R. BALnwix said he
had received a comnumication from Dr. Daniel Lewis,
editor of the " Medical Directory of New York,'" in
which he wrote that on receipt of one hundred subscrip-
tions at one dollar each from New Jersey physicians,
he would add the office hours of physicians residing in
that State.
Is the Therapy of Antitoxin, Nuclein, and Thy-
roid Extracts so Fully Established as to Receive
the Endorsement of the Profession? — This was the
rather cumbersome title of a discussion presented at
the last annual meeting. It was opened with a paper
by Dr. Alexander McAlister, who had devoted most
of his attention to the antitoxin treatment of diphthe-
ria.
Since January, 1895, he had treated forty-five cases
of diphtheria with antitoxin, most of them in hospitals
at Camden; only three had died — one of paralysis of
the heart, one had rheumatic complications, one died
of sepsis. There was a mild degree of diphtheritic
paralysis in eleven, all recovering. The duration of
the disease was shortened, urgent symptoms were
quickly relieved, the results were most gratifying.
Antitoxin was of marvellous value in laryngeal cases.
Dr. McAlister had immunized twenty-one cases.
Two of these afterward had mild diphtheria. Dr. L.
Emmet Holt, he said, regarded the evidence as most
overwhelmingly in favor of the use of antitoxin. Sta-
tistics were then quoted, most of which are probably
known to the readers of the Medical Record. Dr.
McAlister gave no personal experience with nuclein
solution and thyroid extract.
Dr. Barker, of Trenton, related one case which
would indicate the necessity for some caution in the
use of antitoxin. He had employed nuclein solution
to advantage in a case of Pott's disease of the spine
and some other cases in children.
Dr. W. B. Johnson had been called to intubate in
about one hundred cases of diphtheria, and in about
twenty of these cases the physicians had used anti-
toxin. Out of the twenty about fifteen had recovered,
or seven!;y-five per cent. : whereas out of the whole one
hundred cases only about thirty-eight per cent, had
Jul
V I r , I
896]
MEDICAL RECORD.
59
recovered — more than twice as many recovering with
antitoxin than without.
Dr. Deland, of Philadelphia, after stating the case
in a judicial way, thought it must be admitted that
there was in all parts of the world a decrease in the
death rate from diphtheria under antitoxin treatment,
and that, when administered within twenty-four or
forty-eight hours, the serum exercised a beneficial in-
fluence upon the disease.
Dr. Deland had obtained no results from thvroid
extract in goitre, but in some cases of obesity it had
given good results.
Dr. R. C. Newton referred to the txtremelv favor-
able statistics for antitoxin collected by the American
Pediatric Society.
Dr. Stores had collected the cases in which physi-
cians had used antitoxin in Burlington Countv, sixty-
eight cases, with eight deaths.
Dr. Titus said he had used it in sixteen cases, all
recovering but one, which was moribund when treated.
Dr. F. B. Cantwell said they had almost ceased
to dread diphtheritic croup in the St. Francis Hospi-
tal, Trenton, since the use of antitoxin.
Dr. Benjamin had reviewed statistics of about
twenty thousand cases of diphtheria, and claimed there
had not been a decrease in the death rate. When
charged that he had not himself used antitoxin, he
replied that he was not justified in doing so. because
he had had one hundred per cent, recoveries from
other treatment.
Dr. Bishop, of New York, said they had found thy
roid extract of no value in Graves' disease at the clinic
for nervous diseases, College of Physicians and Sur-
geons.
Antisepsis and Antiseptics from the Standpoint
of the General Practitioner. — Dk. C. K. P. Fisher,
third vice-president, selected this topic for his essay.
He held that asepsis depending upon perfect cleanli-
ness was impossible for the general practitioner, espe-
cially in country practice, and that attempts at clean-
liness should be supplemented by antisepsis in cleans-
ing the hands and instruments, the field of operation.
and the external genitals in confinement cases. He
was opposed to routine irrigation of the vagina before
labor, or in the absence of special indication.
There was some discussion upon this paper by Dks.
SiLncRS, Harris, and others.
Chloroform Narcosis — Dr. Floy McEwin, of New-
ark, read a full and practical paper upon this subject,
dwelling principally on the indications and contrain-
dications for chloroform, preparation of the patient for
anesthesia, and the manner of exhibiting chloroform
by inhalation. He emphasized the fact that the ana;s-
thetizer must give his whole attention to the adminis-
tration of the drug.
OmzeTs.—/'n-s/,/cvU, Dr. T. J. Smith; J=-/rsf VLx-
Fresidciit, Dr. D. C. English; Second Vice-President,
Dr. C. R. P. Fisher; Third Vice-President, Dr. A. M.
Halsey; Corresponding Secretary, Dr. E. L. B. God-
frey; Recording Secretary, Dr. William Pierson ; Treas-
urer, Dr. Archibald Mercer.
The next meeting will be held in Atlantic City, on
the fourth Tuesday in June, 1897.
Epileptic Colony — Before adjournment the society
adopted a resolution asking State legislation in the
establishing of an epileptic colony.
The Abscess of Hip- Joint Disease.— Dr. McCurdy
says the general surgeon has as a first principle the
excision of all abscesses no matter where found, while
the orthopcedic is so conser\ative that he never opens
an abscess nor even aspirates. Between these extremes
is the orthopadic surgeon who excises and curettes if
necessary, or leaves alone if the case is running a
harmless course.
AMERICAN NEUROLOGICAL ASSOCIATION.
TzL<enty-Second Annual Meeting, Held at Philadelphia,
Pa., on Wednesday, Thursday, and Friday, June
J, 4, and J-, i8g6.
I'kilsii)i;.nt, F. X. Dercim, M.D., of r'HiLADELnii.-v.
First Day — Wednesday, June jd.
President's Address — The president. Dr. F. X.
Dercu.m, of Philadelphia, delivered an address entitled
"The Functions of the Neuron.'" He dwelt at great
length upon the various views advanced by Nansen,
and quoted several abstracts from this well-known au-
thor's work. Speaking of naked axis cylinders. Dr.
Dercum stated that they were in all likelihood a phys-
iological impossibility in the cerebrum, for were they
numerous we could suppose nothing but a constant over-
flow of stimuli from one cell to another, and conse-
quent inco-ordination not only of thought but also of
action. This is the view ad\ anced by Nansen. The
speaker stated that the question had arisen in his mind
as to whetlier the neuron was not an absolutely fixed
morphological element, and whether it did not possess
a certain, though perhaps limited, power of movement.
Continuing, he said: '• Realizing the practical value
and the wide application of this idea, I have examined
the literature to see whether a similar interpretation of
ner\'ous phenomena has occurred to others, and to
gather such facts if any could be brought forward
in its support. I found that this thought had oc-
curred independently to three observers, one in Ger-
many and two in France. Ramon Cajal, however,
opposes the theory of the mobility of the neuron,
and maintains, on the other hand, that the neuro-
glia cells possess a great deal of mobility. He
points out, for instance, that the neuroglia cells of
the cortex are at times stellate and at others much
elongated. Their processes have numerous short
arborescent and plumed collaterals. Two phases can
be observed in them: first, a state of contraction,
in which the cell body bLxomes augmented while the
processes become shortened and the secondary branches
disappear; and secondly, a state of relaxation, during
which the processes of the neuroglia cells are again
elongated. Ramon Cajal further maintains that the
processes of the neuroglia cells in reality represent an
insulating or non-conducting material, and that during
the period of relaxation they penetrate between the ar-
borizations of the nerve cells and their protoplasmic
processes, and render difficult or impossible the pas-
sage of nerve currents. On the other hand, when the
processes of neuroglia cells are retracted the various
nerve-cell processes which they formerly separated
from each other are now permitted to come into con-
tact. To me it seems as though Ramon Cajal admits
the very thing against which he contends.
'■ Turning our attention for the moment to the subject
of hysteria, we will see what a flood of light may be
cast upon this hitherto so obscure and mysterious sub-
ject. Take the simple example of an hysterical paraly-
sis and see how easily it may be explained. The neu-
rons of a certain area of the cortex, for instance,
re.ract the terminal branches of the neura.xon to such
an extent that the latter are no longer in contact or
sufficiently near to the neurons in the spinal cord which
supply the muscles of the paralyzed parts. When
power is suddenly re-established in hysterically pal-
sied limbs, it simply means that the terminal branches
of the cortical neuraxon, previously contracted, are
again extended so as to re-establish the proper relations
with the spinal neurons. It would be interesting to fol-
low out the ideas here brought forward in their applica-
tion to the various phenomena presented by hysteria.
'• Turning to hypnotism, we can see what a .•'eadv ex-
6o
MEDICAL RECORD.
[July 1 1, 1S96
planation it affords for the phenomena presented : and
leaving this field entirely, we we can see what an enor-
mous value this interpretation of cortical action is for
normal mental phenomena, taking, for example, the
familiar instance of sleep. Numerous other ideas also
suggest themselves in relation with the view here ad-
vanced, but time will not permit of my further discuss-
ing it."
Acute Non-Suppurative Hemorrhagic Encephali-
tis.— Dr. J. J. PuTXA.M, of Boston, read a paper with
this title. The reader first sketched the literature of
the disease, which has been mainly contributed by the
German writers, the latest of whom is Oppenheim, of
Berlin. The principal symptom groups are: i, That
described by Wernicke, as due to hemorrhagic soften-
ing mainly confined to the neighborhood of the third
ventricle;' 2, that described by Striimpell and others,
as attending more diffuse lesions of the hemispheres:
3, it is possible that the hemiplegia of children
maybe due to a similar lesion involving the cortex, as
Striimpell formerly suggested, and certain acute spinal
lesions may belong in a similar category. Oppenheim
has reported a number of cases, showing that, however
grave the svmptoms of this disease may be, the out-
come may be favorable. The reader's case was that
of a voung boy who was attacked suddenly, two weeks
after' having been ill with the mumps, with paralysis
of motion of both eyes and lids, deafness, coma, im-
pairment of swallowing, right hemiparesis, and double
optic neuritis. At the end of three months, however,
he had recovered, except for slight double vision and
slight impairment of hearing and eyesight, and except
that ever since the illness he had been subject to epi-
leptiform attacks of short duration. These attacks are
gradually becoming less frequent. Reference was also
made to another case reported by the reader in 1892,
in which, besides other serious cerebral symptoms, in-
cluding double optic neuritis, temporary loss of hear-
ing had also occurred. The cases reported by Oppen-
heim were given in outline and the interesting fact
noted that his patients, like the one here referred to,
were mainly children. An analysis of these reported
cases was also presented.
Dr. L. C. Grav, of New York, asked if any of these
cases had retraction of the neck.
Dr. Putnam answered that he was not certain as
to its presence in his own cases, but it was present in
the other reported cases.
Dr. Gray thought that the best macroscopical de-
scription of hemorrhagic encephalitis had been given
by Flam some years ago. All cases seen by him
(Gray) had proved fatal. In many instances the di-
agnosis was attended with extreme difficulty. He had
generally been willing to diagnose these cases as men-
ingitis.
Dr. Joseph Collins, of New York, had observed a
case of hemorrhagic encephalitis, with autopsy, which
corresponded with the description given l)y Oppen-
heim. He read the report of the autopsy, which
showed old leptomeningitis, hemorrhagic encephalitis,
and a pachymeningitis hemorrhagica. There was no
case on record in which these three conditions have
been found associated.
Dr. B. Sachs, of New York, said that the recogni-
tion of this form of cerebral disease showed a distinct
advance in neurology. He had observed four cases.
Two patients recovered and two died. In one case there
was some doubt as to whether it was meningitis or not,
as there was slight retraction of the neck but no positive
coma. He looked upon it as a milder disease than
basilar meningitis. In one of the patients who recov-
ered, the cerebral symptoms appeared simultaneously
with the fever. The former lasted four days, leaving
the patient with slight ptosis and paresis of the exter-
nal rectus.
Dr. Grav asked if fatal caes have shown more \io-
lent symptoms than those that recovered.
Dr. Putnam replied that in some of the more violent
cases the patients recovered. In general, the rapid de-
velopment of severe coma is considered an unfavorable
sign. It is frequently quite difficult to distinguish this
condition from meningitis. He believes that the sever-
ity of the symptoms depends on the amount of poison
absorbed into the circulation. We do not yet know the
exact significance of retraction of the neck, which is a
very unreliable diagnostic sign. In one of his own
cases of influenza with symptoms of encephalitis oc-
curring in an elderly person, the brain was found only
oedematous. Sometimes changes are unrecognizable
with the naked eye.
Cerebral Complications of Reynaud's Disease. —
This was the title of a paper by Dr. William Osler,
of Baltimore. After referring to the frequency with
which Revnaud's disease is met w ith in forms of in-
sanity, he said that in a few cases cerebral manifesta-
tions, due apparently to vascular changes similar to
those which develop in the peripheral parts, had been
described. In the case of a man in his wards, already
reported in 189 1 by Dr. H. M. Thomas, in which epi-
leptic attacks occurred in the winter months only, in
connection with loc.l asphyxia and superficial necrosis
of the ears, the patient had also ba-moglobinuria. In
another case, that of a woman aged fifty-two, during a
period of six years, local syncope and asph)xia occurred
at intervals in the fingers and hand of the right side,
sometimes with aphasia, and on several occasions with
transient paralysis of the right arm and leg. In the
final attack the patient died with gangrene of the right
hand and arm. The case of Weiss is believed to be
the only other instance in which aphasia complicated
the disease. In a third patient "falling attacks" of
an indefinite character occurred in a young girl,
with local asphyxia of the legs between the knees and
ankles.
Dr. Riggs asked Dr. Osier how often he had seen
death follow this disease.
Dr. Osler answered that it was rarely fatal. This
was the second fatal case with which he was familiar.
The literature, however, indicated a number of fatal
cases. He considered the complications as having no
direct relation with the disease. The associated con-
ditions were rarely serious.
Tumor of th:' Thalamus. — Dr. Walter Chax-
xi.NG, of Boston, read a paper with this title. The
patient w as an unmarried woman of good heredity, and
by occupation a school teacher. She was of an active,
nervous temperament, and the subject of hay fever and
asthma until the spring of 1895, when she was under
the care of a so-called " hay-fever specialist" and es-
caped the usual attack. Before admission to the hos-
pital, November 29, 1895, she had been for some
weeks mildly exhilarated and extravagant in her ideas,
but not enough so to interfere w ith her work until the
22d. The only physical symptoms she had complained
of were headache and insomnia. Her disease was di-
agnosed by an alienist of experience as mild acute
mania when she came to the hospital. Since her
death her friends have stated that she had weakness of
the left arm before leaving them, but nothing was said
of this when she entered. She was mildly exhilarated,
with expansive delusions and hallucinations of taste
and smell. She was unable to stand because of weak-
ness in the left leg. and her left arm was weaker than
the right, there being no power to move it above the
elbow. Headache, "not severe or localized, existed.
There was little nausea. The pupils were equal in
size and reacted to light. The eyes did not follow
the finger. There was no ophthalmoscopic examina-
tion. The weakness in the left side was not so marked
at the beginning as to attract special attention. It was
July 1 1, 1S96]
MEDICAL RECORD.
61
later that its significance became apparent. Patella
reflex slight!}' exaggerated and alike on both sides:
plantar reflex moderate; urine: color normal, reaction
acid, specific gravity 1.022 ; urea normal, uric acid in
excess; blood count: reds, 4,804,000; whites, 12,400.
The mild maniacal excitement continued for the first
week after admission. The patient was very restless
in the bed, moving her head from side to side and
throwing her right arm overhead. She also often
folded her arms rigidly across the chest and clenched
the fingers. After the firstweek she slowly sank into
a stupor, from which it was diiticult to rouse her. The
physical svmptoms of central disturbance became rap-
idly more marked. There was entire loss of motion
in the left arm, left leg, and later right leg, and ex-
treme extension of both legs. The jaw became re-
laxed, interfering with respiration. The tongue fell
back in the mouth. Breathing became jerky and ir-
regular toward the end, and finally the relaxed jaw-
could not be replaced and death ensued. The autopsy
was made by Dr. E. W'yllis Taylor, of Boston, who
found a boggy, cyst-like mass extending back an
inch behind the posterior border of the optic thal-
amus and forward to the junction of the caudate nu-
cleus with the thalamus, the mass apparency involving
the latter in its entire extent. Microscopical exami-
nation proved the tumor to be a vacuolar glioma. The
mental symptoms in this case seem to have been quite
unlike those of the usual cases of brain tumor record-
ed, in which are found depression, dulness, irritability,
stupor, and even pronounced dementia. Several inter-
esting questions arise, as, for instance: Which symp-
toms probably presented themselves first, the mental
or physical ? Why should there be so much mental
disturbance in such a case? Was the mental trouble
an accident and independent of the tumor? If not,
how can it be satisfactorily explained? What diag-
nostic value do mental symptoms possess in cases of
brain tumor?
Dr. Wh.\rton Sinkler, of Philadelphia, thought
that the appearance of mental symptoms in thalamus
tumors was of much clinical interest. In his experi-
ence somnolence and mental symptoms were of fre-
quent occurrence.
The Ectal Relations of the Right and Left Pa-
rietal and Paroccipital Fissures This was the title
of a paper by Dr. Burt G. Wilder, of Ithaca. The
parietal and paroccipital fissures may be either com-
pletely separated by an isthmus or apparently contin-
uous. When so continuous ectally, there may still be
an ental and concealed vadum or shallow. Diregard-
ing the vadum on the present occasion, the ectal rela-
tions of the two fissures may be designated as either
continuity or separation. That continuity occurs more
frequently on the left side has been noted by Ecker,
Cunningham, and the writer. Hitherto, however, sta-
tistics have included unmated hemicerebrums as well
as mates from the same individuals. The following
statement is based upon the cerebrums of fifty-eight
adults of both sexes and various nationalities and
characters. The speaker had examined forty-eight;
the other ten having been accurately recorded by Bisch-
off, Dana, Jensen, and Mills.
So far as these fifty-eight individuals are concerned,
the most common combination, viz., left continuity and
right separation, is decidedly the rule with the moral
and educated, less frequent with the ignorant, the
insane, and negroes, and does not occur at all in mur-
derers. The only instance of the reverse combination
(left separation and right continuity) was aft'orded by
an insane Swiss woman. The only two known to be
left-handed represented the more frequent combination
of left continuity and right separation. These statis-
tics suggest many special queries and problems, some
of which were briefly indicated. But the speaker
wished this to be regarded as a preliminary communi-
cation, and asked the co-operation of other members
in the effort to obtain satisfactory results of larger
numbers, particularly of brains of well-born, moral,
and educated persons. For this purpose a blank form
was outlined.
Does Antisyphilitic Treatment Prevent the Oc-
currence of the Diseases of the Nervous System
which are Considered Syphilitic in Origin ? — Dr.
Joseph Collins, of New York, read this paper and
pointed out that certain diseases of the ner\'ous system
occur sequentially to syphilis with such frequency that
they are rightfully looked upon as syphilitic in their
origin. These diseases are tabes, general paralysis,
syphilitic spinal paralysis, E.nd such exudative condi-
tions as cerebral thrombosis. After briefly reporting
the history and treatment in nearly one hundred cases
observed in hospital, dispensaiy, and private practice,
the writer concluded as follows:
1. Exudative and degenerative diseases due to syph-
ilis are most liable to show themselves at the end of
the third and beginning of the fourth decade of life.
2. Thorough and prolonged administration of anti-
syphilitic remedies during the activity of the virus
does not seem to materially advance this time limit.
3. That active and prolonged antisyphilitic treat-
ment does seem to prevent the development of such
diseases as locomotor ataxia and general paresis. This
is true of degenerative diseases, though treatment may,
however, have some effect in preventing the exudative
diseases of the nervous system, such as syphilis of the
spinal cord, disease of the blood-vessels, etc.
4. Cases of tabes and general paresis in which syph-
ilis is confessed, and in which treatment has been most
desultory and incomplete, are not more liable to the
early development or to the severe manifestations of
either of these two diseases than those in which the
treatment has been all it should be.
5. That the administration of antisyphilitic meas-
ures in the most approved way does not fulfil the re-
quirements of cure, and that syphilis is often an in-
curable disease.
Dr. P^T^',\M referred to a case that had received
prolonged and thorough antisyphilitic treatment, yet
symptoms of degenerative nervous disease appeared
later in life.
Dr. Gray said that the facts in Dr. Collins' paper
were not detailed as to the symptoms of syphilis nor
as to the exact treatment. In many instances of sus-
pected syphilis an absolutely positive diagnosis is at
times almost impossible.
Dr. Sachs agreed on the whole with the conclusions
of the reader of the paper. In the vast majority of
cases, however, the treatment of syphilis does not pre-
vent the development of tabes or general paresis. A
better w'ayto have arranged statistics would have been
to take all cases of syphilis and ascertain if they de-
veloped nervous disease later in life. The worst cases
of syphilis of the nervous system occur in those
who have never received any treatment. He spoke of
such a person who had de\eloi3ed pronounced general
paresis one year after the initial infection. In late
cases it is often difficult to prove the relationship be-
tween syphilis and the nerve lesion. We should be
careful about adopting Dr. Collins' views.
Dr. p. C. Knapp, of Boston, agreed with Dr. Sachs,
and did not believe it wise to refuse antisyphilitic
treatment when it seemed to be indicated. He asked
Dr. Collins if his cases showed that the development
of nervous disease bore any relation to the severity or
character of the primary or secondary manifesta-
tions of syphilis. When the cutaneous symptoms were
pronounced there was usually less nervous disturb-
ance.
Dr. Osler said that his experience was opposed to
62
MEDICAL RECORD.
[July I I, 1896
the views of Dr. Collins. The majority of severe cases
of nervous disease occurring in syphilitics were in
those who had either been badly treated or not treated
at all. Early, thorough, systematic, and prolonged
treatment will prevent the development of degenerative
disease of the nervous system in later life.
Dr. N. E. Brill, of New York, asked how the reader
could reconcile with his statistics the fact that anti-
syphilitic treatment frequently cures incipient tabes
and paretic dementia.
Dr. Diller had seen nervous disease develop in
spite of early antisyphilitic treatment.
Dr. Preston expressed the opinion that the irregu-
larity with which endarteritis occurs is often over-
looked. He was unable yet to establish the relation-
ship between antisyphilitic treatment and endarteritis.
Nervous disease has been of a milder type in those
who have received careful early treatment, and more
marked in those who have not.
Dr. Patrick said that the author's statistics did not
prove that treatment was ineffectual, and that the ner-
vous diseases might be due to other causes. When
vigorous treatment is carried out for a brief period and
then discontinued, late syphilitic disease of the ner-
vous system is more likely to develop.
The President maintained that it was hardly fair
to draw conclusions from two diseases such as tabes
and general paresis, as the reader acknowledged that
they were not always due to syphilis. The degenera-
tive affections may occur in cases that have been thor-
oughly treated.
Dr. Collins, in closing the discussion, said that he
wished it understood that he had no theories to ad-
vance, but had merely tabulated the results of these
cases. Particular inquiry had been made in the cases
detailed as to the kind of treatment, and in many in-
stances satisfactory knowledge had been obtained. In
cases which had been referred to by one of the speak-
ers, in which the symptoms of tabes and general pare-
sis disappeared under antisyphilitic treatment, he was
not willing to concede that these were genuine cases of
tabes or general paresis, but cases of pseudo-tabes and
pseudo-paresis, in which the lesion was an exudative
one and not a degenerative one, such as is characteris-
tic of these two diseases, and it was his belief that in
these cases antisyphilitic treatment \vn^ of benefit.
He had purposely refrained from saying anything of
gummata and had confined himself to the systematic
syphilitic diseases of the nervous system.
Prognosis and Duration of Attacks of Mental
Disease. — This was the title of a paper by Dr. Henry
K. SrEDM.^N, of Boston.
Dr. Channing called attention to the fact that a
general misunderstanding occurs in the community
as to the curability of insanity. It is much more cur-
able than is supposed. General paresis should not be
classified among the insanities. 'I'he character of the
disease has changed in the last fifty years, and our
views and classification have therefore changed.
Dr. Gray said that to speak of insanity as an entity
was as if one were to speak of all disease as an entity,
and then go back to the old Carlyle tables of mortality
for the prognosis of coryza, pneumonia, tuberculosis,
typhoid fever, and cholera, while to refer to the old
statistics of Pliny Earle was like referring to the hos-
pital results of thirty or forty years ago for guidance
in the treatment of the present day. If we are to ac-
cept the statistics of results of the insane asylums, we
are justified in analyzing their record, and then we are
startled to find that no new type of mental disease, no
original pathological observation, no new departure in
treatment, and not one text-book has ever come from
an American asylum, despite the millions of dollars
and thousands of patients they have had at their com-
mand.
Seco?ul Day — Thursday, June 4th.
Progressive Muscular Atrophy of Sudden Onset.
— This was the title of a paper by Dr. Theoduke
Diller, of Pittsburg. He related the details of a case
which came under his observation three years ago, and
stated that the sudden onset of palsy followed by
atrophy and the absence of sensory phenomena led him
to diagnose the case as one of poliomyelitis adulto-
rum. The beginning of the patient's trouble was in
an ophthalmoplegia. After an absence of two years
the man again came under his care, when the atrophy
and loss of power in the muscles had markedly in-
creased. The biceps, triceps, scapular, and ulnar
groups had become involved and the fiuer movements
of the fingers were lost, as was also the power of supi-
nation. At this time the patient was unable to adjust
or remove his clothing unaided. There was a marked
decrease in the response both to galvanism and fara-
dism in the paralyzed muscles. Dr. Diller considered
the case could be fairly regarded as one of progressive
muscular atrophy, as the progressive feature was for
two years the most important feature of the case.
Ophthalmoplegia as a symptom of progressive muscu-
lar atrophy ftust be rare, for but scant references are
made to it in literature. Strychnine had a very-
marked effect in staying the progress of the disease.
Pitting about the Hair Cups a Trophic Change
in the Skin in Certain Nervous Disorders of Cen-
tral Origin. — Dr. William Browning, of Brooklyn,
described a presumably hitherto unrecognized altera-
tion in the skin. From some seven or eight years' ob-
servation of such cases he was able to give the limits
of its occurrence. So far it has been seen only in
progressive muscular atrophy of spinal origin or in
cases complicated with atrophy evidently likewise due
to chronic precornual disease. In other troubles at-
tended by atrophy, as infantile palsy, neuritis, pseudo-
hypertrophy, etc., it has not been found. It is hoped
that it may prove a useful help in differential diag-
nosis, especially between the forms due to peripheral
and central disease. The change consists of an areola-
like faint depression, frequently oval, in the direction
of the lines in the skin, though it may be irregular or
circular in form, about the exit of each hair. Usually
the depression is a trifie paler than the surrounding
skin, resembling, but not really being, a minute scar.
It is not observed in specially hairy regions like the
scalp, but only over the seat of muscular atrophy, not-
ably on the leg and thigh, though also on the upper
extremities. All his patients had reached or passed
middle life. A drawing to show the appearance in
one case was exhibited.
A Case of Syringomyelia, Limited to One Pos-
terior Horn in the Cervical Region, with Arthro-
pathy of the Shoulder-Joint and Ascending De-
generation in the Pyramidal Tracts — This was a
paper by Dr. F. X. Dercum and Dr. William G.
Spiller, of Philadelphia. Three years after a strain
of the back the patient began to suffer from pains in
the legs, a band-like pain about the lower part of the
chest, weakness in the lower limbs, and a spastic gait.
Complete paraplegia with contractures, more marked
on the right side, wasting of the lower limbs and paraly-
sis of bladder and rectum developed later. Cutaneous
sensibility was lost in the legs and upon the trunk as
high as the nipple on the right side and a little above
the umbilicus on the left. The sense of temperature
was absolutely lost over the right arm, the right shoul-
der and the right side of the neck, and also upon the
adjacent part of the right side of the trunk above the
nipple line. There was some analgesia of the right
arm. The right shoulder- joint began to swell and
from rupture of the capsular ligament cellulitis with
redness and local heat was produced, but with little or
July 1 1, 1896]
MEDICAL RECORD.
63
no pain. In extension the humerus assumed the po-
sition of a subglenoid luxation. Death was due to
exhaustion.
At the autopsy the capsule of the right shoulder-
joint was found much thickened and roughened on the
inner surface. The head of the humerus had disap-
peared, the bone having been eroded to some little
distance below the surgical neck. A cystic tumor was
found in the axilla containing a friable fatty material.
The surface of the glenoid cavity was much eroded,
roughened, and porous; it was abnormally large and
extensive bony deposit had taken place along its
edges. The coracoid process exhibited a thick and
firm accretion around its entire edge.
Sections were made from the level of nearly every
spinal root and from many spinal ganglia.
By the microscopic examination degeneration was
found of the crossed pyramidal tract as high as the
substantia reticularis of the second cervical segment
and of the direct pyramidal as high as the motor de-
cussation upon the right side, and for a short distance
of the crossed pyramidal upon the left. This was be-
lieved to be ascending on account of the following
facts :
1. Absence of any microscopic lesion above the
medulla oblongata.
2. Degeneration of the crossed and direct pyramidal
tracts on the same side of the cervical cord, intense in
the lower cervical region near the lesion and dimin-
ishing gradually in intensity in the cervical segments,
and finally becoming very indistinct in the upper cer-
vical region.
3. Absence of all degeneration in the anterior pyra-
mids.
4. Long duration of a chronic process.
While certain association fibres may be considered
degenerated in these columns, the entire antero-Iateral
column contains such fibres, and the degeneration was
notably in the area occupied by the crossed and the
direct pyramidal tract. This ascending sclerosis was
probably in greater part due to destruction of motor
fibres deprived of their function.
Degeneration of the direct cerebellar tracts and of
the tracts of Gowers was traced as far as the inferior
peduncles of the cerebellum.
Intense pachymeningitis was noticed from the sec-
ond lumbar segment to the exit of the third dorsal
roots.
The arthropathy of the right shoulder was not due
to any special changes in the cord or spinal ganglia.
The posterior roots were not affected even when the
pachymeningitis was most intense: the anterior at one
part of the dorsal cord were degenerated.
In the entire cervical region as high as the second
cervical segment the cavity was limited to the right
posterior horn.
The gliosis extended from the extreme end of the
conus terminalis to the second cen-ical segment. The
microscopic examination explained satisfactorily the
symptoms observed in life.
Rapidly Fatal Cerebritis Resembling Cerebro-
spinal Meningitis. — This was a joint paper by Dr.
James He::drie Lloyd and Dr. Joseph Sailer, of
Philadelphia. The writers called attention to the fact
that fulminating cases of the infectious diseases, such
as small-pox, scarlatina, measles, typhoid fever, and
spotted fever, occur in which the diagnosis is exceed-
ingly obscure and the disease is usually quickly fatal.
These cases as a rule have their most marked symp-
toms in the nervous system. There is delirium pass-
ing into coma, with depressed cardiac and respiratory
centres, with high fever, and in the cases of the exan-
thema often a purpuric or hemorrhagic eruption not
always characteristic. These cases demand especially
two things, first, the determination of the exact effects
upon the nervous system, and second, the determina-
tion of the microbe or toxic agent at work in any
given case. The writers could attempt only the for-
mer study, as the paper was not intended to deal with
the bacteriology of the subject.
The patient was a man, aged twenty-four years, who
was taken suddenly with a chill followed by fever and
intense cephalalgia and radialgia. The patient passed
rapidly into a condition of delirium merging into
coma. Third-nerve paralysis supervened, and on the
third day a copious purpuric eruption appeared. This
.eruption presented ecchymosis, and on the hands le-
sions like erythema nodosum. Blood and pus were
found in the urine and vomiting of blood occurred
before death. The patient died on the sixth dav.
The autopsy revealed disseminated local lesions in
the cerebrum, mid-brain, pons, and post-oblongata;^
some migrated leucocytes in the perivascular spaces,,
little involvement of the membrane, and a diffused
nephritis. From extensive microscopic research the
writers were able to report a disseminated local cere-
britis. The infection had invaded the brain by way
of the connective-tissue structures, blood-vessels, etc.,.
and the nen'e tissues proper were invaded secondarily.
From the clinical standpoint the case probably comes-
under the head of "spotted fever.''
Dr. Osler said he would have liked to hear in
regard to the condition of the kidneys in the case:
reported. The diagnosis of cerebritis and enceph-
alitis can be readily made between cases of infectious
fever and the former. Unless the basal meninges are-
involved we cannot make a positive diagnosis of men-
ingitis, as all those symptoms, such as retraction of
the head and clonic contractions of the muscles, may
be present in pneumonia and yet nothing be found at
the autopsy.
Dr. Putnam agreed with the previous speaker that
so-called meningeal symptoms may occur without
meningitis.
Dr. Charles K. Mills and Dr. William G. Spie-
ler, of Philadelphia, reported the following case: The
patient had never had earache, but had suffered during
the summer of 1895 from severe headache. On De-
cember 20, 1895, he became unconscious and had
three general convulsions which resembled those of
epilepsy. It was noticed that he was partially para-
lyzed on the right side and that he could not talk prop-
erly. His condition later improved very much. On
January 29, 1896, he had another attack of partial un-
consciousness without convulsions, but with aphasia
and decided paralysis. On admission to the hospital
he was in a condition of stupor, he did not speak when
addressed, and had almost total right-sided paralysis,
incontinence of urine and fa;ces, and entire loss of
pain and touch sense over the paralyzed side. He
was found to have right homonymous hemianopsia,,
and double papillitis, most marked in the left eye.
Death occurred February 26, 1896. There was no
evidence at any time of middle-ear disease. At the
autopsy an abscess was found in the left hemisphere,^
just above the level of the callosum. Both tympanic
membranes were normal. Microscopic examination
of the pus from the cerebral abscess revealed only the
ordinary staphylococcus pyogenes aureus. The oc ur-
rence of epileptiform convulsions at the time of the
first attack of unconsciousness, probably due to irrita-
tion of the motor fibres within the internal capsule, is
worthy of note as an instance of the difficulty in diag-
nosticaiing cortical lesions. It is not known in what
portion of the body these convulsions began. The
diagnosis was made of some morbid process located
at the posterior part of the internal capsule involving
the optic radiations and causing pressure. The ab-
scess occupied the posterior part of the external cap-
sule, a portion of the lenticular nucleus, and extended
64
MEDICAL RECORD.
[July 1 1, 1S96
downward into the subthalamic region, but to all ap-
pearances had not cut the fibres of the optic radiations
nor those of the internal capsule. The loss of func-
tion in these tracts was probably due to pressure.
The white matter of the first temporal gyrus was al-
most entirely destroyed, and fibres from the upper an-
terior part of the second temporal were also cut. As
thi cavity was very near the periphery of the first tem-
poral convolution it would not have been diflicult for
the surgeon to have emptied it. Hearing was prob-
ably not seriously affected, although word deafness ap-
peared to be present. In view of the frequency of .
cerebral abscess after suppurative processes in the
lungs, it may be added th.it merely spots of catarrhal
pneumonia were found in both lungs at the autopsy.
No degeneration was noticed anywhere in the motor
tract. At all parts a good half-inch of sound tissue
existed at the posterior part of the internal cr.psule in
the area corresponding to the optic radiations and the
tract of Tiirck. It has been claimed by Dejerine that
fibres arise in the temporal lobe (especially in the
second and third convolutions), pass inward below the
putamen, join the posterior part of the internal cap-
sule in the subthalamic region, and then form appro.xi-
mately the e.xtenial fifth of the cerebral peduncle. Xo
fibres from the occipital lobe are found in this lateral
bundle of the crus. Dejerine has found this tract of
Tiirck degenerated in six cases of lesions involving
the middle and inferior part of the temporal lobe.
In this case the fibres from the first temporal gyrus
were almost entirely destroyed as well as those from
the upper anterior part of the second temporal convo-
lution, and as no degeneration has been found within
the lateral bundle of the peduncle by the method of
Marchi, si.xty-eight clays after the first attack and
twenty-eight days after the second, certainly a period
sufficiently long for this method, we consider that
the case demonstrates the fact that no fibres from the
first temporal and the upper anterior part of the sec-
ond temporal gyrus, including a portion of the upper
middle of this gyrus, enter the fasciculus of Tiirck.
This, of course, does not render impossible or improb-
able the origin of such fibres in the lower anterior and
the whole of the posterior p.irt of the second temporal,
and in the whole of the third temporal gyrus. The
fibres which enter the first temporal gyrus are prob-
ably connected with the sense of hearing, and being
sensory probably do not degenerate downward, which
accounts for the absence of secondary degeneration in
the peduncle.
The Surgical Treatment of Focal Epilepsy; a
Critical Analysis of the Result in Nineteen Cases.
— Drs. B. Sachs and A. G. Gerster, of New York,
presented a paper with this title. For the last six
years the authors have attempted to study in a thor-
oughly unbiassed fashion the results of the various
surgical procedures for the cure or relief of partial
epilepsies. They include not only cases due to trau-
matic injury, but those associated with infantile cere-
bral palsies or some other acute cerebral condition.
Their list of cases does not, however, include those in
which the epilepsy is due to tumor, liefore detailing
their own cases the authors lay special stress upon the
unsatisfactory results to be gained by a mere statisti-
cal inquiry of the cases reported in literature. The
majority of these are reported either too early, or, if
reported, the cases are not properly analyzed. It is
their opinion that the results after operative proce-
dures for the cure of epilepsy should not be considered
unless at least a period of one year has elapsed since
the time of the operation. But they also state that it
is not well to exclude all cases in which the attacks
return soon after the operation, for in some of these
decided improvement sets in later on. A number of
authors have condemned every surgical procedure
without in the least attempting to account for the fail-
ure to cure or to improve the patient. Thus the mere
fact of an addiction to alcohol is of itself sufficient to
explain the failure to cure epilepsy by operative
procedure. The epilepsy which is developed after a
traumatic injury or in association with infantile cere-
bral palsies is evidently due to secondary degenera-
tion of the association fibres in the hemispheres, for
this degeneration originates from the focus of diseased
tissue, and the epilepsy is generally developed in the
course of a year or two. In this same period of time
the epilepsy often appears after the initial injury.
Horsley"s proposition to excise the diseased tissue
and thus prevent the epilepsy is considered to be
based upon sound physiological principles, but in
practice the results have not been so satisfactory
as was expected, and the authors attribute this
chiefly to the fact that after an epilepsy has lasted
for a number of years and after secondary degen-
eration has been fully established, the excision of
the original focus of disease cannot be expected
to do good. It is important therefore, if possible,
to prevent the formation of secondary degenera-
tion in the hemispheres by excision of the diseased
tissues, or to prevent epilepsy by early surgical pro-
cedures in the case of depression of the skull and
other cranial injuries. The authors' nineteen cases
have been minutely tabulated with reference to the
origin of the trouble, the interval elapsing between
the traumatic injury or beginning of the epilepsy and
the operation. The analysis of the nineteen cases
shows that three were positively cured, two greatly
improved, three somewhat improved, while in eleven
cases there was absolutely no improvement. A study
of all the cases shows that those in which there has
been improvement the operation was clone within a
period of two years after the traumatic injury or the
beginning of the disease. The same is true of those
cases that were greatly improved but not cured, the
failure to cure in these cases being ascribed to other
causes, such as alcoholism or want of proper care after
operation. The authors' views and experiences are
summed up in the following conclusions:
1. That surgical interference is advisable in those
cases of partial epilepsy in which not more than one
or at the utmost two years have elapsed since the
traumatic injury or beginning of the disease which
has given rise to the convulsive seizures.
2. In case of depression or other injury of the skull
surgical interference is warranted even though a num-
ber of years have elapsed, but the prospect ot recovery is
brighter the shorter the period of time since the injury.
3. Simple trephining may prove sufficient for a
number of cases, and particularly in those cases in
which there is an injury to the skull, or in which a
cystic condition is the main cause of the epilepsy.
4. Excision of cortical tissue is advisable if epilepsy
has lasted but a short time, and if the symptoms point
to a strictly circumscribed focus of disease.
5. Since such cortical lesions are often of a micro-
scopical character, excision should be practised even
if the tissue appears to be perfectly nonnal at the time
of operation, but the greatest care should be exercised
in order to make sure that the proper area is removed.
6. Surgical interference for the cure of epilepsy asso-
ciated with infantile cerebral palsies may be attempted,
particularly if too long an interval has not elapsed
since the beginning of the palsy.
7. In cases of epilepsy of long standing in which
there is in all probability a widespread degeneration
of the associated fibres, every surgical procedure is
absolutely useless.
A Contribution to the Pathology of Epilepsy and
a Resume of the Utility of Operations in Epilepsy.
— By Drs. Joseph Collins and A. Wiexer, of New
fuly 1 1, 1896]
MEDICAL RECORD.
65
York. This was a report of two cases in which a por-
tion of the cortex was excised. The first case was that of
a young man, twenty years of age, with the usual symp-
toms of focal epilepsy, the patient having had but
three attacks. The cortical area for the right hand
was cut out. Microscopical examination of the tissue
showed chronic meningo - encephalitis, obliterative
changes in the blood-vessels, changes in the ganglion
cells of a degenerative character, and the formation
of neuroglia tissue in the softened area. The patient
was operated upon a year ago and has since been free
from epileptic attacks. The second case was that of a
married woman, thirty years of age, who had epilepsy
for six years of a focal character at first, which later
became general. A similar operation was performed
and the cortex showed unmistakable pathological
changes.
Dr. \V. \V. Keexe, of Philadelphia, and H. M.
Thom.as, of Baltimore, reported a case of a large
tumor removed from the brain with wide opening of
the lateral ventricle. The patient, a young man of
nineteen, with an excellent family and personal his-
tory and no history of accident, in December, 1895,
had an attack of intense headache and vomiting, but
without optic neuritis. The latter symptom followed
in the middle of Januarj', with later blindness in the
right eye, slight vision remaining in the left; slight
protrusion of left eyeball, pupils equal and normal;
smell, hearing, and taste unaffected; paresis of the
lower right face ; sensation and the' muscles of masti-
cation unaffected, no muscular weakness in either
the amis or legs, but a good deal of muscular rest-
lessness of the right hand, persisting even during
sleep; reflexes present; mental condition poor. He
was dull and apathetic and sometimes slightly wan-
dering mentally. After the early headache and vom-
iting, neither of these was a marked feature. There
was slight aphasia. Drs. Osier and Starr saw the pa-
tient with Dr. Thomas, and the conclusion was reached
that it was a tumor in the left frontal lobe, most likely at
the base of the second frontal convolution and prob-
ably suljcortical. On May loth, Dr. Keene operated.
The tumor presented through a rupture of the cortex
at the base of the second frontal convolution, as had
been diagnosticated. The tumor was easily scooped
out by the fingers. The lateral ventricle was then
seen to be widely open. After the operation there
was no increase of the paralysis. In two weeks the
patient had entirely recovered. The tumor was 7.5
centimetres long, 5.5 centimetres broad, and four cen-
timetres deep, and weighed two and a half ounces. It
was a hard non-infiltrating sarcoma.
All of the foregoing papers were discussed collec-
tively.
Dr. a. G. Gerster, of New York, confined his re-
marks principally to craniotomy in reference to cases
of epilepsy. He spoke of the dangers in the use of
the trephine and chisel and recommended the bone-
flap operation as introduced by Krause and performed
by aid of the chisel and rongeur. He considered all
of these methods unsatisfactory and too slow. Inci-
dentally he exhibited Krause's electrical saw.
The greatest danger in cranial operations is due to
hemorrhage on account of the prolonged time of the
operation. Therefore any apparatus is desirable that
will enable the surgeon to work with rapidity and
safety. He presented an American apparatus based
on the principles of the dental drill, and said he had
used the instrument with satisfaction in four cases.
Dr. M. a. St.arr had seen twenty-four cases oper-
ated upon, but none was cured. He has never rec-
ommended, and will not recommend, operation in idio-
pathic epilepsy. He has always had the advantage of
a skilful operator. These operations should only be
done by surgeons who have special experience in this
line of surgery and not by the general surgeon. The
exsection of cysts is very unsalisfactor\-, as death on
the table has often followed. He had seen cases op-
erated on very early in infantile epilepsy due to me-
ningeal hemorrhage without favorable result. When
brain tissue, either scar tissue or normal tissue, has
been excised, the attacks have also recurred. Of eleven
patients with brain abscess operated upon, three re-
covered. All of these cases were seen at the various
hospitals and were usually subsequent to ear disease.
He could not agree with Macewen's view as to the
simplicity of diagnosis of cerebral abscess. He
thought the day of trephining was over. The last
operation witnessed was done in fourteen and a half
minutes by chisels and gouges.
Dr. W. \V. Keexe spoke at length on the report of
the case presented conjointly by him and Dr. Thomas,
and considered the prognosis favorable. The removal
of large tumors seems to be less dangerous to life than
that of small ones, as in the search for the latter we are
likely to damage the brain extensiveh . It is only with-
in the last ten years that cranial surgery really began.
His experience had been moderately large. He agreed
with Dr. Starr, as he (Dr. Keene) had not seen a sin-
gle case of epilepsy cured by operation. He would be
unwilling to accept even two years, but thought three
years preferable as the limit for disappearance of at-
tacks after operation. He had, however, seen consid-
erable amelioration, and therefore thought it worth
while to operate in certain cases. He would not oper-
ate in cases of general idiopathic epilepsy. The
sooner the operation is done after the injury or the
beginning of epilepsy the more favorable the prog-
nosis. After epilepsy had existed five or six years,
he would hesitate in operating. He concluded that
we must have twenty years of experience in cerebral
surgery before this matter can be satisfactorily settled
by the profession.
Dr. J. R. Llovd presented a patient with right
hemiplegia and contracture, unilateral sweating and
flushing of the face and dilatation of the pupil, and
looked upon the latter symptoms as due to an irrita-
tive lesion of the thalamus.
Third Day — Friday, June jfh.
(Edema of the Eyelids in Graves' Disease ; Thy-
roidectomy.— Dr. J. Arthur Booth, of New York,
read a paper on this subject (see p. 45).
Dr. Starr expressed the opinion that operations in
these cases were not always safe, the percentage of
death being twelve out of one hundrecl and eighty-
seven cases. Sudden deaths have occurred soon after
the operation. They were not due to surgical shock,
but to the absorption of thyroid juice during the oper-
ation, thus overwhelming the system by its toxic prop-
erties. The operation of thyroidectomy should not tae
done indiscriminatelv.
A Form of Mental Disease Clinically Resem-
bling Certain Stages of Paretic Dementia. — By Dr. E.
C. Si'iTZK \, of New York. The reader had found in
a long experience sixteen cases of an affection most
important to dit?erentiate, as the termination was in
recovery. So close was their resemblance //o fan. to
paretic dementia, that in every instance that or the
equivocal diagnosis of '"softening'" had been made.
The writer himself had at first regarded them as ap-
pertaining to Yoisin's atheromatous insanity or to his
own group of primarv- mental deterioration. The
speech disturbance was peculiar, being more like that
of febrile delirium than that of a toxic or organic
anarthria. By concentrating his attention, the patient
could correct his errors, and it was the longest words
and those of most difficult enunciation which he pro-
nounced as readily as most persons of average health
66
MEDICAL RECORD.
[July 1 1, 1896
and education. Repeated trials rapidly fatigued him,
and while no real paretic speech could thus be pro-
voked, he was as apt to say "there is rumthing sodden
in the den of statemark " as to quote the passage cor-
rectly. When an expression failed him, he displayed
considerable skill in circumscribing his meaning by
the use of metaphorical or parallel expressions. A
similar feature was found in that similar condition —
bromism. The earliest case of which he had a record
occurred in October, 1879, and was recorded by him
as one of chronic confusional insanity, with a reserva-
tion as to probable atheromatous sequela;. The pa-
tient exhibited a typical confusional delirium. His
age (sixty-four), the arcus senilis, the tortuous tem-
poral arteries, and the characteristic pulse were sug-
gestive. He was promptly committed to an asylum on
his advice. In February, 188 1, he appeared in his
office, and had made a recover)'. This patient was
alive and in good health three years ago. Among the
etiological factors, syphilis and alcohol could be ex-
cluded. Grippe, malaria, railway injuries, dysentery,
and chronic bronchitis played a predisposing role.
Recovery occurred in from four to fourteen months.
The ages of his patients ranged from forty-eight to
seventy-one years. He had found the last eleven
cases recorded among males exclusively not quite two
per cent, of a group of cases including five hundred
and eighty-five paretic dements, forty-one of athero-
matous mental trouble, and twenty-eight of primary
mental deterioration.
Nerve Disturbance from Indigestion — By Dr.
Henry S. Upson, of Cleveland. The paper dealt with
the nervous disorders arising from intestinal indiges-
tion. Three cases were given, one of the nervous phe-
nomena arising in typhoid fever, in brief as follows:
A voung man of twenty-four was seen at the end of the
first week of typhoid. Besides the typical tempera-
ture curves, enlarged spleen, nose-bleed, backache, and
other symptoms, he w^as even thus early somewhat de-
lirious during the day and quite sleepless at night.
Thymol and hydrochloric acid failed to relieve, one-
sixth of a grain of morphine with twenty grains of
Dover's powder did not produce sleep, and within a
week there were coma, vigil, and subsultus tendinum.
The bowels had been throughout very constipated.
During the third week of tlie disease sleep followed
very promptly the clearing of the bowels by calomel,
an eighth-grain every hour during the day and every
two hours during the night. The second case was of
a merchant, sixty years old. He was seen two weeks
after recovery from a severe attack of dysenter)'. The
diarrhoea had been checked by the free use of opium.
He was in a state of what may be termed restless mel-
ancholia. He w-as very nervous, cried easily, slept
almost hone. There were rumbling and moderate
pain in the bowels, with occasional somewhat offen-
sive movements. The patient was given strontium
salicylate and calomel, and was restricted to a milk
diet. He began to sleep fairly well at night, was con-
tented to remain in the hospital, and his extreme pallor
and fairly marked ana;mia with his other symptoms
improved slowly but steadily. The third patient
showed a similar train of symptoms after a mental
shock. She gradually developed a condition of de-
pression, ner\ous irritability, and sleeplessness after
hearing suddenly that her husband had accidentally
shot himself, and in spite of the fact that he made a
good recover)'. She was first seen five months after
this event. In addition to the symptoms already given,
she had rumbling and some tenderness of the bowels,
but there was neither diarrhcea nor marked constipa-
tion. Her condition improved promptly on a milk
diet and one of the salicylates. Conclusions were not
warranted from so few cases, but the author believed
from a somewhat e.vtended experience in these cases
that the type of nen-e disturbance found in typhoid,
and in connection with and after dysenterv' and diar-
rhcta, is found in intestinal indigestion without the
intervention of these disorders, may easily be con-
founded with mild melancholia and neurasthenia: it
presents many points of similarity to nicotine poison-
ing, it must be carefully differentiated from nerve dis-
orders arising by refiex, it is amenable to treatment,
which should not consist exclusively in the adminis-
tration of an antiseptic.
Report of the Committee on Neuronymy Dr.
B. G. Wilder presented the report.
Among the recommendations of the committee were :
1. That the adjectives dorsal and ventral be employed
in place of posterior and anterior as commonly used
in human anatomy, and in place of upper and lower
as sometimes used in comparative anatomy.
2. That the cornua of the spinal cord and the spinal
nerve roots be designated as dorsal and ventral rather
than as posterior and anterior.
3. That the costiferous vertebra; be called thoracic
rather than dorsal.
4. That the hippocampus minor be called calcar;
the hippocampus major, hippocampus; the pons Va-
rolii, pons; the insula Reilii, insula; pia mater and
dura mater respectively pia and dura.
5. That, other things being equal, mononyms (sin-
gle-word terms) be preferred to polyonyms (terms
consisting of two or more words).
Newspaper Rabies. — This was the title of a paper
by Dr. Ikvlnc; C. Russe, of Washington, D. C. He
referred to the frequency with which hydrophobia was
mentioned by the public press at this season. Late
papers on the subject show that there is still a chaotic
knowledge of this badly elucidated afilection, concern-
ing wiiich surgeons and neurologists are by no means
agreed. From examining a great mass of literature
relative to rabies, while working on the index cata-
logue of the surgeon-general's office, Dr. Rosse stated
that he came across hundreds of references to hydro-
phobia of a spurious character, and that these refer-
ences date from the Homeric era to that of Cellius
Aurelianus. -Much other literature was also cited, show-
ing that in by-gone times there were skeptics as to the
existence of such a pathological entity as hydrophobia.
As an extensive traveller in parts of the world where
this disease is supposed to occur geographically, he
had never seen a case, nor had he any authentic knowl-
edge of one from personal observation. The secretary
of the Japanese legation in Washington says he has ^
never known of a case in Japan, and that in Corea,
having more dogs than any other country in the world,
hydrophobia is unheard of. A few Italian and French
physicians and the newspapers appear to be the chief
contributors at the present time. The reader thought
that, in view of the uncertain state of knowledge of
the subject, the newspapers are hardly to blame for
reckless accounts of hydrophobia, since they only hold
the mirror up to nature, and, reflecting public senti-
ment, give us. so to speak, a radiograph of what is
passing in the minds of medical men.
The Collateral Theory of Epilepsy.— Dr. F. W.
Langdon, of Cincinnati, presented a paper entitled
" Epilepsy and Other Convulsive Diseases — A Study
in Neuro-Dynamics."' His conclusions were:
1. That epilepsy, the choreas, and probably most of
the convulsive disorders are the dynamical expression
of an inhibitory insufficiency, not indications of over-
production of ner\e energy nor " explosions" due to
a "molecular instability'' per sc.
2. That the cause of this inhibitory insufficiency is
to be sought for in the end brushes of the collateral
processes of various cortical neurons, the situation
var)'ing with the " type" of the disease, whether sen-
sory, psychic, or motor.
July 1 1, 1S96]
MEDICAL RECORD.
67
3. That the defect consists most probably in a
istructural incompleteness (small capacity, defective
insulation, imperfect contact) or a numerical defi-
ciency, or both, in the collateral processes of the neu-
rons referred to.
4. Defective collaterals may favor occurrences of
■convulsions in two ways: {(/) by impairing connec-
tion with other neurons (inhibitory, storage, etc.); (b)
bv increased resistance to " overflow currents" causing
temporary overcharging of motor a.xis cylinders. This
conception of the anatomico-dynamic basis of convul-
sive phenomena he would call "collateral theor)'."
On this basis cases of epilepsy are classed under
three groups, each of which presents important differ-
ences as regards prognosis and treatment.
1. Primary, or developmental type, comprising the
'' idiopathic'' cases under twenty years of age. In
these, the younger the subject and the better the he-
redity and environment, the better the prognosis under
intelligent treatment, ultimate result depending on
the possibility of promoting further and equable de-
velopment of collateral communications with inhibi-
tory mechanisms.
2. The "accidental" forms: These are due to
trauma, syphilis, lead, to.xins, etc. The prognosis
varies with the longer or shorter duration and the
possibility of removal of the cause; being always
favorable so long as permanent structural changes in
collaterals and inhibitory mechanisms have not oc-
curred.
3. The " degenerative " type : The rare cases of
adult life and old age (not accidental) belong in this
■category. Here palliation only is to be expected, as
in the case of degenerative changes elsewhere. In all
forms the rational indications for treatment are: To
lessen the incoming sensory excitation, by diet, occu-
pation, medicines; and so lessen the intensity of motor
responses which are not provided with suitable over-
flow and inhibitory mechanisms.
Election of Members The following-named gen-
tlemen were elected to active membership: Dr. F. K.
Hallock, of Cromwell, Conn.; Dr. John Punton, of
Kansas City; Dr. Alfred Wiener, of New York; Dr.
Henry J. Berkley, of Baltimore; Dr. F. W. Langdon,
■of Cincinnati.
Election of Officers. — The officers elected for the
■ensuing year were: President, Dr. M. A. Starr, of New
York; Vice-Presidents, Dr. H. R. Stedman, of Boston,
and Dr. H. S. Upson, of Cleveland; Secretary and
Treasurer, Dr. G. M. Hammond, of New York; Coun-
cillors, Dr. F. X. Dercum, of Philadelphia, and Dr.
Joseph Collins, of New York.
Epispadias. — The following operation for the relief
■of epispadias seems theoretically correct and has
yielded satisfactory results in two cases. The steps
are as follows: i. A perineal fistula, made by cutting
from the outside, upon the finger introduced into the
bladder above to distend the perineum or by the use
•of Watson's perineal drainage tube. The subsequent
steps may be proceeded with at once or ten days after,
■when time and rest have allowed dryingand healing of
excoriations. 2. Dissecting-up of the urethra, which
lies open upon the upper surface of the perineum. 3.
Separation by blunt dissection of the loosely con-
nected cavernous bodies. 4. The urethra, laid in the
■gutter then formed, is secured by two sutures through
lower floor of urethra and skin of under surface of
penis. 5. The free edges of the urethra are united
•with continuous catgut ligature over a silver catheter
extending to bladder. 6. The cavernous bodies are
then united with continuous catgut and the skin, which
is usually abundant, with interrupted silkworm gut. —
Cantwell (Annals of Surgery, December, 1895).
Surgery of the Lung. — Dr. Paul Reclus, at the
ninth French .Surgical Congress {La Aledecine Mo-
derne, October 23, 1895) discourses on this subject and
concludes: i. That surgical interference in cases of
tuberculosis must be proscribed. 2. In primary can-
cer no conditions can arise in which pneumonectomy
would be feasible. 3. Where there are cavities inci-
sion is sometimes a justifiable palliative measure. 4.
Resection of a portion of the lung is a last recourse
for hemorrhage. It has been successful in three re-
ported cases. 5. Incision is beneficial in hydatid
cysts, gangrene, and abscess. The intervention in
these cases is radical, but sometimes saves the life of
the patient.
Treatment of Fibroid Tumors by Ergot Prof.
W. H. Byford begins his chapter on this subject as
follows: "i. When properly administered ergot fre-
quently greatly ameliorates some of the troublesome
and even dangerous symptoms of fibrous tumors of the
uterus, e.g., hemorrhage and copious leucorrhoea. 2.
It often arrests their growth and checks hemorrhage.
3. In many instances it causes the absorption of the
tumor, occasionally without giving the patient any in-
convenience; at other times removal of the tumor by
absorption is attended by painful contractions and
tenderness of the uterus. 4. By inducing uterine con-
traction it causes the expulsion of the polypoid vari-
ety. 5. In the same way it causes the disruption and
discharge of the submucous tumor."
Sterilization of Catgut — The thread should be
rolled on a piece of glass and left in ether a day, then
put into nitrate of silver in a dark-colored vessel full
of the solution. Prepared in this way the catgut pre-
serves its flexibility. It should be kept in alcohol or
juniper oil. — I'ratcli, No. 51, 1895.
The Relation of Trauma to Malignant Tumors.
— Dr. Zugler reviews this subject in the Miincliener
med. Wocliensehrift, Nos. 27 and 28, 1895. He bases
his paper on the statistics of the last five years in the
surgical clinic in Munich. In all there were 328 cases
of carcinoma, 117 in men and 211 in women; and
17: sarcomas in 81 men and 90 women. After deduct-
ing tumors of the mamma and genital organs there
were 108 tumors in men and 102 in women. In the
carcinomas there was a history of single traumas 55
times. There had been chronic irritation 92 times.
In the sarcomas a single trauma was noted 35 times,
and 32 times chronic irritations (including warts) were
at fault. Some cases of single trauma seem to stand
in doubtful relation to the formation of the growth,
but as a rule the new formation has been occasioned by
injury. The writer bases his opinion on the continu-
ation of the pains and swellings after the trauma,
which go insensibly into the formation of the tumor.
Dr. Ziegler adopts Virchow's irritation theory of the
high percentage, twenty-five per cent, for single
trauma, and eighteen per cent, for continuous irrita-
tion. The influence of trauma should be considered,
no matter what theory of tumor formation one accepts.
The subject becomes important in connection with
medico-legal procedures and accident insurance.
Chronic Middle-Ear Suppuration Dr. Wilson
(Nezo York Medical Journal, March 28, 1896) says the
continuance of the process is due to various causes,
the most important of which are: i. The development
of granulation on the mucous membrane of the tym-
panic cavity. 2. The retention of masses of exuda-
tion. 3. Lesions of the bony walls of the cavities. 4.
Disease of the naso-pharynx.
68
MEDICAL RECORD.
[July 1 1, 1896
3. Abscesses of the broad ligament.
Hysterectomy. — Dr. Ashton {Medical Bulletin, Jan-
uary, 1896) says the conditions indicating hysterec-
tomy for puerperal septicaemia are: I. Suppurative in-
flammation of the uterus. 2. Tubal and ovarian
abscesses.
Rupture of the uterus.
Vaginal Hysterectomy. — Dr. Davis reports twentj-
one consecutively performed cases of this operation. It
may be employed: i. In all cases where we determine
to perform double oophorectomy. 2. In double pyo-
salpinx or salpingitis. 3. In single oophoro-salpingi-
tis where we have unyielding, chronic urethritis. 4.
In severe displacements near the menopause and all
others not yielding to treatment. 5. Tumors of the
uterus, interstitial or subperitoneal, not exceeding a
child's head in size. 6. In all cases of malignant
diseases of the fundus and cervix, when not involving
the vaginal or pelvic walls. 7. In small cysts and
other growths of one or both ovaries and tubes near
the menopause. 8. In all cases of chronic peri-uter-
ine phlegmasia, with or without suppuration, not
yielding to other treatment. — Journal pj the American
Aledical Association, February, i8g6.
Brain Surgery. — Dr. Edward D. Fisher, of New
York, said that the indications for operation are (i)
traumatism, (2) localized epileptic seizures, (3)
athetosis with or without epilepsy, (4) tumors, (5)
abscess, (6) cerebral hemorrhage, and (7) microceph-
alus. — Report of Medical Society oj t/ie State of Xe7-.i
York, January, 1896.
Tumors of the Thyroid Gland.— Dr. Cook {Brit-
ish Medical Journal, ]une S, 1S95) considers the fol-
lowing conditions as indications for removal: i. If
the tumor be steadily increasing in size. 2. If there
be troublesome pressure upon the trachea, oesophagus,
or ner\-es. 3. If the tumor be so placed as to render
impossible a possibly necessary tracheotomy. 4. If
the patient strongly urge its removal because of its
unsightly appearance or its interference with the
movements of the head.
The Antiquity of Anaesthetics — Dr. Hupp writes
in the A'e7i> York Medical Journal, March 28, 1S96:
" Morton discovered anresthesia, and a priceless bless-
ing it has been to mankind, for it has already saved
thousands of lives and is 'destined for all time to come
to compound the sum of human happiness.' But anes-
thesia did not begin with the lamented Morton. We.
are told somewhere in the Holy \\'rit that ' a deep sleep
was caused to fall upon Adam and he slept,' and it was
during this sleep in the Garden of Eden we are further
told of the first surgical operation : an exsection of a
rib, for ' bone of his bones ' was taken from his side
and the flesh closed up instead thereof, and in this
way his helpmeet Eve was fashioned and in ' soft at-
tractive grace' brought unto him."
Gonorrhoea — Dr. Janel (Ann. des Mai. des Org.
Gcn.-Urin.) uses potassium permanganate in the acute
stage to prevent chronic inflammation of the urethra.
The parts are thoroughly cleansed to remove all the
gonococci possible and to prevent secondary infection.
A dilute solution of sublimate should also be used.
Superficial and fresh lesions of the bladder should be
washed and treated with a solution of nitrate of silver
administered a drop at a time, .\fter infective germs
are destroyed it is projser to begin instrumental exami-
nation. Superficial and fresh lesions may be treated
as above, deeper and old lesions with dilatation, and
localized inflammations with the urethral endoscope.
Both parts of the urethra must be treated, even though
the penile portion alone shows lesions.
Dr. Shoemaker thinks rest an important element and
advises keeping the patient in bed a week, after hav-
ing first given a saline cathartic. All condiments and
stimulants should be forbidden. The penis and scro-
tum should be supported. A blennorrhetic should be
administered in small doses and the amount increased
to the limit of toleration. Copaiba and cubebs may
be given alone or in combination. An alkali mav be
given in addition, and in case of great pain a small
quantity of morphine sulphate. Oil of sandalwood two
or three times daily in five-minim doses is also an
effective remedy.
Closing Arterial Wounds by Suture. — Dr. Hei-
denhain, in the Centralbl.fiir Chir., Xo. 49, 1895, cites
two previously recorded cases, involving in one in-
stance the common femoral, in the other the common
iliac. He also reports a case of his own, in which
during the removal of some cancerous glands from
under the armpit, and after necessary resection of a
portion of the axillary vein, a wound about an inch
and a half in length was accidentally made in the
main artery. The bleeding was arrested by digital
compression and the edges of the arterial wound were
brought together by a continuous suture of catgut.
The bleeding was thus completely arrested. The
lumen of the vessel was not apparently diminished.
The sutures held firmly in spite of strong arterial
pulsation. The patient made a good recovery, and
when last seen, seven months after the operation, was
quite free from relapse. The axillary artery could be
felt pulsating along the whole e.xtent of the armpit.
Orificial Surgery. — The logical conclusion to be
formed from the teachings of orificial specialists is
that the rectum is the focus of existence, contains the
essence of life, and performs the functions ordinarily
ascribed to the heart and brain. — DiezL' York Polyclinic.
Cleft Palate. — Dr. Broca considers it unnecessarj'
to wait until a child is two or three years old before
operating. He does not hesitate to operate on a child
of from three to six months old, provided it can have
proper attention.
Hepatic Abscess. — Dr. M. Fontan (International
Medical Journal), who has treated forty cases of abscess
of the liver following dysentery contracted in tropical
countries, adopts the following rules for operating: i,
a free incision eight or ten centimetres long: 2, the
final resection of one or more costal cartilages to ex-
pose the abscess freely: 3, the separate suturing of
the peritoneum and of the pleura: 4, the complete cu-
rettage of the cavity of the abscess.
Intestinal Anastomosis — Mannsell's Method. — i.
The longitudinal slit which is made in the segment of
the bowel having the greatest calibre (proximal or
distal), and through which the invagination occurs,
should be located at least two inches from the cut end
of the bowel. 2. The mesentery of both segments
must be included in the first temporary suture which
is passed at this intestinal border: this prevents slough-
ing of the bowel at this point. 3. The sutures should
be placed at least a quarter of an inch from the cut
intestinal edge; they should be interrupted, about
twenty in number, and should not be drawn too tightly
when they are tied. 4. The best suture material for
the work is carefully tested and prepared horsehair.
5. The needle best adapted to this work is a round,
straight one (milliner's, Xos. 6 to 9). 6. The inva-
gination, after the sutures have been placed, must be
carefully reduced, rather by manipulation than by trac-
tion: othcnvise the sutures may cut out. 7. In clos-
ing the longitudinal slit, too much of the intestinal
edges should not be turned in, or a contraction may
result at this point. — Wiggix, New York Medical Jour-
nal, December 14, 1895.
July 1 1, 1896]
MEDICAL RECORD.
69
OUR LONDON LETTER.
(From our Special Correspondent.^
JIEDICAL COUNCIL COMING ELECTIONS AR.MY MEDI-
CAL SERVICE AND ITS GRIEVANCES SPLENIC AN.E-
MiA — LORD Kelvin's jubilee — hospital sundav —
SIR T. G. LOGAN.
London, June 19, 1S96.
The General Medical Council having finished its ses-
sion, we are now speculating on the results. Some im-
portant questions which were postponed may perhaps
be determined differently from what would have been
the case had the vote been taken at the late meeting.
Some new members appeared at the last session, as I
have already reported, but there will be more new
blood at the ne.xt, as we shall have fresh elections for
direct representatives. In Scotland, Dr. Campbell
Black, an energetic reformer, will come forward as a
candidate. The Rev. S. Haughton, M.D., has re-
signed the seat for Trinity College, Dublin. In Eng-
land two of the three representatives, Sir VV. Foster
and Mr. Wheelhouse, have signified their intention
not to seek re-election. In the letter announcing this
they insist that they have never failed to advocate the
views of their constituents, so far as compatible with
the acts, and advise a " very deliberate and careful
choice" of their successors. This would be a contrast
to the manner in which they themselves obtained their
seats, through the disgraceful action of the British
Medical Association clique in direct opposition to a
resolution of the association. But this old story was
duly told by your correspondent at the time. It will
be interesting to see if the early announcement is in-
tended to prepare the way for a similar electioneering
proceeding or only for a "very deliberate and careful
choice."
On Tuesday Dr. Farquharson once more called the
attention of the House of Commons to the army medi-
cal service with reference to the difficulty of obtaining
candidates in consequence of the still unredressed
grievances of the medical officers. He asked whether
the new warrant spoken of would be promulgated be-
fore the ne.xt examination, but the official reply was
most unsatisfactory and professed ignorance as to
whether a warrant would be issued. The case of Sur-
geon-Captain Fowler comes before the house to-day,
and unless " my military advisers" retreat there may
be an unpleasant quarter of an hour for them. Dr.
Anderson's case is being pushed by the Civil Rights
Defence Committee, and there are other object lessons
for the public and Parliament which may lead to retri-
bution. As to army surgeons, the authorities expected
to get a supply from the Irish schools, but the most
influential teachers there have warned the students that
if they become candidates before a satisfactory war-
rant is issued they will injure those already in the
service and have to submit to the grievances under
which their brethren labor.
A considerable number of army men were at their
annual dinner on Monday, when the new director-gen-
eral of the department was in the chair, supported by
his predecessor. Of course this was no occasion for
the ventilation of grievances.
Splenic anjEmia has been before the Medico-Chi-
rurgical Society. Dr. S. West related a case very
fully, and several others were mentioned by different
speakers, so that the disease would seem to be less
rare than the number of recorded cases — about twenty
— might lead us to suppose. The usual course of the
disease is gradually increasing debility and occa-
sional pain in the region of the spleen, followed later
by great anaemia with enlargement of the spleen, pro-
gressing to profound cachexia and death from asthe-
nia. Sometimes there are hemorrhages, and in Dr.
West's case these came on early and a hajmophilic
condition ensued. There was also cedema of the
larynx necessitating tracheotomy, but the operation
wound did not heal, oozing continued, and at length
hemorrhage was sufficient for blood to be sucked into
the air passages and prove fatal. At the post-mortem
the liver weighed ninety^-three ounces, the spleen sev-
enty-six. The latter was soft, and one infarct was
found with a state of slight cirrhosis. Both these or-
gans are usually in this state. Some cases are said to
have been benefited by arsenic. The spleen has been
removed for this disease by Sir S. Wells and by Mr.
Gould, who gave an outline of his case and thought
the operation a justifiable one. A case of the disease
in a girl of thirteen was mentioned, one in a iDoy of six-
teen, another in a boy of ten. But there seemed to be
some doubt about the last two. As the disease is rare
and resembles the effects of malaria as well as cir-
rhosis of the liver, the diagnosis is difficult and not to
be made without examination of the blood. Dr. Kan-
thack insisted that the blood should be examined in
all cases of aneeniia in order to obtain a more extended
standard for comparison. The examination should
not be confined to counting corpuscles and estimating
haemoglobin, but the different stains introduced by
Ehrlich should be used to distinguish the several
forms of leucocytes. Von Limbech has suggested that
splenic anaemia is only the last stage of the severe
ancemiaof rickets or of syphilis, and some of the cases
seem to support the suggestion, while others are
scarcely compatible with it. Those which have re-
covered should be particularly scrutinized in these
respects, as should also those in which no post-mortem
has been obtained. Besides splenic ancemia, the terms
splenic cachexia, splenic pseudo-leukaimia, lymph-
adenoma splenica, spleno-me'galie primitive, etc., have
been applied to these cases.
I need only mention the splendid celebration of
the jubilee of Lord Kelvin's work at the Glasgow
University. The feats of the telegraph on the occa-
sion will have familiarized your readers with the event
and most of its interesting features.
The jubilee of chloroform is talked about as a suit-
able celebration for next year, but no active steps have
been taken to organize it, and the question would be
raised, why not make it embrace all anaesthetics.''
Hospital Sunday has passed. Up to last night
nearly /^i 7,000 had been received at the Mansion
House. This seems small compared with last year's
total, but it is not without promise; for up to the
same time last year the amount actually remitted was
less by some ^72,000. We must wait till the later
amounts come in to make a profitable comparison.
Sir T. G. Logan, K.C.B., honorary physician to the
Queen, formerly director-general of the army medical
department, died on the nth inst., aged eighty-seven.
He had a very distinguished career and received many
honors. He was a persona grata in regimental and
official life, a genial companion, able administrator,
and shrewd observer.
Fractures. — Having had some experience in mal-
practice suits, I make it a rule to give my patients
with severe fractures a worse prognosis than I really
expect and I always have witnesses to this. To the
laity all fractures are alike, and because "Dick" had
a broken leg which united perfectly, "Tom's'" leg,
which was fractured in the same place, must neces-
sarily also become perfect. If this result is not
reached, it is due to the doctor's ignorance or care-
lessness.— Dr. Kurtz, Southern Cat. Pract.
^o
MEDICAL RECORD.
[July 1 1, 1896
OUR PARIS LETTER.
(From our Special Correspondent.)
SALTS OF COPPER AS COLORING .MATTER IN CANNED
VEGETABLES DAMAGE TO PUBLIC HEALTH CAUSED
THEREBY — PROTEST AGAINST USE OF — FOREIGN
MEDICAL STUDENTS AND DOCTORS IN PARIS-
GOVERNMENTAL ME.A.SURES REGARDING THEM — THE
PRACTICE OF MEDICINE — INTERNATIONAL CONGRESS
OF SURGERY — INSTITUTE PASTEUR — LABORATORY
APPROPRIATION, ETC.
Paris, June 20, 1S96.
The addition of tlie salts of copper to vegetables sold
in cans, in order to impart to them a brilliant green
color, is always deleterious to the public health, and
although many, perhaps the majority, escape any di-
rect evidence of harm — such as epigastric pain, intes-
tinal paroxysms, diarrhoea, colitis, etc. — yet mischief
is done all the same; not so much because the salts of
copper are cumulative, which they are only in an ex-
ceedingly small degree, but because of the effect upon
the mucous membranes, which in very healthy persons
may resist for a long time but finally yield to the con-
stant irritation caused by their prolonged use. When
green vegetables are cooked they assume a yellowish
tint; yellow from an asthetic point of view is certainly
preferable to green, and from a physiological one less
dangerous to health. It appears that manufacturers
of canned vegetables in France are authorized to pre-
pare their goods with the addition of a certain quantity
of the salts of copper, which the public ignores, and
Professor Duclaux, professor of biological chemistry
at the Faculty of .Sciences of Paris, expresses an offi-
cial opinion that the public should be more thoroughly
warned against the use of canned vegetables, and that
the consultative committee of hygiene should obtain
from the public authorities a decree in these terms or
their equivalent: "The salts of copper are too little
dangerous to prohibit their use altogether, but manu-
facturers who employ them do so upon their own re-
sponsibility, and all the accidents caused by their pro-
ducts are to be placed to their account, even though
it be demonstrated that the can that caused them did
not contain more copper than other cans remaining
inoffensive.''
It is to be hoped that the campaign so well begun
by Professor Duclaux may be carried to a successful
issue, with decided benefit to the public; it is rather
remarkable, however, that while upon the subject, no
mention was made of the many cases of lead-poisoning
that may be and have been caused by canned vegeta-
bles and fruits, leaving coloring matter entirely out of
the question, and attributable to the metal- of the can
itself.
At a recent meeting of the Chamber of Deputies,
in reply to a communication addressed to him with
reference to foreign medical students, the minister of
public instruction replied in the following sense:
The law^ of November 30, 1892, regarding the practice
of medicine in France, having given rise to some er-
rors concerning the obtaining of the degree of doctor
in medicine by foreign students, the government has
taken certain measures to remedy them. Neverthe-
less, it is important to respect the international con-
ventions or agreements relative to this question.
There are actually in the different faculties of medi-
cine of France at present ten hundred and fifty-four
foreign students, or twelve per cent, of the total num-
ber of medical students. The greater part of these
foreign students belongs to Russia, Roumania, Bulga-
rii^, and Greece. England and the United States fur-
nish the smallest contingent. It will be observed
that all of these countries, with perhaps England as
the only exception, are born to political and scientific
life more recently than France, the presence of these
foreign students in French faculties being, therefore,,
an evident proof of the superiority of French instruc-
tion. To close the doors of our establishments to them
would be a mistake, for most of them come to France
only to pursue their studies, and, these terminated,
they return to their native countries. The minister,,
in terminating, announced that he was devising a
means to deliver to foreign students not pro\'ided with
French qualifications, and having terminated their
studies, a special diploma of doctor in medicine, not
carrying with it the right to practise on French terri-
tory.
.\fter this reply of the minister, Professor Lanne-
longue, the eminent surgeon, proposed a resolution,,
which was accepted by the government, inviting the
minister of public instruction to depose a project of
law upon the situation of foreign doctors and medical
students in Fance.
To obtain the right to practise medicine in France,,
foreign students, and doctors of other faculties as well,,
will probably in the near future be obliged to become
naturalized Frenchmen, to serve in the army, and pass-
all the regular examinations at the school of medicine
besides. On these conditions the medical schools of
France are open to the students of all countries. This
sounds very liberal, but when read thoughtfully, and
taking into consideration the fact that a thorough,
knowledge of the French language is also requisite
and necessary, the already existing difficulties are only
multiplied and amount practically to exclusion. Very
few young Americans desiring to establish themselves
in Paris would, if they could accomplish it, be will-
ing to comply with all these requirements, and older
members of the profession would not think of it.
The Faculty of Medicine and the profession at large
are taking much interest in a project which also touches
the American faculties and profession in general as
well; namely, the organization of an international con-
gress of surgery, that shall hold sittings at regular in-
tervals in the four following countries: Great Britain,
the United States, France, and Germany. The official
languages of the congress shall be French, English,
and German, and the first international reunion of
surgery will take place in London, in igoo.
A movement against the Institut Pasteur has been
started by certain interested parties, who accuse the
successors of Pasteur of transforming the institute into
a shop. It seems that to-day the important matter is
not whether the serum is good or bad, whether the dis-
covery is real or only illusory, but whether the Institut
Pasteur, that pious monument to public charity, does
not inconvenience by its radiant expansion a host of
pharmaceutists and small dealers in medical wares. It
should not be forgotten in this connection that Dr.
Roux, who recently received from the French Academy
a prize of 25,000 francs, gave the whole of it, from the
first sou to the last, to the Pasteur endowment fund.
It would seem that inoculations, although they may
cure hydrophobia and diphtheria, are powerless against
envy and greed of gain.
The 250,000 francs appropriation for laboratories
is, after all, not going to be had without some opposi-
tion and wrangling. Dr. Bourgoin, in a speech made
by himself in the Chamber of Deputies a few days
ago, remarked that in his opinion the laboratories
have been well endowed during the last few years.
He .continued: "When I made my experiments with
our masters, Claude Bernard, Wurtz, and Berthelot,
the government provided its laboratories liberally with
long tables, chairs, blackboards, fountains, sinks, etc.
As professors (agre'ges) we received 500 francs a
year; that salary is now augmented to 3,000 francs in
Paris and 4,000 francs in the provinces. As regards
the regular professors, they receive at present from
July 1 1, 1896]
MEDICAL RECORD.
71
6,000 to 9,000 francs in the provinces, and from 9,000
to 15,000 francs in Paris." Dr. Bourgoin thought
that under the circumstances those who wanted to make
individual experiments ought not to demand anything
of the government.
The appropriation, however, is likely to be made.
It is strange how easily doctors become politicians im-
mediately after or even before election, and how will-
ing they are to vote for measures oppressing their own
profession.
GONORRHCEA.
To THE EdITOU of THE MeDICAL ReCORD.
Sir: Dr. Herbert J. Hopkins' paper in to-day's issue
cannot fail to interest the profession everywhere, as
it presents a consensus of the current opinions on
the treatment of gonorrhoea.
The doctor's elegantly written paper, however, con-
tains some points on which we do not fully agree.
The salient ones of these are in his comparison of
gonorrhoeal ophthalmia and gonorrhoeal urethritis.
\N'hile indisputably there is no difference in their pa-
thologv, the organs affected differ so widely in a me-
chanical sense that the same treatment may not apply
to both. But I will not presume to discuss eye-affec-
tions, on which the author is certainly better informed
than I.
Dr. Hopkins will not take it amiss that observation
of the work of others and experience in the treatment
of gonorrhoea have given me views diametrically op-
posed to his. I may sum them up as follows:
1. Gonorrhcea is not a self -limiting disease; if it
were, we would not have that army of chronic gonor-
rhceas, which the treatment advocated in the paper un-
der discussion has failed to affect.
2. It is not "impossible to shorten the course of
gonorrhoea.''
I have the records of a large number of acute cases,
treated according to the formula published in the
Cliuical Recorder iox February, 1896, which show com-
plete disappearance of the discharge within ten days.
I have now the records of twelve cases in private
practice, cured within three days. All these cases, of
which I have preserved the microscopic slides, show
gonococci in profusion. I call them cured: ((?) be-
cause curetting the urethra and examining the prod-
uct revealed the absence of bacteria; (/;) because
strong irritant injections of nitrate of silver made a
week later produced a discharge which contained no
gonococci; (c) because large quantities of beer drank
two weeks or twenty days later produced no discharge;
{d ) because se.xual intercourse three weeks or thirty
days later produced no discharge; (S) because ure-
throscopic e.xamination showed a perfectly healthy
urethra.
The above I attribute to careful, judicious employ-
ment of urethral and intravesical irrigations with grad-
uated dilutions, mainly of potassic permanganate,
and no other medication whatever. I even allowed
those accustomed to it to drink a glass of claret at
meals.
In chronic gonorrhcea — I mean true gonorrhoea with
myriads of gonococci but uncomplicated — I have had
as favorable results with a variation of the method
published in the New Albany Medical Hera/d lor No-
vember, 1895. I may cite a typical case: A physi-
cian of more than average good repute had for twelve
years been "' curing" his gonorrhoea on the plans so
aptly recorded by Dr. Hopkins. His thick, greenish-
yellow discharge was full of pus cells containing gon-
ococci and the other microscopic concomitants of gon-
orrhoea. In live days the gonococci disappeared, three
days later he discharge that had become muco-serous,
ceased, and six months later — on Christmas Day — the
doctor insured me a substantial " morning drop" for
the rest of my life, in the shape of a handsome dia-
mond pin.
The Medical RtxoRD for August 5, 1895, did me
the honor to publish my paper on " Urethroscopy in
Chronic Urethritis," in which this matter is more fully
discussed.
As to the use of balsams : I showed them to be ex-
cellent culture media for gonococci in bacteriological
investigations made in Berlin in 1894 and 1895. Of
these a preliminary note was published in Pick's
Archiv (Vienna and Leipzig, August, 1895). I hope
to publish the paper in full in English, detailing the
methods employed and the results obtained.
The author says: '' During the first three weeks, the
physician is indeed worthy of his hire who insures to
his patient comfort and freedom from some one of the
following complications: Balanitis, phimosis, paraphi-
mosis, follicular abscess, lymphangitis, bubo, cowper-
itis, prostatitis, cystitis, epididymitis."
There are now, according to the above, one hundred
and forty-two physicians in the United States worthy
of their hire, not to mention Felike of Buda-Pest,
Janet of Paris, Frank of Berlin, Goldberg of Cologne,
and others in Europe.
My own experience since December, 1894, runs be-
tween twenty and twenty-five cases daily in private
and dispensary practice. In not a single instance
was the patient ever otherwise than comfortable after
the first irrigation, and not a omplication ever re-
sulted.
George Knowles Swinburne has an experience al-
most double mine within the past twenty-seven months.
He reports only one case of epididymitis, which he
does not attribute to the irrigations.
These hasty notes are not penned to attack Dr.
Hopkins, but in the hope that he may be led to inves-
tigate the treatment of gonorrhcea by hydrostatic irri-
gations. Then another far more able pen than mine
will advocate them to the benefit of suffering humanit}'
and the medical profession everywhere.
Through such writings haphazard will give way to
the true scientific treatment of gonorrhcea.
Ferd. C. Valentine, M.D.
242 West Foktv-Third Street, New Vokk, May 22, 1896.
The Waning Reputation of Colorado. — It was
some time ago intimated in an Eastern paper that the
streets of Denver were covered with the sputa of con-
sumptives. The statement was not far from the truth.
Unless very rigid measures for the prevention of the
spread of consumption in Colorado are adopted and
put into force, Colorado will become a " pesthole."
One thing that may help us out in this country is the
fact that the amount of rainfall seems to be on the in-
crease. There is no question that Colorado has prob-
ably the greatest climate in the world, all things con-
sidered, for the average consumptive, yet, in our
opinion, it would be a fortunate and glorious day for
Colorado to lose that reputation. W'itii a better under-
standing of the cause of consumption and better knowl-
edge of its prevention and better facilities and meth-
ods for its treatment, climate will not long, we trust,
be a desideratum in the management of this disease.
We now look upon tuberculosis and realize that it is
the most contagious of all diseases known to human-
ity. Every consumptive who walks along one of our
sidewalks and deposits a lump of tuberculous matter,
loaded with consumptive germs, is deliberately and,
in most instances, intentionally doing that which will
spread the very disease of which he is dying, and it
was through just such criminal carelessness of some
other consumptive that he contracted tuberculosis him-
self.— Denver Aledical Times.
72
MEDICAL RECORD.
[July 1 1, 1896
^em instruments.
A NASAL BAG.'
By \V. FREUDENTHAL, M.D.,
NEW YORK.
This small apparatus which I take the liberty of show-
ing to you is intended to serve a double purpose. In
the first place, it aids in controlling nasal hemorrhage.
In an article on the etiology of post-nasal catarrh,' I
have tried to show that in this city during the winter
there are quite a number of hemorrhages from the
nose which originate in consequence of the extraor-
dinary dryness of the air in our rooms. I have ex-
perimented and find that at times we have as little as
eighteen to twenty per cent, relative humidity in our
houses. This lack of moisture has the effect of drying
the nasal mucosa, which becomes cracked and fre-
quently bleeds during the continuation of this drying
process, which is induced by our artificial system of
heating. Now, our text-books advise us to stop nasal
hemorrhages by cauterizing the so-called locus Kies-
selbachii or any other affected part. However, if we
take into consideration the etiology of the cases just
mentioned, it will be evident that such treatment will
render a mucous membrane which is already dry still
more so. Therefore such patients have to return to
the physician, until under more favorable climatic con-
ditions the hemorrhages stop of themselves. Al-
though such patients should have a course of system-
atic treatment, it is well to give them a means of stop-
ping epistaxis at home or on a journey. For this
purpose I believe this apparatus will be of good ser-
vice.
It consists (see Fig. i) of two equal-sized rubber
bags. A, A, which are connected by
a rubber septum, j-. On the upper
part of each bag there is an open-
ing that is closed by a screw, n.
Through this opening the bag can
be filled with ice or anything else.
The apparatus, therefore, consists
of nothing more than two ice bags
connected with each other. These
bags are filled, put on the nose, and
fastened around the head with the
two bands, C. The apparatus is
manufactured in three sizes by
Messrs. George Tiemann & Co.
It will be advisable always to
take that size which leaves open
the introitus narium, at the same time, however, cov-
ering the whole external nose. The nostrils are to
be left open for the purpose of plugging the nose.
It is not at all objectionable that the bag should
cover part of the forehead. But it will usually e.xtend
above the eyes, and for the protection of these organs
it is best to cover them with some cotton.
I have repeatedly been called in consultation by
colleagues in severe epistaxes, and I have always
succeeded with comparative ease in controlling the
hemorrhage. As a matter of precaution I invariably
plugged the anterior nares, but each time I had the
feeling that the ice bag had helped me essentially.
During these manipulations the patient generally sat
before me, either in his bed or, still better, on a chair.
In different operations under general anaesthesia I
have used the ice bag as a prophylactic measure.
' Demonstrated before the physicians of the German Poliklinic,
January 17, iSg6.
- " Some Points Regarding the Etiology and Treatment of Post-
Nasal Catarrh, with Remarks on the Hygiene of the Respiratory
Organs," Journal of the American Medical .\ssociation, Novem-
ber 9, iSSj.
Fig.
Thus, I applied it three times during Ash's operation
for deviation of the septum, and in other operations
on the nose in which a severe hemorrhage was to be
expected in plethoric or aneemic subjects. The bag
was put on the nose as soon as or before narcosis was
begun. It appeared to me that by the time anesthesia
was established the effect of the ice could be noticed.
But my experience in this respect is too limited to al-
low any conclusions.
On the other hand, my extensive experience in stop-
ping nasal bleedings of other kinds by means of this
apparatus has convinced me that it is a positive help.
This apparatus serves also another purpose, i.e., to
abort acute coryza. In acute colds heat is found bene-
ficial in other parts of the body, and, reasoning from
this experience, I have applied hot water to the nose
in this bag. The patient lies down and changes the
water as soon as it begins to cool.
In addition I ordinarily use the small receptacle, B
(see Fig. 2), which can easily be fastened to the bags.
Fig. 2.
This helps to approximate the bags to the nose and
will hold any medicament the physician chooses to use
for inhalation. Thus, I have applied camphor or men-
thol in substance or in oily solution on cotton. These
substances are thus inhaled constantly through the per-
forated roof of the receptacle, while at the same time,
of course, the hot-water bags lie upon the nose. In
this manner I have made it possible for some singers
who came to me in the forenoon w ith a bad cold to use
their voice in the evening. In other cases I have also
had good results with this method, and I can therefore
recommend it as a convenience to the profession.
943 M.^DISO.N .^VL.N'fE.
l^tVctUcal Jtcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending July 4, 1896 :
Cases.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-po.x
igi
21
7S
2
160
231
Deaths.
127
3
9
2
II
39
Enuresis. — .\ccording to Foster's " Encyclopsedic
Medical I)ictionary " we have:
Enuresis atonica — Enuresis from debility.
E. continua — Incontinence of urine both day and
night.
E. diurna — Incontinence of urine by day.
E. irritata — Enuresis from irritability.
E. mechanica — Enuresis from mechanical causes.
E. nocturna — Nocturnal enuresis.
E. paralytica — Enuresis associated with paralysis of
bladder.
E. spastica — Enuresis due to spasm of bladder.
Medical Record
A JVeekly youmal of Medicine and Surgery
Vol. 50, No. 3.
Whole No. 1341.
New York, July 18, 1896.
$5.00 Per Annum.
Single Copies, loc.
INSANITY OF PUBESCENCE.'
By HIRAM ELLIOTT, M.D.,
WOODHAVEN, N. Y.
Of the insanities occurring at various periods of life the
study of none is so interesting and instructive as that of
the forms occurring in youth. All ideation is then much
simpler, the brain cells being receptive rather than
elaborative. Little or no effort is made to analyze or
conceal the ever-changing emotions, and, the inhibi-
tions and judgment being comparatively undeveloped,
ready utterance is given to every thought. Cerebral
states are more frankly manifested. Hence, when con-
ditions of mental alienation arise, not only are they
less comple.x, but they are reflected more directly from
the underlying lesions, being less refracted by indi-
vidual characteristics or dimmed by inhibitory power.
In other words, the mental machinery is less intricate,
and therefore more easily understood, and any defects
in its action are more readily seen and appreciated.
All healthy growth or discharge of function is at-
tended with the sensation of pleasure. It is the privi-
lege of the healthy, normally developing youth to
enjoy the height of human felicity. Not only are his re-
cuperative tendencies at their best at this time, but he
is passing through his constructive stage in the strict-
est and highest sense of that term, and every day is
adding to his mental and physical strength. And
when nature awakens in him the procreative function
she endows him with a new element of power, and
adds another attribute of physical perfection.
It is perhaps not too much to say that, physiologi-
cally at least, the chief end of man is to pierpetuate
the species, and that to the procreative function, and
to foster the results of its healthy and legitimate ac-
tivity, all other functions are subservient. Indeed,
nature is so jealous of this power that she usually de-
nies it to idiots and others incapable of rearing off-
spring, and allows it to exist in the human subject
only during the best years of life. And if by chance
or design the organs in which it is seated are removed
before maturity, all the manly and womanly character-
istics, having then no purpose to subserve, fail fully to
develop, and the individual becomes the merest cari-
cature of what he might have been.
The grave constitutional symptoms often caused by
slight lesions of the genito-urinary organs are further
proof of their intimate and extensive relation with
other parts of the body. For example, the simple gentle
passage of a soft bougie into the bladder may quickly
give rise to a violent chill attended by intense prostra-
tion, alarm, and anxiety, accompanied by violent
vomiting, profuse diarrhoea, coldness, and lividity of
the surface, almost total suppression of the urine, all
the evidences of urremia, and a rapidly fatal issue
(Keyes). A slight blow on the testicles has caused
unconsciousness followed by vomiting and prolonged
and severe prostration. Indeed it is within the range
' Read befc re the Brooklyn Society for Neurolojfy, December
26, 1895.
of possibilities that an injury to the organs of procre-
ation may produce a more serious effect on the mind
than an injury of the same extent to the brain itself.
Such then being the importance and sensitiveness
of these organs, the question of their condition is of
the greatest consequence in the study of the disease
incident to youth in both sexes. For, whatever may
be the cause, youth is beset with many ills. Espe-
cially are neurotic and catarrhal conditions prevalent.
So many fairly healthy children at fifteen or sixteen
become skinny and nervous, and develop chorea or
epilepsy or insanity, that we are forced to the conclu-
sion that causes both common and powerful have come
into force; causes with an essentially destructive ten-
dency, decreasing the resisting power of the individ-
ual, encouraging the appearance and growth of
hereditary taints, and often temporarily and even
permanently arresting the mental and physical develop-
ment, and blighting the entire organism. It must have
come within the experience of most physicians to see
the previously healthy children of certain neurotic pa-
rents one by one fall a prey to some nerv'ous or physi-
cal disorder when they reach this critical stage of their
life.
It is maintained that at puberty sexual ideas and
promptings, suddenly forcing themselves upon the
mind, precipitate a sort of chaos; that the assimilative
apparatus being no longer able to meet the extraordin-
ary demands of the organism, chiefly in consequence of
the newly acquired function, the body falls into a state
of malnutrition. This explanation is both inadequate
and illogical. Indeed it is in cases in which the pro-
creative power is lost that the peculiar stunted physique
is most typically seen; and the more nearly the pro-
creative function has been extinguished by early and
excessive abuse of the sexual organs, the more nearly
does the physique conform to this type. On the other
hand, the sexual longings are usually weak or wanting
in the insane pubescent, there being rather an aversion
to and an intense antipathy for the opposite sex in
every way. That accumulation of sexual energy which
normally gives rise to sexual promptings does not ob-
tain, but in its place is found a condition of sexual
irritation, which impels the unfortunate individual to
degrading habits, and even to acts of indecent assault.
These conditions may exist in children long before
they are capable of a sexual idea. Not a few children
of both sexes, either by accident or by imitating their
companions, learn evil habits which induce in their
generative organs such debility that when they arrive
at the age of puberty they seem incapable of natural
sexual promptings. Sexual longings are normal in
the pubescent, and the only question of consequence
regarding them is, will they provoke their unnatural
gratification .'
That they too frequently do is beyond peradventure.
And if the organs misused are so sensitive, it seems to
me idle to shut one's eyes and try to explain the some-
what rapid increase of insanity after the onset of pu-
berty by profound p.sychological discussions regarding
the intricate reactions between the mind and body, or
regarding mental conflicts between the youthful and
adult traits and propensities, relegating the habit in
question to the category of symptoms. To me it is
74
MEDICAL RECORD.
[July 1 8, 1896
evident that neither body nor mind can develop nor-
mally if kept in a state of weakness and irritation by
the excessive practice of an exhausting habit. I do
not wish to seem to dwell unduly upon this disagree-
able topic, but I cannot avoid a matter because dis-
agreeable which it behooves every parent and phy-
sician to look squarely in the face.
Forms. — In the insanities occurring in the period
in question there is not that tendency to conform to
type that is seen in adult life. The same may be said
of the normal mind in youth. The individual charac-
teristics, which when once set give color to and modify
the symptoms of all diseases, are just being moulded
from the still plastic material. Every one accepts the
dogma that insanity is a clinical expression of brain
disease; but no one has so far succeeded even in de-
monstrating a pathological difference in cerebral con-
ditions to correspond to the symptomatic difference
between mania and melancholia. Even in paresis,
in which the pathological findings are comparatively so
constant and definite, the scalpel and microscope have
not revealed why one victim should seem supremely
happy and another wholly miserable. The study of
etiology is equally unsatisfactor}-, identical causation
being found capable of producing symptoms most un-
like. The physical vulnerability and potency of the
individual seem to be capable of directing etiological
factors to the production of certain pathological states,
and the individual temperament to be able to modify
and give color to their clinical expression. An insane
man is the caricature of himself in health. Insanit)'
is mental derangement in the strictest sense of that
term, and out of the resulting disorder propensities
and characteristics, hitherto existing but more or less
held in abeyance, possibly in an exaggerated form,
come to the front and predominate. And often they
have not very far to come. In youth, even in health,
we find little that is fixed — the purposes, the emotions,
the moods are ever changing, and when conditions of
mental alienation arise, we find naturally the most
widely differing phenomena even in the same individ-
ual. Sometimes, however, we find instances of quite
typical maniacal or melancholic perversion in vouth,
but investigation will show a correspondingly well-de-
fined temperament and character, and the absence of
masturbation.
In childhood insanity is expressed almost wholly in
conduct. Occurring as a pure insanity, perhaps only
in children who have practised masturbation very early
in life, there is not much mind to be affected. These
puny unfortunates have the pasty face, sunken eyes,
and unhappy expression, widely dilated pupils and ex-
aggerated reflexes which indicate an exhausted and
hypersensitive nervous system. Intense restlessness,
sudden fits of anger with homicidal tendencies, wanton
destructiveness or crueltj', great timidity, lack of
memory and that curiosity which is so strong in
healthy children, irregular sleep, and capricious appe-
tite are some of the phenomena observed. Two boys
whom I saw in my hospital service, aged thirteen, but
looking more like children of seven, were so mali-
ciously destructive, and so wholly ungovernable in the
children's wards, that they had to be sent to the adult
male ward for management. They were silent and un-
communicative, and when spoken to paid so little
heed that it was difficult to tell whether they under-
stood what was said to them or not. Another boy
whom I saw a short time ago, aged fourteen, but look-
ing only ten, who had masturbated since four, was so
nervous that a single sharp question made him bellow
with fear, and so interfered with his co-ordinative
power that he could scarcely articulate, and could not
walk across the room without fouling with the furni-
ture. His brain seemed little more than a hypersensi-
tive reflex centre, from which all ingoing stimuli re-
issued at once without elaboration or inhibition in ex-
pressions of fear, very much as they might have done
fourteen years before when he was an infant in his
mother's arms. In this failure to understand my ad-
vances, and the tendency to regard them as necessarih
hostile, are seen fundamental principles in the de-
velopment of a delusion — more or less distortion of
ingoing stimuli by the representative apparatus and
their subsequent misinterpretation in terms of a pre-
dominant emotion or idea.
Advancing a few years, when purely mental phe-
nomena begin to come into prominence, we find the
symptoms still more mixed and varied. One day the
manifestations may be characterized by great exulta-
tion, the next by depression, and tlie next by stupor.
Seen at one time the patient presents intense motor
excitability; the next day he may be cataleptic.
Some trivial remark causes first immoderate laughter,
and then tears or anger. The reflexes are much exag-
gerated and the whole economy in a state of irritabil-
ity. Delusions may be vague and indefinite, or well
marked, and vary from the most ambitious to the most
depressing or persecutory type. One lad of seventeen
when first seen was rushing up and down in the most
abject terror. In a few days he was cheerful and so
apparently well that he was sent to do some light
work. He began the day by assaulting his attendant:
he next made an attempt to escape, and was returned
to the ward in a very elated condition. The next
morning he was cataleptic and remained so for weeks.
Coming down into the adolescent period when
mental manifestations come still more to the front and
predominate, insanities become more typical. Some
individuals are adult at twenty with well-marked
mental and physical characteristics, and in such, es-
pecially if not addicted to bad habits, we may have
t}-pical melancholic and maniacal perversions. Of
course the results of the undeveloped brain, such as
cretinism, idiocy, and its cousin, paranoia, which
manifest themselves in all periods of life, are not re-
ferred to above, nor are they discussed in this paper.
And it is proper to remark here tliat it is possibly
this lack of conformity to tv-pe that has given rise to
the term insanity of pubescence, as though it were a
distinct variety of alienation; but it must be seen
from the foregoing that the forms in question have
rather a coincident than an intrinsic connection with
pubescence itself.
Causes. — In nearly every case of insanity in youth
heredity is an etiological actor. The fact is hard to
get at sometimes, owing to the dislike most people
have to discuss any weak points in their family. One
woman positively denied all neurotic conditions in the
family history of her insane adopted daughter, but a
reliable friend of the patient informed me that the
girl's mother was epileptic and her father paralytic.
An e.xcellent family history is often obtained from
parents who are themselves walking demonstrations of
its incorrectness. Some obliging old lady, who has
known the family for years, will know about any ner-
vous, or hysterical, or consumptive, or dissipated, or
epileptic, or paralytic, or insane members of the family,
or any intermarriage of cousins, and will contribute
largely to the evidence that insanity in youth is
strongly hereditary. But then, judged by its worst
branches, what family tree is sound?
Again, the bringing up of many children strongly
predisposes them to neuroses of all kinds. It is an
unfortunate circumstance that parents who beget neu-
rotic offspring generally add to the evil by bringing
them up badly. Next to the stamp of heredity, comes
the impress of the environment as an agent to mould
the character and determine the tendencies of the in-
dividual. Hot-house methods are much to be depre-
cated. Abundant contact with moral, healthy, happy
July 1 8, 1896]
MEDICAL RECORD.
75
people of both sexes and of all ages is an essential
condition to the proper development of a youth, and
no parents, neurotic or otherwise, can grossly neglect
this principle without imperilling the mental health of
their children. Every physician of experience with
insane youth must recall how large a proportion of his
cases have a history of being quiet and home-keeping
youth and the fact of their avoidance of the opposite
sex put forward as evidence against vicious habits.
The cigarette-smoking imp of the street, exposed to
so many pernicious influences, is one extreme, and this
pampered home-keeping youth is the other, and so far
as his health is concerned possibly the worse extreme.
A human being is a dangerous animal to be left too
much alone with himself.
Of the exciting causes of mental alienation in youth,
masturbation stands first. How any one with any ex-
perience with insanity, and who has kept his eyes open,
can hold any other view is most surprising to me.
Not only may this vice cause insanity in youth, but it
may cause it in adult life, and addiction to it aggra-
vates the symptoms and lends gravity to the prognosis
in any case, and is one of the most potent causes of
chronicity in the insane. It operates in three ways.
First, it has an irritant and debilitating action on the
brain and spinal cord, and through these upon the
entire organism; then it may produce disorders of the
genital organs, such as spermatorrhcea or leucorrhcea,
which add to and perpetuate the direct results of the
habit; and, third, there are the effects of that hidden
strife betwixt shame, repentance, and good intentions,
on the one hand, and irritations which imperiously
impel to the act, on the other, which are probably even
more pernicious than the primary direct and physical
effect (Griesinger). True, the habit may be the result
of insanity, especially among those confined in institu-
tions and thus cut off from opportunity for sexual inter-
course. I have seen numbers of such cases, and with
the commencement of the habit the mental manifesta-
tions became more intense, proving beyond a doubt
that a new and powerful factor had come into oper-
ation. Other causes are ill health and overwork, oper-
ating chiefly in adolescence, intemperance and exces-
sive use of tobacco in a few cases, trauma and shock,
grief and disappointment.
Prevalence. — Insanity before seventeen of such
severity as to send the patient to an asylum is rare:
the vast majority of cases under twenty-one come after
seventeen. The reason is not far to seek. Youth is
a very recuperative period, and nature repairs injuries
very rapidly at this time. The struggles of life with
their accompanying disappointments have scarcely
been undertaken. The manifold dissipations have
hardly been learned, and of course their effects not
felt. Childbearing with its train of ills, and the de-
generative changes of later life are unknown quanti-
ties. Clouston says that only 0.9 per 10,000 of the
general population under twenty are sent to asylums
in England and Wales each year, while the proportion
over sixty is twelve times as great. In the State of
New York the total number of patients of all ages ad-
mitted to the public asylums during the five years
ended September 30, 1893, was 22,231, while the num-
ber under 21 was 1,086. But there are more persons
under 21 than over, therefore insanity is more than
twenty-one times as frequent after 21 as before.
Again, the number beweeen 15 and 20 was 1,006;
between 20 and 25, 2,252; 25 and 30, 2,992: 30 and
35, 3,044. In other words, speaking roughly, insanity
seems to be twice as frequent between 20 and 25 as
between 15 and 20, and three times as frequent
between 25 and 30. Again, it is found that of those
admitted under 20, at least one-half are between 18
and 20. So we see how small a number become in-
sane within four years, say, of puberty — about 500 out
of 22,231. It is proper here to remark that the onset
of puberty cannot be a very strong exciting cause of
insanity, when with all other causes the result is com-
paratively so small. The ne.xt two or three years are
the student and initiative years of life, and if the un-
fortunate youth's constitutional powers have been
weakened by faulty bringing-up or bad habits, it is a
very precarious period. How precarious may be
guessed by the fact that at least one-half of all cases
of lunacy occurring under 21 arise in these years.
Course and Symptoms — It would seem that all
forms of insanity are ushered in by a longer or shorter
period of depression, and the forms in question are no
exception to the rule. Restlessness, sadness, irritabil-
ity, taciturnity, and loss of interest in surroundings are
among the symptoms first noticed. The physique of
our unfortunate patient in many cases becomes pecu-
liar and instructive. Puny and thin, he looks
blighted. He seems to have stopped growing, and he
carries into adolescence the appearance of a child.
His face is pale and pinched, his eyes sunken, w-atery,
and shifting. The cold, clammy hands are thin and
clawlike; the skin soft and delicate. The develop-
ment of all the tissues, but especially that of fat and
connective tissue, seems to have been hindered. The.
beard in males is weak or wanting, and the busts do
not fill out nor the hips widen in females; the voice
remains shrill and childish. And it is the operation
of that cause that is able to lay such a blighting hand
on the body, that produces that exhausted and irritable
condition of the whole nervous system, which is so dis-
astrous that its clinical expression is insanity.
After the period of depression has existed for a time,
the multifarious symptoms of which I have spoken ap-
pear. From the profoundest stupor to the most in-
tense excitement; from the most stubborn silence to
the wildest raving; from the pleasantest mood to the
most hostile impudence; from boisterous laughter to
the bitterest weeping; many of the patients pass
through the widest range of symptoms in an incredibly
short time. On the whole maniacal perversions are
thought to be most prevalent, and if noisiness and ex-
cessive activity be meant this is true. But according
to my obsen-ation painful mental states are far the
more common, if indeed they do not give more or less
color to the phenomena in the majority of instances.
Many cases indeed run into a quasi delirium which
seems to be the expression of acute mental and phys-
ical agony — restless, sleepless, raving, refusing all
food, emaciating rapidly, and often dying in spite of
the best efforts of physician and attendant. In others
the tendency is rapidly to dementia without great in-
tensity of symptoms. In these cases the memory soon
fails and the patient becomes solitary, unsociable, un-
tidy and stupid, and soon sinks into fatuity. In
others explosive symptoms continue for years with
little change. Marked hallucinations of the senses
develop and the patient passes a part of his time talk-
ing to himself or to his imaginary enemies. He is
usually careless of his surroundings, given to fits of
obscene and profane scolding, untidy and troublesome
in almost every way. Some cases again run a very
uneventful course, fits of sulking or crying, childish
manner and ta''-., loss of memory and of interest in
surroundings being the chief phenomena. Almost all
insane youth have hallucinations, sometimes of all
the special senses. Delusions, especially regarding
poisoning, or contamination, or the condition of the
viscera, or involving the belief that the patient has
become angelic or divine, are very common. On the
other hand these may be vague and changing or want-
ing altogether. One of the worst cases I ever saw
showed neither delusions nor hallucinations, but spent
her time raving and berating herself for yielding to
her vicious habits. States of confusion, showing
76
MEDICAL RECORD.
[July 1 8, 1896
marked failure of the normal association of ideas, and
arising out of the exhausted condition of the brain, are
so common as to be almost characteristic. Ecstatic,
cataleptic, and katatonic states are frequent.
One peculiarity in all these cases is the tendency to
sudden remission and exacerbation of the symptoms.
A patient who was wildly excited a few hours before
is often found apparently recovered. He admits he
has been out of his mind, is thankful for what has
been done for him, and talks and acts like a well per-
son for days together, in the end to succumb to a
second attack worse than the first. In insane pubes-
cents not addicted to the habit of masturbation, this
tendency is much less marked. In fact these cases
usually run a more even course in every way, and es-
pecially are they more frank and tractable. In females
the menstrual flow may be suppressed for months.
Appetite is usually poor, as the result of delusions re-
garding poisoning or the condition of the abdominal
viscera referred to above ; or it may be due to the
enervated condition of the stomach. The bowels, es-
pecially in females, are obstinately constipated, and in
girl patients the persistent refusal to pass water may
call for the services of the catheter.
Prognosis. — Clouston says that 5 1 per cent, of these
cases recover. Bevan Lewis estimates that 73 per
cent, get well. These figures, however, seem to me too
high; they are certainly not borne out by the statistics
of the public asylums of this State for the period men-
tioned above. From these statistics I find that the re-
coveries under 21 years of age amounted to 28 per
cent, on the number admitted; between 20 and 30, 23
per cent.; between 30 and 40, 20 per cent. Even
these figures are encouraging and, if they prove any-
thing, they are evidence that mental troubles in youth
are by no means hopeless, but that this is not only
a resisting but also a highly recuperative period of
life. Recovery is often complete and lasting. One
of the best specimens of manhood, both mentally
and physically, that I know, an able lawyer and mathe-
matician, spent a short period of his youth in an
asylum. Of those who do not get well, a small per-
centage dies of exhaustion or intercurrent disease.
Quite a number so improve that they are able to be at
home, and remain as a sort of warning to the other
members of the family. The remainder, in different
degrees of dementia, form rather a disagreeable con-
tingent in asylum wards. The average duration of
cases ending in recovery is from six to nine months.
Treatment. — One glance at our patient suffices to
suggest the first principle of treatment. Nature has
failed to make an adult of this youth chiefly because
of the irritated and exhausted condition of his nervous
system. Remove the irritation, if possible, and repair
the exhaustion. Place the patient in quiet, pleasant,
and healthful surroundings with plenty of sunshine.
Ascertain if there be any tight prepuce, or phimosis,
or short frenum, or congenitally small meatus uri-
narius, or vesical stone; any malformed clitoris, or
pruritus vulvae, or leucorrhcea, or cystitis, which by
their irritation not only may cause profound rellex
effects, but also keep the unfortunate youths' minds
on their generative organs and thus provoke vicious
habits. Remember that this habit may be carried on
without manipulation and may exist, lack of evidence
on physical examination, failure of the attendant to
observe it, and the denial of the patient, notwithstand-
ing. One patient of mine, seventeen years old, whom
I brought through a severe attack of insanity, in whom
no evidence of this habit could be found, afterward
boasted to me that she had masturbated all through
her sickness. To stop the habit, the removal of all
provocations and careful watching are of the most ser-
vice. Continuous exhibition of the bromide of potash,
with the hydrobromate of hyoscine in small doses.
seems to be of some use in alleviating sexual irrita-
tion.
To repair the emaciation in the milder cases, or
after acute symptoms have passed by, the hot-spray
bath twice or three times a week claims first attention
for its soothing and stimulating effect. Exercise in
the open air with tonics, especially strychnine and
arsenic in small doses before meals, cod-liver oil in
never more than teaspoonful doses, generous diet at
absolutely regular intervals, and consisting almost
entirely of milk, hominy, potatoes, and bread, with
meat in small quantities, regulation of the bowels, not
too much restriction of the patient's actions, and very
few sedative or hypnotic doses seem to me to be the
chief elements of good treatment in these cases.
In delirious cases, and others refusing food and
medicine, resort must be had at once to the stomach
tube. By this means not only may be administered
medicine, but also that generous supply of food which
is necessary to repair the e.vtraordinary tissue waste,
and which of itself is often more calmative than any
remedy. The staple articles to be given are milk and
eggs, and occasionally broth or peptonoids. In cases
in which the excitement is not very great a pint of milk,
with two eggs, and two teaspoonfuls of whiskey, if
there is any tendency to the typhoid condition, given
three or four times a day, will usually be found suffi-
cient. If the excitement is very great, and there is ex-
cessive muscular activity, the above amounts may be
considerably increased. I have given four pints of
milk so thick that it would just pass the tube, twelve
eggs, one ounce of butter, and other necessary addi-
tions to a patient every day for weeks, yet diarrhoea
was not set up, and only one or two feedings were re-
jected by vomiting. My patient lived and recovered
her mind. In stuporous or cataleptic conditions the
amounts must be much less or fatal diarrha-a may re-
sult. Ten drops of dilute hydrochloric acid added to
each feeding will be of service. These patients should
be kept in quiet surroundings but not left alone; they
should be allowed to roam about practically unre-
strained, encouraged to sleep at any time, and their
noise should be put up with. If they go forty-eight
hours absolutely without sleep, one-eightieth of a grain
of hydrobromate of hyoscine with one-fifth of a grain
of morphine will usually secure a few hours' rest.
And here I must be allowed to say a word about the
alkaloids of hyoscyamus. Hyoscyamine should not
be used; hyoscine, being more effectual and safer,
because less stupefying and depressing, should always
be preferred. Although not well borne by young or
agitated persons, yet, if it becomes expedient to put an
end to an attack of frenzy or to enforce sleep, this
drug, either alone or in combination with morphine, is
the best means at our disposal. For this purpose at
least one-sixtieth of a grain should be given hypoder-
mically, smaller doses usually making the patient
worse. (}reat dryness of the throat, leading the pa-
tient to believe he has been poisoned, headache and
dilatation of the pupils, muscular prostration, the pro-
duction of hallucinations, or increase in the intensity
of those already in existence, and a general feeling of
unrest, are some of the disagreeable after-effects of its
first administration. A few patients, however, soon
learn to like the sensation it produces, and in these
cases it is a very valuable remedy; calming the con-
vulsions, securing sleep, depressing the sexual organs,
stimulating the kidneys, and certainly not interfering
with the action of the stomach or bowels. Others
again, after its administration, pass rapidly into a sort
of delirium with intense restlessness, weak and rapid
pulse, flushing of the skin, and wide dilatation of the
pupils. If sleep follows, it is short and unrefreshing,
and the patient awakes in a worse condition than
before. These effects, however, more rarely follow
July 1 8, 1896]
MEDICAL RECORD.
n
the hyoscine and moqjhine combination referred to
above. Before resorting to such powerful medication
to procure sleep, all the simpler means should be tried.
A hot bath, or a glass of hot milk to which has been
added a tablespoonful of whiskey, sometimes proves
effectual. I think physicians often get too anxious
about this matter and employ hypnotics which some-
times do more harm than the insomnia. Especially is
the routine use of chloral to be condemned. In most
cases natural sleep will come unbidden, unless in the
mean time the physician yields to the temptation to
give his patient some powerful sedative for the sake
of somebody else. In the treatment of very many of
these cases the highest skill is patience.
The term insanity of pubescence has been used in
this paper to include the aggregate of pure insanities
occurring in youth. I have pointed out the difficulty
encountered in classifying these forms according to
present methods, and I must be allowed to express the
conviction that there is no form of insanity so intrin-
sically connected with, or so essentially arising out of
the pubescence itself, as to be well-named after it;
and to venture the opinion that when alienists shall
have discovered a rational basis of classification very
little of our present nomenclature will pass muster.
RUPTURE OF THE PANCREAS.'
By B. F. HADRA, M.D.,
SAN ANTONIO, TEX.
H. B , nine years old, an unusually bright and
well-educated boy, riding a bicycle down-grade, was
struck by the handle against the epigastrium on Au-
gust 13, 1895, at 3 P.M. He fainted, vomited, but
rallied fully in a short time. At eight o'clock he
began to suffer from severe pain in the abdomen. He
was seen at twelve that night by the family physician.
Dr. Graham Watts, who relieved him by opiates. Dr.
Watts watched the further developments expectantly
as no distinct injury could be made out. The boy
improved slowly, but did not regain his usual health.
The most prominent symptom was his excessive and
perverted appetite. He, for instance, could eat six
or eight boiled eggs, detested table salt, and so on.
On the 6th of September his mother noticed a swell-
ing in the region of the stomach, and on the 9th Dr.
Watts could make out an accumulation of fluid behind
the stomach, which latter stood out in high relief with
well-defined borders, resting on a dull area which ex-
tended on the right side to the angle of the ninth rib
and on the left side into the thorax, so that the dul-
ness over the liver and spleen was continuous with it.
Also the transverse colon could be easily recognized
by its prominent contour. Between it and the stom-
ach was a zone of about one inch in width, giving dull
percussion sound. The temperature was between 98.8'
and 99.2° F. This condition justified the assumption of
a pancreatic rupture with leakage into the cavity of the
lesser omentum. The normal condition of urine and
faeces seemed not to militate against it. I fully con-
curred in this diagnosis, and on the 9th, with the good
advice and assistance of Dr. R. E. Moss, an incision
of about two and a half inches was made in the middle
line so as to hit the interval between the stomach and
transverse colon (Dr. Watts operating). There an
area of about one square inch was raised and the
omentum stitched to the parietal peritoneum on either
side of the incision. Opening this area a clear limpid
fluid escaped, looking like the white of egg, entirely
free of bloody admixture, amounting to over a quart.
The internal lining of the sac was smooth, shiny, and
obviously constituted by the endothelial layer of the
lesser cavity of the peritoneum. An introduced finger
' Read before the West Texas Medical Association.
could feel the pancreas deep down in the cavity. A
drainage tube was inserted and the wound closed
around it. The fluid, on examination, was found al-
kaline and changed starch readily into sugar. No
further test was instituted, as there could not exist any
reasonable doubt regarding the nature of the injury.
The patient suffered little thereafter. His tempera-
ture ranged between 99° and 101° F., as some inflam-
matory irritation of the sac soon set in. The limpid-
ity of the secretion, which was very free, changed into
a muddy, flocculent discharge, which excoriated the
surrounding skin in spite of all kinds of precautions.
The pen'erted and greatly increased appetite contin-
ued. Toward the 15th the temperature became normal
and the discharge lessened considerably. On the 2 2d
the boy was considered convalescent. The fistula had
closed, and only slight superficial abrasions and ex-
coriations had to be tended to. He was greatly ema-
ciated, however; but from now on gained steadily and
was bright and cheerful up to about the 10th of Octo-
ber, when the temperature rose as high as 103° and
even 104° F. The bowels became constipated, and a
a very annoying sensation as of dragging on the
stomach was a constant complaint. There was now a
swelling noticeable under the right rectus muscle close
to the upper end of the incision. As a small suppu-
rating fistulous track was detected, apparently leading
under the muscle, it was surmised that a stitch abscess
had formed from one of the buried sutures. On the
i2th we tried to remove this latter and to empty the
abscess by inserting a grooved director and splitting
the parts on it for about one inch. To our surprise
we at once found ourselves in the abdominal cavity,
encountering adherent and angry-looking omental
fringes. They were detached and removed. Now,
inserting the finger in the direction of the before-men-
tioned swelling, a smooth tumor of the size of a hen's
egg was felt, situated between stomach and liver.
Puzzled what to make of it, and not being prepared
for a more extensive operation, we tried to clear up
its nature by searching for a communication between
it and the original fistula, but none was found. \\'e
left it undecided whether it was the gall bladder
drawn over to the stomach by adhesions, or a par-
titioned-off portion of the omental sack, filled with
pus or pancreatic juice. The boy, though, began to feel
better at once; especially the dull dragging sensation
in the abdomen disappeared entirely. Thus it became
evident that the omental adhesions had caused the
new trouble. The suppuration stopped, the tempera-
ture became normal, and only the irritated stitchholes
claimed further attention. The tumor disappeared
gradually. In a word, the patient recovered perfectly.
He is now the picture of health, though a ventral
hernia is threatening.
I would not expect the general practitioner, who, as
a rule, deals little with rarities, to take much interest
in this case, were it not that traumatism of the epigas-
trium, as from blows or falls, is very common. It must
certainly be of great help to have before our minds all
possibilities as to the nature and outcome of such
injuries. From such considerations I collected what
literature at my disposal offered regarding rupture of
the pancreas, which, as I now think, is not the least
common accident after blows and falls upon the epi-
gastrium.
Before all, the diff'erentiation between a real pan-
creatic cyst and an extravasation of pancreatic fluids
into the lesser cavity of the peritoneum (the bursa
omentalis) ought to be insisted upon. It looks like a
matter of course; still there is a good deal of con-
fusion to be found in many of the contributions on the
subject, everything being termed a pancreatic cyst.
There can be no doubt that a true cyst may be caused
by traumatism, and almost all authors believe in such
78
MEDICAL RECORD.
[July 1 8, 1896
an origin for a great number of their cases ; because
from contusion an intra-glanduiar thrombosis of vessels
or ducts, or an intra-ghindular hemorrhage may result
and lead to the formation of a cyst. Hut it is equally
evident that this is quite a different thing from a con-
dition in which the walls are nothing else but those
of the peritoneal pouch in front of the pancreas. The
former formation is a true cystic tumor behind and
under the peritoneum (retro-peritoneal) (Fig. i). The
latter is intra-peritoneal (Fig. 2). The former, there-
FlG. I. — Cyst of the I*ancreas.
1, Stomach; 3, pancreas; 3,
cyst of pancrea.s; 4, lesser
cavity of peritoneum; 5, trans-
verse colon; 6, liver.
Fig. 2. — Discharge of Fluid into the
Peritoneum, i. Stomach; 2, pan-
croas; 3, point of rupture; 4, nlied
lesser cavity of peritoneum; 5,
[ranjiverse colon; 6, liver.
fore, having its own walls, lifts the peritoneum up and
dips into the omental bursa, while the latter is the
bursa itself. The former will vary in its pathological
construction, being a retention cyst, or of a compound
structure, perhaps malignant, containing a variety of
solids and fluids; while the latter will be a more or
less unchanged peritoneal pouch containing blood or
pancreatic secretions, or both. In the latter instance
the traumatism has simply produced a rent in the gland
and, at the same time, in its peritoneal cover, so as to
allow the fluids to pa.ss through the slit into the cavity
that lies in close apposition to the pancreas. Pos-
sibly, though, a real cyst may occasionally burst and
the thinned peritoneal cover with it, so that the con-
tents will be emptied into the omental bursa, in which
case there will be a mixed condition; that is to say, a
veritable cyst t^'ith an extravasation into the lesser
cavity of the peritoneum (Fig. 3). However, I have
not yet found a description of such an occurrence.
As to the differential diagnosis there will seldom
be any difficulty. A real cyst is a more or less
chronic, insiduously commencing growth, whilst in
the other instance a recent traumatism is the begin-
ning. A cyst will be a well-defined, rounded tumor,
more or less movable as a whole, perhaps nodulated,
rarely very large, following the movements of respira-
tion; whilst tlie filled peritoneal sack wiJl be a slack,
elastic, fluctuating mass. The pancreatic cyst will be
found mostly in the middle line above the umbilicus;
sometimes a little to the left; while the other extends,
according to the outlines of the bursa — in the begin-
ning slightly perceptible but growing more and more
in its area — from the right side over the gastro-hepatic
ligament (about in front of the angle of the ninth or
tenth rib) to the left as far as to the outline of the
gastro-lienal and pleuro-colic ligaments, that is, as
far as the anterior axillary line, and upward under
the left brim of the thorax, so that the dull area will
indefinitely reach up to the right and left lobe of
the liver, to the spleen, etc. Thus the dulness on
percussion will extend farther to the left than to the
right. Perhaps also in the back a dull area will be de-
tected, as in one of Lloyd's cases, in which it extended
from the angle of the left scapula down to the lowest
ribs. The apex beat may also be raised to the left.
In either instance the tumor lies behind the stomach
and the transverse colon, though a cyst may work it-
self between both, lifting up the gastro-colic liga-
ment. On percussion in either instance the tympanit-
ic sound of stomach and colon will be made out, and
if any doubt exist, both ought to be inflated by the
usual means. But with a cyst only in extreme cases
will both hypochondriac regions be occupied, while
otherwise the tympanitic areas will appear like islands
on a general dull basis. The interval between
stomach and colon, the site of the gastro-colic liga-
ment, will in a distended bursa form a dull zone, be-
cause here the fluid reaches up to the omental front
wall. With a cyst this zone will not be more detect-
able than under normal circumstances, except the
tumor has gotten into this space, when it will easily
be recognized as a tumor. I may at once say that
this place ought to be selected for probatory puncture.
However, the origin of the omental accumulation
may not be pancreatic at all. Evidently hemorrhage
from any vessel within the omental sack may cause an
accumulation of blood, so that a correct diagnosis may
be impossible. An exploratory puncture will clear up
most of such cases. Whenever the fluid, so gotten,
offers the features of pancreatic juice, that is, if it be
more or less like the white of an egg, or if it chemi-
cally shows the attributes of pancreatic secretion, the
case is, of course, decided. If, on the other hand,
the contents should be a mixture of blood and some
other fluid which is lighter, that is, if the contents
be thinner and lighter than pure blood, it is almost
certain that there exists leakage from the pancreas in
addition to hemorrhage, because there is no other fluid
that could be extravasated in this region, except
chyle, which occurrence is still rarer. Only if appar-
ently pure blood is found, an uncomplicated injury of
some blood-vessel within the lesser peritoneal cavity
has to be looked for. From experience and from the"
result of .Senn's experiments, we know that rents and
ruptures of the pancreatic gland are not accompanied
by much hemorrhage — in one case there was none at
all — but then the large pancreatic vessels themselves
may have been ruptured. For the sake of illustration
I will cite one of J. Lloyd's cases,' who deserves all
the credit for having elu-
cidated these important
and interesting injuries:
■■ .\ man, aged twenty,
had been kicked by a
horse and on recovering
consciousness complained
of abdominal pain. The
other symptoms were:
collapse, frequent vomit-
ing with an occasional
streak of blood in the
vomit, temperature of
100° F., all subsiding in
the course of four or five
days. .After leaving the
hospital paroxysms of epi-
gastric pain with vomit-
ing recurred about weekly, lasting two or three days at a
time. .After three or four months an unusually severe
attack caused the man's readmission. There was
some distention of the abdomen and slight elevation
of temperature. Recovery ensued, but about a month
later a sudden and severe attack was followed by a
swelling in the left hypochondrium. .\n aspirating
needle was inserted and twenty-nine ounces of fluid
withdrawn. Finally, incision was made and a cavity
found containing a further quantity of dark brown
fluid. Death occurred from exhaustion a few hours
later. On opening of the abdomen signs of recent
peritonitis were found. Situated behind the stomach
and co-extensive with its posterior surface was an
enormous encysted ha;matoma containing red coagula.
It appeared as if the hemorrhage might have occurred
' British Medical Journal, 1S92, quoted from .Sajous' .Vnnual.
Fig. 3. — Cyst of Pancreas Compli-
cated with Discharge of Fluid into
the Peritoneum. i, Stomach; 2,
{>ancrcas; ^, cyst of pancreas; 4,
lesser cavity of peritoneum; 5,
transverse colon; 6, liver; 7. place
of rupture in pancreatic cyst.
July 1 8, 1S96]
MEDICAL RECORD.
79
from some ruptured vein in the gastro-splenic omen-
tum, found its way inward, and gradually become
encysted between the peritoneal coat of the stomach
posteriorly and the peritoneal covering over the pan-
creas. No special examination of the pancreas for
injury was made.''
In 1892 I had an opportunity myself to operate in
a case which was similar to this case of Lloyd. The
operation was performed, however, within a few hours
after the injury.
A young colored man had leaped from the platform
of a railroad car while the train was in motion. He
fell Hat on his abdomen against some bridgework.
Brought to the John Sealy Hospital in Galveston, he
e.xhibited all the signs of e.xcessive internal hemor-
rhage and pointing toward the region of the spleen
as the seat of his trouble. I expected to find a rup-
ture of it when I made an incision on the outer border
of the left rectus muscle. But there was only a slight
rent of this organ and not more than a tablespoonful
of fresh blood. Toward the stomach, pent up in the
omental pouch, an elastic mass could be felt. The
patient was then in a dying condition and in order to
get him from the table ali^e, nothing else but closing
the external wound was done. He expired an hour or
so later. Unfortunately no post-mortem e.xamination
was allowed by his relatives; but there seems to be no
doubt that a hemorrhage from some vessel within the
omental bursa had taken place.
As to the further symptoms of pancreatic rupture
there must be mentioned nausea, vomiting, and faint-
ing— which constitute the signs of one form of shock.
Whether this is peculiar to traumatism of the pan-
creas, or whether it is a symptom common to blows on
all abdominal organs, is a question that can be an-
swered only hypothetically. Goltz's well-known ex-
periments show that blows against the abdomen cause
an accumulation of blood in the abdominal veins
while the brain becomes anaemic, and that in this way
shock is produced. Still, there seems to exist, outside
of this mechanism, some influence of the pancreas of
its own on the stomach, perhaps on the whole sympa-
thetic system, either by some reflex action or by alter-
ations in the juices of the body, because, even in
cases of old standing and in diseases of entirely dif-
ferent nature, such complaints are common. Contu-
sions of other glandular organs — for instance, of the
testicles, as is well known — cause a similar complex of
symptoms. Perhaps there is a similar mechanism at
work.
Of more value as a sign of pancreatic injurv is the
e.xcessive and often perverted appetite, setting in
shortly afterward. It is frequently mentioned by
authors and deserves full attention. I do not venture
to give an explanation of it. Urine and faeces rarely
offer pathognomonic features. How much Roentgen's
photographic method will help in the differential diag-
nosis will have to be seen.
Prognosis. — It is well to take it for granted that in
many a case of so-caUed internal injury produced
by blows or falls upon the abdomen the pancreas has
been ruptured, and that the alarming symptoms just
after may be due to such an occurrence. But it is
evident that usually the rent will be so small that it
will readily heal and that the exudate will become
absorbed. Consequently the patient will recover in a
few days. But, on the other hand, an accumulation
will show only in the course of time, whenever it has
become large enough to form a detectable tumor.
Therefore the prognosis ought to be guarded. We
may look for final recovery whenever hemorrhage can
be excluded or when, judging from the symptoms, it
has stopped. That means when the patient comes
well out of the shock, paleness disappears, pulse be-
comes stronger, etc. As to the necessity of an opera-
tion we should also be careful in our prediction.
Judging from the experience in our case in which the
leakage had continued several weeks, the smooth and
shiny appearance of the lining membrane can be taken
for a proof that the otherwise strongly excoriating ac-
tion of the pancreatic juices is powerless on healthy
endothelium or epithelium, here as in other places.
From Senn's studies we know that the portion of
the pancreas above the rupture of the main duct w ill
atrophy. But we can easily imagine that a superficial
rent which does not go through the whole thickness of
the gland will do little harm. Besides, it is mostly
the head of the pancreas that will be directly hit by
the traumatic force, as it is the thickest and at the
same time the most exposed part. Thus the large
portion below the rent will remain undisturbed. If,
however, the rupture occurred in the tail, then perfect
atrophy would set in: but whether this will lead to a
fatal termination is a question not yet sohed. Ex-
periments on animals are certainly not final, but even
they are contradictory. Besides, according to Ziegler,
an accessory pancreatic gland is often found which may
act when the other is destroyed. As a rule, pancreatic
ruptures will by their effect upon the gland itself
rarely produce fatal consquences. It will, of course,
greatly depend upon the extent and situation of the
tear, and upon the time it remains patulous. A small
lateral slit may leak even continually: the pancreatic
secretion may then be absorbed as quickly as it appears
in the omental bursa. But an excessive accumulation,
filling the widely disturbed point, can and must have
a deleterious effect on all the adjoining organs. The
coeliac plexus may suft'er; the pancreas itself, the
liver, the gall bladder, stomach, bowels, spleen, the
large lymphatic and blood vessels, especially the
portal vein, must be pressed on and thus greatly inter-
fered with. The prognosis, therefore, becomes grave
if the extravasate continues to increase. Then only
surgical interference will relieve the patient. How
long the accumulation may go on uninterrupted is not
in my power to state from the literature at my dis-
posal. Perhaps, in the end, the extreme distention of
the sack will produce atrophy of the pancreas by pres-
sure, and the leakage will thus be stopped and the
peritoneum will be given time for absorption. But it
would certainly not be good surgery to wait for such a
termination.
Treatment. — Immediately after the accident indica-
tions for interference will be too vague to be acted
upon. Locating the trouble will be mostly impossible
and an exploratory laparotomy will be called for only if
the symptoms become steadily graver. According to
\vhat was said before, slighter injuries may heal on
their own account. But when there are unmistakable
symptoms of dangerous hemorrhage which do not
quickly abate, the abdomen should be opened as soon
as practicable. If then no evidence of bleeding is
found in the general peritoneal cavity, the omental
bursa ought to be incised with due protection of the
intra-abdominal structures against the pancreatic fluid.
The question whether or not a large transverse in-
cision in the gastro-colic ligament may interfere
with nutrition of the colon can be answered satisfac-
torily. We know from experience in gastronomy that
such is not the case. Next we have to empty the
omental pouch of its coagula, and if a continuance of
the bleedinj; be found an effort ought to be made to get
at the seat of it. By pulling the stomach upward and
the transverse colon downward, and with the use of
reflected light, we may expect to see our way. Per-
haps compression by packing with gauze will answer.
Now, in cases of older standing, in which the contin-
uance of hemorrhage can be excluded, or in which by
tapping a pure or a slightly bloody pancreatic-juice
accumulation has been made out, from all experience
8o
MEDICAL RECORD.
[July 1 8, 1896
at our command, drainage of the sack seems a safe pro-
cedure. We will then make a small incision over the
dull zone between the stomach and the transverse colon,
satisfying ourselves of being below the stomach by
searching for the great curvature, which can always be
recognized by the wreath-like arrangement cf the
blood-vessels. Then the omental pouch should be
punctured with a hypodermic needle and, after the case
has thus been made out, an area of about one square
inch of the omentum must be stitched to the parietal
peritoneum around the abdominal incision, and
opened. After the evacuation of the fluids, a drain-
age tube is inserted and the wound closed around it.
Care has to be taken to protect the surroundings of
the fistula by ointments, as the pancreatic fluid is ex-
ceedingly e.xcoriating. Most probably the secretion
will become less and less, though it may take months
before it will stop entirely. The selection of the
location for incision, whether in the middle or on the
left side, as recently done by Howard Kelly,' seems to
me of little importance. Still, the former is prefer-
able, because the subsequent adhesion of the omentum
to the parietal peritoneum will be so located as not to
interfere with any abdominal structure; while in the
left side by retraction of the previously widely dis-
tended omentum a band may form which would be a
constant menace to the bowels.
.\ very interesting point seems to me the explana-
tion of the modus operandi of the drainage effecting a
cure of the pancreatic rent. Is it the change of the neg-
ativie pressure in the airtight sack into a positive one;
or is it the influence of the atmospheric air, or perhaps
the discontinuance of the pulling asunder of the lips of
the fistula by the force of the ever more distending
pouch? The question whether here, as in other in-
ternal fistula;, ouside drainage is a curative expedient,
seems to me worthy of closer investigation ; or, per-
haps, it is a lack of information on my part that I
know no other explanation than that of Lawson Tait
in connection with abdominal drainage.
Finally, I would like to say a few words in regard
to the tumor felt in our second operation. As stated,
we tried to solve the conundrum by leaving it an open
question between a distended gall bladder in an un-
usual place and a partitionedoff portion of the omen-
tal pouch filled with pus or pancreatic juice, a kind
of a diverticulum. Hut, I confess, neither interpreta-
tion will satisfy anybody. Only quite recently the
puzzle obtained a solution, at least in my mind, from a
paper by Professor Riedel,of Jena,' and I now believe
that which I felt was the head of the pancreas. Rie-
del reports cases in which the swollen pancreas was
found directly under the liver and was taken for the
gall bladder. He describes an instance in which
the pancreatic head presented a hard, easily movable
tumor, rising and falling with respiration, situated
directly under the abdominal wall, easily grasped by
the hand. He says: ''A pitiful smile would have
punished him who before the operation would have
suggested such a possibility." He further shows how
the pancreas may become puffed so as to resemble
even malignant enlargement from irritations due to
inflammatory conditions in connected organs, as the
gall ducts, gall bladder, duodenum, etc., which en-
largement will recede with the removal of the cause.
In our case there was evidently sufficient cause for irri-
tation and the disappearance of the tumor leaves
hardly any other interpretation.
Tight Lacing.— Professor Marchand {Modern Medi-
cine) says tight lacing sometimes causes gall stones
and that cancer is occasionally due to the same cause.
' .Annals of Surgery, December, 1895.
' Berliner klinische Wochenschrift, January 6, 1896.
THE INFLUENCE OF COLD UPON A DIS-
EASED HEART.
By ARNOLD LORAND, M.D.,
KARLSBAD.
At the coroners' inquests held on the bodies of the
numerous victims of the cold during the winter of
1894-95 in London, it was shown that the great
majority of the deceased were either persons with dis-
eased valves of the heart or aged persons with patho-
logical changes in the musculature of the heart. Ap-
parently persons with a diseased or senile heart have
not the same power of resistance against the effects of
cold as persons w ith a normal heart.
The temperature of any part on the surface of the
body is mainly dependent upon the amount of oxy-
genated blood with which it is supplied by the heart.
Therefore the greatest sensation of cold will be felt on
those parts of the peripher)- of the body which are sit-
uated at a considerable distance from the blood and
heat-giving centre, or which first come under the influ-
ence of the cold on account of their position. So the
toes and fingers, the ears and nose, as also the feet
and hands, will be more readily attacked by those
pathological processes which are caused by the local
irritation of the cold upon the surface of the body.
We know that chilblains are most frequently met with
in anEemic young girls with feeble circulation, and
even strong persons with normal circulation, when ex-
posed for a short time to cold of great severity, will
become frostbitten on the toes, which lie far away
from the centre of circulation, and the same parts will
even become gangrenous in old persons with a very
weak circulation. On the other hand, where there is
a flow of oygenated blood there will be a rise of tem-
perature. If there is a flow of blood with an inflam-
mation of the skin or phlegmon in the subcutaneous
tissue, we see the affected part red, and that spot will
also feel warm. From remote times, besides tumor,
rubor, and dolor, " calor" has been accepted as one of
the pathognomonic symptoms of inflammation. The
bright red color will show us that the blood has not
been fully deprived of its oxygen, and there is an in-
crease of temperature in the affected part. The same
effect can be produced by a local irritation, which will
cause an accumulation of arterial blood. The para-
lytic extremity of a person with infantile paralysis,
however, will have a bluish color and will feel cold.
From this we can easily understand that when there
is such a pathological change in the cardiac valves
the periphery of the body will be but scantily fed
with arterial blood, as is the case typically in mitral
stenosis or when there is such a defect of the valves
that venous stagnation in the periphery will result.
This is the case in far-advanced mitral insufficiency, or
when there is such a degeneration of the muscular
walls of the heart that by the feeble contractions of
the same the periphery is badly supplied with the
nourishing and warming agent. Persons with such a
diseased heart will have a keener sensation of cold
and will more readily succumb to exposure to severe
cold of short duration, or of a comparatively small de-
gree of frost of prolonged duration.
When the cold is acting upon our body it has a dou-
ble effect, i.e., the irritation of the periphery of the
body and the irritation of the nervous centres conse-
quent upon this. But I think it would be just as right
to say it has only one effect, as the action upon the
nervous centre is merely the consequence of the irri-
tation exercised by the cold upon the skin. The
amount of the irritation of the nervous centre will ex-
actly answer to the amount of the irritation of the skin.
As the irritation of the skin by the cold, however,
causes by its local effects a mechanical hindrance to
July 1 8, 1896]
MEDICAL RECORD.
81
the circulation, I shall treat the two effects from differ-
ent points of view.
Let us analyze now the local effects of cold when
we expose our hand to the same. We have a sensation
of cold and the hand will become white and corru-
gated, as the first effect. This shows that by the irri-
tation of the vaso-constrictors the vessels of the skin
have themselves contracted. But next we will see that
our hand becomes bright red. This shows that the
vessels have been dilated and the blood can more eas-
ily pass through the same. It circulates better; there-
fore the red color. This effect we must attribute to the
action of the vaso-dilators.
The bright red color of the skin will, however, soon
give way to a bluisii coloration. This shows that the
circulation has become slower, as there was time for
the blood to be deprived of its oxygen. When per-
sons, especially those with feeble circulation, are ex-
posed for a long time to even slight cold, we see their
face and hands become the same color. Evidently in
consequence of the long duration of the cold there is
a slower circulation. I shall refer to this later on.
When now an extremity is still longer exposed to the
cold it will appear white, and this white color may
even become waxy when the extremity is too long ex-
posed to the effects of a severe frost. We know that
persons killed by frost have a very pale color of the
skin, even a waxy whiteness. What does this white
color of the skin indicate? It shows that there is no
supply of arterial blood, as the vessels have been so
contracted that even the blood corpuscles cannot pass
them. And if the extremity be still longer exposed to
the cold after the circulation has ceased in it, it will
become gangrenous.
When the skin has for a long time been exposed to
the cold the circulation will be hindered, as the ves-
sels will become strongly contracted. We shall see
later the consequences of this for persons with a dis-
eased heart.
We know also that cold is able to cause local in-
flammation of the skin. According to Erasmus Wil-
son, chilblain is an inflammation of the skin induced
by the cold. In its erythematous stage the chilblain
is a congested spot, which is first bright red and later
becomes livid. The parts affected by frostbite are
first bright red and later become livid.
When a person takes a cold bath the first sensation
will be one of cold, his skin will be corrugated (cutis
anserina), but the first white color will be followed by
redness of the whole body, and he feels exhilarated
and has a feeling of warmth. If he remains still long-
er in the cold bath the exhilaration is followed by de-
pression. Through the irritation of the skin by the
cold a greater amount of blood has been sent to the
periphery, and the exhilarated state will show that the
brain has been supplied with a strong wave of arterial
blood. This state is, however, followed by depres-
sion, and the surface of the body is but poorly fed
with arterial blood if the stimulating action of the
cold lasts for a long time. Winternitz has shown by
an interesting experiment that through thermal influ-
ence acting upon the skin, there will be an afflux of
blood to the periphery. When a man was put naked
into an empty tub, the lower part of his body being
covered with water (50' F. ), the plethysmograph
showed that the arm was considerably increased in
volume.
Foster ' mentions that when there is increased general
arterial pressure, as for instance that caused by stimu-
lation of a sensory nerve, there is a greater flow of
blood to the brain, causing an increase of the volume of
the brain.
How are these consequences of thermal irritation of
the surface of the body brought about.'' The existence
' M. Foster; " Text Book of Physiology," p. 1,136.
of a stronger amount of arterial blood on the periphery
of the body presupposes a stronger action of the heart.
We know that when the vagus is irritated the contrac-
tions of the heart are reduced in number; the diastole,
however, is longer, a greater amount of blood accumu-
lates in the heart, and with each pulse a stronger wave
is sent to the peripiiery. Uut we know also that
when the splanchnic is irritated the abdominal vessels
contract and there is less blood in the abdomen; but
the periphery of the body is better supplied and a
stronger wave of blood also is sent to the brain; the
pressure in the heart rises. According to the experi-
ments of Strieker, Ostroumoff, and others, this is
caused by reflex dilatation of the peripheral vessels.'
It has been shown through the experiments of Nau-
man that thermic irritation has an effect upon the
splanchnic nerves. When, namely, to the surface of
the body of a frog, whose trunk has been left in con-
nection with the leg only by the ischiatic nerve, a
weak thermic irritation is applied, the vessels of the
mesentery (which as we know stand under the vaso-
motor regulation of the splanchnics) contract and there
is an increased activity of the heart. When a very
strong thermic irritation has been used, the vessels of
the mesentery become dilated and the action of the
heart grows weaker.
When the skin is exposed to the cold we have the
sensation of an irritation of the skin through the con-
tact with the cold. In many persons this causes a
disagreeable feeling. As Foster, however, says, when
the stimulation of the skin exceeds a certain limit of
intensity, the sense of temperature is not appreciated
apart from tiie sense of pain. If we cause pain of cer-
tain amount to a person, we will see a series of symp-
toms which will indicate to us a stronger action on the
side of the heart caused by a reflex action on account
of the irritation of the sensory nerves. If, for exam-
ple, we remove the tuberculous glands from the neck
of a young girl w ithout an ancesthetic, we see the face
become red and the surface of the body feels hot. If
a boy is punished for some mischief and receives a
few blows, the same symptoms are manifested. When
a person, however, receives many blows for a longer
time his face will become pale, the surface of his body
will feel cold, and there may even be cold perspiration
on the whole body. When a person receives blows on
many parts of the body for a prolonged time, let us say
for several hours, he may fall dead. Such a case has
been reported by Taylor.' A man had beaten a youth
of sixteen most severely for two hours w'ith a rope and
a stick. Death followed. At the autopsy no mortal
wound was found, but there was internally a large effu-
sion of blood, which, as Taylor remarks, would ac-
count for the production of a fatal s)'ncope. The
same fatal end we can also see in persons who are
burnt or scalded over large surfaces of the body. In
such a case also there might be no anatomical lesion
which would account for the fatal issue.
When, now, the whole surface of the skin, that large
nervous area, is exposed to severe cold of short, or to
less severe cold of prolonged, duration, through the
sum of the injurious impulses attacking the sensory
nerves on the surface of the body such a ner\-ous ex-
haustion may be brought about that the same fatal is-
sue as in the above case will occur, !.<•., such a person
will die from shock.
As we have seen before, when there is a slight ther-
mic irritation the nervous centres will be gently irri-
tated, the contractions of the heart will diminish in
number, the diastolic period will be longer, the pulse
waves will be stronger, and through the irritation of
' S. Strieker; " Vorlesungen Uber allgemeine und experimen-
telle Pathologie," p. 213.
■' Taylor ; " Principles and Practice of Medical Jurisprudence,"
p. 613. f^dited by Stevenson.
82
MEDICAL RECORD.
[July 1 8, 1896
the splanchnic nerves the vessels of the abdomen will
contract. A.S Ostroumoff, Strieker, and others have
shown, there will be a refle.x dilatation of peripheral
vessels, and the brain will also receive more arterial
blood; when, however, this thermic stimulation passes
on to thermic irritation and then to thermic injury,
there will be an over-irritation of the nervous centre,
the contractions of the heart will increase in number,
but the pulse wave will be smaller and the vessels of
the abdominal organs will dilate; there will be an
accumulation of blood in the abdomen and a contrac-
tion of the vessels on the periphery; there will be but
a .small quantity of blood carried to the heart and
later on even that will cease. In consequence, the
medulla oblongata will not receive a sufficient amount
of blood, and if tliis injurious over-irritation of the
nervous centre persists there will come no blood to the
medulla, and death will follow. The death so caused
is analogous to that following e.\tensive hemorrhage
i.e., it will be a death by syncope, brought about by the
same agent, as we have seen in the case related by
Taylor.
As I have shown above, persons with a diseased
heart have a keener sensation of cold, chiefly on ac-
count of their periphery being scantily supplied with
oxygenated blood, and accordingly we can easily un-
derstand how shock from cold will more readily de-
velop in such persons than in persons with a normal
heart. We might even suppose that persons with a
considerable defect of the heart and very weak circu-
lation might succumb to the prolonged duration of
such a degree of cold, especially with damp atmos-
phere, which would only have a stimulating effect on
robust persons. Several such persons have been found
dead in their lodgings, even in their beds, during a
period of severe frost. It is certain that such a fatal
end can be more easily brought about in persons who,
besides suffering from a heart defect, are badly provided
with food and in a state of starvation, and especially
when the cold is associated with dampness or fog.
Mental depression also increases the susceptibility to
cold.
Finally, I may mention the unfavorable influence of
large doses of alcohol, which, as we know, causes a
fall of bodily temperature. When the surface of the
body is exposed to the cold, there will arise a venous
stagnation, and after this the ve.ssels will so contract
through the persistent influence of cold that even the
red blood corpuscles will not be able to pass through ;
so that the circulation on the surface will cease.
It is evident that when there are such disturbances
in the circulation of the periphery, the resistance
offered by the pressure in the arteries will increase
and a great strain will be put upon the heart. This
will be the more serious in persons who have a weaker
peripheral circulation on account of a heart defect.
To overcome the resistance on the periphery the heart
must make stronger efforts, as the pressure in the
heart should be greater than that in the arteries. The
contractions of the heart must become stronger to over-
come the peripheral impediment, but the main impulse
to the contractions of the heart is given by the pres-
ence of a sufficient amount of blood under a sufficient
pressure. The contents of the heart should act upon
the ganglia and the muscles of the heart, but on ac-
count of the disturbance of the peripheral circulation
the heart will receive smaller quantities of blood.
The same degree of cold that causes a stagnation of
the circulation will also be liable to bring about the
symptoms of shock by reflex irritation of the nervous
centres. Accordingly, as we have seen above, the
l)lood will acciunulate in the abdominal organs and
the heart will not receive the necessary amount. The
chain of fatal circumstances, however, is not yet com-
ple;:e. There will come another hindrance of the cir-
culation through the disturbance of respiration. As
Claude ifernard has shown, when the body is under
the influence of low temperatures, the blood will not be
supplied with a sufficient amount of oxygen. Accord-
ing to Rosenthal, we know that when the blood that
is brought to the medulla oblongata has not a sufficient
amount of o.xygen, the respiratory centre will be irri-
tated and dyspnoea will arise. But there will be an-
other effect. .As has been shown by experiments made
on animals by Traube, Ludwig, Thiry, Strieker, and
others, wlien the blood passing to the medulla is in-
sufficiently oxygenated, symptoms indicative of irrita-
tion of the vagi and of the vasomotor centre are ob-
served, and thus over-irritation of the latter through
the process of suffocation brings about the same symp-
toms as those just described. Hut the disturbance of
respiration has also a bad effect upon the return flow
of the venous blood.
Under certain circumstances the hindrance of the re-
turn flow of the venous blood through gravity, as when
a person has been standing upright for a certain time,
may also have a fatal effect. Such might happen
when a person with feeble circulation (as in conse-
quence of a diseased heart, for instance) should stand
for a certain length of time on the corner of a street
exposed to the cold.
And this is the vicious circle of injurious influences
acting upon a diseased heart. The greater the cold,
the greater will be the sensation of cold, but also the
greater will be the mechanical impediments to the cir-
culation at the periphery, and, w'e may presume, aeteris
parilms, the more will the blood be in want of oxygen.
When the irritation of the sensory ner\es causes symp-
toms of shock, the blood accumulates in the abdomen
and there is a reflex contraction of the vessels at the
periphery. When the circulation at the periphery is
disturbed mechanically, there will lie smaller quantities
of blood carried to the heart, and through the same cause
there will also be a great strain put upon the heart.
When through the action of the cold the blood is in need
of oxygen, the respiratory centre is irritated, dyspncea
arises, and the circulation is again impaired; less ve-
nous blood is received from the heart, but at the same
time the vagi are irritated and also the splanchnic
nerves.
Through over-irritation of the vagi the contractions
of the heart are increased in number and the periods
of diastole are shorter, as has been shown on dogs in the
experiments above referred to. If such animals live
longer, as Strieker remarks, in the last stages the pe-
riods of diastole will again become longer through the
paralysis of the motor centres.'
Shock, as I pointed out, occurs more readily in a
person with a diseased heart: the disturbance of
the circulation on the periphery will also be greater;
the dyspncea (if not caused already by a scanty sup-
ply of blood to the medulla oblongata by reason of
the heart disease — mitral stenosis, for instance) will
be still greater, as the blood is in need of oxygen
through the action of the cold. -Ml these factors act
upon the diseased heart, and are caused by the action
of cold upon the skin. And as the skin is, as I would
say in German, the " Angriffspunkt" (point of attack),
I might venture to say such persons will die by the
skin.
Dieberg, in the Vicrteljahresschiift fiir gcrkhtlkhe
Mcdicin, says that in all cases of death from cold in
Russia he always found the cavities of the heart
full of blood. This might seem to contradict what
I have said above, but we must bear in mind that
there is a difference in the post-mortem symptoms in
cases in which death is caused by the action of very se-
vere cold of short duration and in those in which death
' S. Strieker: " Vorlesungen utwrallgemeine unde.xperimentelle
Pathologic," S. 197.
July 1 8, 1896]
MEDICAL RECORD.
8:
has followed the action of less severe cold for a pro-
tracted period. In the first case there is such a pow-
erful over-irritation of the nervous centres b}' the cold
that the heart stops suddenly and there is no possibility
of expelling the contents of the heart. In the second
case the cavities of the heart are empty just as they
are in syncope caused by excessive hemorrhage ; no
blood comes to the heart and there is no blood there
to be sent to the medulla.
We know from experiments on animals that a strong
irritation of the vagi may arrest the action of the
heart. This has also been observed in men. E.
Briicke,' in his text-book on physiology, relates such a
case. A man in Vienna had complained to his physi-
cian that he sometimes had a feeling of great anxiety
and at the same time his heart would stop. At the
autopsy of the same patient it was found that the vagus
on one side was embedded in a large mass of swollen
lymphatic glands, so that pressure might easily have
been exercised upon the vagus, which arrested the
heart.
What are now the therapeutical points to be gathered
from the above considerations? W'e must remove (i)
the cause and ( 2 ) the consequences.
To satisfy the first indication we must send patients
who can afford it to the South. This will be the more
advantageous, as they will then be free from bronchi-
tis, to which they are inclined on account of the con-
gested state of the lungs. VVhenthis is impracticable
we must warn patients with a diseased heart not to ex-
pose themselves to cold, to clothe themselves very
warmly when they go out, and also to take an abun-
dance of nourishing food.
To fulfil the second indication we must improve the
circulation. Therefore we must administer medica-
ments which stimulate the action of the heart, act as
tonics, and prevent the symptoms of shock. Among
the most powerful stimulants and tonics for this pur-
pose we might use with advantage strophanthus, arsenic
with iron and strychnine (especially when there is
fatty degeneration of the heart), caffeine, etc. A nat-
ural and very efficacious remedy for our purpose is al-
cohol, to be given, however, only in small doses. We
must recommend the patient to take brandy or whiskey,
diluted with double the quantity of hot water, in small
quantities, several times a day; and in connection
with it we might administer with the best advantage
tonic doses of quinine. The stronger kinds of wines,
which contain a greater amount of alcohol — as port
wine or the stronger Spanish and French wines — have
perhaps the advantage over brandy that larger quanti-
ties of them can be taken. For those who cannot
afford wine, we might recommend small cups of black
coffee with a few drops of brandy, or larger cups of tea
several times a day. We know from our own experi-
ence that when w'e have been exposed to cold for a cer-
tain time by walking or standing in cold air or sitting
in a cold room, we have symptoms of depression
which are exactly the same as those which precede the
symptoms of shock. At such times black coffee in
smaller or tea in larger quantities, as also alcohol, re-
moves the symptoms of depression. To a less extent
we will see the same effect from the use of a light cigar
or a few cigarettes. The same remedies are also effi-
cacious to remove the symptoms of mental depression
by causing a greater flow of blood to the brain.
Besides the above remedies, medical movements
will have excellent results by bringing about a better
peripheral circulation and by reflex action upon the
heart. In the treatment of the symptoms of shock we
may obtain very good results by applving friction to
the whole body in connection with a kneading of the
abdomen, which, as I have pointed out in a previous
' K. Briicke: " Vorlesungen iiber Physiologic," S. 113, ii.
Band.
article ' on the " Treatment of Fainting," brings a
greater amount of blood to the heart and brain. l)ur-
ing this operation the patient should lie horizontally
or with the head lower than the body.
ARREST OF SMALL-POX IN ITS VESICULAR
STAGE.
By ALONZO BRYAN, M.D.,
DETROIT, MICH.
On Monday, January 14, 1895, at a stated meeting of
the Detroit Medical and Library Association I ad-
vanced the theory that small-pox can be arrested in its
vesicular stage. About twenty persons were present,
all or most of whom were members of the society, and
they accorded my theory considerable applause and
encouragement.
In the paper which I then read I maintained that
the eruption of true small-pox only extends to and in-
cludes the vesicular stage; and that the vesicles are
simply infectionatria through which pus germs and
saprophites are intromitted to the structure of the true
skin and to the general system. The paper claimed
that the germs of suppuration and of putrefaction are
lying in wait, embedded in the epidermis, ready to
commence their ravages upon the true skin and system
at large as soon as their liberation is eft'ected through
the instrumentality of the maceration of the epidermal
lavers by the fluid of the vesicles.
Furthermore, in the same paper, I declared it as my
opinion that the aforesaid pathological germs might be
forestalled in their pernicious action by means of ger-
micidal fluids applied to the general surface of the
body, whereby a complete maceration of the epidermis
could be effected. To accomplish this object I pro-
posed baths of long duration in antiseptic fluids. In
a word, I suggested the cautious and gradual evolu-
tion of a system of disinfection to be applied to the
entire epidermal covering. When the epidermis was
disinfected it was to be kept that way by means of
suitable antiseptic dressings applied to the cutaneous
surface until the complete desiccation of the vesicles.
By means of such a course I proposed to arrest the
small -pox in its vesicular stage, and completely pre-
vent suppuration of the skin and suppurative fever
with its various dangerous complications. The above
statement expresses only the cardinal principles of the
subject as discussed by the paper. Up to the present
date, June 4, 1896, the paper has never been pub-
lished.
A few days after having read my paper before the
Detroit Medical and Library Association, I assumed
charge on January 2 2d of the Small-pox Hospital at
Detroit. I supposed that I should have abundant op-
portunity to test my theory, but in this expectation I
was rather disappointed than otherwise. My appoint-
ment was looked upon as a political arrangement, my
theoiy was freely advertised and adversely criticised
by the newspapers, the general public was enraged,
and the poor, unfortunate patients at first looked upon
me with dismay rather than with confidence. Suspi-
cion and distrust were depicted upon all of their coun-
tenances. I found the hospital the last place in the
world to exploit a theory. Furthermore, I was de-
prived of my office on March 9th, by reason of a pre-
vious act of the State legislature.
According to mv view it was necessary to commence
the treatment for the arrest of the disease either dur-
ing the primary fever or at least in the incipiency of
the papular stage of the eruption. After the slightest
degree of pustulation had supervened it would be too
late. Nearly all the patients who arrived at the hos-
' Wiener med. Presse, Nos. 70, 71, 1895.
84
MEDICAL RECORD.
[July 1 8, 1896
pital arrived after the vesicles were beginning to be-
come purul-ent.
However, one case was on tiie ground sufficiently
early. It was the case of a woman named Mrs. Lena
Press, who came as a nurse to attend her sister who
entered the hospital fully broken out with the small-
pox. This woman, while attending her sister as a
nurse, in due time came down with discrete small-pox.
In this case the circumstances were such that I only
ventured to apply my treatment with the view to the
prevention of pustulation locally. I made my appli-
cations to the hands and forearms, which showed a
very free and perceptible papular eruption. The pap-
ules all developed into vesicles, but only a very small
number became purulent, dotted here and there. The
vesicles dried up and assumed the appearance of flat,
dark brown, desiccated scales, closely adherent to the
skin. In due time they were exfoliated, leaving no
scars or pits behind.
In this case on every other part of the skin than
those that were treated, the vesicles developed into the
complete and typical pu.stules of variola; the demar-
cation at the elbows sharply showing the difference
between the arrested eruption and that which was al-
lowed to proceed.
And this was the manner in which I proceeded to
arrest the development of the eruption. I first
scrubbed the skin of the forearms and hands with a
strongly alkaline soap and water in order to remove
the oil naturally existing in the epidermis. Then I
washed the skin with alcohol to kill germs and also to
remove oil. Next the skin was washed with a i to
500 solution of mercuric bichloride. Then it was
washed with a solution of hydrogen peroxide. Each
of these washings was of ten or fifteen minutes' dura-
tion. Finally the parts were well wrapped in a thick
envelope of borated cotton.
The above washings were repeated daily for three
days, and the borated cotton was applied for a day or
two longer.
It should be noted that I would not recommend a
universal bath of a solution of the bichloride of mer-
cur)' on account of its possibly dangerous svstemic
effect.
I did not give this woman who was the subject of
experiment universal baths of antiseptic solutions, be-
cause I did not believe she could be prevailed upon
to consent to their use, for she evidently shared in the
mistrust which reigned throughout the hospital.
Indeed, according to my theory, I should have ex-
pected a very imperfect or negative result from the
merely local application of antiseptics. Especially
would I have looked for failure in a case of confluent
small-pox; and for this reason, that after the sup-
puration of a large number of untreated vesicles
enough pus-germs would be found absorbed into the
general circulation to effect a suppuration of the super-
ficially sterilized vesicles, upon the well-known prin-
ciple that bacteria floating inertly at large in the sys-
tem may localize themselves by attacking a weakened
and non-resisting part. Nothing is more clearly de-
monstrated in pathology than that pus-germs existing
in a state of general circulation often concentrate
themselves upon a focus of least resistance and there
display their specific energy. So we might reasonably
expect a vesicle of variola to be such a focus, and
though it might be protected from external infection
it could be successfully assailed from within.
Therefore, in a case of discrete small-pox (such as
the subject of my experiment was), the damage from
the intromission and subsequent localization of bac-
teria migiit be trifling, yet in a case of confluent small-
pox the phenomena of what might be termed intra-in-
fection would doubtless be very grave.
And from this very cause we might infer how essen-
tial it would be to immerse the patient for hours at a
stretch in a suitable germicidal fluid, and at a period,
if possible, before the papules had begun to show any
accumulation of serum at their apices.
The main principle is to macerate the whole epider-
mis thoroughly with some suitable antiseptic fluid;
and to do it before or at the ver\' incipiency of the
eruption.
REMARKS ON SOME SKIN DISEASES OC-
CURRING IN CONNECTION WITH GAS-
TRO-INTESTINAL DISTURBANCES."
By FRED. J. LEVISEUR, M.D.,
DER.MATOLOGIST TO THR Randall's island hospitals and German poly-
clinic
There are a number of skin diseases which occur in
connection with disturbance of the stomach and the
intestine.
This fact is well supported by clinical evidence,
but, viewed from the more elevated standpoint of theo-
retical science, it must be admitted thai the true nature
of this connection is far from being clearly under-
stood. I shall not enter into a discussion of this diffi-
cult question, nor shall I attempt to solve any one of
the many problems with which such a discussion must
confront us at every step; but I simply want to put to-
gether, bring more prominently into view, and com-
ment on a few common and several rare skin affec-
tions w hich appear in patients suffering from intestinal
disturbances, a condition which renders these cases
equally interesting to the clinician and to the derma-
tologist. In doing tiiis it was unavoidable to disre-
gard more or less that somewhat artificial but highly
important dividing line which separates symptomatic
from idiopathic cutaneous eruptions.
One of the most common forms of eczema, called
eczema infantile, characterized by symmetrical red
patches covered entirely or in part with yellowish
crusts (crusta lactea), is in a vast majority of cases due
to derangement of digestion. As a rule, we have to
deal with babies who are unusually fat. In fact, they
are overfed; their little stomachs are constantly full
and distended. Frequent vomiting, nature's safety
measure for infantile gluttony, is not sufficient to re-
lieve the overtaxed organ, which reflects its abnormal
condition through the vasomotor ner\-es by producing
a local hypera'mia of the face. The highly congested
parts begin to itch, the child scratches its face or rubs
it against objects within easy reach. Moisture from
the mouth macerates and again irritates the affected
parts. Occasional constipation alternating with slight
diarrhcea is almost always present. Sleep is fitful and
much disturbed.
In another class of cases of this disease, comprising
children under six months of age, when the salivary
glands are still functionally inactive and conse-
quently unable to dissolve and absorb starch, the gas-
tro-intestinal disturbance is caused by giving the
young infant starchy food.
It has been ascertained beyond a doubt that in a
number of cases the eczema disappears as soon as the
diet is regulated or a radical change in feeding is
made; that on the other hand local treatment alone is
often insufficient to effect a permanent cure. The
baby should be nursed not oftener than four times
during the day and three times during the night, and
at regular intervals. If cow's milk or artificial food
is given its composition should be investigated; its
action should be watched and possible errors corrected
accordingly. .Among medicinal remedies calomel in
the dose of one-tenth to one-fifth of a grain three times
a day can be recommended. Dilute muriatic acid and
■ Kead before the .Manhattan Medical and Surgical Society.
July 1 8, 1896]
MEDICAL RECORD.
85
very small doses of creosote may also be tried. Local
applications should by no means be neglected. 'I'heir
quieting effect alone makes a change of the alimen-
tary regimen very much easier. Some cover the face
with a soothing salve or paste spread on lint, which
is bandaged down in the manner of a mask with aper-
tures for the nose, mouth, and eyes; others attain the
same results by using the calamine-and-zinc solution,
or some mild paste or salve without bandaging.
All writers agree that a large percentage of cases of
acne rosacea is caused by indigestion. We often find
this disfiguring affection in alcoholics, but also in men
and women who drink nothing stronger than tea. These
patients have _/<>/<'/- c.v (?;v, especially in the morning,
sour eructations, constipation, and perhaps a distress-
ing feeling of fulness after meals; in short, all the
symptoms of a mild fermentative gastritis. I have ob-
served that in most cases the teeth are so decayed or
defective and the mucous lining of the buccal cavity
is so swollen and congested that the patients do not
masticate their food properly. I am unable to say
whether the indigestion is the cause of this pathologi-
cal condition of the mouth or vkc versa, or whether
there exist a direct connection between the dental and
the skin affection by way of refle.x action on the dental
branches of the fifth and the vasomotor nerves. It is
possible that these different etiological factors co-op-
erate in producing acne rosacea, which essentially is
an angio-neurotic affection. Of twenty-four cases ob-
served among the workhouse men and women at Ran-
dall's Island (mostly inebriates) fifteen had extensive
dental defects, so that mastication was positively in-
terfered with; in five cases the teeth were ver}' much
decayed, but the patients were able to masticate their
food. In only four cases were the teeth not worse
than would be expected. The age of the patients
ranged from thirty to forty-five years. The most pro-
nounced case of acne rosacea seen by me of late con-
cerned a gentleman who kept a restaurant which was
said to have quite a local fame for good Rhine wine.
This wine was, however, made by the patient himself,
as he told me in confidence, from grapes by a primitive
process. I found that this wine was very sour, prob-
ably on account of imperfect acetic-acid fermentation.
The patient, who was in the habit of drinking a bottle
or two of it every day, had a very pronounced fermen-
tative gastritis. Many of his teeth were missing,
broken off, or decayed, and the gums were swollen and
had a bluish appearance.
It must be remembered that in women near the cli-
macteric neuroses of the stomach occur quite fre-
quently, and it is therefore often difficult to decide
whether some cases of acne rosacea in women with
uterine affections are due directly or indirectly to
reflex from the genital sphere.
In severe cases lavage is indicated and has some-
times a surprisingly good effect on the skin eruption.
It must not, however, be expected that the mechanical
removal of the fermenting masses stops the fermenta-
tion: the latter will promptly start again with the very
next food supply. Careful dieting is almost always
necessary; the amount of carbohydrates should be
limited; alcohol, tea, pastry, the coarser vegetables,
and milk should be forbidden. Bismuth, carbonate of
sodium, creosote, carbolic acid, thymol, and ichthyol
may be employed. I have had good results from the
use of the fluid extract of ergot. According to Wert-
heimer and Magnin, ergot produces very active move-
ments in the coats of the stomach, and Wright found
very active intestinal jseristalsis at the post-mortem
examination of poisoned animals. Besides having
this action on the intestines, therapeutic doses of
ergot increase blood pressure by stimulating the vaso-
motor centre in the medulla. The condition of the
teeth and mouth requires close attention. Cavities
ought to be filled by the dentist, roots removed, and
the use of artificial teeth recommended if necessary.
Local treatment is of course of great importance, espe-
cially scarification of the enlarged blood-vessels.
It would carry me too far if I were to consider the
various drug eruptions w^hich appear in connection
with gastro-intestinal disturbances, as for instance
erythema after the use of quinine, antipyrin, turpen-
tine, balsam of copaiba, sandalwood oil, arsenic, etc.
Urticaria appears in certain individuals after eating
strawberries, gooseberries, raspberries, lobster, oysters,
fish, oatmeal, sausage, etc. That we ascribe the dis-
ease to an idiosyncrasy, a term devoid of scientific
meaning, is an open confession of our ignorance of the
true nature of the poisonous agent. After excluding
all cases of purely ner\'ous origin (for instance, those
caused by anger, shame, excitement, etc.), a distinction
can be made between cases of gastric and intestinal
origin. In the former class of cases the rash appears
in a remarkably short time after the ingestion of the
special article of food, very much like the nervous
effect of some poisonous drugs. If vomiting occurs, it
may cut short the attack and be followed by immedi-
ate relief. One attack seems to confirm and intensify
the susceptibility to subsequent attacks. I do not be-
lieve that neuropathic, hysterical individuals are most
liable to have attacks of urticaria. I have often ob-
served that otherwise healthy persons become neuras-
thenic after repeated attacks of urticaria.
The absence of all gastro-intestinal disturbances
in a case of urticaria is a negative symptom, some-
times of great diagnostical value. It may mean the
bursting of an hydatid cyst of an internal organ.
Urticaria of intestinal origin appears more slowly
and is of a more chronic nature. In some cases there
is dilatation of the stomach and when the patient be-
comes somewhat constipated the attacks appear half
an hour till an hour after meals and last for several
hours. This is a very obstinate form of the disease,
and many remedies may be tried before a cure is
effected. W. Osier has observed eleven cases of exu-
dative erythema appearing with gastro-intestinal crises.
Subsequent attacks sometimes appeared without the
skin lesions. There may be simply colic of all grades
and intensity, from a transient, readily borne belly-
ache to an attack of such agony and duration that re-
peated hypodermics of morphine have to be given.
Vomiting and diarrhcea are frequent but not necessary
accompaniments of the attack. The disease bears no
relation whatever to food and may come on abruptly
in a person in excellent health. Of sixty cases men-
tioned in the literature (Osier's eleven included) thir-
teen died, giving a mortality of 21.3 per cent. There
is no intestinal hemorrhage, as in the infantile pur-
pura of Henoch. The affection resembles in some
respects the giant urticaria, or angioneurotic cedema
of Quincke, which is characterized by nausea and
vomiting appearing in connection with an cedema of
the eyelids, lips, or cheeks, sometimes the backs of
the hands and the legs. If the cedema occurs in the
larynx the disease may prove fatal. According to
Natas there may be a remarkable periodicity in the
outbreak and there seems to be a marked hereditary
disposition in the disease.
Pellagra, an endemic disease, so very prevalent in
Northern Italy and occasionally also met with in
Southern France, develops according to Lambrose
under the influence of a diet of diseased maize. The
disease begins with malaise, indigestion, and diar-
rhcea. Then an eruption appears on the exposed
parts of the body, the exciting cause being ascribed
to the action of the sun's rays. It is an erythema ac-
companied by pigmentation, desquamation, and pruri-
tus. Later on the skin assumes a dark olive-brown
hue and petechias appear on the belly and chest. An
86
MEDICAL RECORD.
[July 1 8, 1896
endemic disease closely resembling pellagra, called
acrodynia or erythema endemicum, was obser\'ed in
Paris about 1830. Mention is made here of these af-
fections because it has been suggested that possibly
other grains, such as oats, may undergo similar changes
and produce similar effects.
Indigestion and constipation are often found to be
associated with pruritus universalis occurring in mid-
dle-aged persons, ft is impossible to say whether the
gastro-intestina! disturbance has any etiological signi-
ficance or is simply a concomitant symptom. If a
conclusion ex juvantibus be allowed, I can say that a
strict milk diet carried out thoroughly in a number of
severe cases seemed to do no good.
That the secretions which the food meets with in
the intestinal canal are antiseptic in their action may
be anticipated, according to Kirke, not only from the
proneness to decomposition of organic matters, such
as those used as food, especially under the influence
of warmth and moisture, but also from the well-known
fact that decomposing flesh (high game) may be eaten
with impunity. The absorption of products formed in
the intestine by the decomposition of the albumin
under the influence of bacteria, a process called auto-
into.xication, has recently been claimed by many au-
thors to be the cause of attacks of erythema, urticaria,
herpes, and pemphigus. An increased quantity of in-
dican (dioxyl sulphate of potassium) is claimed by
Singer to be a sign of idiopathic urticaria caused by
auto-intoxication. The subject of indicanuria in rela-
tion to skin diseases certainly needs more extensive
investigation. Clinical experience confirms the opin-
ion that exacerbations of many skin diseases, eczema,
furunculosis, acne, psoriasis, may be traced to absorp-
tion of poisonous products in the intestine.
640 Mauison ."^VKNUR.
A NEW FLUORESCENT SUBSTANCE.
By LEON BERTRANl), M.D.,
ANTWERP,
SURGEON SS. SOUTHWARK, RED STAR LINE.
I BEG to introduce to notice a new fluorescent chemi-
cal discovered by Dr. Edm. Van Melckebeke, of Ant-
werp, which is called double fluoride of uranyl and
ammonium. I had the honor two weeks ago, at a
meeting of the Societe Medico-Chirurgicale of Ant-
werp, of demonstrating Edison's fluoroscope, which
was very highly appreciated, indeed; but I have to
confess impartially that it is equalled in every respect
by Dr. Van Melckebeke's discover)-, which I had the
pleasure to experiment with myself. Moreover, this
last has the advantage of being very cheap.
The following is the manner in which Dr. Van
Melckebeke discovered his new chemical: First, re-
calling the fluorescent properties of the nitrate of
uranium, he made a solution of that substance and
coated a piece of cardboard with it; but no fluo-
rescence was obtained under the "" X" rays. He then
modified the method of impregnating the cardboard,
and, instead of coating it with the solution, he fixed
the nitrate of uanium on the cardboard through the
medium of a gummy solution. The screen then be-
came fluorescent under the "X" rays.
Dr. Van Melckebeke explains the failure of the first
method to produce fluorescence by the fact that the
solution impregnated the fibre of the cardboard, and
after evaporation of the water the salt remained either
in an amorphous state or in a state of confused cr}'s-
tallization. Fluorescence, like rotator)' polarization,
seems to require a state of perfect crystallization.
Among the chemicals which precipitate in a state
of perfect crystallization are the double fluorides.
Wurtz's Dictionary (vol. iii., p. 561) mentions a double
fluoride of uranyl and ammonium with the formula:
Urpjl.^, XH^Fl.
if one drop of nitrate of uranium and a particle of
fluoride of ammonium are brought together, they will
produce regular octahedrons. But if larger quantities
are used, five hundred and four parts of nitrate of
uranium and one hundred and eleven parts of fluoride
of ammonium, according to the formula of Wurtz and
the equation :
2(UrONO, + 3 H„0) -Y 3 NH.Fl
[504] " [ill]
= Urp,Fl„ NH.Fl + 2 NH.NO, + 6 H^,
no crystals are produced.
Dr. Van Melckebeke increased gradually the quan-
tity of fluoride of ammonium in the proportion of
about one part of fluoride of ammonium to two parts
of nitrate of uranium. He obtained a crystalline de-
posit, which, examined under the microscope, pre-
sented all the characteristics required. After precipi-
tation, the liquid had lost its color entirely.
In order to obtain this result, the proportions to be
used seem to correspond approximately to the formula :
Ur„O.^Fl„, 4 NH,F1, according to the equation:
2(UrON03 -t- 3 H„0) + 6 NH.Fl
= Urp^Fl, 4 NH.Fl'-f 2 NH.NO. -f 6 H..O.
The deposit is put in a filter, is washed with cold
water, and dried. It then appears as microscopic
octahedral crystals, yellowish-green by reflection, and
colorless in thin coats by transmission ; it becomes
fluorescent while exposed to the violet rays. These
crystals are not very soluble in cold water, but are
more soluble in boiling water; hence they may be de-
posited on the surface of objects by simple cooling of
a hot saturated solution.
As far as we know, the chemical is a new one. It
is certainly different from the one mentioned by Wurtz,
as much by its composition as by its crystallographi-
cal properties and by its smaller degree of solubility
in water. It has some analog)' to the double fluoride
of uranyl and potassium, Ur„0,Fl„, 4 KFl, and to the
double fluoride of uranyl and sodium, Ur„OjFl.,,-
4NaFl (see Wurtz's Dictionary Supplement, vol. ii., p.
1,628).
Oxyfluoride of uranium and ammonium can be
spread on pieces of cardboard through the medium of
different excipients, such as a solution of gelatin, oily
varnishes, etc. This is the best way to proceed: On
the bottom of a basin put a sheet of strong blotting
paper and cover it with a boiling saturated solution
of the o.xyfluoride; let it cool, and when the paper is
covered with a cr)'stalline coating decant the liquid.
Repeat the operation two or three times. In order to^
give some solidity to the deposit, cover it with a coat
of gelatin. The fluorescent power of the chemical
prepared in this way seems to vary according to the
thickness of the coat of gelatin.
Dr. Henri \'an Heurck, of .Antwerp, has a good
method of photographing the image thrown on these
screens. He puts the screen in close contact with
the film, and obtains a very good picture in a /ew
moments.
Dr. Van Melckebeke's discovery dates from the be-
ginning of March. The net cost of the double fluoride
of uranyl and ammonium is, in Europe, twenty-seven
cents an ounce.
Scurvy. — Dr. Cheney says that a " black eye" com-
ing on in an infant without traumatism, and perhaps
repeated several times, can rarely be due to anything
else but scurv'y. — Medical News, February 29, 1896.
July 1 8, 1896]
MEDICAL RECORD.
87
^fogrcss of !l¥lcdicitl Science.
The Presence in the Normal Thyroid Gland of
a Substance Containing a Relatively Large Quan-
tity of Iodine. — The demonstration by the distin-
guished Freiburg chemist Baumann, says the Medical
News, of the presence of an organic iodine compound
in the normal thyroid gland must be regarded as one
of the most important of the recent contributions in the
field of chemistry. But, quite apart from the interest
which belongs to it from a purely chemical standpoint,
a much wider significance attaches to the discovery
from its therapeutic aspects; for we are now at least
promised a solid basis from which maybe deduced an
explanation of many well-known clinical facts whicli
have been developed not only from the treatment of
disease of the thyroid gland with thyroid extract, but
from organotherapy in general. .-Vlmost simultane-
ouslv with the earlier reports dealing with the bene-
fits to be derived in certain diseases from the admin-
istration of the thyroid extract, there developed in
chemical circles an unprecedented activity in investi-
gating the constituents of the thyroid gland ; and the
unabated interest which has since prevailed is evi-
denced by the large number of articles dealing with
the subject that have appeared up to the present time.
None of these, however, offers a satisfactory explana-
tion of the beneficial influence which has undoubtedly
followed this form of medication. The incomplete
publications of Notkin, in which it was asserted that
two substances — a protein and a ferment — were re-
sponsible for the virtues of the gland, have been
looked upon, curiously enough, with favor by the
French, although physiological chemists in Germany
and America have not been inclined to consider them
seriously. The crystalline nitrogenous derivative de-
scribed by S. Fraenkel, although of chemical interest,
is insufficient to supply a solution of the problem in
question. The idea that th i element iodine might
stand in some very definite relation to the metabolism
of the thyroid gland is by no means new. Even so
early as 1850 Chatin, who believed that iodine was
present in the air, in water, in all plants, in fermented
drinks, in milk, in eggs, and in the soil, suggested
that its presence was essential to the welfare of the
organism, and that cretinism and goitre occurred only
in those regions in which iodine was entirely absent
from the drinking-water. Others who studied the
constitution of the air and of water denied, however,
the presence of iodine in them, and Chatin 's theory
was at first discredited and afterward forgotten.
Kocher, the distinguished surgeon at Zurich, only a
short time ago, relying upon the fact that the efficacy
of iodine in the treatment of diseases of the thyroid
gland compared favorably with that of the thyroid ex-
tract, suggested that the normal thyroid gland be ex-
amined thoroughly in order to see if iodine existed in
it. Tschirsch incinerated the gland, but failed to find
iodine, and chemists, relying upon his results, natu-
rally look it for granted that this element was absent.
This negative result was perhaps not surprising, con-
sidering the small amount of iodine present in the
crude gland, though Baumann has since detected it in
the ash from one gram of the dried gland. Roos, in
a report of an investigation preceding Baumann's pub-
lication, in which he showed that the thyroid gland
bore a distinct relation to the phosphorus metabolism
of the body, mentioned some experiments which may
really be looked upon as the forerunners of Baumann's
brilliant di.scovery. It had for some time been known
that digestion, moderate heat, and certain antiseptics
did not destroy the active substances of the thyroid
gland, and Roos proved, in addition, that prolonged
boiling in five to ten per cent, solutions of the min-
eral acids apparently did them no injury. It was his
opinion that a portion of the active substance, though
not all, was soluble in water.
Deciduoma Malignum. — Since 1876 there have
been recorded some sixteen cases of a distinct variety
of malignant disease of the uterus having histological
and clinical characteristics peculiar to itself and suffi-
ciently interesting to deserve more attention than has
been bestowed on it. Dr. G. W. Beach has given us
a very full account of the disease, besides quoting a
case that was under his care. The disease was given
the name deciduoma malignum byGottschalk in 1893,
and it is referred to by that name by French authors.
The interesting points which pertain to the disease
are its undeniable relations to pregnancy and its pe-
culiar pathological anatomy. In the histological prep-
arations made of all the cases up to date a constant
element has been found — an immense cell, correspond-
ing to the giant cells of the decidua. These cells are
polymorphous, possessing one large nucleus, rarely
more than two, and have a homogeneous granular pro-
toplasm. These cells invade the tissues and are found
mixed up with other elements in the interstices of con-
nective tissue and inside the muscular bundles. The
development of the disease is very rapid, the neoplasm
invading the blood-vessels and giving rise to free hem-
orrhages and attacking the whole uterine wall. Me-
tastases are very common, the lungs and pleura being
most often affected. In nine out of the sixteen cases-
the patients were under thirty. The growth usually
appears shortly after childbirth or abortion, but in
three cases hydatiform moles marked the commence-
ment of the disease. The majority of authors admit
that the neoplasm develops from the debris of the de-
cidua, but at present it is impossible to say why reten-
tion of the decidua in one case gives rise to hemor-
rhages simply and in another to deciduoma malignum.
The first sign of the disease is metrorrhagia after a
confinement. The hemorrhage is at first intermittent
and scanty, but later on increases and becomes inces-
sant, and curetting has no effect in checking it. The
patient soon becomes cachectic, and toward the close
the discharge becomes putrid and is usually accom-
panied by fever. Death takes place generally by
exhaustion. The disease is very rapid, and general
invasion by metastases is certain. On examination
the uterus is always found increased in size, the os
being permeable or not according as the disease has
progressed. The uterine cavity will be found to con-
tain soft pulpy masses resembling placental tissue
mixed with blood clots, and in places the uterine wall
is softened and the finger sinks easily into the muscle.
The diagnosis in the early stages is difficult. If there
is intermittent hemorrhage after confinement the proper
course is to curette. If the first curetting does not
check the hemorrhage, a second must be performed
and microscopical examination made of any debris re-
moved. If the uterus is found enlarged and curetting
shows softening of the uterine wall in patches, and
the characteristic giant cells have been found by the
pathologist, the only course is to remove the uterus
and appendages as soon as possible. Vaginal hyster-
ectomy has been performed in five instances with re-
covery in two only, but time enough has not elapsed
to show us more than the immediate results, which,
however, are good. As the evolution of the disease is
so rapid everything hangs on an early diagnosis. —
Indian Alediral Gazette.
Hip Amputations Before applying the tube (in
Wyeth's technique) the tendons of the hamstring mus-
cles should be cut, in order to equalize the subsequent
retraction of the muscles when the circular cut is
made. — D.awb.arn.
MEDICAL RECORD.
[July 1 8, 1896
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, July 18, 1896.
THE CTRRHOSES OF THE LIVER.
The history of our knowledge of the cirrhoses of the
liver is closely identified with French medicine. It
speaks well for the breadth and liberality of the Ger-
man scientist that in an elaborate discussion on this
subject by Professor Senator, before the Hufeland
Medical Society, he gives full credit to his French
medical brethren.'
Laennec was the first to separate the cirrhoses from
other diseases of the liver, which he did in his cele-
brated treatise on " Auscultation," seventy-eight years
ago. The description which Laennec gave of atrophic
cirrhosis remains good to-day, and his name is still
associated with one form of this malady. Later au-
thors soon showed that there were other forms, how-
ever, associated with hypertrophy of the liver and with
jaundice, and having a different cause and clinical
history. Many attempts to describe and differentiate
the types were made, but it was not until 1876 that
Charcot and Gombault gave a classification which to
some e.xtent still holds. According to these authors,
there is the common cirrhosis of Laennec, with
granulations and an atrophy, and due to a proliferation
of connective ti.ssue, starting from the portal vein and
its branches. Then there is a cirrhosis associated
with hypertrophy and jaundice, which starts essen-
tially from the system of biliary ducts, and which is
due to obstructions and inflammations in these organs.
A third form of hypertrophied liver was noted, as oc-
curring in persons suffering from hereditary syphilis.
The distinction between the first two types of cirrhosis
— that of portal origin and that of biliary origin — is
still, according to Senator, to be maintained, and has
been supported by the further and more elaborate re-
searches of Ackermann and other pathologists. It has,
however, been found that the precise course of these
two types, as described by Charcot and Gombault, is
not always observed and that mi.xed forms undoubt-
edly occur. In order to meet these clinical distinc-
tions, Senator describes two varieties of the atrophic
or granular form. One of them he calls portal cirrho-
sis with hypertrophy of the liver, the othe. cirrhosis
with icterus. It had been noticed that cases of biliary
cirrhosis were followed eventually by an atrophy;
hence. Senator establishes a special class of this form
of disorder, which he calls "biliary cirrhosis with
secondary atrophy," and a variety of this he calls
' Archives gcnerales de Medecine.
"biliary cirrhosis with hypertrophy of the spleen.''
The third and final type is called a "hypertrophic
cirrhosis with icterus."
The atrophic cirrhosis of Laennec is characterized
by an atrophy of the liver and enlargement of the
spleen, absence of icterus, and absence of bilirubin
in the urine; later by ascites and dilatation of the
veins of the abdominal wall and of the gastro-intes-
tinal tract. This is undoubtedly a common type of
atrophy, and is associated usually with excessive in-
dulgence in alcoholic drinks. While some authors
consider that in this disease the primary trouble is a
degeneration and wasting of the liver cell, with sec-
ondary proliferation of connective tissue, it is gener-
ally taught that connective tissue, starting from the
portal system, begins to grow first and that the cell
atrophy follows it. The biliary cirrhosis with atro-
phy in its typical forms is due to obstruction of the
biliary passages by the catarrhal products or by cal-
culi. Here the leading symptoms are decoloration of
fjecal matters, at first enlargement of the liver, fol-
lowed by atrophy, without swelling of the spleen and
without ascites. The urine contains bilirubin in
abundance.
In the third form, that known as cirrhosis of Hanot
or the hypertrophic cirrhosis with icterus, the liver is
enlarged. The discoloration of facal matters is little
marked and variable. The urine, which is rather
abundant, contains generally some bilirubin. The
spleen is enlarged and there is here also no ascites nor
portal stasis.
This last type of the disease is, according to Sena-
tor, very rare, and he admits to have seen only about
a dozen cases. Men are more often affected than
women, and the essential cause seems to be a catar-
rhal condition of the bile ducts. The distinctive fea-
tures are the large liver and the hypertrophied spleen,
the enlargement of the liver occurring quite early.
This form of cirrliosis is more benign than the portal
type and runs a variable course, during which the pa-
tient gets now better, now worse. It lasts sometimes
ten or a dozen years. A cure is not impossible in
these cases and death, when it does result, is due to ma-
rasmus and profuse hemorrhage, or, jDerhaps, to a peri-
tonitis.
As regards prognosis and therapeutics. Senator has
little to add to what is already known. The progno-
sis is bad in all the forms, except, perhaps, in that
due to the presence of calculi or other movable ob-
structions to the biliary duct. In general, the prog-
nosis is bad in accordance with the smallness of the
size of the liver, and cases of hypertrophied liver are
more favorable than those in which it is of normal vol-
ume.
The portal cirrhosis of Laennec, though incurable,
can be very much ameliorated by treatment. Alcoholic
drinks must be forbidden, and a non-irritating diet,
composed largely of milk, must be prescribed. Milk
and iodide of potassium, though they seem to be borne
by Frenchmen and Italians, agree less with the German
constitution; at least. Senator states that, according
to his experience, few Germans can habituate them-
selves to a milk diet for more than a few weeks. It
July 1 8, 1896]
MEDICAL RECORD.
89
is necessary in their cases to add something else.
Senator is a little skeptical as to the value of iodide of
potassium in cases in which there has been no syphilis.
He considers it important to puncture the abdomen
and relieve the ascites as early as possible, and he
finds that the use of calomel and digitalis is helpful.
In the biliary types of cirrhosis he uses injections
containing a litre of oil and a little soap and water,
or solutions of salicylate of sodium, i to t.ooo, all com-
bined with careful massage of the liver, and from time
to time la.xatives, especially those known as chola-
gogues. Prolonged baths, with massage during the
bath, and the cures that one gets at such places as
Carlsbad, exercise a favorable influence upon the ex-
cretion of the bile.
AGAIN THE DISPENSARY ABUSE.
The dispensary abuse is being recognized and the
evils of which it is capable appreciated by the lay
public, and this fact is a promise that the near future
will bring a remedy. The subject received intelligent
consideration at a recent meeting of the municipal
section of the Civic Club of Philadelphia — an associ-
ation constituted solely of women — in a paper read by
one of the members, Mrs. Francis Howard Williams.
The facts upon which the paper was based were ob-
tained through personal investigation conducted
through the medium of a series of questions pertinent
to the knowledge desired. After dwelling upon the
origin, the usefulness, and the necessity of dispensa-
ries in large communities, the abuses of the system
were graphically described. The speaker went on to
say that :
"In our desire to make relief easy for the suffering
poor, we have weakened their natural powers to help
themselves; we have diminished their self-respect and
sense of independence; we have made them less help-
ful as men and women, and more helpless as members
in a community in which to live is already difficult,
and the way open only to those who bring to the con-
test a wholesome consciousness of their own worth,
with a hearty disposition to work. Not only do the
needy and deserving resort to the dispensary. Many
go there who would be ashamed to receive a benefit of
another nature. There are hundreds who do not scru-
ple to accept a bottle of medicine who would scorn
the gift of a loaf of bread ; many who use a doctor's
time and accept his advice who would refuse a pair of
shoes from their shoemaker, although, perhaps, the lat-
ter is twice as able to give of the fruit of his labor.
It is not only the poor w^ho are willing to depend upon
the dispensary; there are some cases among the well-
to-do.
" I have been informed that the members of the
medical profession, in their anxiety to secure clinical
service, are responsible largely for this evil, and that
dispensaries are necessary feeders to hospitals; never-
theless, it is evident that if they benefit the medical
practitioner at first, he loses in the long run."
Several illustrative instances were cited, showing
that an unrestricted establishment of dispensaries is
hurtful to the healthful self-respect of the members of
a community, while at the same time depriving the
physician of the proper rewards of his labor. The
remedy proposed is as follows:
'' Cut down the power of dispensaries; restrict their
establishment; oblige them to have telephone commu-
nication with the charity organizations; establish
beneficial associations, in which the physicians are paid
salaries, and in which they can afford to treat patients at
moderate fees; refuse dispensary aid to persons who
are able to pay, and refer them to the beneficial asso-
ciations for treatment.''
DEATH SCENES IN FICTION.
We do not see on what ground, either of art or science,
of public good or private morals, the publishing of
medical descriptions of death in popular novels can be
justified. We do not mean to say that the novelist
should not allow his patients to die if circumstances
compel it, or that he should not describe the way they
die in as pathetic, dramatic, or tragic a manner as he
chooses. But to introduce into the pages of novels
technical descriptions of deaths from diphtheria, opium
poisoning, tuberculosis, or other malady, is offensive
to good taste and is a misuse of the art of fiction. If
people want to know exactly how a person dies who
has a cancer of the uterus, there are excellent technical
descriptions in a large number of standard works; in
fact, the literature of medicine is burdened with such
descriptions, some of them joining literary skill with
technical knowledge.
We are led to these remarks by a perusal of the
death-bed scene in a case of diphtheria as described
by the at-one-time novelist "Ouida." This lad\- is,
happily, one of the passed among fiction writers, but
she seems to be trying to make up for her decaying
powers by silly sensationalism. This is the manner
in which she describes death from diphtheria: "The
poisonous growth filled every chink of the air passages,
as though they were tubes mortared up and closed her-
metically. His face grew purple and tumid. His
eyes started from their sockets. He had no sense left,
except the mere instinctive mechanical effort to gasp
for the air he would never breathe again. Blood
foamed in froth over his lips, which were curled over
the white teeth and were cracked and blue. His eyes,
starting from their orbit, had no sight. Suddenly the
convulsions ceased." This, according to "Ouida,"
with a few additional trappings, such as nuns kneeling
around on the floor, and shadowy lights thrown
through the room, etc., constitutes a supposed realistic
description of a death-bed scene from diphtheria.
It is, perhap.s, truer than the death-bed scene from
opium poisoning, as described by Marion Crawford,
where the patient sinks away with his pupils widely
dilated. But, after all, it is not a true picture of the
way patients die from this disease. It is partly tech-
nical, partly imaginary, and altogether exaggerated, a
mongrel affair, such as all medical descriptions of
maladies and deaths by novelists must necessarily be.
90
MEDICAL RECORD.
[July 1 8. 1896
Mems of tltc ^mccK.
Prof. H. Leloir, of Lille, France, died recently at
the age of forty-two years. He had been professor of
dermatology in the University of Lille since 1886.
He was best known for his original work on the sub-
ject of neuroses of the skin, but had written many
valuable essays on leprosy, lupus, and other derma-
tological subjects. In collaboration with Vidal he
wrote a treatise on skin diseases which is recognized
as one of the best in any language. His last work
was the preparation of the article on " Dermatoneu-
roses" in the " Twentieth Century Practice." While
he was engaged on the final section of this article last
winter, he was the victim of a railway accident, re-
ceiving very severe injuries from which he never en-
tirely recovered, and which probably contributed to
the fatal termination of his last illness.
The Cholera in Egypt continues with about three
hundred and fifty deaths daily. The disease has now-
made its appearance among the British troops at
Wady Haifa and Cairo as well as among the native
soldiers. The cable reports that the health authori-
ties of Dantzig made an official certification of a case
of .Asiatic cholera in that city on July 7th. None has
since been reported, so it is probable that that was an
imported case from Galicia or the pro\-inces of south-
ern Russia, where the disease is believed .still to lin-
ger. It is denied that it exists any longer in .St.
Petersburg or Moscow.
Yellow Fever and Small-Pox are still prevalent
in Cuba, the latter being even more deadly than the
former. The victims of yellow fever are chiefly tlu-
foreign soldiers stationed in the coast towns, but the
sniall-pox attacks natives and .Spaniards alike, and
those in the interior as well as the inhabitants of the
seaport cities. Santiago seems to be the greatest suf-
ferer from both these disea.ses. especially small-pox.
Hot Weather in England. — There is much suffer-
ing in the .southern part of England from unusually
high temperature, which, however, would not be re-
garded as excessive here, tlie tiiunnometer, registering
only about 80" F. in the shade. A correspondent of
Ilie Ltvuet \s moved to suggest a practice " which is
said to be in common use in Florida and other parts
of .America'" ( !). It is, namely, to cool the bed with a
tin vessel like a warming-pan, filled with ice. To the
English, who have a horror of damp sheets, such a
measure would hardly conunend itself.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, 1). C. Changes in the medical
corps of the U. S. Navy for the week ending July i i.
1896. July 7th. — Medical Inspector J. C. Wise de-
tached from the Washington navy yard and ordered
as a member of the board of inspection and survev
July 15th. Medical Inspector R. A. Marmion de-
tached from the board of inspection and survev Tuh
ijth and ordered to the Washington navy yard.
Passed Assistant Surgeon S. S. White detached from
the naval academv and ordered to the Thetis. Passed
Assistant Surgeon G. A. Lung detached from the
Thetis, ordered home, and granted two months' leave.
July 8th. — Surgeon P. A. Lovering detached from the
New York naval hospital and ordered to the Oregon.
Passed Assistant Surgeon C. H. T. Lowndes de-
tached from the Washington navy yard and ordered
to the naval hospital at Philadelphia. July 10th. —
Surgeon C. U. Gravatt ordered to Norfolk with draft of
men and then home with three months' leave. .Assist-
ant Surgeon R. G. Brodrick ordered to the Franklin.
Government Laboratories in India — The govern-
ment of India is about to establish a bacteriological
laboratory at Agra and a chemical laboratory at Cal-
cutta.
Trouble in a Brooklyn Hospital. — It is reported
that the superintendent of nurses and one of the sur-
gical stall of Seney Hospital in Brooklyn have re-
signed because of disagreement with the governing
board.
An Ether Prize Fund for the Boston City Hos-
pital.— .\ prize of S20 is hereafter to be offered semi-
annually to the surgical interne of the Boston City
Hospital '■ who administers ether in the most skilful
and humane manner.""
Physicians are Hazardous Risks. — Several of the
accident insurance companies have recently raised the
premium rate for physicians, upon the ground that they
do not belong in the preferred class, being really
extra hazardous risks.
Records of Medical Heroism .A hall of honor has
been establislied in the \'al de Grace Hospital, in
Paris, where the names of F"rench medical men who
died in the ])erformancc of their duty are inscribed on
marble tai)lets. .A list of one hundred and forty-three
practitioners has just been placed on its walls, all of
whom perished in the yellow-fever epidemic in .San
Domingo, 1801 -1803. — Medical Press.
Dr. William H. Welch, of Baltimore, received tlie
degree of LL. 1). from his alma mater, Yale, at the
recent commencement.
Protection against Law Suits. — It is stated in the
Aiaryliuhl .Mi-iliiiil and Siiri^ical Journal that a well-
known surgeon of Baltimore keeps a book in which
he has printed a form which all patients must sign
before submitting tiiemselves to an operation while
under his care. In the case of a married woman the
operation is explained to herself and her husband and
both sign the release, and, in case of the absence of a
husband, the nearest responsible male relative wit-
nesses the signature of the woman.
A Collective Investigation Concerning Negro Mor-
tality.—The graduates of a Southern college are to
make an inc]uiry into the causes of the large mortality
among negroes in cities. It is said that the death
rate among negroes in the larger cities of the South is
twice that of the whites.
New Jersey State Board of Medical Examiners.
— .At the annua! meeting of the New Jersey State
board of nijdical examiners held at Asburv Park on
July 1 8. 1896]
MEDICAL RECORD.
91
July 6th, the following officers were elected for the
ensuing year: President, Dr. William Perry Watson,
of Jersey City; Secretary, Dr. E. L. B. Godfrey, of
Camden; Treasurer, Dr. A. Ubelaker, of Morristown.
Resolutions were adopted e.\pressive of the apprecia-
tion of the board of the services of Dr. Watson.
Anthrax in New Jersey. — Anthra.\ has again
made its appearance in Greenwich Township, Cum-
berland County, N. J., where some cows have died of
the disease. The disease has also made its appear-
ance at Paulsboro.
Obituary Notes. — Dr. Willia.m A. Piper died at
Philadelphia on July 6th at the age of seventy-seven
years. He was born at Milton, Pa., where his father
was a prominent practitioner, and he was graduated
from Jefferson Medical College in 1844. He was at
one time a member of the board of health. — Dr.
Harry Clavtox, a young physician of Middletown,
Del., was drowned in Silver Lake on 'ulv 6th by fall-
ing from a boat in an attack of vertigo. He was a
graduate of the University of Pennsylvania. — Dr.
Theron Z. Gibbs, of Fort Ann, N. V., was instantly
killed at that place, on July 14th, by a railway train
which struck him as he was crossing the track. He
was si.\ty-nine years of age, and was graduated in
medicine at Castleton, Vt., in 1853. — Dr. Charles
Stever died at Philadelphia on July 6th from the
rupture of an aneurism, at the age of fifty-six years.
He was born at Norristown and was graduated from
the University of Pennsylvania in 1862. He was for
three months in 1S61 a volunteer in a Pennsylvania
regiment, and upon graduation became an assistant
surgeon in another volunteer regiment. In 1867 he
entered the regular army as an assistant surgeon and
continued in this position until 1878. In 1885 he
was appointed a medical officer of the United States
Marine Hospital Service at Philadelphia. He was
for a number of years one of the visiting physicians
to the German Hospital. He was an officer of the
Grand Army of the Republic and was connected with
a number of other organizations.
Surgeon-Major Heuston, of the British army, pro-
fessor in the medical school at Tientsin, has been
made a mandarin and received the decoration of the
Order of the Double Dragon from the Emperor of
China.
James M. Anders, M.D., LL.D. — At the recent
commencement of Ursinus College the degree of doc-
tor of laws was conferred upon Dr. James Anders,
professor of the principles and practice of medicine
in the Medico-Chirurgical College of Philadelphia.
Report on the Langerhans Case.— Professor Ehr-
lich's official report on the serum used in the Langer-
hans case has been published by the Prussian cultus-
minister. Ehrlich comes to the conclusion that the
serum was entirely normal in its constitution. He
says: "In the Langerhans case No. 216 of the Hochst
works was used. This No. 216 had been officially
tested on December 16, 1895, and passed on for sale
on December i8th, the e.xamination having demon-
strated the required one hundred immunizing unities
per cubic centimetre, perfect sterility, and the pre-
scribed admixture of carbolic acid. Immediately
after the announcement of the death this serum was
subjected to a careful re-e.xamination. As the legal
authorities had disposed of the remainder of the bottle
used for the injection, samples of the same pass num-
ber that had remained at the station were taken, and
also bottles of the same number from the stock of the
Charite Dispensar)', where Professor Langerhans' bot-
tle had come from. The serum again showed the re-
quired one hundred unities per cubic centimetre, and
bacteriological examination proved it to be free from
germs, so that there can be no question of any subse-
quent formation of poisonous bacterial products. By
a number of experiments on animals the admixture of
carbolic acid was shown to be no higher than per-
mitted. Thus, on re-examination too, the serum an-
swered to the tests exacted. Nevertheless, it seemed
important to ascertain whether, perhaps, toxic effects
produced by this number had been noticed anywhere
else. About thirteen hundred portions of this serum
had been brought on the market, and if it really con-
tained toxic substances it seemed extraordinary that
no one had drawn attention to the dangerous qualities
of this particular number. Researches were made in
the hospitals that had received No. 216 serum from
the Hochst works (serum depot of the Royal Charite'
Dispensary, Julius Hospital in Wiirzburg, General
Hospital in Hamburg, sick club of the Royal Dock-
yards in Kiel, Municipal Hospital in Magdeburg,
Krefeld Hospital) ; in none of these places had any
special, much less any toxic, effect of the serum been
observed. According to the statement of the director
of one of these hospitals, a child of eighteen months
had been given a dose of sixteen cubic centimetres,
without showing any alarming symptoms. This is at
least ten times the dose used for Professor Langer-
hans' child. The director of the Hamburg Hospital
gave an account of immunizing experiments on chil-
dren. He says that four bottles of the No. 216 serum
were used for immunizing children in the eye depart-
ment; not only were no ill effects observed, but it
might be confidently asserted that none existed. Thus
the clinical communications also contradict the as-
sumption that substances of strong toxic action were
contained in the serum. On the contrar}-, the No. 216
serum has shown itself to be a preparation answering
to all the tests at present exacted, and perfectly nor-
mal in its constitution." — British Meilienl Journal.
Philadelphia County Medical Society. — \i the
stated meeting of the Philadelphia County Medical
Society, held on June 24, 1896, Dr. A. J. Downes ex-
hibited "Collapsible and Removable Bobbins for .All
Forms of Intestinal Approximation; a New Continuous
Double-Knot Intestinal Suture; and a New .Abdomina'
Retractor.'' The bobbins resemble Barnes' uterine
dilators and act pretty much in the same way. With
the aid of the new suture it is contended that cicatri-
cial constriction at the site of approximation may be
avoided. Dr. \. \. Eshner read a paper entitled
■■ Progress in Organotherapy," in which he detailed
the many varied applications of organic extracts in the
92
MEDICAL RECORD.
[July 1 8, 1896
treatment of disease, and traced the successive steps
by which this position has been reached. Dr. Jay F.
Schamberg reported a case of '' Severe Stomatitis Fol-
lowing the Administration of Potassium Iodide," oc-
curring in a woman fifty-four years old, presenting a
syphiloderm of the face and multiple gummata of the
tongue. The dose employed was five grains thrice
daily, and there was no evidence that mercurials had
been ingested.
Pathological Society of Philadelphia. — At the
stated meeting of the Pathological Society of Phila-
delphia, held on June 2Sth, Dr. A. A. Eshner pre-
sented a specimen of carcinoma of the stomach, with
secondary involvement of the liver; carcinoma of the
liver, gall bladder, and pancreas, probably secondar)'
to carcinoma of the thyroid gland; and an enlarged
cirrhotic liver, with an enlarged spleen, manifesting
during life symptoms of biliary cirrhosis, although
sections shown by Dr. Steele exhibited hyperplasia of
the periportal connective tissue. Dr. J. Dutton Steele
presented a heart exhibiting stenosis of the tricuspid,
mitral, and aortic orifices; and also demonstrated in-
farction of the kidneys and spleen. Drs. Eshner and
Steele presented jointly a specimen of obliterating
pericarditis, probably tuberculous; the bronchial
glands were anthracotic and tuberculous, and the
lungs contained foci of cicatrized tuberculosis; the
suprarenal glands were cystic. During life symptoms
of Addison's disease had been present. Dr. Joseph
Sailer described the changes in the nervous system
due to tetanus. These consisted essentially in alter-
ations in the anterior horns of the spinal cord. Dr.
\V. G. Spiller presented, for Dr. J. Hendrie Lloyd and
himself, sections of the cord from a case of subacute
paralysis, showing amyloid bodies in great profusion.
Dr. .\. K. Taylor presented, for Dr. M, H. P'ussell and
himself, liver, spleen, and specimens stained of blood
from a case of leuka-mia. He further presented, for
Dr. I'ussell, specimens of carcinoma of the stomach
and liver. Dr. A. Hand, Jr., showed a section of a
liver from a case of hypertrophic cirrhosis in an in-
fant.
The Buffalo Medical Journal for June is. a women's
number, edited by Dr. Maud Josephine Frj'e, assisted
by seven other physicians of the gentler sex. All the
original communications are by women, and the items
are en subjects relating to professional women. The
number is one of great interest and retlects credit upon
the able editors. We would suggest that copies be
sent, as a missionary enterprise, to some of the con-
servative old back numbers in London, who are car-
ried once a year to the annual meetings of their socie-
ties to squeak out their horror and detestation of
women who practise medicine.
Dr. C. W. Stiles, zoologist of the Bureau of Ani-
mal Industry of the United States department of
agriculture, has been elected honorary member of the
Academy of Medicine of Paris.
The Tsar of Russia is an active member and the
Tsarina an honorary member of the Russian Red
Cross Societv.
SAMUEL SEXTON, M.D.,
NEW YORK.
The death, at his residence in this city, on July iith,
of Dr. Samuel Sexton, although not unexpected by the
many friends who were acquainted with the serious
character of his last illness, removes from the profes-
sion of New York a conspicuous personality. His
distinguished position in his specialty made his name
well known on both sides of the Atlantic, and gave to
his original researches and his earnest advocacy of
new methods an authority and influence that were
shared by few if any of his peers.
Dr. Sexton was born in Ohio in 1833, ^f'd was
graduated in medicine from the University of Louis-
ville in 1856. In May, 1861, he enlisted as assistant
surgeon of the Eighth Ohio Volunteers, but resigned
his commission in October, 1862, and resumed the
practice of his profession. After coming to New Vork
he devoted himself to the treatment of diseases of the
ear, and was a frequent contributor to the medical
press and the author of many brochures. His paper
upon the " Causes of Deafness among Public-School
Children" was widely circulated in 1882 by the na-
tional bureau of education at Washington. This pa-
per won for him from Venezuela, in November, 1889,
the medal of honor created by the decree of June 7,
1877, for those who render great service to the cause
of public education; and in December, i8go, the
same government conferred upon him the highest hon-
or in its gift, the decoration of the '• Husto del Liberta-
dor." An article in the Medical Record of February
ig, 1887, upon an " Injury to the Ear Caused by the
Blast of a Bursting Shell," attracted wide attention
among army and navy men as well as among those in
civil practice.
Dr. Sexton's most valuable work in otology was the
elaboration and improvement of the radical ojjeration
of extirpation of the ossicles for the cure of chronic
deafness, which was the subject of a paper presented
by him to the Otological Society in 1886. In spite of
much opposition by his confreres, he eventually suc-
ceeded in establishing his method upon a sound basis
and in obtaining suitable recognition for valuable
pioneer work. He read a paper on the same subject
at the International Congress in Berlin, and two years
later performed the operation in London at the request
of several British otologists. It was not, however,
until the appearance of his treati.se on " Rare Forms
of Ear Diseases" that he obtained the credit that was
due him for the large amount of original work he had
performed and the great care with which he utilized
the vast amount of material at his disposal. He stud-
ied his specialty from the broad standpoint of a spe-
cially skilled general practitioner, and was always im-
pressed with the necessity of treating the ear as a part
only of the general organism. Thus, in his directions
for general treatment, he was painstaking to an almost
extreme degree, and his numerous consultations with
patients from all parts of the world were models of
thoroughness, precision, and skill. Full of resources
and of original ideas, it was natural that he should be
radical in his views and persistent in their presenta-
tion. His scholarly paper on the "Treatment of
Chronic Catarrh of the Upper Air Passages'" exem-
plifies in a marked degree these special attributes of a
broad and well-trained mind. In his intercourse with
his professional brethren he was the soul of honor,
and although strong in his convictions was ever cour-
teous in their expression, and to all who knew him he
presented the well-rounded character of a cultured
gentleman.
July 1 8, 1S96]
MEDICAL RECORD.
93
^acicttj 'Reports.
AMERICAN LARYNGOLOGICAL ASSOCIA-
TION.
Eighteenth Annual Congress, Held at Pittsburg, May
14, 15, and 16, i&
President; William H. Daly, M.D., Pittsburg.
First Day — Thursday, May 14th.
President's Address. — The President in opening
the congress called attention to the rapid progress of
laryngolog)' during recent years and its present envia-
ble position. He made a plea for the retention of
interest by specialists in the problems of general med-
icine. We have learned, he said, the importance of
clearing the upper tract of all obstructions, such as
adenoids, enlarged tonsils, etc. Many problems in
disease of the accessory sinuses yet remain to be
solved. He paid a warm tribute to Manuel Garcia,
and spoke of the worldwide sense of loss felt in the
death of Dr. Wilhelm Meyer. He welcomed the con-
gress to Pittsburg and expressed his belief that the
programme before it had never been equalled in its
comprehensiveness by that of any previous session.
Etiology of Deviations of the Nasal Septum —
Paper by Dr. John O. Roe, of Rochester. Causes of
deviation are predisposing and exciting. The former
include diathetic, as strumor, syphilis, tuberculosis,
rickets, and cretinism. Civilization increases the lia-
bility to deviation, as does also the aquiline type of
nose. Deviations are rare among primitive races, es-
pecially the Indians, who live an outdoor life and
whose mothers fasten their children's mouths so as so
develop nasal breathing. Exciting causes are inter-
nal, such as defective development and disease of the
septum or of other nasal structures. The septum is
made up of cartilage and the bony ethmoid plate and
vomer. The latter is originally composed of two
laminae with an intervening cartilage and begins to
ossify at the sixth week of fcetal life, though the process
is not completed till after puberty, and the union of
the laminse is from behind forward. This process is
generally completed by the third year but occasionally
does not happen at all. Hypertrophy in excess on
one side will cause displacement. Disease also of
the cavernous tissue of the septum and of the inferior
turbinates will produce the same result. Other causes
include external injuries, malformations of the superior
maxillae, highly arched palate, heredity, and a dispro-
portionate development of the whole face.
Where there is a deflection there is generally a re-
sultant turbinate enlargement on the concave side.
This is an effect (not a cause), and is probably due to
the excessive amount of air passing through the pa-
tent nostril. No one can breathe properly through
one nostril alone, no matter how large it may be.
Anterior obstructions may be due to deviated sep-
tum, chronic turgescence, growths, operations, disloca-
tion of the triangular cartilage, and flattened ala nasi.
As to trauma, it is frequently an exciting cause,
operating more commonly in males of all ages, and is
apt to be followed by callus on the convex side. If
there is intranasal disease requiring constant expul-
sion of discharge, the habit of picking the nostril and
of blowing the nose constantly with the same hand
will operate in the same way.
The Operation for Deviation of the Nasal Sep-
tum.— Paper by Dr. .Vrthur \\'. Watson, of Phila-
delphia. The author believes that many of the preva-
lent operations are unsatisfactory because they lose
sight of the fact that a deviated septum is longer than
a straight one and make no provision for reduction in
the amount of tissue. We must first reduce the septum
to a size that will fit into a straight line between the
points of attachment of that portion of the nose.
This is done by removing a portion of tissue in the
general line of deviation. If the latter is horizontal
we must take out an elliptical piece gradually conver-
gent at either end; if vertical a wedge-shaped piece
should be taken, with apex superior and extending as
high as possible, the base reaching to near the base
of the septum, where it may be joined by a horizontal
incision. The excised portion should always include
the protruding angle and the amount of tissue to be
removed can be estimated by the eye. We should not
cut the mucous membrane on the side opposite the
incision, as it helps to hold the edges in line, thus
facilitating union and avoiding perforation. Incision
should be on the convex side of the septum. To bring
the portion into line, some variety of crushing forceps
may be used with advantage.
No less important is the second step of the opera-
tion (one often neglected), viz., retaining the septum
in position. Failure to do this long enough is re-
sponsible for much lack of success. Healing of the
cartilage requires from three to four weeks. The best
support is furnished by a flat ring-head pin, the head
being covered with a piece of rubber tubing. The
pin should be inserted from the concave side of the
septum just back of its anterior edge and passed diag-
onally through to the other side, then across the verti-
cal incision, if there is one, and then back into the
septum until the head lies on the septum within the
nostril. Care should Be taken not to produce a de-
flection in the opposite direction. In this way both
nares are left free for respiration and cleansing.
Padding of the pinhead prevents ulceration, and the
pin may be worn for three weeks or more without dis-
comfort.
Should the deviated bony septum require additional
support, a pad of iodoform gauze may be placed be-
tween the septum and outer wall at the point of devi-
ation, but the bony part heals more quickly than the
cartilaginous, and hence the gauze may be removed in
from seven to ten days, still leaving the pin in situ.
In order to operate properly we must have suitable
illumination and the parts must be as free as possible
from blood. Cocaine anaesthesia is preferable to
ether.
Discussion on these two papers was opened by Dr.
E. Fletcher Ingals, of Chicago, who thought that
nutritive changes were by far the most frequent e,\-
citing causes of septal deviation. He thought the
effect of trauma was overestimated.
Dr. Morris J. Asch, of New York, agreed w ith the
last speaker as to the overestimation of trauma as an
exciting cause. He referred to his own operation
presented to the association in 1889. It might leave
some intranasal roughness, but it left the nose pervious
for respiration. •
Dr. S. O. Vander Poel, of New York, had done
the .^sch operation often. He laid stress upon the
necessity of overcoming the resiliency of the septal
cartilage. In his hands the pressure of the pin had
caused pain and even ulceration. Perforation had
sometimes resulted at the junction of the two incisions.
Later he had used the Adams forceps to break up the
septum, but even then the evil results of pressure from
the pin were experienced as before.
Dr. Carl Seiler, of Philadelphia, regarded the
.Asch operation as but a revival of the one proposed
by Dr. Glascow several years ago. He believed that
if the pin was placed ai the bottom of the septum, the
evil results of pressure would be avoided. It should
be driven in from the outside at the notch of the nasal
bones down to the cleft between the two palatal per-
94
MEDICAL RECORD.
[July 1 8, 1896
tions of the- superior maxills. It should at first be
left projecting a little distance above the skin of the
nose so as not to be covered in by the swelling of the
soft parts.
Dr. J. E. Nichols, of New York, regarded the Asch
operation as good for cartilaginous deviations. All
resiliency must be destroyed in cases of bony devia-
tion. He made a compound fracture of the bone and
applied the cork splint devised by Berens. He did
not believe in the use of the pin unless all resiliency
was broken up.
Dr. D. Bryson Delavan, of New York, had dis-
carded the pin several years ago. While Dr. Asch
may not have devised an entirely new operation, he
has elaborated a practical technique. Trauma will
not account for all deviations. They may come from
mouth breathing, especially that due to adenoids.
Dr. W. E. Casselberrv, of Chicago, would lay
great stress on heredity. No one operation would
suffice for all cases. We must take into account the
patient's age, mode of anesthesia, etc. Deviations
were chiefly cartilaginous, with some encroachment on
the bone. He used as retaining-measures gauze pads
and intranasal tubes.
Dr. John N. Mackenzie, of Baltimore, would rise
to do a dead man historical justice. The main fea-
tures of the Asch operation were set forth many years
ago by the late Dr. James Bolton, of Bridgeton, Va.
Dr. W. K. Simpson, of New York, was impressed
with the success of the Asch operation. He consid-
ered it bad surgery to plug the nares with gauze. He
used splints in each nostril at first, but in a few days
removed the one on the sound side. The splints were
a most effective measure against hemorrhage.
Dr. C. M. Shields, of Richmond, noted that many
of the deflections were accompanied by thickening on
the convex side, and this he first sawed off before
straightening the septum.
Some Reflections on Atrophic Rhinitis. — Paper
by Dr. W. Peyer Porcher, of Charleston, S. C.
After a reference to the various current theories re-
garding the nature of this disease, he laid down the
theory that it was not a disease /<■/■ j^, but was a re-
sult of other inflammations ending in a purulent dis-
charge which washed away the epithelia and led to
destruction of the mucosa.
He narrated the history of a woman, aged thirty-
four years, with good antecedent history, in whom .scab
formation had begun fifteen years before, following an
attack of measles. The left inferior and middle tur-
binates were gone, and those of the right side seriously
damaged. Intranasal stimulation and iodides given
with a view of increasing secretion were of no avail.
Finally the left antrum was opened and irrigated, but
without relief to the crust formation. He had finally
resorted to a solution of iodine and iodide in glyce-
rin on cotton tampons with a view to causing hyper-
asmia. This greatly relieved his patients. Crusts
were still formed, but they came away more freely.
Dr. Seiler regarded the Gottstein cotton tampon
as efficacious, even without its being medicated. The
secretion it excited moistened the inspired air and the
cotton filtered it. He had recently used aseptic wool
for the same purpose, but regarded it as distinctly in-
ferior.
Dr. Thomas Hubbard, of Toledo, had used an al-
coholic solution of acetanilid. The proper way to em-
ploy the cotton was to wrap it around the turbinated
bones.
Dr. C. C. Rice, of New York, regarded cleansing
and oiling the nose as the essential treatment. We
must avoid overstimulation.
Dr. G. a. Leland, of Boston, had used cocaine in
ten-per-cent. solution over the turbinated areas for its
secondary effect, which was that of congestion. The
addition of resorcin to the cocaine solution obviated
the bad systemic effects of the latter.
Dr. a. W. de Roaldes, of New Orleans, had em-
ployed electrolysis with cotton-wrapped electrodes.
Dr. Roe favored mild silver-nitrate solutions and a
mild galvanic current. Scabs do not come from the
nasal mucosa alone, but may signify some disease of
the accessory cavities.
Dr. Nichols had used with much satisfaction a so-
lution of orthochlorphenol, in solutions' of from ten
per cent, up to full strength.
Dr. Macke.nvie would protest against the unregu-
lated use of cocaine in the nose.
Dr. Inoals did not believe it harmful if the amount
in solution did not exceed two grains per week. He
had used the yellow oxide of mercury in weak solution
in oil, and had been pleased with the results obtained
with a one-fourth-pcr-cent. solutiim.
Laryngeal Photography with the Aid of the Arc
Light. — Paper by Dk. Thomas R. French, of Brook-
lyn. In the earlier experiments of the writer in laryn-
geal photography, the method had several disadvan-
tages, the principal one being the source of illumina-
tion, which was .sunlight, an uncertain and unreliable
agent. Recently he has succeeded in utilizing the arc
light, so that good pictures can be taken at any time.
Formerly he brought the patient to the light, but now
the light to the patient, and results already obtained
bid fair to surpass any former ones. Not only the lar-
ynx but the naso-pharynx and posterior nares can be
pictured.
As the distance between the camera and object to
be photographed was very short, one of the greatest
difficulties was to adjust the light to the sensitive
plate so that a depth of focus would be obtained.
To do this, a small diaphragm, a rapid shuttle, a
very sensitive plate, and a powerful light are neces-
sary.
The necessary outfit consists of an automatic two-
thousand candle-power arc lamp, partly enclosed in a
metal box. On the latter's front face is a condensing
lens, which at a distance of nine inches from the arc
gives a focal distance of twenty inches. The lamp
and accessories are fitted to a narrow board on a table
sufficientlv high. Tilting of the board raises or low-
ers the light by means of a special device for that pur-
pose. On a shelf beneath the table top is placed the
rheostat.
The manner of manipulating the apparatus is the
same as with the sunlight condenser.'
The beam of light should be caught upon the fore-
head mirror several inches inside the focal point. At
first the focus is found, and with it perhaps a good
photograph. If, however, a good result is not reached
at the first sitting, the focus and the amount of light
needed being known, there is no difficulty in obtaining
at the seconcl sitting as many pictures as desired. If
the apparatus is in good order a picture may be made
in as little time as is required for an ordinary careful
laryngoscopic examination.
Presentation of Instruments. — Dr. Inoals exhib-
ited a portable air compresser so devised that the air
pump and spray tube could be folded up within the
cylinder. -Mso a nasal saw with a reversible han-
dle.
Dr. Seiler presented a double-screw hook attached
to a spiral and covered with another spiral, which
acted as a shield. Rotation exposed the hook and
caused it to engage in any soft object. It was merely
a special application of the principle of the flexible
shaft of the dental engine, and could be used to remove
soft foreign bodies from the ears and air tract.
Dr. Roe presented an improved case of instruments
for operation on the nasal septum.
' Sec New York .Medical Journal, December 13, 1884,
July 18, 1896]
MEDICAL RECORD.
95
D» HuBUARD showed a new variety of nasal wire
ecraseur.
Recent Progress in the Treatment of Malignant
disease of the Larynx was the title of a paper
read by Dr. D. Bryson Delavan, of New York. In
general, the lives of patients suHiering from epitheli-
oma have been shortened, he said, rather than length
ened by the efforts of the surgeon. This statement is
based upon the fact that the average duration of life
in such cases without removal of the larynx has been
a year and a half. Indications are, however, that for
operations there is a more promising future. Tiiese
maybe divided into the following classes: ist, thy-
rotomy with or without partial laryngectomy; 2d, com-
plete laryngectomy by the Solis-Cohen plan; and 3d,
complete laryngectomy in cases of extensive laryngeal
disease with glandular involvement.
As to thyrotomy, Butlin has laid down the following
propositions :
ist. Every malignant growth of the laryn.x of intrin-
sic origin which can be dealt with should be treated
by an operation in the absence of a decided indication
to the contrary, and operation should be performed
with the least possible delay.
2d. Every tumor of the larynx suspected to be malig-
nant, of intrinsic origin, of limited extent, and appar-
ently within easy reach of free removal, justifies an
exploratory thyrotomy in a suitable patient, in the ab-
sence of infiltration of surrounding structures and of
affection of the lymphatic glands. In thyrotomy good
illumination must be provided and the parts to be ope-
rated upon swabbed with cocaine, in order to contract
the blood-vessels and prevent parenchymatous bleed-
ing.
For after-treatment the tampon cannula should be
immediately removed from the trachea, the interior of
the larynx dusted with iodoform and boric acid, and
the patient laid with the operated side down, with one
small pillow under the head. The wound is not
plugged w^ith gauze, but dusted twice daily as above
indicated. The patient mav try to drink a little ster-
ilized water while leaning with the upper part of the
body bent well over the edge of the bed. If this suc-
ceeds, milk may at once be taken.
The advantages of the Solis-Cohen method, in which
the larynx is completely removed and the severed end
of the trachea secured to the external edges of the cer-
vical incision, are:
ist. Danger to life from inspirative pneumonia is
greatly lessened.
2d. Swallowing is as easy as under ordinary cir-
cumstances.
3d. In at least three cases power of phonation has
been acquired, with a voice fully as satisfactory as
that by any artificial appliance.
4th. The patient's comfort is greatly increased, and
disfigurement and the necessity for an artificial larynx
done away with.
As to the third variety of operation, Cheyne says
that, as compared with cancer in the breast, the disease
in the throat is in some respects more favorable for
cure, in others less so; less favorable because less ex-
posed to view and to operation, but more favorable as
regards glandular deposits, for in the neck we have an
extensive glandular area freely exposed to view.
Preliminary tracheotomy some few days before the
operation is advisable. The patient must not be too
old, must have good vitality, must have no physical
defect likely to complicate recovery, and must have
good surroundings.
In reviewing the recent progress in the treatment of
malignant disease of the larynx, it must be apparent
that it has nearly all been made by long and close
study of the subject by accomplished surgeons. The
time has long past when an unsuccessful attempt at
laryngectomy by one not fitted for this woik can bring
anytiiing but reproach to the operator and discredit to
the operation.
Dr. Porcher related his experience with one case
and his distrust of the Trendelenburg cannula.
Dr. Seiler thought more credit was due to Ameri-
can surgeons than had been given by the reader of the
paper, and referred to a case done as early as 1885,
by Dr. Roswell Park, of Buffalo.
Dr. H. L. Swain would lay special stress upon the
necessity of removing all the cervical glands. These
will sometimes reduce in size after preliminary trache-
otomy before laryngectomy is done.
Dr. Asch thought that stuffing the trachea with
gauze would answer just as well as the Trendelenburg
cannula.
Dr. J. Wright, of Brooklyn, would discountenance
the performance of these operations by any one except
the practised general surgeon.
Intubation in the Adult with Special Reference
to Acute Laryngeal Stenosis. — By Dr. W. E. Cassel-
berrv, of Chicago. The adult cannot be treated exact-
ly like the child with reference to intubation, and
acute stenosis with its helplessness and exhaustion is
not identical with chronic stenosis. The paper dis-
cussed four cases of diphtheria, one of acute laryngeal
oedema, and one of obscure origin but probably also
edematous. The diphtheria cases all terminated fa-
vorably, but presented various difficulties. In one in-
tubation had to be done with the patient in a semi-
recumbent position. In another at one time firm
spasm of the glottis occurred. In a third three at-
tempts were required to successfully place the tube.
All the cases showed some intolerance to the tube.
One patient nearly succumbed from accumulation of
viscid secretion in the windpipe and larger bronchi be-
low and around the tube. Extraction of the latter re-
moved the difficulty.
The case of acute oedema was complicated by spasm
of the masseter muscle. This prevented wide opening
of the jaws and intubation failed. Tracheotomy was
performed, but the patient died just at its completion,
probably from heart failure in connection with pul-
monary cedema.
The liability to pressure decubitus in acute laryn-
geal cedema should be remembered. The other case
was probably one of laryngeal and subglottic cedema,
and recovered. Conclusions were as follows :
ist. For one accustomed to the laryngeal mirror, in-
tubation in the adult is easier and more certain under
its guidance. A sitting posture of the patient should
be adopted where possible.
2d. A restless patient may be wrapped in a blanket
and seated in a straight-backed chair. The head
should be tilted backward and a gag used, with the
finger as a guide as in children.
3d. A patient lacking composure and unable to be
moved from bed should be placed close to the latter's
right edge, so that the operator can stand at the pa-
tient's right. The head and shoulders should be well
raised by pillows, the neck moderately extended, and
the method by the sense of touch otherwise carried
out.
4th. In moribund cases the tube may be inserted
while the patient is recumbent, the latter being on the
right side of the bed and the operator at his right.
Spraying the fauces with cocaine facilitates manipu-
lation. Extraction of the tube is done in the usual
way. The author's posture method of feeding subse-
quent to intubation is carried out with greater diffi-
culty in adults than in children, on account of the
difference in size and weight. The author's experience
seemi to justify the statement that in the diphtheria
of adults intubation may advantageously be substi-
tuted for tracheotomy. So also in acute oedema, un-
96
MEDICAL RECORD.
[July 1 8, 1896
less the exhaustion is extreme, a single attempt may
be made. The smallest-sized adult tube should be
used in order to avoid pressure decubitus. In cases
of "set-jaw," or pharyngeal swellings, intubation is
contraindicated. It is permissible in laryngeal ar-
thritis deformans, traumatic cedema, laryngismus strid-
ulus, and in cedema secondary to chronic specific or
tuberculous disease.
Dr. Simpson said that the word "acute" should be
used with some reservation, because there was a vast
difference between the acute stenosis of diphtheria and
that engrafted upon a chronic inflammation, as the
cedema of Bright's disease or other stenosed condi-
tions, which were not sufFic'ent to impede breathing.
The tonguevshould be weii drawn forward.
Dr. HUBE.A.RD had seen two cases of acute a-dema
of the trachea while the larynx was normal. In
tracheal stenosis intubation would be unsuccessful.
He had tried tracheotomy in one case unsuccessfully.
The condition was caused by erosions following spe-
cific ulceration. The second case was one of iodine
poisoning, in which there was cedema not only of the
trachea but of the face and pharj'nx, while the larynx
escaped. It was only relieved by pilocarpine.
Dr. Roaldes believed that intubation was useful in
fracture of the larjnx.
Spindle-Celled Sarcoma of Nose ; Specimen and
Slides. — Case reported by Dr. J. E. Bovi-.4n, of Cin-
cinnati. Paper read by title. The patient was a male
who complained for several months of severe nose
bleed, obstruction, and occasional acute pain: notice-
able bulging was seen under the left nasal bone. On
tilting up the end of the nose a red liver-like mass was
seen, occupying the entire nostril and limited behind
by the posterior nares. By the wire ^craseur the
growth was removed in two pieces and the base curet-
ted. Hemorrhage was profuse, but was controlled by
plugging with iodoform gauze.
The tumor was as large as a hen's egg and the at-
t.ichment, about one and one-half inches long, appeared
to be confined to the inferior turbinate. Examination
showed spindle-celled sarcoma. There was no recur-
rence after twenty-two months. The paper closed witii
a list of cases reported since Bosworth's tabulation of
1889.
Naso-Pharyngeal Fibrous Tumors — Paper by Dr.
E. Fletcher Ingals. The case was reported of a boy
aged eleven who, ever since his fourth year, had had
a fulness of the cheek associated witii nasal stenosis.
His general condition was good; the voice had a nasal
twang, sense of smell was deficient, and there was a
m.iss filling the left nostril and pushing over the sep-
tum, extending back and attached to naso-pharynx.
This was removed under cocaine ai.d the galvano-
cautery ecraseur. There was considerable hemorrhage,
checked by ])lugging with surgeon's lint steeped in sat-
urated solution of iodoform in ether and then in boric
acid. Subsequent cauterizations removed all traces
of the mass but caused considerable cicatricial tissue
in the vault. The swelling in the right cheek was
treated with submucous injections of twenty-five per
cent, of lactic acid and two or three per cent, of car-
bolic acid in twelve per cent, of glycerin. These in-
jections caused the disappearance of two-thirds of the
tumor. The writer advocated this measure in cases
in which the knife or galvano-cautery was inappli-
c.ible.
Naso-Pharyngeal Fibromata. — This was the title
of a paper by Dr. Chari.es M. SHiEi.tts, of Richmond,
who reported two cases with exhibition of slides and
photographs.
Case I. — Male, twenty-three years. Growth firm,
filling naso-pharyngeal space and left nostril, attached
to paryngeal vault and partly its posterior and left
lateral wall: also to outer wall of left nostril for half
its length. The growth crowded the nasal septnm to
the right, completely occluding the latter nostril, caus-
ing typical " frog face'' and " dead" voice. Under ten-
per-cent. cocaine injected hypodermatically into left
nostril, a bougie carr)-ing a silk thread attached in
turn to a sharply bent loop of cold wire was worked
through the nostril down into the throat and out
through the mouth. The wire was then fashioned
into a well-rounded loop and the nasal ends threaded
through the cannula of a snare and tightened. Grad-
ually increasing tension was e.xercised for five hours,
when the wire broke. The next day a galvano-cautery
snare loop was applied in a similar manner, and the
growth quickly severed. It measured one and one
quarter by one and two-fifths inches. Some fourteen
months later a fragment the size of a grain of corn
was removed from the left nostril and some thickening
was found at the site of the main tumor in the pharj-n-
geal vault.
Case II. — Woman (negress), aged forty-eight.
(Many writers have claimed that women are exempt
from this class of diseases. Dr. Shields had never
seen a similar case in a negro.) The tumor filled the
entire naso-pharynx, pushing the palate well forward,
but with no nasal attachment. Electrolysis faithfully
tried for six weeks gave little result. Microscopical
examination of a fragment removed showed true
fibroma. Dr. Shields thought that but very few (if
any) of such growths could not be reached through
the natural passages and consequently that resection
of the superior maxilla was rarely required. He re-
garded as unworthy of consideration ligatures, caustics,
thermo-cautery, and evulsion. The hot or cold snare
would generally answer. The use of irido-platinum
wire is to be preferred on account of its stiffness, or
the hot snare. The current should be used interrupt-
edly, with time for the patient to rest between its ap-
plications. Pain is thus minimized and hemorrhage
avoided. Moreover, the cold wire will sometimes
break. In tumors with a broad base a groove can be
made by a preliminary heating of the irido-platinum
wire, thus preventing slipping of the latter. Finally,
this mode of treatment effectually cauterizes the base
of the growth.
Dr. Casselberrv remarked that in operating on
this class of tumors it was often advisable to slit up
the mass with the cautery knife, so as to afford a hold
for the wire. He l)elieved also in the utility of elec-
trolysis for these growths.
Tuberculous Infection of the Lymphoid Tissue
of the Pharynx, with Some Remarks on Laryn-
geal Infection. r;q)er by Dr. junaiiian Wricht, of
Brooklyn. This paper was intended as an addendum
to the paper read by the autlior at the congress of
1S95. He repeated Dieulafoy's experiments in twelve
unselected cases, inoculating guinea-pigs with tonsils
and adenoids, uhich in each case were examined his-
tologically and bacteriologicaliy, with negative results.
The animal experiments made by Dr. W. H. Park also
resulted negatively. Tubercle bacilli having been
found by Strauss and others in healthy noses and
thro.its. Dr. Wright is inclined to think that Dieula-
foy's results were due (as Cornil suggests) to surface
contamination. Results similar to those of Dr.
Wright have also been published by Ricardo Botey, of
Barcelona.
Reference was also made to a case seen by Dr. W.
F. Chappell, of New York. The patient had tubercu-
losis of the naso-pharynx following an operation for
adenoid. Tissue taken from this patient and subjected
to the same methods of examination as in the twelve
unselected cases was found to contain tubercles and
tubercle bacilli histologically, while Dr. Park by ani-
mal inoculation also obtained positive results. This
goes to prove that Dr. Wright's methods were not at
July 1 8, 1896]
MEDICAL RECORD.
97
fault in the twelve cases that were supposed clinically
to be non-tuberculous.
In taking sections of tissue from a tuberculous Lirvnx
Wright found indisputable evidence of the penetration
of intact epithelium by the bacilli, but he is not pre-
pared to say whether this is possible in healthy
throats.
The Relation of Diseases of the Nose and Throat
to Disorders of Digestion — Acute Diseases of the
Nose and Throat. — Paper by Dr. H. R. Brown, of
Chicago. Pharyngeal hyperemia is frequently pres-
ent in stomach cough. Asthma frequently results
from digestive disturbances. Angioneurotic oedema
of the laryn.x, laryngeal hemorrhage, attacks of uncon-
sciousness in laryngeal phthisis, hemorrliagic affec-
tions in hepatic cirrhosis are all caused by disorders
of the gastro-intestinal tract. Swallowing secretions
from sores often upsets the stomach. A distended
stomach by upward pressure on the diaphragm may
cause glottic spasm. In t}-phoid fever laryngeal com-
plications are not at all infrequent. There is, how-
ever, no direct proof that disease of the upper air
tract is caused by gastric disturbances, but clinic.il
experience stronglv suggests that this is true.
Chronic Disease of the Nose and Throat. — Paper
by Dr. T. R. French, of Brooklyn. Chronic nose
and throat disease is often associated with digesti^■e
disturbances, but we cannot always demonstrate the
relation of cause and effect. Many causes of catarrhal
disturbances act by first influencing the digestive
organs. The writer alluded to observations made on
fifty medical students, all of whom had pharyngeal and
faucial catarrh. In forty-seven there was digestive
disturbance, fourteen were constipated, only one had
a clean tongue, forty-five were rapid eaters, thirtv-
three smoked, sixteen had nasal obstruction, and two
were mouth breathers. The smokers did not seem to
have any worse pharyngeal condition than the non-
smokers. In twenty-three cases of gastric disturbance
in women, half of whom were distinctly neurotic, all
had pharyngitis, four had clean tongues, four nasal
obstruction, four had additional mouth breathing.
The portion of the gastro-intestinal tract affected did
not seem to have any bearing on the pharvngeal con-
dition. Disorders of the stomach and bowels often
produced reflex vasomotor disturbances.
Dr. Casselberry remarks that Tiirck had found the
same bacteria in the stomach as in naso-pharyngeal
secretion. By curing the pharyngeal disease we would
cure the stomach condition also.
Case of Gun-Shot Wound of the Pharynx. — Re-
ported by Dr. D. \. R.-\nkin, Alleghany. A man was
shot in 1847 '" the phar\'nx, the missile passing in on
the right side about two inches below the lobe of
the ear, going across the pharynx and coming out at
a corresponding point on the right side. Nothing
could be learned from the patient as to the occurrence
of hemorrhage or difficulty in deglutition after the
wound. The latter cicatrized on both sides and the
man lived nearly fifty vears.
Second Day — Friday, May ijf/i.
Contribution to the Pathological Anatomy of
Ethmoid Disease — Paper Jby Dr. John X. M.acken-
ziE, Baltimore. The writer related several clinical
histories of the ordinary type of the disease and gave
detailed pathological reports upon the tissue removed
from the ethmoid region. The tissue showed evi-
dence of chronic inflammatory changes similar to all
intranasal inflammations, the glands having been
gradually destroyed by invasion of leucocytes and by
the contraction of the fibrous tissue resulting from the
inflammatorj- changes. To the tissue removed in such
cases the name of myxomatous tissue was generally
given. The writer would take exception to such an
application of this term. He advanced the following
propositions :
1. So-called myxomatous degeneration is not in
reality a mucoid change at all, but a simple inflamma-
tion. The word " myxomatous" is used in a loose
sense. The nasal chambers are in reality the last
place in which we would naturally look for a mucoid
change. Myxomatous polyps are in reality only oede-
matous fibrous tissue, not myxomatous. They repre-
sent chronic degenerative destruction by round-celled
infiltration and fibrous changes, and are a legacy of
simple inflammation. He would suggest the term
'"endorhinitis" as applicable to such cases.
2. Our usual method of using the term myxomatous
is erroneous, because the question is approached from
the clinical side alone and the tissue removed is
rarely examined microscopically.
3. Ethmoiditis, even though purulent, may last for
years without causing any bony lesion. Yet many
writers intimate that caries and even necrosis are very
frequent accompaniments. A primary original necro-
sis in these cases has not been established. Pent-up
secretion may cause osteitis but not necrosis. He did
not believe that nasal polyps ever arose from necrotic
bone.
4. The various changes found represent successive
stages of the same affection and hence a varietj' of
names is not necessary.
5. A marked similarity exists between the granula-
tion tissue and sarcomatous tissue. Hence we must
examine different portions of the masses removed be-
fore forming our conclusions.
Sero-Purulent Maxillary Sinusitis in Chronic
Lead Poisoning. — Paper by Dr. H. L. Wagner, of
San Francisco (read by title). Patient was a male of
thirty-two and for twelve years a carriage painter;
family history negative. He had complained for three
years of severe right supra-orbital neuralgia. Pains
occurred daily at intervals of from one to twelve hours.
He had hyperosmia, all strong odors producing an
attack. Various opiates and coal-tar derivatives had
failed to give relief, as had also resection of the right
supra-orbital ner\-e. All teeth in the upper jaw, some
decayed, had been extracted without improvement in
the patient's condition.
Examination showed a well-built man with yellow
skin, flabby muscles, no syphilis, eyes and ears normal,
and slight dry pharyngitis. Left nares normal. On
right side was slight hypertrophy of middle and lower
turbinates. At entrance of hiatus semilunaris a daily
crust formed, easily removed, and a slight sero-puru-
lent discharge (containing staphylococcus aureus and
a few non-pathogenic cocci) could be obser\-ed only
every second or third day. Transillumination showed
little difference between the two sides; face not
swollen externally. No pain was felt from pressure
over supra-orbrtal region. Right upper gum was
hypertrophied, but no blue lead line visible. Pres-
sure on region of right first molar caused severe neu-
ralgic pain.
A diagnosis was therefore made of right antral
trouble. The antrum could not be probed or irrigated
through the hiatus, and Dr. Wagner therefore perforated
through the hard palate. The injection of warm ster-
ilized water was followed by a sero-purulent discharge
from the nostril. The antrum was then opened with a
large trephine through the canine fossa under chloro-
form anesthesia. The cavity showed in the lower and
side walls a peculiar grayish-blue hypertrophy of the
mucosa. Probing revealed no caries, but pressure in
certain places caused great pain, r^xamination of a
bit of the hypertrophied mucosa showed loose connec-
tive tissue infiltrated with much serum and a fair num-
ber of round inflammatory cells, the tissue being cov-
98
MEDICAL RECORD.
[July 1 8, 1896
ered with columnar epithelium and containing some
micrococci.
After thorough removal of the tissue dry treatment
with borated gauze gave no relief and other methods
were also unsuccessful. The urine was then e.xamined,
but no albumin, sugar, or lead were found. Fresh
tissue from the antrum, however, gave the characteris-
tic lead reaction with sodic sulphate. Under the
iodide treatment all pain disappeared after a few days,
as did also the crust formation and sero-purulent dis-
charge. Traces of lead were later detected in the
urine.
The writer believes that in his case the antrum dis-
ease, including the neuritis of various nerves, must be
ascribed to the deposit of lead, perhaps as an albu-
minate. Similar conditions have been observed in a
few eye cases in which optic neuritis with severe
cephalalgia was caused by chronic plumbism.
Study of Irruption of the Teeth into the Nasal
Chambers. — Resume of reported cases and report of
additional cases. Paper by Dr. A. W. MacCoy,
Philadelphia. The writer gave a complete bibliogra-
phy to date of this class of cases and related some
of his own. Teeth in the nose may cause not only
local irritation and purulent discharge but also reflex
cough and larvngeal spasm. In one of his own cases,
in the examination of the nostril in a case of sarcoma,
the presence of a tooth in the nostril was accidentally
discovered, and the question suggested itself as to
whether such presence may not have been the exciting
irritation which eventuated in malignant formation.
Control of Hemorrhage in Operations on the Nose
and Throat. — By Dr. A. Coolidce, Jr., of Lioston.
In undertaking any operation under an anaesthetic, the
position of the p.atient is a first consideration. The
customary horizontal position is frequently contraindi-
cated because it is possible that blood may enter the
pharyn.x or larynx. When the operation is confined
to the nasal cavity, such an accident may be headed
off by the preliminary plugging of the posterior nares.
The Rose position (head hung perpendicularly over
the end of the table) is to most operators awkward,
though it prevents escape of blood into the lower phar-
ynx. The Trendelenburg position protects the trachea
from blood in thyrotomy and operations on the lower
pharynx. For operating, however, on the upper re-
spiratory tract, advocacy is made of setting the patient
in a chair opposite to the surgeon. If the body be in-
clined well forward, blood from the mouth or naso-
pharynx flows well outward. Of course, the patient
must be under absolute control. This position is con-
sequently more satisfactory with children than with
adults.
To check hemorrhage compression if possible is to
be preferred. Styptics are unreliable, irritating, and
cause loss of time.
Nasal hemorrhage can generally be stopped by plug-
ging the anterior nares, and every rhinologist siiould
know how to do this thoroughly and well. Naso-
pharyngeal hemorrhage can be controlled by filling
the cavity with gauze from below — just as we plug the
posterior nares. The amount of bleeding depends on
the size and number of vessels which may enter the
part removed and the amount of contraction which is
allowed by the structure of the intervascular tissue.
Troublesome bleeding is seldom met with in adenoids,
tonsils, and myxomatous growths. The reverse hap-
pens with sarcoma and fibroma attached to the basilar
process. To control hemorrhage from the latter, im-
mediate firm plugging both anteriorly and posteriorly
should be done. In the adenoid cases less blood is
eventually lost with the curette th.;n follows the appli-
cation of the forceps. In tonsillotomy the cold-wire
snare with general anaesthesia, or the hot-wire snare
with cocaine, will generally prevent bleeding.
Intermittent Dysphonia Spastica — ^By Dr. F. I.
KxiGHT, of Boston (read by title). Dr. Knight re-
viewed briefly what is known in regard to this affec-
tion, which in its well-marked chronic form he con-
tinues to think very rare. He added a report of a
recent case, in order to call attention to the intermit-
tent character of the affection. The patient was a
clergyman and the attack manifested itself only dur-
ing the latter half of a sermon. This was presumably
on account of fatigue. It appeared suddenly after
the gentleman had spoken in a perfectly normal voice
for an indefinite time. Dr. Knight said this was the
only patient of the kind who had consulted him who
did not unmistakably betray his affection during the
interview.
A Case of Unusual Laryngeal Growth. — By Dr.
J. W. Gi.KiTSMANN, of New York. The patient, a
Russian Jew, aged thirty-eight, had suffered from
hoarseness for one year, but without emaciation, pain,
cough, dyspnoea, or cervical adenopathy. The larynx
showed on the right side a snow-white mass extending
from the anterior commissure to the arytenoid carti-
lage. It seemed to lie between the true and false
cord, looking very much like a bunch of cotton stuffed
into the ventricle of the larynx. Its surface was
slightly corrugated and its border a little irregular.
The movements of the right side of the larynx were
apparently normal. Adduction was perfect. Other-
wise the organ seemed free from disease.
By means of a Landgraf's double curette a piece
was excised, but it proved to be too superficial for sat-
isfactor)' microscopical examination. Bleeding after
operation was slight, and there was no special reaction.
A fortnight later a second and larger piece — about
one-fourth of tiie whole growth — was removed, and re-
ported after examination to be a hard papilloma of
the larynx, probably malignant and possibly carcino-
matous. It was made up of a proliferated papillary
mucosa with a thickened epithelial covering, appar-
ently horny on the outside. The underlying epithelia
were greatly proliferated and the nuclei split up. In
consequence of connective-tissue proliferation there
was a small-celled proliferation of the submucosa.
The epithelial layer showed a tendency to invasion of
the subepithelial tissues as in carcinoma.
The marginal glands were also changed. The cy-
lindrical epithelia appeared to merge from one follicle
duct to another, instead of being distinctly separate,
as under normal conditions.
The patient disappeared from view after the second
operation, and the later history is unknown. The writ-
er of the iiaper had found no reference in literature to
a tumor of the snow-white color this one presented.
Such a color was to be regarded as strongly suggestive
of malignancy. Cancerous growths did not by any
means produce in their incipiencv hvperamia or in-
flammation of the cords.
A Report of Cases of Tuberculosis of the Lar-
ynx, with Results of Treatment as Far as As-
certained : The Topical Use of Bromoform, Form-
aldehyde, Guaiacol, and Protonuclein. — By Dr. S.
Soi,is-(\)HKN, of Philadelphia. Dr. Cohen related the
clinical histories of several cases, advocating espe-
cially the use of formaldehyde. His plan is to cleanse
the larynx with a spray of hydrogen peroxide, followed
by alkaline detergents. The formaldehyde occurs com-
mercially in a forty-per-cent. solution, known as for-
malin. A ten-per-cent. solution of formalin there-
fore equals a four-per-cent. solution of formaldehyde.
Water is used as a diluent, but as the solutions do not
mix well extemporaneously it is well to have them
prepared and kept on nand. Cocaine is first applied
in four-per-cent. solution, and then two- to ten-per-
cent, solutions of formalin rubbed in according to the
tolerance of the patient and the progress of the case.
July 1 8, 1896]
MEDICAL RECORD.
99
A slight burning pain was generally felt, lasting, how-
ever, only two or three minutes. Dr. Cohen has found
that it reduces cough, as does also bromoform. The
latter produces a certain amount of local anaesthesia.
Dr. Gleitsmann called attention to good results
obtained by him witli parachlorphenol. It produced
a shrivelling and absorption of infiltration not obtained
from lactic acid, which was better adapted to ulcerated
surfaces. Two-per-cent. solution was strong enough,
and in order to prevent stickiness therein he mixed
the remedy in equal parts of glycerin and water.
Some oif the Unusual Manifestations of So-called
Catarrhal Laryngitis — By Dr. C. C. Rice, of New
York. The following views were advanced:
I St. There are tw^o ordinary types of catarrhal lar-
j'ngitis — one following and dependent upon nasai ob-
struction, and the other upon a larvngitis sicca, an
extension downward of atrophic rhinitis and dry phar-
yngitis. In these two processes the same pathological
condition exists from the commencement of the nose
to the bronchial tubes.
2d. Laryngeal disturbances occasionally occur,
which from their appearance might belong to one of
these two ordinary types, but the significant point is
that they are present when the nose and pharynx are
in excellent condition, or, still again, the laryngeal
disorder, although in kind like that of the nose, is
much greater in degree, which is the reverse of the
usual condition.
3d. There are several disturbances, usually classi-
fied under "catarrhal laryngitis," which seem to bear
little or no relation to a previously existing nasal or
pharyngeal disease. They are commonly observed in
singers and public speakers, and are undoubtedly
caused by overuse of the voice and improper methods
of breathing and of tone production.
4th. We also find:
(a) General tissue atrophy of the soft parts of the
larynx and pharynx, which produces a disordered rela-
tion and a general muscular weakness of the larynx.
(/') Permanently enlarged and usually congested
epiglottis, the larynx as a whole being normal.
{/) "Choked voice," caused by actual enlargement
of the ventricular bands.
(</) Permanent and perhaps congenital vascularity
of the vocal bands.
{(') Localized congestion of some portion of the lar-
ynx, indicating probablv overuse of the transverse ary-
tenoideus, or possibly of some muscular group.
(/) " Singers' nodes," from incorrect vocal methods,
and cured by proper breathing and singing.
ig) Muscular fatigue with hoarseness or aphonia.
5th. These various disorders should be recognized
by proper names, their etiology appreciated, and they
should not be confused with the phenomena of a sim-
ple catarrhal laryngitis.
6th. Little dependence can be placed upon topical
treatment, unless special care be given to proper
methods of breathing and voice production.
Dr. Roaldes had noticed redness of the cords, es-
pecially in bassos and baritones. He thought the
condition more common in patients of gouty and rheu-
matic tendencies. The condition was less frequent in
tenors and sopranos.
Dr. Simp.son called attention to the fact that few
singers escaped more or less laryngeal trouble, and he
had sometimes been led to think that singing was an
unnatural use of the voice.
Dr. Nichols had observed persistent redness of
the cords in an alto singer, who nevertheless sang
jiierfectly.
Report of a Case of Incomplete Fracture of the
Left Cornu of the Thyroid Cartilage, Resulting
from Self-inflicted Violence.— By Dr. .\. VV. df:
Roaldes, of New Orleans. The patient, a man aged
thirty-seven, swallowed an olive seed. He experienced
a sense of a foreign body in the throat, and manipu-
lated the latter violently from the outside in trying to
dislodge the seed. The sense of a foreign body disap-
peared, but the patient felt at the same time a creak-
ing sensation in the throat. The next morning noth-
ing could be seen except a projection on the inner
side of the throat, without any marks of external vio-
lence. The mucous membrane over the site corre-
sponding to the left cornu of the thyroid seemed to be
poked inward by something underneath. The report
concluded with an enumeration of the anatomical
points which led the writer to regard the affection as
one of the thyroid cartilage rather than of the hyoid
bone.
Perichondritis of the Crico-Arytenoid Joint from
an Unusual Cause. — By Dr. H. .S. Birkett, of Mon-
treal. The case was reported of a young man who in
the course of a gonorrhital attack had inflammatory
joint trouble, alifecting the ankle, knee, and shoulder
of the left side. In the course of this a soreness and
difliculty in swallowing was experienced on the corre-
sponding side only of the throat. Examination showed
the mucosa over the left crico-arytenoid joint swollen
and osdematous. The left aryepiglottic fold was not
swollen. The true cords were white, and the abduc-
tion and adduction of the left one were decidedly
slower than the corresponding movements of the right.
Outside pressure over the aft'ected joint was painful.
Voice was hoarse. Treatment consisted in applying
the ice-water coil, affording great relief.
Third Day — Saturday, May i6th.
The Sequelae of Syphilis and Their Treatment.
— The discussion was opened by Dr. C. H. Knight,
of New York, who spoke of the sequela:; and treatment
of syphilis as affecting the nose. He said that it is
not always easy to diagnosticate late nasal syphilis.
It is often mistaken for sarcoma, and excision of the
upper jaw needlessly advised. The grade of severity
of symptoms depends on the fact as to whether only
the soft parts are involved or whether the hard parts
are also affected. Syphilis is responsible for some
septal perforations, but by no means for all. When
the bone is involved we have two problems to solve:
I St, when and how to remove dead bone; and 2d, how
to remedy resulting deformity. The writer advocates
conservatism in dealing with sequestra unless they are
quite detached and accessible.
If dead bone is firmly attached or embedded, or if
we cannot accurately define its limitations, or, again,
if it is high up in the nasal cavity in the ethmoid re-
gion, we must approach it with great caution. The
Rouge operation enables us to remove large sequestra
when they are loose and of extreme hardness.
External deformity from loss of cartilage is fre-
quently slight, but when the bone is destroyed the de-
formity is often hideous. For these cases the writer
advocated the Martin platinum bridge.
Several cases were related in detail. This method
is believed to be an excellent one with certain precau-
tions. The active stage of the disease must have been
long passed, and the patient must have had radical
treatment. The bridge must be so constructed and
shaped as to avoid friction and pressure. The dis-
section of the -soft parts must be wide enough to ob-
viate tension after the bridge has been placed in posi-
tion. The writer, in closing, alluded to the use of a
simple plate of platinum slipped under the skin of the
dorsum nasi, the dissection in preparing a bed for the
bridge having been made through the nostril. This
plan is much simpler and is equally effective in mod-
erate deformities.
Dr. J. E. Nichols, of New York, continued the dis-
lOO
MEDICAL RECORD.
[July 1 8, 1S96
cussion, speaking of the question as it concerned the
pharvnx. It mattered relatively little how severely
the uvula and tonsils might be affected, but it was
quite another matter when we came to consider lesions
of the soft palate. The epiglottis might be partly or
even wholly destroyed without causing much trouble.
If adhesion of the pharyngeal mucosa occurred to the
inferior portion of the posterior faucial pillar, there
were apt to be difficulty in deglutition and impaired
movements of the tongue.
When the soft palate is at all adherent to the phar-
yngeal wall great care should be taken to avoid all
caustic applications, which aggravate the very condi-
tion they are intended to relieve. The iodides should
be systematically given.
When complete adhesion occurs the patient be-
comes, perforce, a mouth breather. The voice is
affected, and traction from cicatrization upon the ori-
fices of the Eustachian tubes is apt to develop aural
complications. There is more or less danger of otitis
media, muco-pus accumulates in the naso-pharynx,
and anosmia comes on.
The writer then referred to the various means which
have been tried to remove these adhesions. These in-
clude the cautery, knife, and subsequent digital or in-
strumental dilatation. No matter how deeply we may
incise or how thoroughly dilate, cicatrization is apt to
advance from below. He then described an operation
devised by himself some years ago and subsequently
reported, in which the adhesion bands are operated
upon on the same general principle as is followed in
the surgical treatment of " webbed fingers.'" He be-
lieved this operation to be practicable in every case,
for there was no case on record in which the naso-
pharynx was entirely shut otT by adhesion from the
oro-pharynx. The opening might be difficult to find
and might be so .small as to admit only a fine
probe.
Dr. W. K. Si.mpso.v, of New York, discussed the
question as affecting the larynx. He drew attention
to points of difference between the " sequela" of syph-
ilis and the significance of the term as applied to other
diseases. In syphilis they are to be expected and
vary only in the length of time of their occurrence
and' in their nature. True sequela; are those resulting
from tertiary manifestations, and find their best ex-
pressions in'chronic thickening, loss of substance from
ulcerations and broken-down gummata or from peri-
chondritis, falling-in of laryngeal walls from loss of
cartilage, and ankylosis of various articulations, paral-
ysis, and various deformities.
The two leading conditions produced are loss of
voice and laryngeal stenosis. Aside from sequels
resulting from structural change, there i? often a hy-
peraemic condition which interferes with a perfect con-
trol of the voice, noticed especially in singers. This
condition is liable to come on from overuse, exposure,
sudden climatic changes — affecting, consequently,
sailors, etc. Moreover, smooth intralaryngeal swell-
ings may mask an underlying gumma, and hence the
difficulty of intubating such cases.
Attention was next called to the difficulty of differ-
ential diagnosis between syphilis, tubercle, rheuma-
tism, and malignancy. Without the finding of tuber-
cle bacilli we can never be sure of tubercles, however
strong the other points may be. Illustrative cases
were quoted.
In the treatment the writer referred to the general
use of the iodide and mercury, either alone or in com-
bination, mentioning the recent paper of Irsai, who
advocates intramuscular injections of bichloride di-
rectly at the site of the lesion. When stenosis is ab-
sent this general treatment is sufficient. When ste-
nosis exists some mechanical treatment is necessary,
either tracheotomv or some form of dilatation. Allu-
sion was made to the unsatisfactory results with the
Schrotter instrument. Not until we had the O'Dwyer
tube at our disposal were we convinced of the toler-
ance of the larynx in these cases to long and contin-
ued pressure, which is the main feature sought in
bringing about a cure. The pressure of the intubating
tube undoubtedly causes absorption of morbid tissues
and wears out the tendency to recurrence of the stric-
ture.
The author then laid down the general rules of
technique for intubation in this class of cases.
The discussion was continued by Dr. John O. Roe,
who said that the most serious nasal cases were those
of hereditary syphilis. The cartilage disappears and
often the bone, sometimes even the nasal bones them-
selves, so that there is a sulcus or cavity where the
nose ought to be. In adults the disease was generally
confined to the cartilaginous septum. Abscess fre-
quently occurred and the sesamoid cartilages might
be destroyed. He then described a subcutaneous flap
operation, designed in these cases to restore the sym-
metry of the nose.
Dr. Ro.\ldes was opposed to the Rouge operation
alluded to by Dr. Knight. As good results can gen-
erally be obtained by intranasal procedures. The
drill can be used to pierce the sequestrum in different
directions, and the latter can then be crushed.
Dr. E. Fletcher Ingals had found syphilitic ul-
cerations of the cartilaginous septum rare, unless the
bony septum was also involved. Of perforations of
the former, probably not more than ten per cent, were
syphilitic. In giving the iodide in tertiary lesions,
the dose should be gradually increased up to the max-
imum and as gradually decreased, then increased
again, and so on. In this way the large amounts of
the remedy so frequently needed would be much better
borne.
Dr. W. Peyer Porcher called attention to the con-
dition of the nose in leprosy as contrasted with syph-
ilis. In treating the latter he was partial to mercury
controlled by minute doses of opium.
Dr. Thom.\s HfBB.^RD, of Toledo, believed that
mercury was liable to increase the destruction of can-
cellous bone, unless the parts could be kept thoroughly
disinfected.
Dr. D. liKV-soN- Delav.an- said that he had had one
case in which there was total occlusion of the naso-
pharynx from the oro-pharynx by adhesions. He
called attention to the risk in operative procedures of
both primary and secondary hemorrhage.
A Case of Fibro-Chondroma of Branchial Origin,
or So-called Supernumerary Ear, Removed from
the Throat of an Infant Six Weeks Old.— I'his
case was reported by Dr. A. W. de Roaldes, of New
Orleans. The family history in the case was nega-
tive. Immediately after the birth of the child a queer
noise was noticed in its breathing and it seemed to
have attacks of partial strangulation. . These were
ascribed to phlegm and croup, but an examination by
the reporter of the infant's throat disclosed the pres-
ence of a growth. The child's external ears were
normal in appearance. When it cried the growth
seemed to come down from behind the palate. On
continued crying it seemed to descend still farther to
the aditus laryngis; finally, it would assume a third
position on the dorsum of the tongue. It was noted
that its covering was of a cutaneous (not mucous
membrane) character. The naso-pharynx seemed to
be free. The attachment was made out to be to the
left posterior pharyngeal pillar. It was removed by
evulsion and contained cartilaginous nodules, appear-
ing in general like a supernumerary ear. The micro-
scopical examination showed its outer covering to be
identical in its histological elements with the true
skin. The mass also contained fat and connective
July 1 8. 1896]
MEDICAL RECORD.
lOI
tissue, and a diagnosis was made of branchial chondro-
libroma.
Acute Disease of the Lingual Tonsil. — Dr.
Henry L. Swain, of New Haven, said that apparently
not much had been written on this subject, but if he
was to judge by his own experience during the last
three years, the condition had formerly been over-
looked by him. In any case he had persuaded him-
self that acute lingual tonsillitis was often the cause
of symptoms referred to other parts of the throat, sim-
ply because the latter were more frequently the seat of
disease and more easily accessible to view.
The anatomy of this region makes it evident that
the inflammation is rarely of the peritonsillar type.
The symptoms of the varieties of lingual tonsillitis
were then described. The writer recognized three
forms of the malady, the simple, the follicular, and
the peritonsillar. Symptoms were the same in kind
as in other acute throat affections, modified by the dif-
ference in the locality affected. Persistent cough is
a frequent and troublesome feature. The larynx is
often blamed therefor, while the lingual tonsil is at
fault.
If the deeper tissues are affected the symptoms as-
sume a severer type. The epiglottis and even the
glottis may become involved. Life may become en-
dangered and even tracheotomy may be required.
As to treatment, he preferred applications of glyce-
rite of boroglycerin followed by a powder of tannin
with the addition of a little morphine. Hot demul-
cent gargles were a valuable adjuvant. Systemic
remedies were indicated as in the ordinary forms of
tonsillitis.
The paper closed with the history of a case of ab-
scess of the lingual tonsil slowly developing after an
ordinary faucial tonsillitis. The attack was ushered
in with a sharp attack of cedema of the glottis. The
abscess had formed close to the aryepiglottic fold and
had broken well back toward the arytenoid cartilages.
Treatment of Simple Acute Laryngitis and Bron-
chitis.— Paper by Dr. Thomas Hubbard, of Toledo.
The existing literature on the use of expectorants is
full of inconsistencies and much of the treatment
advised is irrational. .Stimulating expectorants, forti-
fied by opiates and local palliative treatment, are quite
too popular to the unwise exclusion of a judicious use
of relaxing expectorants.
Attention is called to the essential features of acute
inflammation of the middle respiratory tract. Bron-
chial hyperaemia with more or less swelling produces
a condensation of the cellular elements, since the same
number of epithelial cells occupy smaller areas in
proportion as the calibre of the tube is lessened.
This is one reason why it is so difficult to re-establish
the mucous flow, the outlets from the glands being
thus closed. Retained mucus ferments and becomes
acid and irritating, whether within the substance of the
membrane or on its surface.
The first indication then is to re-establish the mu-
cous flow. The best relaxing expectorant is apo-
morphine, given in one-thirtieth-grain doses every
two to four hours. Except in severe cases and debili-
tated persons the subsequent use of stimulating ex-
pectorants is rarely necessary. The proper use of
relaxing expectorants greatly lessens the need for opi-
ates. All forms of abortive treatment are deprecated.
Squamous Epithelioma of Velum Palati Cured
by Injections of Caustic Potash. — Dr. Hubbard
also reported the following case: The patient, a male,
had suffered for more than a year from a mass, of flat,
tabular type, situated partly in the ^elum palati and
partly in the right anterior faucial pillar. All inter-
nal and local treatment had been without avail. Co-
caine habit had become established. In August, 1894,
he was on the verge of collapse from malnutrition.
being able to take only a small quantity of milk and
ice cream. The cocaine habit was first cured, but the
pain incident to deglutition could not be relieved.
With a curved platinum needle caustic-potash injec-
tions destroyed a conical-shaped tumor mass. When-
ever proliferating epithelial growths were seen around
the edges the injections were repeated in lesser
amounts. Cicatrization and improvement in general
health rapidly ensued. The patient gained forty
pounds in two months. Up to two years after the first
injection there had been no return of the growth.
Sarcoma of the Nasal Chambers and Accessory
Sinuses. — Dr. A. A. Bliss, of Philadelphia, reported
two cases of this kind.
Case I. Child of four years with negative family
history. At the age of one year its left nostril was
observed to be occluded by what the attending physi-
cian called polypi. The tissue was removed, but re-
currence had taken place in the course of six days.
During the ensuing eight months the nostril was
cleared out no less than thirty times. When seen by
Dr. Bliss the left nostril was occluded and the septum
was deviated to the right. There was no swelling
over the antrum. The left eyeball was protruded.
There was no glandular enlargement. The antrum
was opened and found filled with a fungoid mass.
The orbital roof was found intact. The post-nasal
space into which the growth had extended was cleared
out by the finger and cutting forceps. There was con-
siderable hemorrhage, which was stopped by stuffing
with iodoform gauze. There was no recurrence, but in
six weeks the glands under the jaw became enlarged
and symptoms ensued suggesting involvement of the
respiratory centres and of the brain. Death from ex-
haustion in six weeks.
Case II. Boy of nine, with negative family history.
Left nares occluded, cervical glands enlarged, and
exophthalmos. It was stated that the boy had been
well up to three weeks before. His general condition
was so bad that operation was considered unadvisable.
During the congress the following papers were read
by title: "Some Thoughts about the Prophylaxis of
Nasal Catarrh," by Carl Seller, M.D., Philadelphia;
" A Case of Myxoedema of the Throat," by J. W. Far-
low, M.D., Boston ; "Tracheal Stenosis," by Samuel
Johnston, M.D., Baltimore; "The Treatment of the
Early Stage of Diphtheria," by S. H. Chapman, M.D.,
New Haven; "Erysipelas of the Air Passages," by
Wm. Porter, M.D., St. Louis; "Some Observations on
Laryngeal Tuberculosis," by S. O. Vander Poel, New-
York; "Reflex Epilepsy from Lymphoid Disease of
the Pharyngeal Vault," by U. G. Hitchcock, M.D.,
New York.
At the executive session the following were ad-
mitted to active fellowship: Dr. G. V. Woolen, In-
dianapolis; Dr. Emil Mayer, New York; Dr. Ward,
Pittsburg; Dr. T. Melville Hardy, Chicago; Dr. W.
F. Chappell, New York.
Election of Officers for the ensuing year resulted as
follows: President, Dr. C. H. Knight, New York;
First Vice-President, Dr. T. Morris Murray, Washing-
ton; Second Vice-President, Dr. D. N. Rankin, .Alle-
ghany; Secretary and Treasurer, Dr. H. L. Swain,
New Haven; Librarian, Dr. J. H. Bryan, Washington.
The next congress will be held at Washington in
connection with the triennial meeting of the Associ-
ation of American Physicians.
Eczema of the External Auditory Canal Dr.
Hermet {Annales O///., October, 1895) considers ni-
trate of silver the best agent to employ. After first
cleansing the parts by means of boiled water, soak
cotton in a solution of one to ten, introduce into canal,
and leave it there for twenty-four hours.
102
MEDICAL RECORD.
[July 1 8. 1896
OUR LONDON LETTER.
(From our Special Correspondent.)
DR. fowler's grievance in parliament — MEASLES
LONDON UNIVERSITY ELECTION — ST. ANDREW'S
AND DUNDEE— CREOLIN HOSPITAL FESTIVALS —
SMALL-POX CAVENDISH LECTURE.
London, June 26, 1896.
Sir W. Foster brought forward Surgeon-Captain
Fowler's case in tiie House of Commons, in accord-
ance with the notice mentioned in my last. Several
other speakers condemned the abuse of power which
had worked such injustice, but the authorities pleaded
that a technical breach of military discipline had been
committed by the medical officer, who had failed to
conform to the regulations. This defence was ac-
cepted by the house, and so far justice is still refused.
But what a defence in face of the repeated declara-
tions of high officers that the doctors are only " civil-
ians." And this defence is set up for dismissing a
surgeon against whom no charge of incapacity is made,
and that at a time when the authorities are at their
wits' end to find eligible candidates for the army medi-
cal service !
Vou will remember that the only omission of duty
charged against Dr. Fowler was that he did not report
misconduct which he had reproved, because military
officers, his seniors, were present, and they were the
parties to make the report, according to the " Queen's
Regulations." Nevertheless, a scapegoat was wanted,
and who so helpless as the doctor.'
■• Murder by Measles" is the rather sensational title
of an article in the Nhieteeiith Century, by Drs. Waldo
and Walsh. The authors point out that there is a
large mortality from this disease, especially in poor
districts. Indeed, they estimate the case mortality of
such a district at about three times that of the richer
quarters. They tell us, further, that in 1894 measles
killed in London about twice as many per.sons as fe-
vers and small-po.x combined. On these and other
figures they put in a plea for the notification and iso-
lation of measles. Assuming '"the wisdom and neces-
sity" of such preventive measures in other specific
fevers, they pronounce it illogical to exclude measles
with its greater mortality. Ihey consider it a mys-
tery why it should be thought right to attempt to con-
trol diphtheria, while measles and whooping-cough are
left free. And yet they admit tiiat the co>it of isolat-
ing cases of measles must be enormous, though they
regard that as a sort of national insurance. But it is
not the cost alone that has caused ardent notification-
ists to recoil before the proposal to extend this meas-
ure to measles. Notification without isolation would
be of no avail, but with the present pressure on our
hospitals this looks impossible. Drs. Waldo and
Walsh give us no estimate of the " ample hospital ac-
commodation" that would be necessary to isolate the
enormous numbers of cases of measles. Nor do they
indicate how the popular opinion of the unimportance
of this disease is to be changed to such a conviction of
its deadliness as to support the advocates of notifica-
tion and isolation.
Convocation of the London University met on
Tuesdav, when the election of a representative of the
graduates on the senate took place. A list of three
persons, to be submitted to Her Majesty for selection
of a fellow, was duly proposed, viz., Mr. Rivington,
Sir J. Lister, and Mr. R. M. Stephenson. The advo-
cates of transforming the university into a teaching
bodv worked for Sir J. Lister, and are disappointed at
the result, for he received only eight hundred and
forty-six votes against nine hundred and sixty-three
cast for Mr. Rivington, who, although a well-known
medical reformer, desires the university to remain as
it is. .\n attempt was made to make the great repu-
tation of Sir J. Lister subservient to his party, but it
must be remembered that Mr. Rivington is a distin-
guished graduate and also a teacher of great experi-
ence. It is not improbable that the result will en-
courage the government to prolong the status quo.
The Dundee College, which was to be incorporated
with the University of St. Andrews, has not been able
to secure the terms which it desired, and for some
time past the public has been made acquainted with
the dift'erences between the two bodies. The new col-
lege at Dundee seems to plume itself on its modern
foundation. The ancient university has no notion of
sinking its history and privileges in a mere college of
to-day. The university authorities are willing to
grant Dundee College affiliation or incorporation on
such terms as a college might expect from its univer-
sity, and, while wishing success to the college, regrets
the bitter attacks which it has made on St. Andrews.
The truth seems to be that the college at Dundee wants
to finger the funds of the university, to which it fan-
cies itself the heir, and is longing to walk into its in-
heritance. But the end is not yet, and the venerable
university may outlive the upstart college. Litigation
has been carried on between the two, and will proba-
bly be continued.
Creolin has been extensively exploited as a non-poi-
sonous disinfectant, but its absolute safety must not
be too confidently relied upon in face of the results of
an investigation made at the Veterinary College. In
consequence of the eftect of a lotion of one in twenty
on some valuable ferrets, and of a stronger lotion on a
dog, other dogs and cats were experimented on with
the application, always with toxic effects and often fa-
tal. Professor Hobday concludes that creolin is a
narcotic and irritant poison to dogs and cats, and es-
pecially when applied over a considerable area of the
body, and its effect is more rapid when diluted with
water than when used pure or in the form of an oint-
ment. It is not so easily absorbed from small wounds
as from a large area of skin. It would seem, there-
fore, that more care in its use is desirable than has
been previousy considered necessary.
The Princess of Wales visited St. Mary's Hospital
on Tuesday, and spent about an hour an a half in the
wards, speaking a kindly word to each patient. Like
other hospitals, St. Mary's is in want of funds, but it
enjoys royal patronage. For the memorial Clarence
wing ^4,700 was raised at the annual dinner last
week.
A bazaar on behalf of the Northeastern Hospital for
Children was opened on Tuesday by the Duchess of
Connaught, who was accompanied by the duke. The
object is to pay off the debt, which amounts to ^3,000.
The present income is ^,500 short of the requirements
of the hospital, which is located in a poor district.
Purses were presented to the duchess, containing be-
tween ^.600 and X7°°' ^^^ l^he bazaar continued open
on Wednesday and Thursday.
The annual dinner of the Metropolitan Hospital
took place on Tuesday, when jQi.ibz was announced
as the result. This hospital is in much need of help.
It contains one hundred and sixty beds, but the treas-
urer says only sixty-six could be used, for want of
funds. It is situated in a densely populated and poor
neighborhood, and has separate wards for Jewish pa-
tients. It has, therefore, an extra claim on the rich
members of the lewish community.
Gloucester seems to have learned the lesson of the
epidemic. It is estimated that when the outbreak be-
gan there were nine thousand unvaccinated children
July 1 8, 1896]
MEDICAL RECORD.
lO'
in the city. Of tliese more tlian eigiity-si.x liundred
have been vaccinated, but Dr. Bond and his staff will
not relax their efforts while one child remains unpro-
tected. They have had a hard time, and, I hear, have
inspected some nine thousand iiouses. Some other
places, warned by the calamity of Gloucester, are put-
ting their houses in order; for the neglect of vaccina-
tion has been very widespread. In London there are
districts where the authorities have been growing more
and more remiss. Hackney and Islington are among
these, and are being haided over the coals. In the lat-
ter an outbreak of small-po.K has already begun.
The Cavendish lecture was this year delivered by
Mr. Bryant, who devoted it to " Vaccination and its
Discoverer." It may therefore be regarded as one
part of our celebration of the Jenner centenary.
OUR BERLIN LETTER.
CFrom our Special Correspondent. )
OOPHORIN TABLETS FOR THE MENOPAUSE THE MICRO-
ORGANIS.M OF CEREBRO-SPINAL .MENINGITIS I.M-
PROVED INSTRUMENT FOR AUSCULTATION LOCALIZ-
ING INTERNAL ORGANS.
June 20, 1896.
Considerable interest is manifested in the recent ex-
pe;iments of Professor Landau, in regard to the al-
leged efficacy of ovarian e.xtract in overcoming the
varied and distressing symptoms attending the meno-
pause. The distinguished observer gives his reasons
for the method on the assumption that the phenomena
of the climacteric is based upon a loss of power in the
ovaries, and in order to balance such a deficiency that
ovarian extract is indicated. He began by giving the
minced ovaries of freshly slaughtered animals, but
finding them unpalatable for the patients, he succeed-
ed in obtaining an extract which he now administers
in tablet form. Each tablet contains 0.5 gram of the
extract, and three or four are given thrice daily until
an hundred or more are taken, after which, if no suc-
cess is obtained, the treatment is suspended. He
claims to have cured twenty-four patients of the
twenty-seven treated. No secondary symptoms have
been reported in contraindication of the treatment.
Professor Heubner recently reported, in the Verein
fiir Innere Medicin, that he had succeeded in isolating
a new germ, which he obtained by the puncture of the
spinal column by Quincke's method in living cases of
epidemic cerebro-spinal meningitis. Heubner is the
first one who has succeeded in demonstrating this coc-
cus during life. This organism is called a " meningo-
coccus," and is identical with the gonococcus. It has
the same form and lies intracellular. Sometimes it
assumes the diplococcus form, and other times tetro-
genous form. There is a very striking difference in
grow'th which characterizes this meningococcus from
that of the diplococcus of Frankel, namely, that cul-
tures made from meningococcus grow very rapidly,
whereas those made from diplococcus grow very slowly
and after a time lose their virulence. Thus far exper-
iments to prove the positive disease by inoculating an-
imals have not been successful. Heubner succeeded,
however, in reproducing this disease in animals by in-
oculating them in the spinal region with a pure cul-
ture of this meningococcus. Former experiments of
Jager and Weichselbaum were unsuccessful because
the proper animals were not selected. Mice are not
susceptible to this poison, while horses, sheep, and
goats are. Heubner was able to cause the disease by
inoculation into the spinal cord in two goats. He lays
much stress upon the demonstration of the presence of
the meningococcus for differential diagnosis.
Dr. Schwalbe has perfected the improved instru-
ment for auscultation, the " phonendoscope," which
the Italian professor, Bianchi, invented. Schwalbe
reported very good results from its use. It consists
of three parts — a resonance box (of metal), two rub-
ber tubes for the ears, and a disc which can be placed
against the box. This instrument conducts the sound
of the organs to the ear, and can partially replace
percussion. It produces by percussion different
notes, according to the organ on which it is placed.
The inventor claims to be able to distinguish even
different lobes of the lung. According to Schwalbe's
experience, one can hear better with the '" phonendo-
scope" than with the unaided ear. It can be emploved
on parts of the body difficult of access, and eliminates
extraneous and artificial sounds. It is specially good
for physicians who are hard of hearing.
Professor Grummach has just published another
method for localizii>g the internal organs. He has
experimented with it, together with Dr. Rene de Bois-
Reymond. They illuminated the person on whom
the experiment was made with extraordinarily strong
Roentgen rays, and were able to see the contours
of the organs distinctly on a fluorescent screen placed
behind the patient. The laryngeal cartilages, as well
as the bodies of the vertebrae and the ribs, were to be
seen distinctly as dark shadows. The movements of
the diaphragm were clearly demonstrated. The nor-
mal movements of this muscle were from five to six
centimetres, but in pathological cases only 1.5 centi-
metres. The experimenters claim to show the ascend-
ing aorta, the heart, and the stomach as shadows. In
one case of arterial sclerosis the arteries of the arm
showed fine dark lines by the illumination. They also
claim to have seen the sclerosis of the coronary arteries
of the heart. Further, they were able to demonstrate
old calcified centres in the lungs.
GERMS AND SERUMS.
To THE Editor of the Medic-^l Record.
Sir: After reading the articles in your excellent jour-
nal in reference to antitoxin, I cannot refrain from
writing you a few lines about germs and serums in
general.
When will the medical profession learn that they
are being made dupes of by some of the chemical
manufacturing companies? These companies discov-
er (?) some great drug or cure. Now, how do they
set about to get rich from it? The answer is easy.
Some physician of national repute and high-sounding
title is sought. He is informed that the very moon
revolves about his magnificent reputation and name;
in other words, that he is the great medical mogul.
They inform him of the wonderful remedy, supply him
with some, give him to understand that it will be worth
his while to write a scientific article for print about it
What does he do? Tries it in a few cases, writes a
long, learned discourse, and gives it up to the company.
What do they do? Print his learned article and strew
it broadcast over the land. No one dares doubt the
wonderful virtues of the remedy, for does not the rec-
ommendation come from the great So-and-So?
No one wants to be outdone, so the lesser lights rush
into print — everybody goes wild. After a time some
doubting Thomas finds nerve and gall enough to call a
halt, and in about the length of time it would take the
midday July sun to lick up a frost the remedy is a
dead cock in the pit. The theory is exploded, but the
company has grown rich.
Understand, I do not say all chemical companies are
working the profession for what can be gotten out of
it, because we are under a thousand obligations to
many of them for the standard and reliable prepara-
tions they have put on the market.
I04
MEDICAL RECORD.
[July 1 8, 1896
What of antitoxin? Time will demonstrate, as it
has almost done already, that it is a delusion and a
snare. If so, you say, how are we to account for the
reports of cures made by the leading men in the pro-
fession? Here let me say we are only human — big
guns, little guns, and all. Enthusiasm carries them
off their feet. Everything must bend to the theory;
if we look through blue glasses we see blue.
I know of a man with a national reputation who se-
cured a little vial, at great cost and trouble, of a new
fad. He held it up before a class and said : " Behold !
the science of a thousand years, concentrated in this
vial!" The fact of the matter was that he could not
have told what was in the vial to "save his immortal
essence."
I doubt the efficacy of antitoxin upon two grounds:
First, mistaken diagnosis and slight attacks; second,
unreliability of figures.
As to the first reason — too many cases are diag-
nosed diphtheria which are not diphtheria. But, you
say, the culture and test will settle it. I say no. We
are overenthusiastic over germs and germ theories.
The pendulum has swung too far and must come back.
Time will prove that we have been too positive about
disease germs. Stick a pin there.
Many and many a case of follicular tonsillitis has
been called diphtheria, and a wonderful cure reported,
and perhaps the physician was sincere in his diagno-
sis. Beware of the diagnostic powers of a man who
reports anywhere from fifty to a hundred consecutive
cases of diphtheria without the loss of a single one,
antitoxin or no antitoxin.
The greatest medical man in New York or Paris is
just as apt to make a wrong diagnosis as a doctor not
known outside of his little country village. And with
all due respect I say that in many, many cases, were
we to judge of the true success of the two physicians
by the bona-fide cures made and real good done, the
cross-roads man would carry off the palm. Cartloads
of men with national reputations are dismal failures
in actual practice. Theory is one thing and practice
another.
As to the second reason — difference in severity of
epidemic, location, care, etc., leads to unreliability of
figures. Another reason is that when we are dealing
with the human organism we are dealing with a com-
pound, complex, complicated affair. So that if we
give a remedy and the patient gets well, what definite
reason have we for assuming the patient would have
not recovered without medicine?
Lincoln Phillips, M.D.
Hartwell, O.
MEASUREMENTS OF THE APPENDIX.
To THK Editor of the Medical Record.
Sir: Some one has advised us to give the appendix
vermiformis a rest; but, if you, Mr. Editor, will per-
mit, I should like to give the measurements of the ap-
pendix as I have found them in some post-mortem
examinations made.
In one hundred and fifty cases I have found the
length of the appendix to vary from two and a half
to nine and three-quarter inches. Only two came
above the general measurement — one six and a half,
and the other, the longest I have been able to
find any record of, nine and three-quarter inches.
Both of these extra long appendices w-ere found in
males; the canal communicated freely with the caecum ;
they were almost free, having only a short mesentery,
contained some hardened f^cal matter, otherwise were
in an apparently healthy condition.
C. J. RiNGNELL, M.D.
Minneapolis, Minn.. June 12. i8q6.
DOES THE APPENDIX DEMAND SURGICAL
REST ?
To THE Editor of the Medical Record.
Sir: With due deference to Drs. Morris and Wyeth,
whose surgical skill and other attainments are the
pride of our common profession, I must submit that
they do not, in a measure, apprehend the situation,
and they fail to rise to the exigencies of the occasion.
The question is not whether the treatment given ap-
pendicitis by Drs. Morris, Deaver, Wyeth, McBurney,
and others is the best treatment in their, or equally
skilful, hands. This was long ago demonstrated, and
there can be no question but that in the hands of the
surgical expert the mortality is practically ;///.
Nor would there be question if surgical experts were
easily procurable. But, as a fact, appendicitis is
common, expert surgical skill is extremely rare, and
these few surgical experts are not so self-sacrificing as
to respond to telegrams unmindful of the financial re-
sponsibility of patients and physicians.
The practical question for myself as a general prac-
titioner, a large part of whose practice is surgical, is,
what percentage of appendicitis cases ought I to sub-
mit to the knife?
In the solution I ask aid from the profession, and
the statistics of Drs. Fenger, MacArtney, and others are
valuable to me, if true, while the statistics of Drs.
Morris, Deaver, et aL, as surgical experts deriving
their data from consultation practice, are practically of
no value at all.
To refer me to statistics of ninety -eight per cent.
of recoveries at the hands of surgical experts, not surgi-
cal operators, when I invite aid, is to give me a stone
when I ask for bread. The question whether eighty-
five patients out of one hundred ' die under conserva-
tive management, or whether the mortality in general of
appendicitis is only about five per cent.,' is a most im-
portant one, as is also the question whether relapse in
cases surviving medical treatment is common or other-
wise. To such of us as have " sweat blood " in deter-
mining for or against operation in certain cases, it is
important tiiat these questions be discussed without
overestimating the tendency toward recovery on one
hand or offering the expedients of the surgical presti-
digitator on the other. The opinions of Senn, Fenger,
Keen, Lamphear, and others counselling conservatism
give us moral support in management of very many
cases by medical aid alone. If we listen to the protesta-
tions of another school, represented by Morris in the
East and Murphy in the West, we shall of necessity op-
erate in the great majority of cases. In the aggregate
will it be for good or ill? When Dr. Morris asks:
"Why is Dr. Greene willing to have nine per cent, of
appendicitis cases die under medical treatment?" he
is manifestly unfair in his presentation of the ques-
tion, inasmuch as he implies that more might be saved
by general adoption of surgical practice. This is
simply begging the question at issue. The general
practitioner bases his practice on:
ist. The assertions of observers like Fitz, Hektoen,
and Taft, who assert that thirty-five per cent, of all
dead bodies show more or less evidence of appendi-
citis. So far as I am aware this is not disputed, and
must of necessit)' indicate the inherent tendency of
the disease toward recovery.
2d. The expressed opinion of many surgical oper-
ators of great experience who are recognized by the
general profession as writers and teachers of author-
ity. These men may or may not equal the surgical
expert in certain technique, but it is to the consensus
of their opinion that the general practitioner must turn
for moral support, particularly in medico-legal cases.
' Wyeth: Medical Rf.cord. May 9, i8g6.
'Fenger; American Journal of Obstetrics, August,
1893.
July 1 8, 1896]
MEDICAL RECORD.
105
3d. The almost universal testimony of most intelli-
gent general practitioners in different sections of our
country that a ver)' large proportion of appendicitis pa-
tients get permanently well under medical treatment.
Under such circumstances I believe the general
practitioner can fairly demand of the surgical expert
that the latter give practical recognition of this well-
nigh universal testimony, and can serve notice on him
that he has no moral right to promulgate rules for the
guidance of the general practitioner based on experi-
ence that leads him to conclude that eighty-five per
cent, die under conservative management.
We general practitioners, who have devoted time
and money to learn from them in post-graduate work
how to diagnose and surgically treat appendicitis, know-
that the mortality rate is not so high and that their
statistics are not drawn from cases as they occur to
the rank and file of the profession.
Nor does it avail to insinuate unrecognized cases
under the head of peritonitis, obstruction of the bow-
els, or typhoid fever, when the competent practitioner
recognizes that any obscure abdominal inflammation
may prove to be appendicular and when cases of sup-
posed intestinal obstruction or even of acute gastritis
threatening death demand and receive surgical inter-
ference in order to establish a diagnosis.
What we contend for is that the radical position
presupposes moral cowardice or ignorance on the part
of the general practitioner, when the fact is that he can
give as much reason "for the faith within him '" in his
particular environment as Dr. Morris can in his.
To step from a carriage to the splendid appoint-
ments of a modem operating-room is one thing. To
travel before daylight ten miles through mud and rain;
to be confronted with unsuspected appendicitis that
has demanded operation for days; to personally send
messages over warring telephone lines, messages that
must be repeated from one to the other; to secure
under these circumstances necessary assistants, but
with instruments and dressings hastily procured; and
finally to operate successfully after 3 p.m. on a dark
and rainy day in a countn,- farmhouse is quite a dif-
erent picture. As for myself, I have experienced both.
Would the gentleman demand ninety-eight, or even
ninet)'-one per cent, of recoveries under these untoward
circumstances?
Dr. Morris alleges that he " arouses the ire of fellow-
surgeons" and " the emnity of general practitioners."
This is to be deplored, as it is not a question of feel-
ing but of fact. Dr. Morris' standing in the profes-
sion must disarm any suspicion that he had any feel-
ing toward Dr. MacArtney's statistics, but in our
section it has been somewhat the fashion that if any
conservative man dared lift his voice he has been
'■ jumped on " by surgeons who were making abdom-
inal sections even upon, in one alleged case, typhoid
fever, and whose zeal for operation, in my opinion, is
stimulated by the opinions of radical men.
It has been repeatedly urged in the past that we had
no ground for argument in the face of statistics and
opinions of men like Dr. Morris and others. As stated
in the beginning, what is the best treatment in the
hands of the surgical expert has been demonstrated.
What is the best treatment in the hands of the general
practitioner cannot be determined on that line at all.
I believe the solution is at hand when the general
practitioner begins to gather statistics, lift his voite,
and demand a hearing.
J. H. Greene, M.D.
Dubuque, Iowa, June 13, 1896.
A BAD HABIT OF SOME SMOKERS.
To THE Editor of the Medical Record.
Sir: Your editorial on "Anti-Cigarette Leagues"
touches upon a subject not only of great public inter-
est, but one that is ill understood by a majority of the
laity. The main facts presented, will not, I think, be
controverted by thinking men. There is one most im-
portant point, however, which has been overlooked in
summing up the evils of cigarette smoking, namely,
deep inhalation of the smoke. Inveterate cigarette
smokers are invariably addicted to smoke inhalation.
Granting that the ill effects are due to the absorption
of nicotine and other noxious material by the mucous
membranes, it will be conceded that the amount ab-
sorbed by the chronic smoke breather will be many
times that taken up by one who smokes a cigarette as
he would a cigar. Cigar smokers are not smoke
breathers. It is, therefore, not only the short smoke
offered by the cigarette, but also the pernicious habit
of smoke inhalation, wherein lie the evil and danger
to our boys and young men.
Frank P. Pr.\tt, M.D.
Jackso.n, Mich.
SPECIALISM.
Asthma. — Chloride of methyl spray upon the back,
up and down the spine especially, it is said will cut
short an attack.
To the Editor of the Medical Record.
Sir: To the doctor who reads his medical journals
regularly, nothing is more entertaining than the occa-
sional rows which occur between physicians on the
one hand and specialists on the other. The present
wrangle in the Medical Record between the general
practitioner and the appendicitis operator is a thing
of beauty.
I plead guilty to the offence of being merely a com-
mon every-day general practitioner, nor do I blush at
the admission. I am this by choice. I believe I can
be a more useful man, and, generally speaking, a more
broad-minded man, as I am than by becoming a spe-
cialist. So long as human nature shall be what it is,
so long will it be hardly possible for a man to devote
himself exclusively to one thing without losing more
or less of his general view. Every thoughtful doctor
will see the necessity of making allowances for this
tendency in our nature and of excusing the poor spe-
cialist with his limitations for many of his airs of im-
portance. We must do this, because specialists when
watched closely by the general practitioner are some-
times useful, and when carefully controlled and re-
strained undoubtedly do good in certain cases. Fur-
thermore, by hammering at the same thing all the time,
they evolve a fact now and then which may be of use
in building up the science of medicine as a whole.
But when one of these individuals gets to that point
of folly and impertinence that he, so to speak, bursts,
and rises on his hind legs to inform the great medical
profession that every man who does not treat his pa-
tients according to his peculiar formula or theory is
incompetent or unscrupulous, it is time for the profes-
sion to call such a ridiculous person down and sit on
him heavily. It is time for them to bring his atten-
tion to the fact which he must have forgotten, that his
specialty, no matter how important, is only a side show
in the practice of medicine, and that he, no matter
how brilliant he may be, is only one of the agile tum-
blers in that side show.
No, sir! The general practitioner has during the
last few years been fooled too often by specialists
great and small to be thrown off his guard to-day by
every utterance these one-idead people see fit to give
out. He cannot do his duty by his patients unless he
takes a firm stand and uses his own judgment and ex-
perience in passing upon the jarring and often utterly
io6
MEDICAL RECORD.
[July 1 8, 1896
unreasonable and contradictory statements with which
the journals teem. A specialist is like a man in the
theatre with an opera glass at his eye. He .sees with
unusual clearness the actor on whom his glass is
turned, but he sees little else. The rest of the stage
he cannot see, and as for the great audience about
him, he is for the time being hardly aware of its
existence. But all the same he is merely a unit in
the multitude, any other unit of which may be as good
and as intelligent as himself.
The question of " fat fees" has been brought up by
both sides in your recent communications, and there-
fore I claim i^ermission to allude to it. My e.xperi-
ence is that specialists who have seen patients of mine
do not usually charge more than a fair sum for their
services. On the other hand, I am sorry to say that a
specialist may be a very mean and sordid man. I
have seen it possible for such a one to send an un-
righteous bill to a patient, and, when a polite and
proper protest was made, to assume an offensive, men-
acing attitude, and finally to get down to the level of
a greedy pawnbroker.
To come to the question of appendicitis: I have
been practising sixteen years and have seen some
cases. Not being a specialist, I have not seen any-
where from fifty to five hundred cases in the last year,
but in sixteen years I have seen some and known of
others. I wish to testify here earnestly that every case
1 have seen which was not operated on got completely
well. I cannot say the same of those which were oper-
ated on. Not one of these patients who recovered
has had a recurrence. One of these was a lady
who was pregnant between five and six months, about
three years ago. She got well, and passed through
her confinement safely at the proper time. She has
had no trouble since and is to-day a well woman. Of_
course it is in order for some one to say that these
were not cases of appendicitis, but such an one will
talk in vain, because I know they were, and tell the
precise truth, statistics and specialists to the contrary,
notwithstanding.
It is the duty of every practitioner to treat every
case of appendicitis with a view to save his patient
the expense and danger of a surgical operation. Sur-
geons may prate as they please about the freedom from
danger in opening the abdomen, but it is a grave and
serious procedure ; I have a strong impression that no
surgeon would look upon the matter lightly if there
arose the question of opening his own abdomen. And
even if he has operated successfully on twenty or thirty
consecutive cases, he can give no guarantee that the
thirty-first will not end fatally. It is this uncertainty
hanging over each case which confounds all the sta-
tistics, and makes them of no interest or value to the
friends or the physician of any patient who may have
apix;ndicitis. What shall it profit a woman if her
husband is killed by having his belly cut open, if you
show her the dry figures which exhibit the pre\ious
successes of the surgeon who cut him!
It is the business of the family ])hysician to decide
in every case of appendicitis if an operation is neces-
sar)'. He can decide just as well as the surgeon, be-
cause the latter has no means of diagnosis which are
not within his reach. And when we reflect that some
surgeons are so far gone as to assert that every case of
appendicitis should be operated on, the solemn duty
of deciding the question for or against operation has
got to rest on the shoulders of the general practitioner.
Heaven deliver me and mine from that kind of sur-
geon! He is a reckless and dangerous man.
It is worth while to consider what would happen to
the people if the general practitioner did not stand
between them and the specialist. By the time the eye-
man had clapped on enough glasses to satisfy his
longings, and the nose man had gouged out enough
noses, and the throat man had cauterized his fill of
thoats, and the stomach man had let down his buckets
and other paraphernalia into the last stomach he felt
called upon to annoy, and the appendicitis hero had
satisfied himself that he did not need another appen-
dix, and the circumcision dragon had carried off his
allowance of foreskins, and that fearful nondescript,
the orificial surgeon, had humbugged all the human
apertures which he longs to get at, and this recent
iconoclast who has suddenly jumped into the arena,
whose mission in life is to pull the testicles out of old
men, shall have got his bag full of the contents of
other men's bags — by the time these and many others
had exhausted their efforts and become satisfied, there
would not be a whole man or woman left in the coun-
try. It is becoming more and more the duty of the
physician, to the community rather than to himself, to
resist the fads which are more abundant in the medi-
cal field to-day than ever they were before.
We must have specialists, and the rank and file of
the profession w ill be ever glad to learn any facts they
may discover whenever they can agree among them-
selves for a reasonable time which are their facts
and which are their theories. Furthermore, we shall
render proper respect to every man who respects us in
return and who respects himself; but the day is not
here, nor will it ever come, when the general practi-
tioner will consent for a moment to be pushed into
the attitude of a schoolboy, while the specialist stands
over him with the awful airs of a schoolmaster. All
honor to the large-minded man who gives freely of his
discoveries to jiis fellow piiysicians with the modesty
and dignity which marks the true man of science as
well as the true gentleman. We all know that kind of
man when we see him, and recognize his value. We
also know the other kind of man — the little chap with
a swelled head. We would suggest to him that he go
into the woods and commune with himself. After a
while it may dawn upon him that he is only a man
after all, and that he may not be a very big one.
W. J. Shrewsbury, M.D.
Brooklyn.
Pellotine Tolly presented a communication to a
Berlin medical society concerning pellotine, a new-
hypnotic, which is not, like most of our modern reme-
dies, a synthetic product, but is an alkaloid of a cac-
tus-like plant, the Anhalonium Williamsii, intro-
duced by Hefter. The natives of India, he said, had
long known of the virtues of this plant. The first
experiments on animals had seemed to indicate that its
action was somewhat similar to that of strychnine, but
experiments on the human subject, on the discoverer
Hefter himself, demonstrated that pellotine is an hyp-
notic of the first order. Given in doses of one-third
to one grain, it caused, in most of the cases observed
by Tolly, a sleep of about four hours' duration, induc-
ing at the same time in almost every instance a
slowing of the pulse. According to Tolly's experi-
ence, it acts well in the pains of locomotor ataxia, in
neuritis, nervous excitement, alcoholic delirium, etc.
The only by-effects noted were tinnitus, a sensation of
heat in the head, and vertigo. The speaker thought
the remedy was worthy of a trial, a change in hypnotic
remedies being in many cases of absolute necessity.
Ichthyol in Burns This drug is efficacious in
treatment of burns of the first and second degrees. It
alleviates pain, reduces oedema, and promotes healing.
It is used dry, diluted with zinc oxide or bismuth,
the powder being spread evenly over the surface; in
ointment (ten to thirty per cent.) ; or as a combination
of these two methods.
July 1 8, 1896]
MEDICAL RECORD.
10:
^cuT ;in6tvximcnts.
A NEW SPECTACLE LENS— A COMPOUND
ACHROMATIC PERISCOPE.
By F. park lewis, M.D.,
BUFFALO, N. V.
With the more general recognition of the importance
of refractive errors in their effects not only upon the
eyes, but often upon the general nervous system, has
come increased nicely in determining the focal correc-
tion, the proper position of the lenses before the eyes,
r\ A
B
A. I, Convex flint-glass cylinder; 2. convex crown-glass meniscus.
B. I, Concave flint-glass cylinder; 2, concave crown-glass meniscus.
C. I, Sectional view of both crown and flint glass' lenses cemented together
cover (for correcting chromatic aberation); 3, conca\e or convex crown-g!
the right adjustment of the frame, and an endeavor to
relieve the eyes in every possible manner of unneces-
sary or unequal strain. Comparatively little atten-
tion, however, has been given to an element of quite
as great, and in some instances greater, importance —
the construction of the spectacle lens itself. The im-
perative necessity of a correction of all spherical and
chromatic aberrations in the objective glass of the tel-
escope and the microscope has compelled the makers
of lenses to employ the highest skill in their construc-
tion. The necessity is equally great in the correc-
tion of the higher refractive errors; but, with the ex-
ception of the sphero-toric lens, which, valuable as it
is, has not come into general use because of the neces-
sity of special moulds other than those usually em-
ployed, there is no compound focal glass by which
spherical errors can be eliminated, and none whatever
by which a complete spherical and chromatical cor-
rection can be secured. In order to meet the require-
ments of this class of cases, the writer has devised a
lenticular combination, which has proved to be of such
practical value that a brief de-
scription may not be without in-
terest. Its simplicity and the fact
that it can be constructed at a
cost not largely in excess of the
ordinary compound lenses give it
a very general application. The
necessity of a lens of this kind
was suggested by the difficulty of
securing as high visual acuity
after the e-xtraction of cataract
and in other cases in which lenses
of short focus were required as
the absolutely clear media would seem to warrant.
Aphakial patients were peculiarly annoyed sometimes
by the sensation as of a blue haze surrounding every
object, even after the most perfect possible correction
with a lens had been secured. A suggestion made
some time before by Mr. Herbert Spencer, the well-
known maker of microscope objectives, that it was pos-
sible to secure achromatism in such strong lenses, led
the writer to order in the construction of such glasses
a combination made by cementing a flint-glass cylinder
of the proper refractive value upon a crown-glass lens
having a piano-spherical surface. The result, while
far better than that obtained from the ordinary test-
case combination, was still unsatisfactory. The con-
struction was therefore devised of a combination lens
based upon the following principles: The spherical
surface was to be a meniscus, either concave or con-
vex as might be desired, the proximal surface of which,
except a circle at the centre of suitable dimensions,
was to be ground to a smooth surface. The plain sur-
face of a cylindrical lens which was placed at the
proper angle was then to be cemented upon this pro.x-
imal surface, a narrow vacuum being left between the
two lenses. One lens w-as to be of
crown and the other of flint glass, in
order that chromatic correction should
be obtained. The strong spherical lens
being periscopic, spherical aberration
was therefore largely eliminated.
While viith such a combination the
exact values obtained in microscopical
objectives would not be secured, the
general effects have been so vastly
superior to any heretofore employed
as to make this
satisfactory one.
especially useful
kial and highly
astigmatism, it
; 2, plain flint-glass
ass meniscus.
lens an exceedingly
While it has been
in cases of apha-
myopic eyes with
has in some instan-
ces given relief in moderate degrees of
ametropia in which ordinary lenses
have not proved comfortable.
In such it has been especially valuable in giving
periscopic vision, whereas with the convexity or con-
cavity wholly in one side of the lens — a necessity in a
compound glass — its focal imperfections are manifestly
so great as to make the correction at best approximate.
It is evident that in such formulas as the following:,
chromatic aberration cannot be avoided except by
combining glasses of different refractive index, and
the spherical correction can be obtained only by the
use of a periscope :
R. + 1 1 D. sph. = -f 175 D. cyl. ax. 15°
L. -|- 14 D. sph. = 4- 175 D. cyl. a.x. 15°
R. — 9 D. sph. — — 2D. cyl. ax. hor.
L. — 10 D. sph. = -)- 125 D. cyl. ax. 90'
But in actual practice the most complete correction
has been obtained in the above and many other com-
binations, which have at once proven to be simple,
relatively inexpensive, and eminently satisfactory.
Front View of Compound Achromatic Periscope,
The lenses are made by the Failing Optical Com-
pany, of Buffalo.
Gonorrhoea. — Dr. Shoemaker says the physician
should caution jiatients suffering from gonorrhoea from
carrying the finger to the eye before the hands have
been thoroughly washed, as virulent ophthalmia is ex-
cited by contact with gonorrhceal pus.
io8
MEDICAL RECORD.
[July 1 8, 1896
llXedicaX Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending July 11, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis,
Measles
Diphtheria
Small-pox
Cases.
Deaths.
95
93
15
5
53
6
5
6
I So
10
214
26
0
0
The Jenner Centenary in Berlin. — In Berlin,
as elsewhere, the Jenner centenary was celebrated
on May 14th, commemorating the first vaccination
practised one hundred years before. On invitation
of the city, several hundred physicians assembled
in the great hall of the Rathaus. After an ad-
dress of welcome by Virchow, who called Jenner one
of the greatest benefactors of humanity, Oerhardt de-
livered the oration, in which he pictured in brilliant
colors the life and labors of Jenner. Kruse, a deputy
in the Reichstag, also spoke, referring to the antivac-
cinationists and warning his hearers against an under-
estimation of the harm they were capable of doing.
The city councilman. Dr. Strassmann, delivered the
oration in behalf of Berlin. In connection with the
celebration was an exhibition of objects relating to
vaccination. There were many Jenner portraits and
letters, the pioneers of vaccination in Germany were
commemorated, and even the antivaccination litera-
ture of the century was well represented. The im-
pression made by this celebration was that the storm
of the opponents of vaccination was not likely for
many years to come to avail much against compulsory
vaccination law.
Starving in Heart Disease. — At a recent meeting
of the Berlin Medical Society, Dr. Hirschfeld read a
paper on the nutrition of patients with heart disease.
He took the somewhat startling position, in which, how-
ever, he was sustained with the approval of many of
his hearers, that patients with heart disease, in the
stage of imperfect compensation, should take as little
food as possible, not even enough to sustain the body
weight. It was formerly the custom to give as much
nourishing food as possible, with the idea of strength-
ening the heart. The speaker maintained, however,
that in this way too much work was thrown upon the
heart, and that the organ was spared and its muscle
strengthened by giving very little food, say about a
pint and a half of milk a day. Senator, among others,
agreed with the speaker in this view.
Regulatory Glycosuria. — Dr. Gustav Klemperer,
in a paper at a recent meeting of the Society for
Internal Medicine, opened up a subject of great gen-
eral interest, namely regulatory glycosuria and renal
diabetes, starting from the remarkable fact that in
diabetics who have at the same time albumin in the
urine the glycosuria ceases as soon as the disease of
the kidney has reached the point of cirrhosis. Thus,
a patient with typical granular atrophy of the kidney
had formerly four per cent, of sugar in the urine.
If, then, only healthy renal epithelium excreted sugar
and the diseased epithelium did not, the case must
have been one of renal diabetes, which Klemperer
thought was also demonstrated by the following:
First, it is certain that the diabetes produced in
animals by phloridzin poisoning is of renal origin.
for the proportion of sugar in the blood of such ani-
mals is not increased after extirpation of both kid-
neys; and, furthermore, when the phloridzin is in-
jected into the renal artery of one side saccharine
urine is excreted only from the corresponding kidney.
Klemperer has succeeded, as did von Mering, in pro-
ducing phloridzin glycosuria in man. This occurred
independently of the nature of the food, even when
this contained no trace of starchy matters and there
was no increase in the amount of sugar in the blood.
It had, therefore, all the characteristics of renal dia-
betes. But as this renal diabetes is possible only
when the epithelium of the kidney is sound, the sjjeaker
was unable to produce phloridzin glycosuria in a num-
ber of patients suffering from granular atrophy, liut,
on the other hand, Klemperer did not look upon the
glycosuria, which was often noted after the exhibition
of strong diuretics, such as calomel, digitalis, caffeine,
and the like, as of renal nature, but regarded it as a
regulatory glycosuria. In these cases the organism is
ridding itself of a surplus of sugar, for this glycosuria
occurs only when there is an increased ingestion of
sugar at the same time with the exhibition of the diu-
retic, and examination shows also that the proportion
of sugar in the blood is increased. Klemperer said
that the object of his paper was to direct the attention
of clinical investigators to the existence of a renal di-
abetes, in order to determine whether this experimen-
tally produced variety of diabetes is also an actual
clinical fact. He had himself observed a case of this
nature, but in this instance the renal affection was al-
ready in the stage of granular atrophy. The patient
excreted regularly, under the most varied dietetic con-
ditions, about 0.35 per cent, of sugar, but the propor-
tion of sugar in the blood was never increased. The
sjDeaker believed that the recognition of this form of
diabetes was of practical therapeutic significance, since
it would have an influence upon the regulation of the
diet.
Syringomyelia. — Professor Eulenburg recently re-
ported a very interesting case of syringomyelia to
the Berlin Society for Internal Medicine. The dis-
ease had appeared in consequence of an injury of the
hand. Through inadvertence a small piece of zinc
was left in the wound of the hand, and this had re-
sulted in a severe phlegmon. The first symptoms of
muscular atrophy appeared soon afterward, first in the
arm on the side of the injury. F'.ulenburg held to the
traumatic origin of the affection, but did not believe
that the presence of the zinc in the wound was of any
etiological significance. The case was one of great
importance, in relation to the laws governing accident
insurance in Germany.
Medical Philadelphia. — The Medical and Surgical
Reporter says liiat it is not, as we had supposed, ad-
ministering weekly rebukes to its readers in that city
for their lack of energy and failure to keep abreast of
the times. " Readers of the Reporter," it truly says,
'•are necessarily fully abreast of the times. Even
those physicians of Philadelphia who do not regularly
read the Reporter cannot be said to be far behind the
times. The generous support of New York journals
indicates that a considerable portion of the Philadel-
phia profession is, or at least ought to be, as far ad-
vanced as is the profession in New York, concerning
whose doings it is much better informed than it is of
current work at home. However, the Reporter has
never alleged ' a lack of energy or failure to keep
abreast of the times' on the part of the Philadelphia
profession as practitioners of medicine. Its com-
ments have been upon the business policy and the fat-
uous methods of the body medical, the effects upon
Philadelphia's reputation, and the derogation of the
city's claim as the medical centre of America."
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 50, No. 4.
Whole No. 1342.
New York, July 25, 1S96.
$5.00 Per Annum.
Single Copies, loc.
(Dvininal JKrticU-s.
THE ENDOTHELIUM OF THE FREE SUR-
F"ACE OF THE PERITONEUM.
Bv BVRON ROBIXSON, B.S., ^[.D.,
CHICAGO,
IROFESSOR OF GYNECOLOGY IX THE POST-GRADl'ATE SCHOOL.
Valentine discovered the peritoneal endothelium. In
1862 Von Recklinghausen discovered that a solution
of nitrate of silver produced dark lines between endo-
thelia. In 1865 His introduced the name endothe-
lium for the peritoneum instead of epithelium. Endo-
thelium in general is a nucleated membrane, as the
endothelial plates of blood-vessels and 13'mphatic ves-
sels, ;.nd the lining of lymph sinuses. Many capilla-
ries have their wall composed of simply a single layer
of endothelium, /.c, flat,
membranous nucleated
plates joined edge to
edge so as to compose a
hollow tube for fluid
conduction. Endothe-
lium is derived from the
middle genu layer of
Pander and Baer. In
this article will be dis-
cussed that form of en-
dothelium which lines
the free surface of the
peritoneum. In other
words, we will consider
the connective - tissue
cell which is flat and
smooth on one side, for
the peritoneal endothe-
lia are only modified
connective-tissue cells.
The origin of peritoneal
endothelia is no doubt
due to fluid pressure in
lymph spaces and visce-
ral motion independent
of the body wall. I mean
by this that the fluid pressure in lymph spaces became
so constant and so vigorous that the fine partitions grad-
ually atrophied or became absorbed until the spaces
coalesced so much that a lymph space of varying
size arose. This enlarged space is lined by what we
are terming endothelial plates. Added to this, the
viscera adjacent to these developing and coalescing
lymph spaces become more and more independent in
their movements relative to the body wall. Thus, by
increasing development of lymph spaces and by in-
creasing independent motion of viscera and body wall,
the great lymph sac — the peritoneal cavity — was
formed with its smooth lining endothelial plates.
This evolutionary process in producing a monster
lymph sac with smooth walls was an act of adaptation
of the viscera to their environments. The need of
progressive visceral growth and fi.xation of body wall
was motion and this was accomplished by fluid in a
Fig. I. — Drawn {rum Frog's Cisterna
Lymphatica Magna. (Oc. 2, ob. 8 a,
Reichert.) The surface directed toward
the cisterna is shown. Eight stomata
vera are shown ; some partially open,
others tightly closed. Some of the cells
of the stomata vera are marked with
nuclei. There are scores of other sto-
mata vera adjacent and distributed simi-
larly, 2, The stomatavera cells show-
ing no nuclei ; a, with two nuclei ; 4,
with one nucleus ; 5, an enlongated
stoma verum.
smooth sac. It reduced friction to a minimum and
increased motion to a maximum.
By peritoneal endothelia is implied a layer of flat-
tened, smooth cells lining its free surface. The plates
of endothelia are so arranged edge to edge that a con-
tinuous, non-interrupted membrane is produced. Per-
itoneal membrane is different from mucous membrane
or the membrane which lines glandular cavities. Mu-
cous membranes possess epithelium and arise from
hypoblast or ectoderm. The peritoneal membrane,
serosa abdominalis, is derived from mesoderm or me-
soblast. The naked-eye appearance of normal peri-
toneal endothelium is that it is shiny and glossy. The
eye can distinguish no lines or unevenness on its sur-
face; it is smooth. In color it is grayish-white, pink,
or pearly, depending, however, on its vascular condition
to some extent. It is transparent and many structures
may be observed beneath it. The endothelial layer
itself does not change so much in appearance as do
the subjacent structures. Fat makes it appear yellow,
pigment cells dark, while bile-stained subjacent struc-
tures give it a variegated color. In short, its color
arises from subserous organs and conditions. Previ-
ously diseased endothelia returned to normal may even
show a mottled condition.
To the touch the endothelial membrane feels smooth
and moist. It is slippery from the viscid condition
of its secretions. It is so thin that one could perhaps
not distinctly feel less than four or five la)^ers between
the finger and thumb.
The best method for ob-
serving the thin portion
of the endothelial layers
is to allow it, especially
that from the omentum
majus and gastro-splen-
ic, to float in a large cap-
sule of water, when the
thin, delicate membrane
will move about, some-
times almost invisible.
On exposure to the at-
mosphere it quickly be-
comes dry,wrinkled, and
brittle. A brownish col-
or appears to arise when
it becomes dry.
The extent of the per-
itoneal endothelium is
not very much less than
the extent of the skin.
The endothelia, i.e., the
connective - tissue cells
flattened and smooth on
the free surface, are the
essential elements of the
peritoneum. Without
the endothelia the peri-
toneum is robbed of that
element which endows it with physiological properties
and is the principal factor in preventing the invasion
of disease.
The preparation of the peritoneal endothelium and
the interpretation of its appearance under the micro-
FlG. 2.— Drawn from Omentum Majus of
New-iiorn Child. It represents what I
shall term a giant (6) endothelial cell
surrounded by many small irregular
ones. This irregularity I think cannot
be the result of trauma, as it was han-
dled with precaution. The giant cell is
less stained than the adjacent endo-
thelia. The omentum of this new-
born is in a state of wild irregularity as
to shape, size, and grouping of endo-
thelia. 1, 2, 3, 4, stomata vera ; 5,
stomata spuria (adjacent in the mi-
croscopic field, not here shown, are
other smaller giant endothelial cells sur-
rounded by smaller groups); 6, giant
cell ; 7, common endothelia.
I lO
MEDICAL RECORD.
[July 25, 1896
scope are the first steps to a knowledge of structure
and function, and it is the second step to make such
knowledge of practical benefit to combat peritonitis,
the vigilant enemy of mammalian life. The first pre-
caution in prepar-
ation for the obser-
vation of the peri-
toneal endothe-
lium is that the
membrane be as
fresh as possible.
The second is that
all possible trauma
to the membrane
be prevented ; ma-
nipulating, drag-
ging, and tearing
must be avoided.
The membrane
should be handled
only in a fluid me-
dium, and even in
the fluid with as
little movement as
is compatible with
results. For the
fresh specimen an
a n i m a 1 may be
Fig. 3. — A, Drawn from Adult Human Omen-
tum Majus, (Oc. 4, ob. 3, R ) It shows, i,
stoma verum surrounded by six cells ; 2,
stoma verum ; and 3, a verj' brown spot on the
surface of an endothelial cell, perhaps a rift or
precipitated debris; 3, free edge of trabecula.
Note the irregularity of the endothelial cells
over a field of fat globules ; doubtless the ir-
regular jjrowing fat globules account for the
irregular shape and size of the endothelia.
/?, Drawn from an adjacent trabecula foe.
4, ob. 3, K.) surrounded by si.x cells, i, Sto- killed and the parts
ma verum with two long rifts and a round, . , . ^
white spot in it; i, 2, endothelia quite irregu- 01 tllC peritOIieum
lar ; 3, 3, free edge of trabecula. Note in both ^ 1^ t^vimlno/-!
.^ and A- that the inter-endothelial lines extend tO OB e.xamuiea
into the stoma verum and that the granular Ofentlv CUt OUt with
substance shimmers through. ^ '
very sharp scissors
and examined in serum from the animal's abdomi-
nal cavity, or placed in a large capsule of distilled
w^ater. Small bits of the membrane can be snipped off,
allowed to float on the slide, and then e.xamined in
serum, water, or a drop of glycerin applied to the
under surface of the cover glass just before it is
placed over the specimen. A one-half-per-cent. so-
lution of common salt (\aCl) is an excellent me-
dium. Much knowledge
may be gained by the mi-
croscopical examinations
of such specimens; in fact
all the knowledge of peri-
toneal structure rested on
such examinations up to
i860. But I shall base my
investigations and inter-
pretation on peritoneal en-
dothelium treated with Ag
No. 3 solutions, as Von
Recklinghausen taught
thirty-five years ago, be-
sides the more modern re-
agents. The Ag No. 3 SOlu- Fig. 4.— Gastro-Splenic Umeni
. ■ 1 111 r r two months' Fcctal I'ig (oc.
tion should be of from one- „, rj, showing endothelia g
quarter to one -half per
cent., always in distilled
water, and should be freshly
made every two weeks (two
grains of Ag No. 3 to an
ounce of distilled water).
For example, a rabbit is
killed by Isleeding or other
method. The abdomen is
ojDened with care and a solution of Ag No. 3 is
poured over the peritoneum /// si///, while the animal
lies on its back. No viscera or peritoneum should be
touched or traumatized before the Ag No. 3 is poured
on the peritoneum. The silver solution should remain
from two to fifteen minutes. But by experience and
knowledge of desired results one soon learns how long
to leave the silver solution on and how much sunlight
turn of
3, ob. S
ing endothelia grouped
around stomata vera. i. Stoma
verum which shows a distinct ver-
tical canal lined with granular cells,
which stain well with Ag No. 3 ;
2 is not quite so plain, as sonic of
the guarcl cells have dropped out.
The foetal pig shows the most typ-
ical grouping of endothelia of all
animals which I have examined.
The typical endothelia groups sur-
rounding a stoma verum only occur
on germinating tracts. It appears
that with age the endothelia become
more polygonal.
Fig. 5 is drawn from human omentum
over a field of fat globules. The irregu-
larity of its endothelia is doubtless due to
the irregular expansion of the fat glob-
ules. I, I, Stnmata vera ; 2, 2. endo-
thelia representing centres of endothelial
groupin.g. Sc\ eral endothelial cells wtre
required to cover one fat globule, and the
microscopic focus required readjusting
for endothelia on the top of the fat
globule and at its base. In this cut ir-
regularity of endothelial contour and
variati'm of focus for uneven surface are
noticeable.
should be allowed to shine on it. The results de-
pend on the strength and time the silver solution
remains on the endothelium and the duration and
intensity of the sunlight. I have examined speci-
mens two months after mounting in glycerin, which
were continually exposed to light and they improved
with age. The silver-stained endothelium should
remain in distilled water for an hour before it is
placed in common water, for the salts in common
water interfere with the
working of the Ag No.
3 solution. If one
wishes to check the ef-
fect of the silver solu-
tion on the membrane
it should be placed in
a salt solution, one-half
per cent. Any trauma
exercised not only is
liable to desciuamate
the endothelium, but it
will be liable to disturb
the peculiar structures
known as stomata vera,
as well as the inter-en-
dothelial substance,
and, as this last-named
material is pliable,
semi-tluid, it can also
become disarranged.
What does one see
on looking at a silver-
stained peritoneal endothelial b])ecimen through a mi-
croscope.'' First, he sees irregular dark lines which
separate brownish spaces from each other. These dark
lines are precipitated albuminate of silver, the inter-
endothelial substance being of an albuminous nature.
Some have claimed that the dark lines are only pre-
cipitated albuminous fluid substance which exists in
furrows on the endothelial membrane, for all admit a
serous fluid exists on the surface. Some claim that
the lines are elastic fibres. Schweigger-Seidel enun-
ciated and defended this view persistently, and as
proof said that if the peritoneal endothelium be first
washed with diluted glycerin or diluted sugar solution
the silver solution will not produce the dark lines.
However, Klein positively denies the assertion. He
repeats the rinsing of the membrane, and says the sil-
ver solution then produces the lines as before. Also,
that by rinsing the peritoneal endothelium with water
the silver solution will still produce the dark inter-
endothelial lines. Hence this is sufficient proof that
the dark inter-endothelial lines are not on the surface
at all, but in the semi-fluid inter-endothelial substance
between the plates. I can say that 1 have repeatedly
watched the effect of the silver salts on the inter-endo-
thelial lines, from just perceptible dark lines until a
week later, when the lines have thickened in breadth,
and also to .some extent shown some connection wiih the
substance on the endothelial plate; the endothelial
plate will gradually brown deeper and deeper from the
circumference of the plate, /.(■., from the inter-endothe-
lial line toward the nucleus of the cell plate. But
the dark, irregular, inter-endothelial lines appear first.
Now, in many endothelia the nucleus remains an oval
or round clear space, /.<•., the silver solution did not
brown it, but the circumference of the nucleus is in-
tensely brown. The only reasonable explanation 1
can offer for this phenomenon is that the nucleus is
higher than the rest of the cell and therefore the silver
solution flows away toward the edge of the plate; con-
.sequently, we shall assume that the dark, irregular
endothelial lines are precipitates of albuminate of sil-
ver and therefore that they represent the outline of the
peritoneal endothelial plates. There is a wise provi-
July 25, 1896]
MEDICAL RECORD.
Ill
sion in this inter-endotlielial substance being semi-
fluid, in that it accommodates motion and friction to
such a degree that tlie endotlielial plate will not be
torn. The brownish precipitates on the endothelial
plate after the application of silver solution must be
of an albuminous nature also.
Perhaps it is albuminous fluid
lying on the uneven surface of
the endothelial plate, of a na-
ture similar to that of the in-
ter-endothelial substance.
In the inter-endothelial sub-
stance is the seat of the physi-
ology of the peritoneum. .At
the common junction of sever-
al (three to fourteen) endothe-
lial plates may be observed an
oval or round opening known
as a stoma. The m.outh of this
opening takes on a deeper stain
than the surrounding endothe-
lial plates and it is lined by
granular polyhedral cells.
The stomata-vera cells no
doubt are young cells and con-
tain more precipitable albu-
min, and hence are darker than
the adjacent endothelia. The
opening shows itself to have depth and hence may be
termed a vertical canal. The interpretation is that the
stomata (stigmata) vera are vertical canals lined by
granular polyhedral cells and serve as a communication
between the peritoneal cavity and the subperitoneal
lymph channels. It seems to me that they regulate
serous fluids.
Again, on the single inter-endothelial lines are found
black dots, stomata spuria, or pseudo-stomata, which
Fig. 6. — From Human Broad
Ligament. .Age 39, dead 20
hours. Ag Nu. 3. ^Oc. 4, ob.
4, R.) The drawing represents
two stomata vera ; i is open.
2 is closed. The endothelia
are quite small and of a fairly
uniform shape. Thisspecimen
was taken from the peritoneum
where it diverged from the
lower surface of the Fallopian
tube. In this locahty the sub-
serous lines — fibrous and elastic
— are very rich in quantity,
making it appear that the peri-
toneum which loosely surrounds
the Fallopian tube is quite
thick and strong. The germi-
nal endothelia surrounding the
stomata vera are intensely
brown.
with logwood, we note sharply defined round or oval
bodies, which are interpreted as nuclei. Thus, in the
technique of preparations of peritoneal endothelia
much of the interpretation is dependent upon the kind
of reagent employed. I must say that neither the
technique of microscopical preparations of peritoneal
endothelia nor the interpretations thereof are univer-
sally agreed upon. Many claim that the interpreta-
tions of what is known as stomaia vera rest on a faulty
technique.
The shape of the endothelia varies in different ani-
mals and is dilTerent in the embryo and in the adult.
However, generally analogous-shaped endothelia are
found in analogous localities. Afonassiew, Musca-
tello, and others appear to think that the general and
original form of an endothelial cell is polygonal. My
e.xaminations include man, the cow, sheep, horse, pig,
cat, bird, dog, rabbit, frog, and the embryos of pig and
man. So far in the e.xaminations I cannot generalize
any single form of endothelial cell. It is probable that
the polygonal form outnumbers any other single form.
Again, the endothelial cells or plates in the embryo
are quite different from those in the adult. The frog
possesses the largest and most irregular forms of endo-
thelia of any animal I have e.xamined. The horse
and cat possess large areas of very uniformly shaped
endothelia.
The outlines of the peritoneal endothelia are gen-
erally those of curves and straight lines. Occasion-
ally we find sinuous outlines which may resemble the
cranial sutures. But sinuous outlines is the chief
characteristic of endothelia covering lymph channels.
Some endothelia are perfectly round, some show ob-
tuse angles, while others show acute angles. They
may be oval, square, spindle-shaped, or present grace-
ful loops and necks, or assume the shape of a rect-
angle. They may be triangular (pig), pentagonal, or
Fig. 7 — A^ New-Born Human Omentum Showing
Stomata Vera and Spuria and Very Irregular
Shape and Size of Endothelia. i, Stomata vera,
a typical case ; 2, 3, 4, other stomata vera ; 5,
stomata spuria ; 6. stoma verum with its granu-
lar polyhedral cells ; 7, 8, endothelia dropped
out.
By Drawn from a foetal (two months) pig's
diaphragm, abdominal side. It shows a typical
stoma verum (i ) and it represents it distinctly
as shimmering through the common endothelia
(2 and 3). There is a round black dot in the
centre of the stomata vera through which
growth process takes place. The endothelia on
this fcetal pig's diaphragm are much more regular
in shape and size than on new-born humans.
Fig. 3. — (/') Pleural Side of Diaphragm.
Drawn from pleural surface of three-
month&old dog. Ag No. 3. 1, i, i,
Stomata vera ; 2, 2, 2, stomata spuria ;
3, 3, 3, nucleus
lympli vessels.
Fig. 9. — (<0 .Abominal Side of Diaphragm. Dog's
(three months old) diaphragm. Cent. tend.
Abdominal side. Ag No. 3, (Oc. 2, ob. 8 a,
R.) 7, 7, Merabrana limitans, from which the
endothelia have been shed ; 1, stomata vera ;
2, 2, 2, stomata spuria, inter-endothelial stoma.
are interpreted as connective-tissue corpuscles or
lymphoid corpuscles. It is supposed that the young
connective-tissue corpuscle projects upward between
the endothelial plates and becomes stained with the
Ag No. 3 solution. .Vgain, in the preparation of peri-
toneal endothelium with silver salts we notice that
portions of the membrane take on a very much denser
coloring from the silver than do the adjacent portions.
The intensely browned portions with very irregularly
sized cells are interpreted as young endothelia or
germinating endothelia. We also note in preparing
some portions of the endothelium that certain cells
are vacuolating, /.<-., tlie endothelia are multiplying to
produce lymph channels. If the endothelia are stained
hexagonal. The length may exceed the diameter, per-
haps by si.x times. But the peritoneal endothelia
do not vary in size like the endothelia covering lymph
channels. In many cases, especially in embryos or
new-born, the long, rectangular endothelial plate may
assume a bent or curved shape to accommodate blood
vessels and trabecula;. .\ peculiar appearance is lent
to the surface of the endothelium by the reception of
an acutely pointed angle in the recess of two or more
other endothelia. The uniform shape of considerable
areas of endothelial surface in some animals produces
a beautiful mosaic, which is occasionally only varied
by stomata vera and spuria. In other regions the
delicate mosaic is relieved of its unifonnity, especially
112
MEDICAL RECORD.
[July 25, 1896
Fig. 10. — Horse's Gastro-Hepatic Omen-
tum. (Oc, 4, ob. 3.) Drawn with abso-
lute care, i, One of the nuclei of a
jfTanuIar cell, i.e. , the protoplasm has
shrunk ; 3, granular cell of stoma
verum ; 4, rift between two endothelia,
debris brushed off ; 5, balf-cells not
brushed off ; 6, half-cell fallen off; 7, 8,
nuclei closed and open (very numer-
ous); 7, a cellaround which seven endo-
thelia arc grouped intercellularly ; 10,
rift or precipitate. The drawing is
taken from between two tendons and is
much lighter in color than the endothe-
lia covering the adjacent tendons. Note
the uniform shape and size of endothe-
lia. Large tendinous bundles e.xist
under this endothelium.
in the omenta, by germination and vacuolation of
cells, while streaks of fat globules may come in to
vary the scene.
The varied shape of the endothelia found in the
adult body I am now fully convinced is an acquired
condition and that the
early embrvo possesses
a much greater uni-
formity than the adult.
The acquired shape of
the endothelia of adult
life rests on three fac-
tors, viz. : (ff) the elastic
character of the endo-
thelial plate and (A)
the expansion and con-
traction of vessels
(blood and lymph) and
organs. (Another fac-
tor may arise, which I
have so far been unable
to settle, and that is in
the regeneration of en-
dothelia there may be
formed different-sized
and hence different-
shaped endothelia. But
perhaps this hypothesis
may rest on the idea
that endothelial plates
are originally of the
same size, but that one
plate is subject to e.x-
pansion while the other
is subject to contrac-
tion, and the plate is so incidentally four.d in one or the
other condition. So far as the elastic feature of endothe-
lial plates is concerned it is a well-known clinical fact.
The distention accompanying ascites and the sudden
contraction of the peritoneal endothelia immediately
following the evacuation of the ascitic fluid are suffi-
-cient proof. Of course the chief elastic force lies in
the subserous elastic fibre. But the endothelial plate
must contract very much to readapt itself to its origi-
nal form. If it did not contract enormously the edges
would overlap.
However, we
must not allot
too much elasti-
city to the endo-
thelial plate, for
the inter-endo-
thelial semi-
fluid substance
has also no
doubt shared in
the e.xpansion
and actually
shared in the
contraction.)
(1) The semi-
fluid, soft,yicld-
able inter-endo-
t h e 1 i a 1 sub-
stance allows
varieties of
shape. This
view appears
the more rea-
sonable when in all probability ascitic fluid rests
on peritoneal inflammatory origin; hence the ver}-
oedema alone accompanying peritonitis would expand
the inter-endothelial substance. In experiments I
note that alcohol and formalin contract the endo-
thelia while water expands them. Again, by observ-
FiG. II. — Omentum of Horse, perhaps Twelve Years
f)ld. I, I, Stomatavera; 2, z, nuclei; 3, rift ia
cell edge; 4, stoma-verum cell with two nuclei; /I,
stomata vera with two cells, each having a nucleus
(note tt has nine cells around itl; 6, an extension of
the stain; 4, stoma verum, five nuclei in it ; 7, a
granular cell of stomata I (oc. 4, ob. 3, R.;
there are here four stomata vera ver>' granular) ;
ti, rifts between cells; 12, stoma spurium ; 5 shows
stomata vera indefinitely divided with a nucleus to
each cell. This drawing is of epithelia lying ad-
jacent to regions with innumeral>le stomata vera.
It is from the surface of a trabccnla. The horse's
peritoneal endothelia is characteristic for peculiar
irregularity and grouping of endothelia. This en-
dothelium lies in a germinal tract.
ing many specimens occasionally one will be found
in which the bent or curved endothelium will spring
forward and backward in the waving water, such condi-
tion being best observed by elevating the cover glass
above the slide sufiiciently to allow free fluid currents
in various directions. On organs, to which the endo-
thelia are quite fixed, but which e.xpand and contract
in a rhythm, the endothelial plates no doubt expand
and contract, yet some of its adjustability must be due
to the semi-fluid albuminous inter-endothelial sub-
stance.
The acquired. shape of the endothelial plates from
expansion and contraction of vessels due to emptying
and filling I have investigated to a considerable extent.
If one of the figures is observed, a typical sample may
be seen in a frog's mesentery, in which the endothelia
covering the blood-vessels are enormously elongated
transversely over the vessel from its emptying and fill-
ing. Of course an elastic endothelial plate is like
rubber, which, being repeatedly stretched, loses some of
its original shape and gradually assumes a shape in ac-
cord with the direction of its chief tension. Now the
acquired shape of endothelia is not alone due to the
emptying and filling of blood and lymph vessels, but
the shape of endothelia may be gradually moulded by
fixed organs which
have a definite move-
ment to go through.
For example, the
stomach is fixed at
the pylorus and the
entrance of the ctso-
phagus through the
diaphragm, but the
chief portion of the
stomach as it
empties and fills re-
peatedly passes, no
doubt, through the
same motions, and
in this manner cer-
tain portions of the
peritoneal endothe-
lia will acquire a
shape peculiar to the
direction of the chief
force. The same
may be said of the
emptying and filling
bladder. Whatever
the factors be, the
peritoneal endothe-
lia assume a won-
der f u 1 1 y varied
shape — a multiform
outline. In other
words, the major and
minor diameters
vary in a wide de-
gree. It may be noticed that on the mesentery and
diaphragm of the horse, cat, dog, and other animals,
organs which possess a high range of motion, the
endothelia are smaller and more uniform than in
many other parts. In adult animals the endothelia
are subject to a wide range of shape. The shape of
the endothelia in embryos and new-born also has a
wide range. I have noticed in pig cmbrj'os enormous
numbers of triangular endothelia and also those hav-
ing the shape of a cone with a cur\'e for a base. An-
other element which produces acquired changes in the
shape of endothelia of both new-bom and adults is the
development and disappearance of fat. Fat globules
simply collect and expand in a connective-tissue cor-
puscle, and as the fat globules accumulate and expand
the endothelia immediately over them acquire new
Fig. 12. — Gastro-Splenic Omentum of Thrcc-
months-old Ftctal Pig. This is a typical
group of endothelia surrounding two stomata
vera. (Oc. 2,0b. 8 rt.) i p<tints to stoma vera
with one cell broken away ; it is surrounded
by ei.ehl endothelial plates ; 2. 2, nuclei ; 3. 3,
cndolheiial plates; 4, stomata spuria ; 5, stoma
verum surrounded by plates ; 6, 6, stomata
spuria ; 7, inter-endothelial stoma ; ^, 3, en-
dothelial plates. This very typical figure is
drawn as closely as possible to nature. It
illustrates the originiil arrangement of the
endothelia of the peritoneum and I cannot
too highly recommend the ftetal pig for peri-
toneal study. Its stomata cannot be mistaken
and its vertical lymph canals show appre-
ciable depths.
July 25, 1896]
MEDICAL RECORD.
1 1
shapes. The endotlielia on the top or summit of the
fat globule become much more varied in shape than
the endotlielia at tlie base or circumference of the fat
globules. I sketched several figures of fields of fat
globules to show the very marked variation in the
shape of the endothelia covering them. Under his-
tology should be included the shape of the germinat-
ing and vacuolating cell, for these are simply renew-
ing the place of dying comrades. It may be stated in
general that the germinating or growing cells are
of all shapes from polyhedral to polygonal. The
granular polyhedral cells lining the vertical lymph
channels or composing the stomata vera are one typical
set. The innumerable round and oval forms accom-
panying many tracts of peritoneal germination repre-
sent another set. The germinating cell is almost end-
lessly variable in shape, i.e., outline.
The arrangement of the endothelia is a subject of
more significance than its shape, for in the arrange-
ment appears to be the original physiologic indica-
tion. It appears to me that the pig embryo shows
more definite arrangement in its endothelia than any
of the above-mentioned animals. One can note very
systematic arrangements of endothelial plates around
stomata vera, on the gastro-splenic omentum, and quite
Fig. 13. — From a Young Dog's Kidney. The peritoneum was snipped urT
with a pair of scissors. (Oc. 2, ob. 8 rt, R.) Aij No. 3. Note the i;roup-
ing of cells, i and 2 are two endothelial ceils around which eight cells are
grouped. The cells are quite uniform. The fibrous and elastic network
below the endothelia is very dense. Two endothelial cells are not drawn
brown from the .-Vg No. 3.
symmetrical. In other portions of the pig's perito-
neum the triangular shape of some endothelial plates
allows a symmetrical mosaic to be produced. The
first arrangement of endothelia to \vhich attention may
be called is that around stomata vera. The stomata
vera are situated at the common junction of from three
to fourteen endothelial plates. In the embryo pig there
exists the most typical and symmetrical arrangement
of endothelia about the stomata. The endothelia as-
sume a cone shape and their sharp points meet in
common about the stomata. It would appear that in
these embryos the symmetrical arrangement of endo-
thelia about stomata vera was a design of nature to
accomplish the purpose of physiology in the perito-
neum. I am convinced they are preformed openings,
original, anatomic, and physiologic structures for the
purpose of holding in definite relation the peritoneal
cavity and the subperitoneal lymph channels. The
circu.nEerential edges of the stomata vera are lined
with granular polyhedral young cells, around which arc-
symmetrically or otherwise placed endothelia. The
stomata vera are at the common junction of endothe-
lial plates.
The endothelia tend to group themselves about
stomata vera. The number of endothelia composing
the group include from three to fourteen cell plates.
The best samples of endothelia around stomata I found
in the embryo pig, but the frog and other animals also
produce good samples.
Again, there is a tendency for the endothelium, espe-
cially in early embryos and even in adults, to arrange
themselves in relation to blood-vessels. The elon-
gated shape of the plates is easy to make out, grouped
in large numbers along the course of the blood-vessel.
Great whorls of long rectangular endothelia, curv'ed to
suit the course of tlie vessel as it lies in a trabecula,
rtay be plainly viewed in embryos and in a less typ-
ical condition in adults.
If one examines the centrum tendineum of the dia-
phragmatic ijeritoneum under the microscope, long,
straight dark and light streaks may be observed. The
dark streaks or cords are the tendons of the dia-
phragm, while the light streaks are the spaces between
the tendons. By careful observations of the abdomi-
nal diaphragmatic serosa it will become apparent that
the endothelia covering the tendinous or dark streaks
are of a larger size than those covering the light spaces.
Hence the distribution of the endothelia is arranged
in two tracts over the diaphragm. The explana-
tion first given to the phenomenon by Ludwig and
Schweigger-Seidel was that the endothelia cover-
ing the light spaces between the tendon bundles of
the diaphragm were over lymph channels. In other
words, the lighter inter-tendinous spaces are really long
lymph tracts, and as endothelium approaches lymph
channels it is known to change its outlines and be-
come more sinuous and smaller. For the purpose of
demonstrating the arrangement of the endothelia on
the tendinous and inter-tendinous portions of the
diaphragmatic abdominal serosa the rabbit is first rec-
ommended. So far as the arrangement of the perito-
neal endothelia is concerned, it is simply irregular.
The irregularly shaped endothelia become arranged so
that they wrap themselves around the trabecula, leav-
ing no subserous tissue exposed to the abdominal
cavity. I generally found the endothelia more irregu-
lar in shape and arrangement on the viscera than on
the omenta, diaphragm, and parietes. No doubt this
greater irregularity of shape and arrangement on the
viscera is due to the greater and wider motion of vis-
cera. The shape and arrangement of endothelia differ
in different organs and even in the same organs of the
same animal. The wide variation in shape and ar-
rangement of peritoneal endothelia
must rest on {a) original or (/<) ac-
quired condition. What the primor-
dial arrangement of the endothelia
is we are not yet informed, though
some think the original shapes of the
endothelia are polygonal and others
think they are preformed about
stomata vera. In primordial ar-
range ment of endothelia it appears
to me, judging from my own work,
that they are prefomied about sto-
mata vera.
As to shape of endothelia it ap-
pears probable that they were originally polygonal.
The acquired shape and arrangement of endothelia are
a matter which rests more on physical forces of a tangi-
ble nature. Motion, friction, expansion, and contrac-
tion unfold a long evolutionary story in acquired con-
ditions of the endothelia of the free surface of the
peritoneum.
After the consideration of the shape and arrange-
ment of the endothelia we will take up the constituents
of the inter- endothelial substances, which include
three divisions, viz.: (a) the stomata vera, (/') the
stomata spuria, and (c) the inter-endothelial substance
itself, or rather inter-endothelial space..
The stomata vera are round or oval openings situ-
ated at the common junctions of three or more endo-
thelial plates. They were discovered by Von Reck-
linghausen by injecting milk or other finely divided
matter into the peritoneal cavity of animals and
Fig. 14 is drawn from
omentum majus of
new-born child to show
grouping of cells
around a stoma verum.
I, 2, 3. Nuclei ; 4, gran-
ular cells ; 5, endothe-
lium. The group is
composed of eight
cells.
114
MEDICAL RECORD.
[July 25, 1896
Fig. 15. — Young Dog's
Gastro-Hepatic Omen-
tum. (Oc 4, ob. 3, R. )
A group of ten cells
surrounding a stoma
verum with two nuclei.
I, Nucleus of stoma
verum ; 2, stomata-
vera cell or guard cell ;
3, one of the group of
endothelia ; 5, rift be-
tween endothelial
plates.
then tracing its absorption through the abdominal
serosa by the aid of staining with silver solution.
The careful methods of experiments by which Von
Recklinghausen arrived at his conclusions in regard
to the stomata vera on the dia-
phragmatic serosa are worthy of the
highest admiration. With persistent
and indefatigable labor he worked
the matter out systematically from
beginning to end, the chief part of
which may be read in Virchow's
Archiv. The stomata vera are
among the chief structures in the en-
dothelia of the free surface of the
peritoneum. They are found dis-
tinctly in all the animals enumerat-
ed in this paper. In fact no animal
was found without numerous sto-
mata vera. The typical locality of
the stomata vera are omenta and ab-
dominal serosa of the diaphragm.
However, my best specimens gener-
ally come from the gastro-splenic
omentum. They may be found open or closed. The
embryo pig, the rabbit, and the frog furnish in my ex-
perience the most typical stomata vera. It appears to
me that the stomata vera are the centres or preformed
openings around which endothelia group themselves.
Of all animals examined the embryo pig on its gastro-
splenic omentum furnished the most typical, systematic,
and numerous grouping of endothelia about stomata.
If one examines the stomata vera situated at the
common junction of several cells, with a high power
after staining with Ag No. 3 solution, there can be ob-
served at their mouths which open on the free surface
of the peritoneal endothelium small, reddish granules
possessing a nucleus. These small masses are much
darker red than the surrounding area and of a distinctly
granular character and they may present a granular
polyhedral shape with nuclei. They are in all proba-
bility young germinating cells lining the surface of the
canal known as tJie stoma verum. The silver solution
intensifies their color. After considerable time spent
on examinations of many scores of specimens, I am con-
vinced that the stomata vera are canals lined with gran-
ular polyhedral nucleated cells. The stomata vera are
not only mouths, but canals of more or less perceptible
length. In short they are vertical canals lined with
granular cells passing through a definite distance and
structures of the peritoneum. In the embryo pig the
stomata vera may appear like the interior of a long,
thick cylinder or like the cavity of a well lined
with stone. The stones may represent the granular
cells. In the diaphragm of the rabbit I could find
some of the stomata-vera canals passing, obliquely
from the peritoneal endothelia in the subserous lymph
channels showing a distinct length. If trauma be in-
flicted on the specimen examined, one may frequently
observe a part of the granular polyhedral cells which
line the vertical canal broken away, adherent in a
beaded line, and floating about in the glycerin under
the cover glass. It shows distinctly where it was pre-
viously situated and waves about as a still intact
membrane. Again, trauma which may be due to the
Ag No. 3 solution will produce a cleft between
the lining membrane of the vertical canal or stoma
verum and the smooth mouth made by the common
junction of the endothelial plates. The cleft may be
empty or filled with granular debris. The cleft or rift
between the granular lining cells of the stoma verum
and smooth circumference produced by the common
junctitm of the several endothelial plates may be com-
pared to the separation of the mucous membrane of
the ureter from its outer wall produced by passing a
sound. The loose mucosa of the stomach may also be
compared to this result of traumatic separation. It is
easy to separate the stomachic mucosa from the outer
wall. It may be that the granular lining membrane of
the vertical stomata vera contracts by the application of
Ag No. 3 solution. The vertical canals of which
stomata vera are the mouths are not always perpendi-
cular to the peritoneal surface. They pass from the
endothelia of the free peritoneal
surface to the subperitoneal lymph
channels in an oblique direction.
The specimens obtained from a rab-
bit's diaphragm after injecting a
carmine solution into its abdomen
Fig. 16. — From Woman
of 30 Delivered Twelve
Hours, who Died of
Kclampsia and Acute
Peritonitis. Bit off a
broad band reaching
from uterus to rectum.
This sketch was drawn
with .\g No. 3. (Oc.
4, ob. 3, Rj. Stoma
verum is perhaj)s a
vacuolated cell, as is
also 3 ; 4, shed en-
d o t h e 1 i a (the whole
patch is germinating
and very brown) ; 5,
nucleus. It shows that
on peritonitic bands
new endothelia fre-
quently spring up, /.^.,
connective-tissue cor-
pu.scles flatten out and
assume endothelial
functions. The only
difference that 1 have
so far noted between
endothelia found on an
old inflammatory peri-
toneal band and com-
mon original peritoneal
endothelia is that the
new endothelia found
on the old peritoneal
band of exudate are
generally smaller.
Fig. 17.— Sheep's Omentum Majus. (Oc.
4, ob. 3, R.) Some of the granular cells
contain nuclei. The figure represents
two stomata vera surrounded by some-
what irregular, coarse, granular endo-
thelia. Stoma verum I has nine granular
cells around its open mouth, while 2 has
four granular cells around its closed
mouth. The granular cells 3. 4, and 5
contain double nuclei show.ing rapid
growth or division. Some stomata vera
show an elongated mouth closed like the
human lips, and may have a dozen granu-
lar cells lining the circumference of the
mouth. 6 and 7 are common surface en-
dothelia and 8 is a nucleus of same.
fourteen hours before death would indicate that many
of the stomata of the lymph channels lie immediately
beneath an endothelial cell of the iJeritoneal surface,
and it would appear that occasionally the endothelial
cells show marked symptoms of a very granular nature
and a semi-fluid character. It is difficult and almost
impossible to assert whether the granular condition of
the peritoneal endothelium immediately over the stoma
of the lymph endothelia is original or acquired. But
when a stoma verum of the peritoneal endothelia is
found directly over a stoma verum of the endothelia
covering lymph channels the picture changes to some-
thing more definite. By slowly turning the fine ad-
justment screw of the microscope one can view the in-
terior of the vertical canal with its granular lining
cells for some distance, especially the obliciue canals.
The most typical specimens for studying tiie relations
of the stomata vera of the endothelia of the free peri-
toneal surface to the subserous lymph channels came
from the serosa on the abdominal side of the dia-
phragm of a rabbit which had been injected with a
solution of carmine the day before it was killed. The
carmine had obtained access to the subserous lymph
channels and was impacted into stomata of the endo-
thelia covering the lymph vessels. The carmine made
them easy to observe, by reason of its red color. The
frog shows the relations well in some specimens. The
stomata vera may be found closed, partially or com-
pletely, or they may be found wide open. The frog
and rabbit show typical specimens in regard to the
degree of closure. Again, there is a condition of the
stomata vera which induces endless discussion and
many interpretations. In short it appears to me to
be a condition in which the stomata are filled with
granular material like grains of com meal colored dark
red. Is it not this condition that sorely puzzles Mus-
catello? He concedes they are stomata, but a kind of
July 25, 1896]
MEDICAL RECORD.
115
closed stomata which allow passage of finely divided
matter, when it really forces the granules apart and
slips through. He claims that such stomata vera are
just like the apertures in the walls of blood-vessels
which every now and then allow the e.xit of a cer-
tain number of blood corpuscles. Of course it is easv
to recall similar conditions asserted by \'on Reckling-
hausen, when he said he could see whorls produced in
the milk globules and see the milk globules duck into
the peritoneal endothelia and disappear, but he never
could find the real mouth which received the milk
globule until he marked the spot of ducking under the
milk globule and then allowed Ag No. 3 solution to
Fig. 18. — The Peritoneal
Side of the Diaphragm of a
Woman 26 years old. Dead
three days. Ag No. 3. (Oc.
4, ob. 3.) The figure shows
four stomata vera, i, 2, 3, 4.
Enormous numbers of sto-
mata vera exist on the
peritoneal side of the dia-
phra'^m, more than were
found itn the pleural side.
Fig. ig.-'I'rawn from the
Pleural Side of Same Dia-
phragm as Fig. 18 (woman
26 years old). The figure
shows three stomata vera.
I, 2, 3. No. 2 is wide
open and Nos. t and 3 are
closed, while No. 1 shows a
slight mouth and No. 3 nu-
clei ior two granular cells.
No. 2 has si.x granular
cells around its mouth.
The stomata vera here
(pleural side) are larger
than in Fig, iS (jjeriloneal
side). 4, a granular cell
or a cell much more
browned than others.
trickle under the cover glass, when by its stain it
showed at the marked spot the stoma verum but no
open mouth. All that Von Recklinghausen could see
was the dark granular cells marking the stoma verum,
which had opened to allow the milk globule to pass
and then closed, leaving no trace of an open aperture.
It is like a swimmer diving in water: he has left no
aperture behind — all is closed. Those who have
■watched frogs in a pond during the summer season
will note the water entirely covered in places by green
vegetation ; the frog dives through this vegetation into
the water beneath, but the springy vegetable matter
closes immediately after the frog and no trace is left
behind. This granular or filled condition of the mouth
of the vertical canal is not well understood. It may
be that the canal has an elastic sphincter and that an
excess of granular cells exists at its mouth. Also the
granular polyhedral cells themselves may entirely fill
the stoma but the microscope be unable to discrimi-
nate the absolute outlines of the granular cells.
What are the functions of the stomata vera? First,
the endothelium immediately surrounding them stains
darker red than that more distant; so far as we know,
this indicates more precipitate albumin, newer cells,
or younger protoplasm. Hence it would appear that
the .stomata vera are the source of new endothelia to
supply the ranks of dying comrades. Second, it
appears to me from investigations that they are the
regulators of peritoneal fluids. For example, if in-
flammation attacks the stomata vera, too much or too
little fluid will prevail in the abdominal cavit)'. In-
flammation of the granular cells which line the vertical
canals— stomata vera — would enlarge them and ob-
struct the return flow of peritoneal fluid, resulting in
ascites. The active condition of the stomata vera may
account for the rapid death in perforative peritonitis,
for the reason that they then quickly absorb the toxic
matter existing in the peritoneum and transfer it
immediately to the vast subserous lymph lakes of
the diaphragm. The stomata vera, as anatomic
and physiologic structures, give at least a reason-
able explanation of the existence and regulation of
the peritoneal fluid. Ascites must of course rest
on inflammation of the cells in the vertical canals
or the stomata vera. The claim that stomata vera
only exist on the diaphragmatic serosa of the pieri-
toneum must be emphatically denied. Dubar and
Remy claim that matter in the peritoneal cavity is ab-
sorbed by other regions, and no doubt this is true,
though I have as yet found no absorption of carmine in
the other portions sufficient to warrant this assumption.
The claim that stomata vera do not exist as anatomic
and physiologic structures is generally based on the
idea that they are irregular in numbers and distribu-
tion; that large areas exist witjiout a trace of them.
Others claim that stomata vera are the product of Ag
No. 3 or of some trauma. They are simply the results
of precipitation in the intercellular substance. Mus-
catello even claims that they are the result of the re-
traction of endothelia and precipitation of the inter-
cellular substance. Muscatello
says the stomata vera are the
same kind of openings as those
which exist in the walls of the
blood vessels, that will under
certain circumstances allow the
escape of many white blood cor-
puscles. This comparison makes
no denial of the existence, only
it belittles the high significance
of the stomata vera. I at first
thought that I would be able to
note some especial difference in
endothelia and stomata in differ-
ent animals to account for the
difference in resistance against
peritonitis, but so far no light
has broken on that subject. For
example, the mare resists perito-
nitis so slightly that laparotomy
is not practical and puerperal
fever is rapidly fatal. So far as
I am aware solipeds do not resist
peritonitis well. Man and dog
are about equal in this respect,
while the pig resists peritonitis
to a high degree. Yet so far the
microscope has indicated to me
no marked differences. Much
stress is laid on the fact by
some that irregularity in number and distribution
contraindicates the stomata vera as being anatom-
ical structures. It is true that anatomic structures
are generally regular. The irregularity and distribu-
tion of the stomata vera may be acquired. Again,
Schweigger-Seidel and Dogiel claim that the granular
polyhedral cells projecting into the stomata vera are
the nuclei of the group of endothelia surrounding the
stoma verum. This I have disproved in many speci-
mens, especially those of the embryo pig, in which
the nuclei of the endotheli.il plates surrounding the
stomata are distinctly shown in the cells themselves,
far removed from the edge of the stoma verum. One
might describe even two kinds of stomata vera, viz. :
((?) the stoma verum which connects a lymph chan-
nel directly with the peritoneal cavity and {/>) a sto-
ma verum which leads into capillary lymphatics from
the peritoneal cavity and has polyhedral granular-
mouthed cells only at one end, the peritoneal opening
being a simple aperture between endothelia (Klein).
The most significant variety is those connecting the
peritoneal and lymph trunks directly. I mention here
a noticeable feature in the lympiiatic channel i of the
diaphragm of a rabbit on the abdominal side. It is
Fig. 2o. — From Frog's
Lymphatica Cisterna Mag-
na, Peritoneal Side, (Oc,
4, ob 3, R.) It shows sto-
mata vera mostly closed.
I is open, the remainder
closed. .Ag No. 3, y2%,
(It is very difficult to say
positi\'cly that some are
open, for the space is filled
with granular matter
which resembles the sto-
mata-vera cells. The
figure was sketched under
good sunlight, as near to
nature as possible.) 2,
2, endothe'ia ; 3. a stoma
\ erum, one of the cells of
which shows a nucleus.
ii6
MEDICAL RECORD.
[July 25, 1S96
that the stomata are far more numerous in the wall of
the lymph channel than they are on the peritoneal en-
dothelia immediately over them. It may be that fluid
material will pass through the inter-endothelial sub-
stance of the peritoneal serosa without a distinct aper-
ture or stoma lined with dis-
tinct cells, but the apertures be-
came more marked and distinct,
yes, even lined by granular cells,
when they reach the wall of the
l_\mph channels. At least it is
ver)' evident in specimens which
I have examined that the walls
of the lymph channels show
■Stomata much more frequently
tiian the peritoneal endothelia
which lie immediately over
them. I may be deceived by
the closure of the stomata of the
peritoneal endothelia. The
superior number of stomata in
the walls of the lymph channels
directly underlying the perito-
neal endothelia, which has so
few, would indicate more spe-
cia' use. It seems to me that it
would indicate that fluid matter
could more readily pass through
the inter-endothelial substance of the peritoneal endo-
thelium than it could through inter-endothelial sub-
stance of the lymph-vessel endothelium.
The subject of inter-endothelial material or space is
all-important in the study of the free peritoneal surface,
as it appears to me the chief physiology of the perito-
neum lies in the inter-endothelial spaces. I noted above
that the chief anatomical structure w-as located at the
common junctions of several endothelial cells, stomata
vera, and it appears to me that the chief physiologic
function occurs through the means of this structure,
/.(•., the regulation of fluid currents and the production of
new endothelia. We also noted that on the single in-
ter-endothelial lines there are black dot-like droplets,
which are interpreted by Virchow as lymphoid cells ; hy
Von Recklinghausen, Oedmansson, Klein, and others
as connective-tissue corpuscles, whose function may
be to produce new cells. They are known as stomata
spuria. Now, besides stomata vera and spuria there is
a large inter-endothelial space filled with matter which
stains dark and brown with Ag No. 3. The precipi-
tate produced by the Ag No. 3 solution, of one-quar-
FlG. 21. — From Frog's Lym-
phatica Cistema Magna,
Cisternal Side. (Oc. 4,
ob. 3, R.) Ag Xo. 3, 2%.
The stomata are closed.
Specimens frt), peritoneal,
and (i), cisternal, side are
drawn from the same speci-
men, I first drew (a) and
then reversed the slide and
sketched (/->. One can-
not decide the difference
of the stomata on each .side
in separate specimens. i
and 2, stomata vera.
Fig. 22. — Omentum of a Woman Aged 30. (Oc. 4, ob. 3.) i, Stoma verum (it
is really divided into a light half anda dark half, and both contain nuclei
or glistening spots); 2, 3, 4, 5, germinating cells intensely browned with
permanent nuclei (notice that besides the stomau vera (J and 8 there are
ttve other intensely brown cells, no doubt new germinating cells ; many
similar adjacent fields exist); 10, 11. 12. common flat surface cndotliclia.
The interpretation lies in the stomata vera 6 and 8, It looks as if it was
jelly-like, granular protoplasm and was precipitated, aggregated into clumps
by the -Ag No, 3. In cell 4 the nucleus has two nucleoli,
ter per cent, to one-half per cent., is considered to be
an albuminate of silver. The precipitate begins slowly
in fresh specimens and gradually increases in breadth
from a fine, dark, irregular line, just percJeptible with
a high microscopic power, to a broad line extending
even over the surface of the adjacent endothelial plate.
The centre of the line one might say is black, but the
color of the line becomes brown as it recedes, ?>.,
precipitated material on the endothelial plate is nearly
always brown. It appears from the use of Ag No. 3
solution on the peritoneal endothelium that the endo-
thelial line may be announced as black, while that on
the surface of the plate is brown. Whether this is due
to two different kinds of material, one for the surface
of the plate and one for the inter-endothelial space, on
Fig. 23, — Horse s Omentum to Show F.ndotheIia Grouping around a Stoma
Verum. i, 2, 3, Endothelia; 4, rift between cells (the endothelia appear
to be new themselves ; they are surrounded by l<jng fields of new or germinat-
ing endothelia); 6, 6 show some of the adj.icent growing endothelia ; 7,
stoma verum (oc, 4, ob, 3); 8, 8 show a field non-prepared which lies on
the border of still newer germinating endothelia (6, 6); 9. rift between
cells, /.«-., a shrinkage of the granular protoplasm.
which the silver .solution acts differently, or whether it
is due to the quantity being greater in one place than in
another is still uncertain. It may be that a thin layer
of albuminous substance appears brown and a thicker
one dark. It may also be thought that the age of the
material on which the Ag No. 3 solution acts is dif-
ferent. The matter on the surface of the endothelial
plate may be older than the inter-endothelial matter.
However, the inter-endothelial substance is a soft,
semi-fluid materi-
al of an albumin-
ous nature. It is
pliable and yield-
ing, allowing con-
siderable motion
to an endothelial
cell without de-
stroying its integ-
rity of position or
of function. It
adapts the cells to
strains and trauma
w i t h out rupture.
Really the endo-
thelial cells are
resting in a semi-
fluid bed, and the
inter - endothelial
substance acts like
a buffer in sudden
motion. It endows
the endothelia with
power to suddenly
alter their course,
position, and rela-
tion without losing
the integrity of
structure and func-
tion. This inter-
endothelial semi-
fluid bed adapts
itself readily to
sudden changes, as
in the filling and
emptying of or-
gans and vessels.
In an overfilled
bowel the peritoneal layer gives way first. I have proved
that peritoneal rents occur first in overfilling of dog's
Fig. 24. — Gastro-Hepatic Omentum of a Woman
of 45. Two vacuolated cells which are widely
expanded, almost sullficiently to be called a
lymph sinus, A has five stomata vera, B
has two stomata vera, 2, 2 ; 3. another vacuo-
lated cell begins. COc. 2, ob. 8 a, R.) Ag
Xo. 3 applied. One of the best places to
study vacuolation is on the adult human
omentum, especially along the large trabecular.
4, 4, 4 arc very brown spots. In these germinal
tracts the entlothclia are of all sires and shapes.
This was taken from a region where numerous
vacuolated cells existed of all sizes.
July 25, 1896]
MEDICAL RECORD.
1 1
intestines, showing that the inter-endothelial substance
is put to active service in dilatation and contraction of
oro^ans and vessels. The inter-endothelial substance
shares in intiammatory attacks, for the endothelia des-
quamate, leaving only the pitted, semi-Huid bed, which
can but feebly protect itself and because of its fluid na-
ture absorbs the invading hosts. The endothelial plates
are so adjustable and the'inler-endothelial line is of such
a magnitude that the endothelial plate has a considera-
ble range of normal adaptability. To the anatomic and
physiologic structures (stomata vera and spuria) found
in the inter-endothelial semi-fluid albuminous bed must
we look for new revelations in further research, which
must be of an experimental order. If one places peri-
toneum in water and allows it to remain several hours,
the inter-endothelial line appears to enlarge, i.e., it ap-
pears to swell by absorption of water, and the reverse
is true if one places the peritoneum in alcohol or for-
malin. When the endothelia are brushed off they
leave an oval depression, but the inter-endothelial line
is frequently left almost intact, and even it remains if
the sunlight carefully regulated with distilled water,
one will soon be able to detect with the naked eye
brown spots or patches, and when these brown patches
are mounted in glycerin they are seen under the micro-
scope to be chiefly composed of germinating endothe-
lia. The young growing protoplasmic cell readily
stains a dark brown with the silver solution. Germi-
nating endothelia present all grades of cells from the
polyhedral to the multiple-sided, sinuous-bordered
cells. These germinating endothelia are apt to be
found along large blood-vessels. Certain propositions
in regard to germinal peritoneal endothelium may be
made :
1. Germinal cells generally grow over the surface of
the common endothelia of the peritoneum. They pro-
ject entirely above the surface, so that even different
foci are required for them and for the peritoneal endo-
thelia.
2. The germinating endothelia are of all grades of
size and shape.
3. Their common and typical location in animals is
Fig. 25.— Woman's Omentum Majus. Eight
vacuolating cells. (Oc. 4, ob. 3.) i, An endo-
thelial cell on the bottom of the lymph smiis
or capillary very much browned, as well as 2 at
the bottom of another stoma verum in lymph
sinus endothelia ; 4, stoma at bottom of large
sinus or vacuolated cell; 5, 6, 7, 8,9, germi-
nating endothelial cells around the circumfer-
ence of the lymph sinus or vacuolated cells ;
9 also shows the brown growing endothelia
between and among the vacuolated cells. 7
is doubtless a karyokinetic figure. Note
that the growing brown lymph endothelia of
the vacuolated cells is continuous directly
with the lymph endothelia (10, 11, 12, 13. I4.
15, 16) to the right, /..-., these seven vacuolated
cells will soon form a new lymph sinus or capil-
laries. The vacuolated cells are widening
stomata.
Fig. 26. —Young Dog's Lymph Sinus, or well-de-
veloped vacuolated cell in a region of germinal
endothelial cells. 1,1,1, Open stomata on the
lymph sinus ; 2, 2, 2, 2, endothelia covering the
lympll sinus or vacuolated cells ; 4, 4, 4 show
the edge of the vacuolated cell or lymph sinus
is brown and hence young protoplasm. Note the
very brown endothelia surrounding the vacuo-
lated cells (4, vacuolated cells, Ag No. 3). The
vacuolated cells continue to multiply and form
lymph sinuses. Observe how the endothelia
enlarge as they diverge from the lymph-sinus
border.
Fic. 27.— Drawn from the Mesentery of
Frog. (Oc. 4, ob. 3, R.) Thesketch
represents a nodule of germinating en-
dothelial cells elevated above the
surface. 1 represents the stalk of the
nodule ; 2, the growing nodule ; 7, one
of the quite granular endothelial cells
in the top of the nodule ; 6, nucleus
of common surface endothelial cells;
5, intra-endothelial stomata ; 3, com-
mon surface endothelia. This stalk
Ci)of growing, germinating endothe-
lial cells, of a protoplasmic character,
is elevated above the surface of the
common endothelia. Notice the
grouping of cells in the nodule at 6.
the stomata spuria— black dots— seem to be left intact
also: but for some reason the black dots on the inter-
endothelial lines sometimes appear to increase in
number. The stomata vera disappear on brushing.
The regeneration of peritoneal endothelia will be
considered here only as it affects the normal perito-
neum. It does not partake of the domain of patho -
ogy. The regeneration of peritoneal endothelia will
sfrnply be considered as a natural process whereby
new endothelia are produced to supply the ranks of
dving or worn-out comrades. The endothelia of the
p'jritoneum are like a standing army which demands
a steady recruiting to supply the various kinds of loss.
The peritoneum being an organ of intense vascular
and functional activity, its needs are vast, and they
are fullv supplied bv what we shall term germinating
endothelia. We might call these young as well as
germinating endothelia, but I adopt the term germmat-
tng from Klein as an apt expression. One soon has
the attention drawn to germinating endothelia m the
microscopical study of the peritoneum. If epithelium
from an omentum majus or gastro-splenic, fresh from
man, rabbit, dog, or any animal we have so far exam-
ined, be carefully placed in a solution of from one-
eighth per cent, to one-half per cent, of Ag No. 3 and
on the omentum majus and gastro-splenic. However,
they may be found almost anywhere in the peritoneal
sac.
4. The intense brown color they quickly assume on
the application of a silver solution characterizes them
as young, germinating, protoplasmic cells, with consid-
erable precipitable albuminate.
5. They grow in irregular tracts, cords, or nodules,
and are especially common about the edges of the
lymph spaces and vacuolated cells.
6. The stomata vera will be considered as one of
the chief sources and the stomata spuria as a secondary
source.
The rabbit, dog, and man may be studied advanta-
geously for excellent specimens of growing endothelia.
Yet some very typical specimens I secured from the
frog. For a long time I studied the germinating en-
dothelia as to classification and am still unsettled as
to the best, but we may simply describe the germi-
nating endothelia as {a) nodules, (l>) cords, and {■)
Ijatches. It may be that both cords and patches can
result from the fusion of nodules. Accessible litera-
ture concerning germinating endothelia is not abun-
dant: it is even very scarce.
In the first place it may be noted that the germination
ii8
MEDICAL RECORD.
[July 25, 1896
of endothelium of the normal peritoneum difters from a
pathologic process but little, and it may be very diffi-
cult even for. an expert to make out the difference be-
tween germinating endothelium, i.e., regenerating en-
dothelium, and the proliferating endothelium of an
infiammator)- process. I think that in some cases it
is impossible to decide on an omentum of some ani-
mals whether the process is actual regeneration of ger-
minal endotholia or the result of a chronic peritonitis.
This paper is entirely confined to normal and re-
generating germinal endothelia. Neither do I wish
to enter into questions relating to the subperitoneal
lymph vessels, e.xcept so far as to discuss the very sig-
nificant vacuolation of cells — a step in the process of
proliferating or multiplying endothelial plates.
Active germinating endothelia may be found on the
omentum of man, frog, dog, and rabbit, in some of
which it is rich and abundant. Splendid specimens
of germinating endothelia may be found on the lat-
eral portions of rather wide trabecula;. If one place
variable in extent. The cells may be single, in rows,
or united into large patches. The' new growing cells
may have one, two, or three nuclei.
The patches or tracts of germinating cells are only
the result of fusion of the cords. The blood-vessels
of these patches are not easy to make out in their re-
lations and development. Neither have I fully satis-
fied myself in regard to the ner\-e supply in its chief
relations.
A feature in regard to the germinal endothelia is that
they are not so easily differentiated from the normal.
The normal endothelia are very easily broken away
from their attachments. For example, by the slight
trauma in carr}'ing portions of the peritoneum of cows
and sheep fresh from the slaughterhouse to the labo-
ratory, the normal endothelium is badly desquamated,
but the germinating endothelium is so much more ad-
herent that it is more easily and accurately studied.
Conclusions. — i. The endothelium is the essential
structure for physiologic function of the peritoneum.
Fig. 2S. — Human Omentuni of a Woman
Thirty Years of Age. Dead twenty-four
hours. .Ay No, 3. (Ob. 5, oc. 4,) The
lightly shaded common cncjothelia and the
darkly shaded jierminating endothelia which
are growing up over the surface require dif-
ferent foci. I, I, Common endothelia ; 2. 2,
germinating endothelia ; 3, dumps, debris ;
4, lymph or capillary sinus with a stoma
verum seen at its bottom ; 5, stoma verum.
This figure shows merely the formation
of a lymph sinus in the midst of germinat-
ing endothelia. 4 is a vacuolating cell
which will eventually end in a lymph vessel.
Fig. 29. — Omentum of Woman Aged Thirty,
Twenty-four Hours alter Death. Ag No. 3.
(Oc. 4, ob. 3. R.) This is an interesting
specimen, showing two vacuolated cells.
I, 2, 3, 4, 5, show the common endothelia
brushed off and lymph endothelia irreguhir
and many stomata spuria ; 6, 7, 8, 9, 10,
II, stomata vera of lymph capillaries. 1,2
are become lym])h sinuses or capillaries.
The endothelia adjacent to the vacuolated
cells I and 2 (or lymph sinuses or lymph
capillaries) are chiefly of agerminal charac-
ter, but some resemble common endothelia
in character.
Fig. 30. — From Rabbit's Omentum Majus. A typical
lymphatic sinus surrounded by typical germinal en-
dothelia. I, I, I, The lymph or capillary sinus;
2, 2, a secondary lymph sinus ; 3, 4, 5, 6. 7, the
germinal endothelia (note the three elongated cells
at Si; 9, closed stoma verum. It appears that such
lymph sinuses arise by the vacuolaiion of cells ; the
cells by repeated vacuolation form large, numerous,
and irregular endothelial plates ; here they have really
become a lymph channel. (Oc. 4, ob. 3, R.) This
drawing is tiikcn from a vast region of germination.
Note, how the endothelia enlarge as they recede from
the sinus, 1, i, 1.
under the microscope a portion of a frog's mesentery,
mounted in glycerin, the typical germinal growths may
be observed. I'irst, one may note nodules or club-
shaped bunches of endothelia projecting above the
common surface endothelia. The nodule or club has
a small constricted neck or stalk, which starts dis-
tinctly from its common surface. Some have the
shape of a half-sphere and the flat surface rests on the
endothelia. The stalk appears to me to have its origin
from {a) stomata vera, (l>) stomata spuria, (c) from the
circumference of a lymph sinus. The lymph sinus
may be a vacuolated cell. It seems that the endothe-
lial cells have grown in such a shape as to fit the nod-
ule. Sometimes the nodule resembles a cone. The
stalk may be composed of one or several endothelial
cells. Two nodules may originate from the same point,
and this fact induces me to consider both stalks as
originating from a stoma verum. In .some specimens
may be obser\-ed cords of germinating endothelia.
They run in various directions, but they lie chiefly on
the circumference of lymph sinuses.
No doubt such areas of gemiinating endothelia
are what Klein designated as perilymphangeal. The
vacuolating cells seem to multiply the endothelia
indefinitely and thus form new lymph channels and
sinuses. The endothelial cells growing from the cir-
cumferences of the areas of vacuolated cells are very
2. The peritoneal endothelium lines an enormous
lymph sac, which originated from fluid pressure and
independent motion of viscera and body wall.
3. There are four distinct elements in the free peri-
toneal serosa, viz. : {a) the endothelial plate, (/') the
stoma verum, (c) the stoma spurium, ( d) the inter-
endothelial substance or space.
4. The endothelium is an elastic connective-tissue
corpuscle, flattened and smooth on one side and oval
or irregular on the other side, with various processes
jutting from it. It contains a sharply defined nucleus,
centrally or excentrically located. The plate is cov-
ered by an albuminous, semi-fluid substance, which is
precipitated by Ag No. 3 and is probably originally
polygonal in shape. However, the plate acquires a very
varied shape from living forces. It contains a reticu-
lated network. There are certain apertures in the
plate which I have designated intra-endothelial sto-
mata, but so far I have not been able to defnie their
structure or function. It may be such intra-endothelial
stomata are the result of trauma or of reagents. The
utility of the peritoneal plate is in permitting maxi-
mum motion with minimum friction ; it also allows the
location and fixation of friction of inter-endothelial
structures, /.(•., an adjustable bed of inter-endothelial
substance, stomata vera, vertical canals to regulate
fluid currents and grow endothelia, with .stomata
July 25, 1896]
MEDICAL RECORD.
119
spuria, which are additional points where endothelium
can renew itself.
c;. Stomata vera are vertical canals located at the
common junction of several endothelial plates lined
by germinal, granular, polyhedral nucleated cells.
The canal opens with one end in the peritoneal cavity
and the other end into the subperitoneal lymph chan-
nels. A second kind of stomata vera is those which
represent simply a discontinuity between the perito-
neal endothelia, with no mouth lined by granular cells
but with the subperitoneal end opening into lymph
spaces and lined by granular polyhedral cells. These
stomata vera or vertical canals regulate fluid cur-
rents and are the source of new endothelia. The sep-
tum cisterncE lymphaticae magna; of the frog shows
typical examples. It may be that lapid death from
perforative peritonitis is caused by the stomata vera
quickly absorbing to.xic microbes. The stomata vera
appear to possess an elastic sphincter to control the
degree of opening or closing of the mouth. The gran-
ular cells of the stomata vera on the application of
Ag No. 3 become dark brown or reddish, which
doubtless indicates that they contain more precipi-
tatable albumin than the adjacent endothelia.
6. The stomata spuria are located on an inter-
endothelial line. The application of Ag No. 3 pro-
duces a black dot or droplet-like appearance. The
stomata spuria are probably connective-tissue cor-
puscles or the processes projecting upward between
the endothelial plates. They have been compared to
lymphoid corpuscles. They are not likely to be ac-
cumulated products of reagents or of trauma. They
are no doubt also sources of new endothelia.
7. The chief arguments against the existence of
stomata vera and spuria in the peritoneal serosa are
their irregular distribution and number and also that
they are accidental products or trauma or reagents.
The argument may be proposed that the stomata vera
or spuria ate not preformed openings, but are the re-
sult of dragging and widening of the intercellular sub-
stance due to motion of the abdominal wall and viscera.
Through these openings red and white blood cor-
puscles and leucocytes may find passage, in con-
sequence of circulation disturbances. It may be
asserted that the stomata spuria are only a sudden
widening or enlargement of the inter-endothelial lines.
8. The inter-endothelial substance is a semi-fluid,
albuminous material which becomes black or brown
by the application of Ag No. 3. The inter-endothe-
lial lines appear to thicken and broaden as they de-
scend toward the subendothelial tissue. It exists
chiefly in the form of a thin, straight, curved or sinu-
ous line between the endothelial plates. The size of
the line depends on the strength and duration of the
Ag No. 3 and sunlight. The soft, yielding semi-
fluid material in which the endothelia rest allows a
wide range of movement and considerable adjusta-
bility of the plate; also it permits the plate to assume
varied shapes to suit environments and correlation of
forces. It adapts the endothelia to sudden motion,
acting as a buffer to prevent trauma. It no doubt al-
lows fluids and even solids to pass through it, either
tow'ard the peritoneal cavity or toward the subperito-
neal lymph channels. The inter-endothelial substance
is the seat of the physiology of the peritoneal serosa,
as it has located in it structures known as the stomata
vera and spuria.
9. So far as my experiments in intraperitoneal in-
jections and microscopical examinations are concerned,
the diaphragmatic serosa is the only territory where
the material is absorbed. However, both my experi-
ments and microscopical examinations are too limited
for any definite conclusions. The reasons for the dia-
phragmatic serosa being the only region where material
is absorbed are given by Bizozzero. Salvioli, and Mus-
catello as due to the anatomical fact that the mem-
brana limitans possesses perforations only on the se-
rosa of the diaphragm. So far, I am not definitely
able to confirm the above opinion of apertures being
confined to the membrana limitans exclusively, but
certainly stomata vera do not appear any different on
the diaphragm than they do in other regions.
10. The absorption of organic and inorganic finely
divided material being confined chiefly to the dia-
phragmatic serosa, it seems that a stream must be
directed toward the diaphragm, which may account
for rapid deaths in perforative and other kinds of peri-
tonitis. The idea of a current toward the diaphragm
is based on the result of experiments; e.^., carmine
suspended in fluid is what I employed to inject into
the rabbit's peritoneum and the red granules could be
found in the subserous region of the diaphragm, espe-
cially in the large-branched connective-tissue cor-
puscles and the lymph channels.
11. The views of Muscatello, that the peritoneal
serosa is normally a continuous sheet or surface with-
out any apertures except those made when leucocytes
force their way through the soft intercellular substance,
which apertures may persist, I do not consider in accord
with experimental and microscopical evidence. Cer-
tainly the stomata vera found on the sheep's mesentery
or the frog's cisterna lymphatica magna are absolutely
and distinctly anatomical structures, and cannot be rea-
sonably interpreted as merely temporary apertures pro-
duced by a few leucocytes forcing themselves through
the inter-endothelial substance. No number of leuco-
cytes forcing their way through inter-endothelial sub-
stance would leave behind an aperture lined by dis-
tinctly granular, polyhedral cells capable of being
outlined by a microscope.
12. In our labor on the peritoneum of man, the horse,
bird, dog, pig, cow, sheep, rabbit, frog, and embryos
of pig and man, it was observed that the endothelium of
the peritoneum was easily desquamated by trauma and
inflammation. In many specimens of tubes, ovaries,
and uteri which Dr. Lucy Waite and I removed, by
immediately staining with Ag No. 3 it was found that
the inflammation of the organs and the accompanying
trauma of removal nearly always desquamated the en-
dothelia so much that it destroyed the specimens for
proper stud}". Severe inflammation desquamated al-
most every plate from its bed.
13. The structures located in the free surface of the
peritoneal endothelium show powers of rapid absorp-
tion, and hence free drainage of the abdominal cavity
is the prophylaxis against invading septic peritonitis.
14. Beck' experimentally demonstrated and con-
firmed the well-known clinical fact that the perito-
neum absorbs material more than three times faster
than the pleura. In opening bodies in autopsies it is
well known that inflammatory pleuritic bands are far
more numerous than inflammatory peritonitic bands.
The reasons that inflammatory pleuritic bands are in
excess of peritonitic bands is that tiie slower absorp-
tive power of the pleura allows ample time for exudates
to form. If the pleura or the peritoneum is given
time to oppose the invasion or absorption of material
protective exudates arise. The rapid absorptive
powers of the peritoneum, over the pleura, is an im-
portant clinical fact, and in all probability is due to
the inter-endothelial structures, viz., stomata vera and
spuria, and also its extensive inter-endothelial sub-
stance.
NoTF.. — Since the above article was written I have consumed
several months of investigation on the inter-endothelial sub-
stance or space in quite a number of animals, employing the one-
fifteenth oil-immersion lens (Reichert), and the reagents Mueller's
fluid, osmic acid, and tannin. The investigation has induced me
to discard the term inter-endothelial substance and to substitute
'Wiener klin. Woch., 1893, No. 46.
I20
MEDICAL RECORD.
[July 25, 1896
for it inter-endothelial space. The dark inter-endothelial lines are
capable of being dissolved into two lines, each one bordering on
the edge of the cover plate. Also, these two parallel lines show
numerous anastomosing protoplasmic processes passing trans-
versely from one to the other. The hypothetic inter-endothelial
cement substance is dissolved into a network of anastomosing
processes, and hence we will hereafter speak of a space and not a
substance. The anastomosing processes belong chiefly to the
lower portion of the endothelial cell, ;'.<■., the protoplasmic part.
The cover plate or metamorphized indurated portion has but
slight connections with the anastomosing processes. The sug-
gestions of Dr. A. Kolossow, of .Moscow, Russia, induced me
to employ osmic acid and tannin as fixation and reduction agents.
The effect of these reagents is to produce specimens by means of
which more definite obser\'ations can be made and conclusions
drawn. The investigations show that the endothelia of the peri-
toneum are connected organically into cell colonies.
SOME FORMS OF NON-OBSTRUCTIVE IS-
CHURIA.'
Bv ALE.XAXDER W. STEIX, M.D.,
KEW YORK .
Inability to empty the bladder may be due to
1. Atony of its muscular parietes, or to
(a) Deficient contractile power of the so-called de-
trusor from overstretching of its fibres (duration usu-
ally temporary).
(/') Loss of power of detrusor from atrophy and fatty
metamorphosis (duration permanent).
2. Neurotic retention, or
(a) Deficient power of the detrusor concomitant
■with some psychical or other functional disturbance of
the nerve centres, viz., alcoholism, narcotism, stupor,
etc. (duration temporary).
(/>) Paresis, or cystoplegia, due to organic derange-
ment of the nerve centres (duration usually permanent).
3. Spastic or reflex retention, due to irritation from
some neighboring organ, inducing sphincterismus
(disappears with the cause that produced it).
The degree of atony resulting from overdistention
of the bladder may vary from a slight and temj^-orary
impairment in the expulsive power of the bladder to
a complete and permanent inability to empty its con-
tents, depending upon the age and health of the per-
son, the condition of the bladder, the degree of disten-
tion, and the length of time the detrusor fibres have
been upon the stretch. In the aged and feeble this
condition is not uncommon, and permanent disabilitv
of the viscus often results from a single inattention to
its behests. In the young and robust atony is much
less frequent, and the bladder once relieved of its bur-
den regains its functional acti\ ity. We may recog-
nize five stages or degrees of atony :
1. An enfeebled expulsive action of the bladder.
2. Retention relieved without catheterization.
3. Retention relieved after single catheterization.
4. Retention requiring repeated catheterization.
5. Retention requiring continued catheterization.
We have perhaps all experienced the momentary
difficulty of micturating that obtains when we have per-
mitted the bladder to become unduly distended.
Availing ourselves of the first opportunity for relief,
we find the flow occurs only after a moment's hesita-
tion, requiring some effort to start it, and when the
stream comes it is at first small and feeble, increasing
in force as the sphincters relax and the detrusor fibres
regain their power. Regarding the other fomis of
retention, I recall some typical phases that may serve
to furnish the practical data for the above title. It
will be observed that in these, as in most cases of
atony, the impaired motility was preceded by a defi-
cient sensibility of the bladder.
A middle-aged gentleman has on several occasions
' Read before the American Association of Genito-Urinarv
Surgeons, June i, 1896.
during the past few years, when much engrossed in
business affairs and neglectful of self, suffered from
attacks of retention. His bladder fills to a degree
without creating any marked discomfort, after which
a sudden and urgent desire to micturate comes on.
He suffers greatly with tenesmus and strains ineffec-
tually until he gets into a hot sitz bath. Thus the
necessary relief is always afforded and he has never
been obliged to resort to catheterization.
A prominent politician, a free liver in an alcoholic
sense, consulted me because he thought there was some-
thing wrong with his "waterworks." He had no
pain, at the most a vague feeling of having imper-
fectly evacuated the bladder, and on coughing or
sneezing stillicidium would occur. This was the
first and only intimation he had of something being
wrong, and he sought advice for what he affirmed was
an inability to hold his water. There was no me-
chanical impediment, Ijut on palpation it was found
that his bladder was distended up to the umbilicus.
He was so sceptical on this point that I asked him to
evacuate the bladder as much as possible by his un-
aided eft'orts, and I would demonstrate to him that his
bladder was still surcharged or in a waterlogged con-
dition. It was certainly a great temptation to relieve
him at once, because he could not be made to realize
his condition; but it was not done. Incidentally it
may be mentioned that he died somewhat suddenly
some months afterward, and at the autopsy all there
was foimd of one kidney was its fibrous capsule, the
excreting elements were completely atrophied. The
other kidney was in the condition of compensatory
hypertrophy; there was no calculous history. In one
instance the bladder will be but slightly distended
and occasion more urgent symptoms than in one in
which it has risen above the umbilicus. In the latter
case the nerve endings of the vesical neck, never very
sensitive perhaps, require only a slight cause, such as
vicissitudes of temperature, free indulgence in spirits,
etc., to obtund them still more. Expulsive factors,
both muscular and nervous, are always very feeble
when compared with the retentive factors, as only the
latter are directly subject to sensation and volition.
The frequency of micturition is not alone due to the
quality of the urine, as I think we in practice too
often imagine it to be, but it depends in a great meas-
ure on the degree of tonic contraction existing in the
vesical walls, which contraction is at first augmented
as the muscular fibres are subjected to tension. The
retentive and expulsive factors are so admirably ad-
justed one to the other as to bring about a harmonious
sequence of action, and the feebly developed detrusor
will gradually accommodate itself in power to any
embarrassment to the escajK of urine so long as the
vesical neck retains its sensibility; but as soon as this
is lost the fate of the patient is in most cases sealed.
The thin, pale, flaccid, and insensible detrusor, asso-
ciated as it often is with feeble health or exhausting
disease, only requires to be once overstretched to be-
come jjermanently atonied. If the muscular fibres
have undergone no structural change other than over-
stretching, they will of course recover their tone more
readily than when atrophic or fatty changes have in-
volved their texture, which is the frequent outcome of
old age, and in such cases recovery is obviously not
to be anticipated. A gentleman of spare build and
feeble health, while out yachting with a party of
ladies, was obliged to hold his water all day, and when
he got a chance to nucturate found that he could not
do so. He had not passed his urine e.xcept through
the catheter from that time to the clay of his death,
more than twenty - six years. He was then about
eighty years of age. In this instance there was no
obstructive or mechanical impediment to the escape
of urine at the time of the advent of the trouble, and
July 25, 1896]
MEDICAL RECORD.
121
but slight concentric hypertrophy of the prostate when
I examined him, twenty-tliree years afterward. The
tco sudden removal of the hydrostatic tension was ap-
parently responsible for the mischief. This, though
an exceptional case, impresses us again with the les-
son that we have repeatedly learned that the length of
time taken to empty the bladder should at least ap-
proximate to the length of time that overdistention
has existed. Secondary retention is always to be
feared when the bladder has once suffered prolonged
distention. Hence catheterization should be repeated
until the bladder manifests its accustomed expulsive
power by the force and volume of the stream and is ap-
parently free from residual urine. A good manct uvre,
whicii will sometimes succeed and should always be
resorted to, is to pass the catheter as far as the vesical
neck, allow it to remain until it begets the desire to
urinate, and then quickly remove the instrument. The
bladder is thus coerced, as it were, to perform its natu-
ral function.
In some persons the only confession that nature
makes of a neurotic temperament is through the uro-
poietic viscera, while others of the same family who
may be decidedly neurotic show no disturbance what-
ever in this respect. The surplus of nerve force not
taking the habitual channels expends itself upon the
sphincters in an efflux of motility, producing w'hat we
term sphincterismus. In some instances the patient
will tell us that when he has the desire to micturate
he feels a sense of constriction at the vesical neck,
which he finds impossible to overcome with the most
powerful effort of the abdominal muscles and dia-
phragm, and is obliged to wait until a momentary' re-
laxation of the sphincters occurs. Thus spasm and re-
laxation alternately recur a number of times during
an act of micturition. Such persons are apt to suffer
from dysuria with partial retention. A gentleman,
aged thirty-five, was in such a high state of nerve
tension while on shipboard that he could not pass
water except with the aid of the catheter in either of
his trans-Atlantic trips, though he never experienced
the slightest difficulty while on terra firma. In him
the inhibitory influence on the vesico-spinal centre
was very apparent and effective.
A maiden lady said she never felt the natural im-
pulse to micturate, and did so morning and evening
more from habit than from necessity. She was sub-
ject to hysterical attacks about the time of her menses,
when she indulged pretty freely in whiskey. I was in-
variably summoned in the dead of night, and would find
her in a condition of semi-alcoholism, suffering from
retention of urine. There was so much vaginismus
that extreme delicacy of touch had to be exercised,
and so much sphincterismus that the catheter was felt
to be firmly grasped at the vesical neck. Upon the
introduction of the instrument an enormous quantity
of pale limpid urine escaped. For five consecutive
months, at almost precisely the same time, this seance
had to be repeated, until she was considerate enough
to go South. She never required but one catheteriza-
tion for each attack.
An elderly gentleman, somewhat ataxic, says that
for a period of years he has noticed a gradual but
steadily increasing difficulty in emptying his bladder.
He ascribes his trouble to an attack of paresis which
he had ten years ago. Ther> was at first simply a
hesitation in micturition, with an enfeeblement of the
expulsive power This increased until for more than
two years he has not been able to micturate without
exerting the full expulsive action of the diaphragm
and the abdominal mus:les. He dreaded instrumen-
tation and was inclined U- have pretty well alone, liut
about six weeks ago, coming home from the club <;ne
night, he had absolute retention, for the relief of
which he called to his aid a well-known surgeon «ho
lived near by. Up to this time he was free from cys-
talgia, the urine remained uniformly clear, there was
no undue frequency in micturating, and hence he
leaves nothing to the imagination in his phraseology in
saying that his present condition, with excruciating
pain, great frequency in urination, broken rest, and of-
fensive, ropy urine has been brought about by the dirty
catheterization of his former surgical attendant. This
is an experience which you can doubtless multipl)-.
The long-suffering, patient bladder copes successfully
with the enfeebled contractile powers, until retention
occurs or residual urine accumulates, necessitating arti-
ficial means for relief, when at the same time the patho-
genic sparl: is introduced, which sets up a conflagration
in the viscus not readily extinguished. This case
stands in a striking contrast to another one above cited,
in which the bladder was indifferent to septic germs,
and tolerated with apparent equanimity rude instru-
mental manipulation for more than a quarter of a cen-
tury.
"' Strange ! that a harp of a thousand strings
Should keep so long in tune."
Urine is and will remain aseptic so long as certain
micro-organisms do not have access to it and remain
in contact with it long enough to effect the hydrolysis
of the urea. If the bladder is capable of completely
emptying itself within a few hours of the introduction
of these organisms they will not have time to induce
the fermentative process, but if some change exists in
the physiognomy of the viscus whereby it will contain
residual urine they will find a most favorable culture
medium prepared for their reception and multiplica-
tion, and the attendant sequelse are to be anticipated.
This latter patient had either a vulnerable spot on the
vesical mucous membrane which the pyogenic organ-
isms could invade directly, or, which is more probable,
the viscus was incapable of thoroughly discharging
its contents. Fermentation of the urea ensued, irrita-
tion and inflammation resulted. Another noteworthy
point in this case was the enormous manufacture of
mucus. The production of so much mucus in so short
a time from a membrane devoid of goblet cells and
with but few and very minute racemose glands, is a fact
most interesting in the metabolic activity of the blad-
der.
Hence, to prevent microbic infection, we have, first,
to be scrupulously careful in having the instrument
and lubricant employed in a thoroughly aseptic condi-
tion, particularly in cases in which the bladder is
suspected to contain residual urine. Most atonied
bladders, especially those of elderly subjects, will con-
tain residual urine after ordinary atheterization, un-
less this is effected with the patient in an erect pos-
ture, which for obvious reasons is not done. In the
recumbent attitude, the bladder manifests its loss of
inherent power by the slow and feeble character of the
stream, which discontinues often before the viscus is
half empty, requiring firm pressure over the hypogas-
trium to renew it. Second, we reiterate the injunc-
tion not to remove the internal tension too soon,
particularly because of the hypera;mia of the mucous
surface which it occasions, whereby the most favorable
environment will be obtained for the development of
the pyogenic germs. Third, to inject an antiseptic
solution after each catheterization, especially at the
finish, and to aspirate and irrigate the bladder as a pro-
phylactic measure. For the microbes of ammoniacal
or catarrhal cystitis may be destroyed betimes ; not so
when the pyogenic organisms have invaded the sub-
mucous coat, producing suppurative cysiilis. Then we
have a much more aggressive and intractable matter
to contend with.
Various local conditions, some of which have al-
ready been described, may reflexly induce spasm of the
122
MEDICAL RECORD.
[July 25, 1S96
extra- and intra-pelvic sphincters sufficient to cause
retention. The bladder often manifests its sympathy
with neighboring organs when in trouble; it cries out
in painful tones, enduring the burden of a disease lo-
cated elsewhere, of which it is entirely innocent. I
call to mind a strikingly illustrative case iji which
sphincterismus with retention was induced by a deep
stricture of large calibre, which was relieved by the re-
laxing effect of ether. Frequent but unsuccessful at-
tempts at catheterization had been made at intervals
by adepts, and it was decided to perform external peri-
neal urethrotomy without a guide. The patient was
anesthetized, brought into the amphitheatre, put in
position, and the stafY introduced. The operator was
about to make the incision, when to the great astonish-
ment of all present, the instrument glided into the
bladder with the utmost facility. A catheter of larger
size was immediately substituted and introduced with
equal facility, and the bladder emptied.
Although somewhat irrelevant to the subject in
hand, I am impelled to speak of a recent experience.
It was a case of retention due to a periurethral abscess
located in the perineum. The man was thought to
have a tight stricture, ulceration of the urethra, and
extravasation of urine. In this belief he had been
reijeatedly but unsuccessfully catheterized with small
instruments. When I saw him there was unmistak-
ably some extravasation, but no stricture was apparent.
If an abscess exists in the perineum associated with
difficult micturition, the sooner it is evacuated the
better, and this should always be done before instru-
ments are introduced, otherwise a urethral communi-
cation may be made with the abscess, endangering ex-
travasation of urine, as obtained in this case.
MENIERE'S DISEASE— APOPLECTIC FORM.
liv THOM.VS A. KENEKK'K, M.D.,
NEWPORT, RHODK ISLAND.
For many years Meniere claimed to have seen certain
cases with such decidedly characteristic localized and
reflex symptoms as to convince him there existed a
lesion, the pathology of which alone remained to be
demonstrated.
His opportunity came in 1861, when his patient
died after an illness of five days, during which she
exhibited the typical symptoms of this rare disease.
He then showed in this case that the lesion was a red-
dish plastic exudation into the mucous membrane and
labyrinth of the internal ear, there being no other evi-
dence of trouble.
Previous to this demonstration, we read, he was
convinced of this lesion, as men are frequently to-day
with other diseases, in which a diagnosis of the path-
ological changes is borne out by tlie symptoms, mak-
ing a post-mortem examination almost an unnecessary
requirement.
Still, with these facts in view, doubt is frequently
expressed from different parts of the world as to its real
existence, owing possibly to its exceedingly rare oc-
currence in the true apoplectic form.
It must be admitted that with the light of our present
knowledge of anatomy and physiology, together witli
the art of physical diagnosis, if we are given certain
well-marked, definite, and localized symptoms associ-
ated with and pointing exclusively to a limited and
special area, we have collected all the knowledge re-
quired for a correct and .scientific diagnosis.
A consideration of the lesion and the physiology of
the immediate and distant effects is a preliminary
necessary to a claim for the report of a case of this
character, in which sudden deafness, vomiting, and
di ;ziness were the prominent and only phenomena.
The anatomical parts involved and affected are the
membranous labyrinth, and the terminal endings of the
auditory and vasomotor nerves. These terminal end-
ings are not distributed generally over the membranous
surface, but in well-defined spots characterized by a
thickening and by peculiar epithelia provided with
stiff pointed cilia, called auditory hairs, whose function
is to aid in the transmission of sound waves. It can
be readily appreciated how a sudden exudation into
and upon this membrane would prevent at once the
further performance of this function.
Hogyer affirms that these same terminal endings
from their communication with the cerebellum form
an apparatus whicli regulates according to the position
of the body the movements of the eye and probably
those of all the muscles exerted in the preservation of
equilibrium.
This theory is also shared by Moos, Lowensky, and
Politzer. So that for the giddiness we have only to
trace the auditory nerve to its connection with the
cerebellum, this being the main peculiarity which dis-
tinguishes this one from all the other cranial nerves.
The \omiting and perverted vision are then accoimted
for by rellex action through the ocular and vasomotor
system. Trousseau has noted a giddiness similar to
that of Meniere's disease dependent upon a chronic
gastric catarrh, proving the close relationship existing
between the stomach and these same terminal endings.
The accompanying report, I trust, may add a little to
our limited knowledge of this subject.
On the morning of September 22, 1895, 1 was called
to see a Mr. J , and found a man about forty-five
years of age, robust and healthy in appearance, un-
married, and by profession an architect. He was then
fairly comfortable and gave the follow ing brief history :
He had always been perfectly well; he had no history
of disease, specific or otherwise, and since childhood
he had lived a careful and regular life. I learned,
however, that he had been an indefatigable worker.
Besides attending to his profession during the day he
applied himself to developing ingenious devices long
into the night. Many of these have been patented
and are successful. This mode of life he had car-
ried on for more than twenty-five years with hardly a
single day's holiday or interruption.
The previous night he was suddenly aroused during
sleep by a most violent attack of vomiting, consisting
of large quantities of dark greenish fluid accompanied
with persistent and alarming dizziness. There were
noises in the ear on the right side and also marked deaf-
ness. .-V thorough physical examination found him in
splendid general condition, with no rise in tempera-
ture, no pain, no disturbance of the different reflexes,
nor of motion or sensation. Microscopical examina-
tion of the urine gave negative results. Flxamination
of the tympanum on the affected side showed a slight
congestion of this membrane. The vomiting and diz-
ziness continued for several hours, then ceased, only
to return again the instant he attempted to raise his
head or even turn it from side to side. The vomiting
yielded finally to small doses of ipecac, but the dizzi-
ness and deafness persisted, the latter being absolute
on the right side. In addition to these were certain
symptoms of perverted vision which may or may not
be of importance, but as a matter of interest I report
them. He saw by his bedside the slanting roof of a
conservatory on which sat a glazier rapidly fitting in
panes of glass. The moment the glass was laid, it
slipped through, w-hen the glazier would quickly try
another with the same result. This scene continued
until the afternoon, when it was replaced by the figure
of a woman dressed in brilliant red. At first the fig-
ure was short in stature but gradually increased in
length until it appeared one hundred feet high and
seemed to be surrounded bv mi'.lions of active little
July 25, 1896]
MEDICAL RECORD.
12'
mice. These disturbances vanished toward evening,
and but for the dizziness he appeared perfectly com-
fortable.
With these localized and sudden symptoms, and the
absence of any general disturbance, in a previously
strong and healthy man, this diagnosis was therefore
decided upon. In this condition he remained, the
slightest attempt to rise giving him the sensation as
if he and the bed were rapidly revolving. The vom-
iting ceased, but the deafness remained until about
two weeks, when this and the giddiness graduallv im-
proved, and at the end of si.x weeks he managed with
a tottering gait and by the assistance of a friend to
daily reach his office, which he persisted in doing
imtil he fully recovered.
The treatment consisted of at first large doses of
quinine and later a combination of bromide and iodide
of potash, but with no marked success. Galvanism
•was applied and really seemed to give decided benelit
and was persisted in, though I am of the opinion the
disease ran an independent course toward recovery,
with possibly some assistance in the process of absorp-
tion by the electricity. I have seen this man within
the past few days and he assured me that all the
symptoms have disappeared and that his recovery has
been complete.
The diagnosis was made on the presence of these
three distinct symptoms produced evidently by a lesion
such as Meniere discovered, and which, by direct and
reflex action and according to physiological teaching,
is traceable and confined to the region previously de-
scribed.
progress jot Medical s>cicnce.
Abnormal Labor Pains and Their Treatment. --
Dr. Schaeffer, we are told in an article summarized in
the Amci-ican Journal of the Medical Sciences, di\ides
abnormal labor pains into those which are purely
atonic and those which are partially spasmodic in
their character. . There have been various divisions
made of atonic pains, some referring them to the va-
rious portions of the uterus, and others dividing them
according to the degree of atony which is present.
The uterus contracts more frequently when atony is
present, but much less effectually. Such pains do not
increase in vigor as dilatation advances. The pauses
between these pains are shorter than in normal cases.
In the latter portion of the period of expulsion atonic
pains are more frequent and longer than in normal
cases, so that in some patients the same effect is pro-
duced, although in longer time, which is obtained by
normal pains. The amount of actual work done by
the uterus is found by careful observation to be much
greater than in cases of normal contraction. The
work done by the uterus is most efficient in the first
portion of labor; while compensation is wholly or
largely effected in the latter part. It is observed that
the latter portion of birth in these cases is practically
accomplished by contraction of the abdominal mi:scles,
and that these contractions are greatly influenced in a
reflex manner by uterine pains. The diagnosis of
atonic pains is often neglected, and this condition is
mistaken for other complications. In partially tetanic
pains there is no special delay in the rupture of the
membranes. The most frequent cause of this condi-
tion is endometritis of the cervix, resulting in slow
dilatation and increased suffering. Another cause of
this condition is frequent examinations during labor,
and the irritation which they produce. An abnormal
position of the uterus may also produce partially te-
tanic contractions. The treatment of this condition
consists in placing the patient in a favorable posture.
in the use of warm baths, and in hot vaginal douches.
For weak pains, when simple atony of the uterus is
present, small doses of ergolin, given by hypodermatic
injection, are found useful. It was observed to pro-
duce an effect in about eight minutes after its admin-
istration.
The Leucocytes in Tuberculosis Drs. Stein and
Erbmann have made a new study of this subject, based
on the accurate observation of sixty cases. In many
of these the clinical diagnosis was confirmed by post-
mortem examination. In counting the white corpus-
cles a modification of the method of Thoma was used,
in which, instead of counting the corpuscles in the
squares of the blood counter, all those in a number of
fields were counted, after estimating the contents of
the space covered by the field. For many interesting
details the original should be consulted; the following
conclusions give the most important results; In begin-
ning phthisis the number of leucocytes is normal. In
advanced cases, but in which cavity formation has not
taken place, the number is also normal. After attacks
of haemoptysis there is usually moderate leucocytosis,
which disappears after the cessation of the hemorrhage.
In advanced tuberculosis with chronic infiltration, but
in which destruction of tissue is slight or has not yet
begun, the leucocytes may be normal. Increase of leu-
cocytes is encountered in cases with cavity formation,
in cases with chronic suppuration as the result of ca-
rious processes, in final exudative processes, and in
cases with hyperplasia of lymph glands. As regards
cavity formation the following statements are impor-
tant; If leucocytosis occurs in a tuberculous case in
which there is no chronic suppuration and no exuda-
tion, ulcerative change, i.e., cavity formation, may be
diagnosed. If in a case with normal leucocytes for a
long time an increase takes place, excavation may be
concluded. So long as the leucocytes are not in-
creased the existence of a cavity, at least one of con-
siderable size, may be excluded. The cause of the
leucocytosis is not the tuberculous poison itself, but
a secondary infection, a septic process, which may be
the result of various bacteria. — Dentsches Arcliiv fiir
klniische Mcdicin.
Pneumonotomy. — From an article published in the
British Medical Journal we learn that Dr. Quincke
lias tabulated and analyzed fifty-four cases of pulmon-
ary abscess treated by surgical operation. These
cases, seventeen of which were treated by the author,
are arranged in three groups ; the first of acute ab-
scesses, both simple and gangrenous ; the second of
chronic abscess and putrid bronchiectasis; and the
last of putrid suppuration caused by a foreign body in
the lung. In a large proportion of the fifty-four cases
(eighty-three per cent.) the inferior lobe of the lung
was the seat of the disease. Of the total number of
patients, twenty recovered and twenty died; in the re-
maining fourteen cases, the surgical treatment either
failed altogether or gave but imperfect results. The
author makes out from his collection of records that
while the mortality from operative interference is al-
most equal in acute and in chronic cases, the percent-
age of complete recoveries is higher by about forty-
five in the former than in the latter. It is concluded
that the operative treatment of acute pulmonary ab-
scess will be attended with complete success in two
of every three cases. The prognosis of such treatment
in cases of chronic, and especially putrid, abscess is
much less favorable. The author believes, however,
that in future better results may be attained by earlier
inter\ention. Surgical treatment, he holds, is indi-
cated in cases of acute abscess which show no ten-
dency to spontaneous healing. The prospects of an
operation in such cases are better than those of an ex
pectant treatment. If such suggestion be generally
124
MEDICAL RECORD.
[July 25, 1S96
followed chronic pulmonar)^ abscess with secondar)'
bronchiectasis will, it is thought, less frequently be
observed. Notwithstanding the less favorable pros-
pects of operation in cases of chronic pulmonary ab-
.scess and sacculated bronchiectasis, such treatment is
here recommended for these morbid conditions with
the view of protecting against acute secondary inflam-
mation the portion of lung still remaining sound. In
cases of multiple bronchiectasis, although a priori a
good result could hardly be e.xpected from surgical
operation, still, the author thinks, improvement may
be brought about by such treatment. .As such a con-
dition constantly threatens fresh and fatal mischief, an
operation, though not clearly indicated, need not be
regarded as unjustifiable. In discussing the diagno-
sis of pulmonary abscess the author regards as impor-
tant indications the purulent nature of the expectora-
tion and the presence in the discharge of minute
portions of broken-down lung tissue. The quantity of
expectorated fluid, he points out, atTords no sure indi-
cation of the size of the cavity. In considering the
diagnosis of the seat of a supposed pulmonary abscess,
he states that when on general grounds the existence
of such a cavity is assumed, and a localized area of
dulness exists without any distinct local symptoms of
suppuration, this area should be selected as the object
of the surgical attack. If not the precise situation of
the disease, it will in most instances serve as a guide
to the purulent collection. Kxploratory aspiration is
objected to as a measure of diagnosis. It will not
show whether the cavity be a large or a small one, and
is a very probable source of danger in cases in which
the affected portion of lung is not adherent to the wall
of the chest. The author, in concluding his paper, de-
scribes his method of treating pulmonary abscesses,
which consists in resection of portions of one or more
ribs, free exposure of the parietal layer of pleura, and
in making with the thermo-cautery a free opening into
the cavity after he has assured himself that adhesions
exist between the lung and parietal pleura, or by a
prolonged application of caustic has artifically estab-
lished such adhesions. Pleural adhesions at the seat
of operations he regards as an imperative condition in
pneumonotomy. If there be any doubt as to the exis-
tence of such adhesions the surgeon must act upon the
assumption that they are absent.
Acute Nephritis from Oxalic- Acid Poisoning.—
At a late meeting of the Pathological Society of Lon-
don {The Lancet), Dr. Hale White brought for\vard two
cases of "Acute Nephritis due to Oxalic- .\cid Poison-
ing." The first was fatal, apparently from uramia, six
days after the acid had been swallowed. The necropsy
revealed acute tubal nephritis, with several minute
masses of oxalic crystals in the kidney only visible
with a high power. Neither patient showed any cede-
ma, high-tension pulse, or ha;maturia, nor did they
complain of pain in the loins, although this might
have been obscured by the general abdominal pain.
The symptoms appeared, judging from these two cases,
to be scanty urine — the fatal case had almost complete
suppression — and albuminuria. The urine contained
granular and epithelial casts, together with calcium
oxalate crystals. Both the crystals and the albumin
were found in both cases in the first specimen of urine
passed after the acid had been swallowed. In the case
which recovered the crystals disappeared from tiie
urine in twenty-four hours, the albumin persisted four
days and the casts about a week. The quantity of
urine gradually increased until on the fifth, sixth, sev-
enth, and eighth days from swallowing the acid much
more than normal was passed, and it was pale and of
low specific gravity. Seven days after taking the poi-
son this patient passed a quantity of phosphates in his
urine, and after this he often passed a considerable
quantity of uric acid. In the fatal case the oxalate
crsytalsand the albumin remained in the urine till the
end, and the amount of urine passed in twenty-four
hours varied between a drachm and four ounces.
Cancer of the Cervix Uteri. — Dr. Cordier {Inter-
national Journal of Surgery, June, i8g6, p. 158) draws
the following deductions: i. Cancer of the cer\-ix
uteri, if left without surgical interference, always kills.
2. The disease, in most instances, is, primarily, a
local process. 3. Early hysterectomy will cure quite
a percentage of these cases. 4. The microscope,
while a great diagnostic assistant, is not infallible in
its findings. 5. The experienced surgeon is war-
ranted in resorting to a hysterectomy, even in the
doubtful cases. 6. All malignant pregnant uteri
should be removed when seen before the disease has
advanced beyond the period of a probable cure.
The Tonsillar Cough — According to Dr. Furet,
this cough may result from any pathological alteration
of the tonsils. It wrs sufliciently explained by the
complex innervation of the gland. In fact, the glosso-
pharyngeal, the lingual, the spinal, and the pneumo-
gastric nerves were blended and became entangled
at their outer surface, where they formed a small
plexus, which Andersch had described under the name
of the tonsillar plexus. It must not be forgotten that
the tonsils were inclosed by the muscles of the pillars
of the fauces, which were very distinctly connected
witii the muscular apparatus of the larynx. Tonsillar
cough was violent, spasmodic, and even extremely
painful. It was frequently accompanied by reflexes
in the neighboring region, and particularly by water-
ing of the eyes. It was distinguished from the cough
due to affections of the respiratory tract by the com-
plete absence of expectoration, and, owing to this fact,
it did not yield to any of the remedies generally used.
— La J'ressd Medicale.
Results of the Bacteriological Examination of
One Thousand Cases of Suspected Diphtheria. —
Drs. Hewlett and Nolan publish a review of results of
the bacteriological examination of specimens from one
thousand consecutive cases of suspected diphtheria,
forwarded by medical officers of health and practi-
tioners from all parts of the kingdom to the institute
for diagnosis. In five hundred and eighty-seven cases
the diphtheria bacillus was found, in four hundred and
nine cases it was not found, and in four in.stances
there was doubt as to its presence. Two specimens
were from cases of conjunctivitis: in one the diphthe-
ria bacillus was found; in the other, which was asso-
ciated with faucial diphtheria, only the streptococcus
pyogenes. In one instance specimens were taken from
the fauces and from the vagina of the same case, and
bacilli were found in each. In another, a pure cul-
ture of the diphtheria bacillus was obtained from a se-
vere case in which the infection of the throat probably
originated from a diphtheritic wound of the finger in-
curred during laboratory work. Examinations were
also made to determine the time of disappearance of
the bacilli from the throat. This was found by them,
as it had been by former observers, to be exceedingly
variable. The bacilli were commonly found for two
or three weeks; in one instance they remained for
seven weeks, in another for nine weeks, and in another
for twenty-three weeks. In the latter case they re-
mained virulent for guinea-pigs. In conclusion, the
authors insist upon the desirability of a bacteriologi-
cal examination in all cases in which the throat symp-
toms are at all doubtful, as many of their cases which
were not regarded clinically as diphtheria proved to be
such. They also emphasize the necessity of repeated
examinations after convalescence, with isolation, until
the absence of the infective agent has been shown. —
British Aledieal foiirnal.
July 25, 1896]
MEDICAL RECORD.
125
Medical Record:
A Weekly Journal of Medicine atid Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, & 47 East Tenth Street.
New York, July 25, 1896.
DIPLOMA MILLS AND STATE PROTECTION.
In spite of the strenuous efforts of all honest men
interested in the advancement of medical qualifica-
tions and in the face of laudable endeavors in enact-
ing suitable laws to such an end, it is quite discourag-
ing to notice that the State of Wisconsin in particular
comes boldly to the front as an open abettor of fraud
and by the sanction of authority offers a direct en-
couragement for the free and shameful sale of medical
degrees. The profession of that State owes it to itself,
to common decency and fair play, to everything that
is right and honest, to see to it that such a traffic shall
be duly exposed and promptly stopped. Whatever
may have been the intention of the framers of the law
at present in force in Wisconsin, it is quite evident
from the following correspondence, kindly forwarded
by one of our readers, that the literal construction of
the provisions of the act makes possible the most out-
rageous abuse of statutory provisions:
"'.\lways give your Full Address every time you write,
no matter how often it may be.' "
"Fred. Rutland, M.D., Fres. ; A. Neve Rutland,
M.D., Sei: ; Jules Gordon, M.D., Treas.
" Incorporated under the Law of the State of Wisconsin.
"Wisconsin Eclectic Medical College,
"of Milwaukee, Wis.
" Correspondence Department,
" 1 00 1 West Congress St.,
"Chicago, III., July, 1896. J
" Dear Doctor : We notice your name in a Medical
and Surgical Directory, but with a * appended. This
usually means (although not necessarily so) that the
person so designated is not a graduate of a medical
school, and has no diploma. If, however, it should be
that you are a graduate, and have a regular diploma,
then we can but tender our most sincere apologies for
troubling you on the matter. But, on the other hand,
if you are not a graduate, and have no regular diploma,
then the perusal of the enclosed prospectus cannot
fail to be of the most primary importance and interest
to you. We would also desire to draw attention to
the fact that to practising physicians our fees are
much reduced from the regular rate. To this class
our fees are $35. all inclusive.
" .As proof of our legal standing and right to confer
the degree of M.D. we can supply certified copies of
our charter at 25 cents each, simply covering the cost
of certifying officer's fee.
" Trusting soon to hear from you and standing ready
to answer any or all questions you may wish to submit,
" We are, yours very sincerely,
"Wisconsin Eclectic Medical College,
" Fred. Rutland, M.£>., Fresident."
Accompanying this letter is the following circular:
"This is a True Copy of the Charter of Our College.
" United States of America.
"The State of Wisconsin,
" Department of State.
" To All to Whom these Fresents shall come :
" I, Henry Casson, Secretary of State of the State of
Wisconsin, do hereby certify that there has been this
day filed in this department an instrument in writing,
purporting to be Articles of Association, with a view of
forming a corporation to be known as
"Wisconsin Eclectic Medical College,
" at Milwaukee,
without Capital Stock, the business and purpose of
which shall be to conduct a Medical College, etc., and
verified as a true copy by the affidavit of Fred. Rut-
land, M.D., and Ann Neve Rutland, M.D., who appear
in said instrument as two of the signers of said articles ;
therefore the State of Wisconsin does hereby grant
unto the said
" Wisconsin Eclectic Medical College,
" at Milwaukee,
the powers and privileges conferred by Chapter 86 of
the Revised Statutes of the State of Wisconsin and all
acts amendatory thereto, for the purposes above stated
and in accordance with their said Articles of Associa-
tion.
" In Witness Whereof, I have hereunto set my hand
and affixed my official seal, at the Capitol in the City
of Madison, the thirty-first day of December, in the
year of our Lord one thousand eight hundred and
ninety-five. "Henry Casson,
[Seal.] " Secretary of State."
These are the plain facts in the case and can speak
for themselves. The college in question, judging from
the print in the circular letter, is situated in one corner
of the upper story of a business block and evidently
has abundance of room for a correspondence depart-
ment.
The prospectus to which reference is made in the
personal letter takes it for granted that there are great
numbers of deserving students who cannot practise
medicine because they have not means enough to at-
tend high-class colleges, and therefore that the college
in question will make it easy for such aspirants who in
its estimation should have legitimate privileges for
obtaining a living, in spite of the oppressive and un-
just laws in other States. To such as have, " owing to
the medical laws, practised medicine illegally the Wis-
consin Ecle tic Medical College comes as a boon and
a blessing." Again, " it is possible for students to
graduate without attendance." It is apparently suf-
ficient to "arrange for their examination before a
notary public of their town and if the examiners of
126
MEDICAL RECORD.
[July 25, 1896
this college can be satisfied they can be legally and
lawfully graduated, receiving the diploma of the col-
lege conferring the degree of doctor of medicine with-
out attendance at the college." Of course an examina-
tion appears to be requisite, but w^here is the guarantee
that the conditions requiring it will ever be fulfilled
or ever be anything more than the merest pretext for
a graduation fee? The object of this missionary work
is too transparent for explanation or discussion. What
can we think of any State legislature that could make
such doings possible? What will eventually be the
standard of medicine in Wisconsin when it can be
lowered to such a level? Surely our good brethren
of the Wisconsin State Society should take this matter
in hand, promptly and with a becoming seriousness of
purpose.
IS PULMONARY CONSUMPTION A FACTOR
FOR THE ELIMINATION OF THE UNFIT?
Dr. Thomas J. Mays, of Philadelphia, in the discus-
sion of this question calls attention to the fact that in
addition to the inherited tendency to pulmonary dis-
ease, nervous diseases — such as insanity, idiocy, hyste-
ria, chorea, epilepsy, and asthenia — may be translated
into pulmonary consumption between parents and
children, and that the latter may be convertible into
the former in the same way. Dr. G. Fielding Bland-
ford says: " I have found phthisis and insanity fre-
quently coexisting in the same family." Dr. Stearns
says: "We often see a consumptive having a child
which, instead of developing consumption, develops
insanity, and vice versa." Dr. Clouston makes the ob-
servation that the death rate from pulmonary con-
sumption among the insane is four times greater than
it is among the general population, and both diseases
are very common among different members of the
same family, and that heredity toward consumption
may determine insanity and heredity toward the latter
may produce the former. The forms of insanity com-
monly associated with phthisis are monomania of sus-
picion and melancholia. Dr. Mays says that there is
a similar prevalence of consumption in families bur-
dened with idiotic children. The influence of hered-
ity in transforming nervous diseases into pulmonary
consumption and the rever.se is so obvious that even
lay writers have observed it.
The poisons of influenza and of whooping-cough, and
alcohol, lead, and mercury are powerful e.xciting causes
of pulmonar}' consumption. In fact.any influence which
depresses or disintegrates the brain and nervous sys-
tem may prove an exciting cause of jnilmonary con-
sumption. Dr. Mays states that the above facts would
seem to brand the consumptive as a degenerate and
unfit to survive the struggle for existence; but he goes
on to show that the nature of many of these stricken
with this disease stamps them as beings of the highest
order of beauty and intelligence. Dr. Churchill says
that the connection between acute sensibility and
phthisis is so striking that poets of all times and all
countries have employed their most touching accents
to deplore the premature fate of some of those victims
to consumption whose youth was bright with promise
of future excellence and distinction. The author says
that high intelligence and physical beauty belong to
a certain type of phthisical temperament and that, in
all probability, both are the outcome of a refined ner-
vous organization, delicate by reason of the exalted
place it has obtained in the process of evolution, more
easily unbalanced by unfriendly influences, and conse-
quently less fit to undergo the severe and exhaustive
struggles which are necessary in the present imperfect
state of our civilization. More people succumb to
phthisis and insanity between the ages of twenty and
thirty than at any other time of life, which fact would
seem to conform to the above statement.
The author concludes as follows: '' Facts, therefore,
fail to confirm the belief that pulmonary consumption
is designed to purge society of the unfit; on the con-
trary, sufficient reason has been given to show that
many of those who fall victims to this disease are
drawn from a class of society which represents the
most progressive type of human development. "
Has the author actually proved that the consump-
tive is not eliminated as unfit? The fact that he suc-
cumbs is evident proof that he cannot sustain the
struggle for existence under present conditions. His
faculties may be brilliant, but he is in an unstable
condition in that his physical development has not
kept pace with his nervous and mental evolution. In
barbaric ages, war, famine, and disease were regarded
as a means of disposing of surplus population, but
the economist tells us there need be no fear of over-
population, as three-fourths of the products of the
earth go to waste annually. The altruistic feeling
that now prevails abhors the idea that nature should
employ disease as a means of elimination. It seems
more reasonable to regard it rather as an acci-
dent of the human race, a misfortune which science
can in time rectify. Dr. Mays gives statistics to show
that pulmonary consumption is on the decrease, and
says the reduction is due to better food, better cloth-
ing and shelter, better homes, better physical and
mental training, better sanitation, and elevation of the
moral standard. It is to be regretted that in addition
to these means, that hold so much promise to future
generations, we cannot have laws preventing the mar-
riage of consumptives, that those to whom the moral
side of the question would not appeal might still be
controlled. It is also to be regretted that the many
suffering from this disease seem doomed, and that
medical science holds out so little prospect of imme-
diate relief; but we have evidence that we are slowly
progressing, and science may yet find the means of
wiping out pulmonary consumption as effectually as it
has small-pox.
A Dumb Thermometer. — A member of the Zurich
Medical Society recently exhibited a self-registering
clinical thermometer on which there were no degree
marks. The instrument could be left with the pa-
tient's family to take the temperature in the absence
of the physician, and the latter could then read it by
means of an attachable scale of glass or metal.
July 25, 1896]
MEDICAL RECORD.
127
2TICU1S of the ^mccK.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the Medical
Corps of the United States Navy for the week ending
July 18, i8g6: July 14. — Surgeon R. C. Persons,
orders to duty at naval hospital revoked and ordered
to continue on present duty; Passed Assistant Surgeon
H. N. T. Harris, ordered to the Pensacola navy yard.
July 15. — Surgeon S. H. Dickson, ordered to the
Texas; Assistant Surgeon J. M. Moore, detached from
naval hospital, Norfolk, and ordered to the Texas.
July 17. — Assistant Surgeon A. Farenholt, detached
from the Motitercy and ordered to the Mare Island
hospital, California.
Anti-Vivisection Legislation The following pre-
amble and resolutions were passed by the American
Surgical Association at its session in Detroit, May
27, 1896:
" Whereas,
"(i) The American Surgical Association has
learned that the committee on the District of Colum-
bia in Congress has reported favorably a bill ad-
verse to the practice of vivisection in the District of
Columbia, and
" (2) The passage of such a law will put an end to
all the experimental work in the governmental labo-
ratories at Washington from which have emanated
important and useful discoveries, especially as to the
diseases of animals, and
"(3) The passage of such a law by Congress will
be used as a lever in promoting the enactment of sim-
ilar laws in other parts of the country and so do dou-
ble harm;
" Therefore, Resolved, by the American Surgical
Association,
" (i) That to their personal knowledge the mar\'el-
lous progress of surgery, especially within the last
twenty-five years, is due very largely to experiments
upon animals, and the continuance of such experiments
is absolutely essential to the further progress of surgi-
cal science.
" (2) That in their opinion the humanity of the entire
profession is too well known and too constantly and
conspicuously shown in their enormous charitable and
kindly work to allow the assertion that they would
countenance the practice of cruelty or the infliction of
needless pain in such experiments to be believed by
the American people or their representatives in Con-
gress.
" (3) By reason of this very humane sentiment, this
Association protests against the passage of the bill in
question, because it will be a cause of untold cruelty
to both man and animals by arresting to a great extent
the beneficent progress of surgery.
'■ (4) That a copy of these resolutions be sent to tiie
President of the United States and to the Senate and
House of Representatives.
" W. W. Keen, H. L. Burrell, Joseph D. Brv.wt,
committeer."
Jefferson Medical College Hospital. — Eckley Brin-
ton Coxe, Jr., has contributed $5,000 for the endow-
ment of a free bed in the contemplated new Jefferson
Hospital.
The Spanish Soldiers in Cuba. — During the last
third of June there were about 8,000 men lying ill in
the Spanish military hospitals in Cuba, of which num-
ber 1,300 were suffering from yellow fever. The mor-
tality rate of this disease is increasing. The epidemic
of small-pox shows no signs of diminishing.
Dr. Frank Whitman Ring, of this city, died on
[uly i7tli, in New Haven, from disease of the heart.
He was born in Portland, Me., forty-eight years ago,
and studied medicine in Bowdoin College, where he
received his degree in 1S78. He came to New York
to practise in 1S79, '^^^ soon became associated with
the Manhattan Eye and Jilar Hospital, retaining his
connection with this institution up to the time of his
death. He was a member of several medical societies
of this city, and was the author of a number of papers
on subjects relating to his specialty. He had two
brothers who are phvsicians, and he leaves a widow
to whom he was married but a few months ago.
Obituary Notes Dr. Willi.am H. M.\ilack died
at Downingtown, Pa., on July 12th, at the age of 59
years. He had been a paralytic for many years, but
as one time was a prominent practitioner and an ac-
tive politician. — Dr. Charles DeCosta Brown died
in New York City on July 12th, at the age of 79 years.
He was a native of Philadelphia and was graduated
from the University of Pennsylvania. He practised
medicine for a time, but subsequently engaged in the
practice of dentistrv. During the war he acted as gov-
ernment embalmer. He was a prominent member of
the Masonic fraternity. — Dr. Friedrich Arou.ST Ke-
kule, professor of chemistry and first examiner in
pharmacology at the University of Bonn, died on July
i6th. — Dr. E. B. Stevens, of Lebanon, O., died at his
residen e, July nth, in his seventy-third year. For
seventeen years he edited the Cincirmati Laiieet and
Observer, now the Laneet-Clinie, and afterward con-
ducted the Obstetric Gazette. He was professor of
materia medica and therapeutics in the Miami Medi-
cal College from 1865 to 1873, and in the University
of Syracuse from 1872 to 1877.
Arsenic in Cigarettes. — Dr. William Murrell pub-
lishes in the British Meilical Journal of July 11, i8g6,
a preliminary report of an analysis which he has made
of the paper wrappings of smoking tobacco and cigar-
ettes. He found that of seventeen samples of tobacco
and cigarette packages arsenic w'as present in the labels
of six. The presence of arsenic in the wrappers of
cigarettes, he thinks, must be attended with consider-
able risk to the smoker, for the coloring matter easily
rubs off on to the fingers, especially when moist, and
from the fingers on to the cigarettes. Most packet
tobaccoes are put up by machinery, but the papers are
spread by girls, who must of necessity in the course
of their work absorb a good deal of arsenic. The
danger is both to the consumer and to those engaged
in the manufacture of cigarettes. The presence of
arsenic is by no means confined to the cheaper brands.
128
MEDICAL RECORD.
[July 25, 1896
for it occurs abundantly in many of the high-priced
packet cigarettes. The rice papers, which form the
wrappers for the cigarettes, and the tobacco itself have
been e.xamined by Dr. Murrell, buc the experiments
are not yet sufficiently advanced to permit the formu-
lation of positive conclusions.
The Cholera in Egypt — During the first half of
July, 5,441 cases of cholera with 4,602 deaths were
reported in Egypt. The unusually large percentage
of deaths is doubtless to be explained by the fact that
most of the cases that recover are not reported, and it
is probable that the number of cases was much nearer
9,000 than s,ooo. In the Soudan there were 269
cases with 165 deaths on July i8th among the Egyptian
and English troops.
War Dogs and the Wounded. — A special feature
in this year's German manceuvres, says a writer in La
France Militaire, will be supplied by war dogs which
have been most admirably trained for seeking the
wounded and carrying dispatches. At the command
'• seek," accompanied by a gesture indicating the di-
rection in which the dogs are to search, they will start
off without allowing themselves to be disturbed by any
surrounding circumstances; they will find the men who
figure as wounded with unfailing certainty, take apiece
of their clothing — cap, helmet, or piece of cloth torn
off, and bring this back to the ambulance men, whom
they then conduct to the spot.
Wholesale Prosthesis. — The Italian government
recently sent an artificial-limb maker to Africa to
supply hands and feet to about two hundred and fifty
native soldiers who had been captured by the Abys-
sinians and, after having each a foot and a hand cut
off, were set free again.
The Third International Psychological Congress
will be held at Munich, Bavaria, from the 4th to the
7th of -August, in the halls of the university. The
work of the congress will be distributed through five
sections: (i) The physical basis of psychical phe-
nomena, the anatomy of the brain, and the province of
psycho-physics in general. (2) Phenomena of con-
sciousness in the strict sense of the term, psychology
of the normal individual, including laws of associa-
tion, activity of the imagination, doctrines of the emo-
tions and of the will, the evolution of the personality,
facts of ethics, etc. (3) Psycho-pathology, genius and
insanity, illusions of the senses, fixed ideas, sugges-
tion, psychology and criminolog)-. (4) Psychology of
sleep, dreaming, hypnotism in its application to the
healing art, telepathy, mind reading, etc. (5) Com-
parative psychology, mental capacities, and moral
conceptions of the lower races of mankind, grapholog)-,
the relation of psychology to pedagogy, the instruc-
tion of backward children through suggestion, and
kindred topics.
A Field for the Energy of Anti-Vivisectionists. —
Attention has been called in the London Tiiius to the
feather ornaments of women's hats, and especially to
those from the osprey. In order to obtain these the
parent birds are killed during the breeding-season and
their young are left to starve to death. This agitation
has, however, had little effect, and the feathers continue
to be worn by many women who are doubtless moved
to tears at the thought of the cruelty practised by
physiologists in their experiments. But, as the
British Medical Journal well says, " more suffering is
produced to supply the bonnets for one garden party
than in all the physiological laboratories of the world."
The Jenner Centenary in Japan was held in Tokio
on May 14th, the occasion being one of great solem-
nity. There were many speakers, including the presi-
dent of the House of Peers, the minister of education,
the surgeon-in-chief of the army. Count Hijikata, and
the British minister to Japan. Many Japanese nota-
bles and the members of the diplomatic corps were
present.
The British Medical Association will hold its
si.xty-fourth annual meeting at Carlisle on Tuesday,
Wednesday, Thursday, and Friday, July 28, 29, 30,
and 31, 1896. The president-elect is Dr. Henry
Barnes, physician to the Cumberland Infirmary, Car-
lisle. The address in medicine will be delivered by
Sir Dyce Duckworth, lecturer on medicine, St. Bar-
tholomew's Hospital; that in surgery will be delivered
by Dr. Roderick Maclaren, senior surgeon to the Cum-
berland Infirmary. The scientific business of the
meeting will be conducted in nine sections.
Hebrew Medical Men at the Moscow Congress.
— It is stated in the St. Petersburg ViedomosH that the
Russian minister of the interior has decided to per-
mit the entry into Russia of foreign Jews without dis-
tinction of calling. Such persons, however, must be
provided with passports bearing the vise of a Russian
consul, who shall have previously received the requi-
site authority from the Russian minister of the in-
terior. The announced intention of Virchow to resign
his post as president of the German committee for the
International Medical Congress, unless the Russian
government altered the passport regulations in favor
of the Jewish members of the medical profession who
will visit Moscow from Germany, has probably had
something to do with this action of the Russian min-
ister. The present law practically prohibits the en-
trance into Russia of any Hebrew, whatever may be
his occupation or the business which takes him to that
country.
Homoeopathic Representation on the Medical Staff
of a Hospital A committee of the board of man-
agers of tlie Chester (Pa.) Hospital has reported favor-
ably upon a petition of homctopathic practitioners for
representation upon the medical staff of the hospital.
The Center County (Pa.) Medical Society, at its
session at liellcfontc on July 14th, listened to papers on
"Gastro-Intestinal Antisepsis," by Dr. W. B. Hender-
son, of Philipsburg; on '' Post-partum Hemorrhage,"
by Dr. George F. Harris, of Bellefonte; on "Typhoid
Fever," by Dr. E. A. Russell, of Unionville.
Dr. Samuel Wilks, president of the Royal Col-
lege of Physicians, has been appointed one of the
physicians extraordinary to the Qhieen, in place of the
late Sir George Johnson.
July 25, 1896]
MEDICAL RECORD.
129
^^cuicius
and
Notices,
Medical Jurisprudf;nce, Forensic INIedicine, and
Toxicology. By R. A. Witthaus, A.M., M.U.,
and Tracy C. Becker, .'\.B., LL.B., and Collaborators.
Volume HI. New York: Wm. Wood & Co., Publishers.
This is the third of the four volumes which this treatise
comprises. The two previous volumes have already been
noticed in these columns. The present volume is made u])
of the following--named articles: "Vision and .\udition in
Their Medico-Legal Relations." by Dr. J. H. Woodward;
"The Medico- Legal .'Xspects of Insurance," by D. Murray
and G. J. Edmonds; " Insanity in its Relations to Medical
Jurisprudence," by Dr. E. D. Fisher; " Mental L'nsoundness
in its Legal Relations," by T. C. Becker; " Care and Custody
of Incompetent Persons," by Goodwin Brown, and a table
of cases cited in the volume.
The chapters by Dr. Woodward are carefully prepared,
although the discussion of many of the subjects embodied is
by no means exhaustive. In some instances, such as in the
chapter on simulated blindness, the preponderance of quoted
matter is striking. The visual shortcomings associated with
and dependent upon traumatic neuroses and hysteria are in-
adequately considered. On the other hand, the chapters
which embrace the traumatic affections of the eye and its
environs are handled more skilfully and satisfactorily. Rela-
tively inadequate space is given to audition as compared with
that given to vision, fifteen pages to the former, one hundred
and ten to the latter. In the dissociation of nerve impulses
following injury in hysteria, in malingering, conditions which
are continually being worked over in courts of law, much in-
formation of value can be obtained by examination of the
auditor)' apparatus : and although Dr. Woodward does not
attempt to treat any affections of the ear except those due to
injury, we believe a brief consideration of these subjects
would not have been amiss, even if consideration had been
given them under another caption.
The medico-legal aspect of insurance is considered by Mr.
D. Murray, of the Equitable Life Assurance Society, and
G. J. Edmonds, Esq., of the New York bar.
The manner in which the matter is presented, as well
as the way in which the subject is conceived, are both deser\-ing
of the highest praise. There is no obscuration of facts by
words, no tedious citation of matter that is not directly per-
tinent.
The most pretentious article in the volume is by Dr. E. D.
Fisher, whose contribution covers about two hundred pages.
The writer has contributed to his reputation as an alienist
and to medico-legal knowledge. Dr. Fisher follows Krafft-
Ebing in both cla.ssification and definition with the close-
ness of a genuine disciple. If space permitted the e.xtensive
consideration of this article, such as it deser\'es, it would be
necessary to point out, here and there, positions assumed by
the author which we do not think are shown to be tenable,
either by virtue of such assumption or by any arguments ad-
vanced. For instance, impulsive insanity is said to be a men-
tal state similar to those which he has just previously been
considering with moral insanity, hallucinatory mania, de-
mentia with apathy, etc. Nor do we see the necessity
of considering the opium habit as a mania, for psychical ex-
altation, the siiw qua iioii of mania, is not a part of it.
.Amitioris paranoia is a most unfortunate designation to
indicate what is desired to be conveyed by the term paranoia
reformatoria. In discussing paranoia Dr. Fisher differs ven'
radically from other writers, particulariy in his statement that
paranoia is rare in any form before puberty, as most au-
thorities, such as Krafft-Ebing, Krapelin, Werner, <■/ a/.,
believe that one great class of paranoias, /.<■., those presenting
the rudimentar)' form of paranoia, is present before puberty.
The various forms of insanity are taken up by the author
and illustrated in many instances by typical cases related by
word and picture. The mental perversions attending on
alcohol and epilepsy are particularly noteworthy.
In one particular we must take serious exception to Dr.
Fisher's teachings, and that is concerning aphasia. He says
"aphasia may be simply motor, in which there is difficulty
to express the ideas desired by reason of impaired articula-
tion, or there may also be a loss of the names of things,
/.<■.. amnesic aphasia, .so that communication has to be car-
ried on by gesture." In the first place, communication is
never carried on by gesture, for gesture is not the product of
cognition, but is an external expression of feeling strictly
analogous to an oath, and is very similar to if not quite a
reflex act. Communication may, however, be carried on by
pantomime, but this may also be destroyed in motor aphasia,
the condition constituting what is known as amimia. So that
the inference which the sentence quoted would give, ru'z., that
in motor aphasia communication of percepts and concepts can
still be made in some way, is a decidedly erroneous one. The
importance of this matter is brought home to one most em-
phatically if he be called upon to affirm or deny the testa-
mentary capacity of one with motor aphasia. And most
emphatically do we deny that an extreme degree of detnentia
is always present with mind blindness, in which apraxia, or
loss of the faculty to use things properly, is present. It
would be just as tenable to hold that there is necessarily de-
mentia in those cases in which the percept of words is lost.
Ne.xt to Dr. Fisher's article is one on the legal relations of
mental unsoundness by Mr. Becker, which naturally follows
on the discussion of insanity from the physician's point of
view. So far as we are capable of judging, this is a lucid ex-
posidon of what it purports to consider. The second part,
on criminal respon.sibility, has been done with the aid of Dr.
Fisher.
Mr. Goodwin Brown, who as State lunacy commissioner
has had opportunity to make himself familiar with the
custodianship of insane persons in the State, writes a most
useful and exhaustive article on the care of incompetent per-
sons and their estates. As a reference work for the prac-
tising physician, this contribution is invaluable. It not only
gives a careful consideration of the processes of inquisition
and supersedeas, and intructions as to committees and guar-
dians, management of estates, etc., but an exhaustive digest
and resume of the statutes of all the States. The latter must
be of great ser\-ice to ever)' examiner in lunacy, as well as to
physicians and lawv'ers generally.
The volume as a whole is abreast of its predecessors. In
some respects it is in advance. If the succeeding volume
maintains the standard of merit of those that have gone be-
fore it, we shall be able to say that at last we have a system of
medical jurisprudence worthy of highest commendation.
Directions for Work i.n the Histological La-
boratory. By Dr. G. Carl Huber, Assistant Pro-
fessor of Histology and Embr)ology in the University of
Michigan. Ann .■Xrbor: George Wahr, Publisher.
This little volume of 175 pages, half of which are left blank
for drawings, consists of twenty-five lessons more especiallv
arranged for classes in the Lfniversity of .Michigan. The
directions are explicit, sufficiently comprehensive, and the
little work fulfils what it purports to do. The lessons on
examination of the blood are least satisfactory.
Science Progress; A Monthly Review of Cur-
rent Scientific Investigation.
The February number of this magazine contains among
other contributions a highly interesting article on emancipation
from scientific materialism, by Professor Ostwald, of the
University of Leipzig, the continuation of a suggestive article
on the space relations of atoms, by Dr. A. Eiloart, formerly
of the New York Post-Graduate School, and a decidedly
valuable article on the suprarenal capsules, by Dr. Hallibur-
ton, professor of physiologv' in King's College, London.
This number maintains the commendable scientific standard
set by its editors.
Traits de Chirurgie Cerebrale. Par A. Broca.
Chirurgien des Hopitaux de Paris, Professeur Agrege a la
Faculte de Medecine, Membre de la Societe de Chirurgie, et
P. Maubrac, Ancien Prosecteur a la Faculte de Medecine
de Bordeaux.
Treatise on Cerebral Surgery. By Prof. A. Broca
and Dr. P. Maubrac.
The increasing interest in brain surgery is shown not only by
the numerous articles upon this subject which appear in the
medical journals, but also by the publication of monographs
and formal treatises, of which the present one is the latest.
Professor Broca has been known as one of the few surgeons
in France who has taken an active interest in this subject,
and the record of his operations in this book ninnbers thirty-
one. The work opens with a chapter on the anatomy of the
convolutions of the brain, which is followed by a chapter
upon the topography of the various functional areas as re-
I30
MEDICAL RECORD.
[July 25, 1896
lated to the skull. These chapters are very carefully pre-
pared, and give a risume of all the various methods pro-
posed for determining the relations between the surface of the
head and the convolutions of the brain. The third chapter
presents in clear form the facts of localization upon which are
based the diagnosis of local lesions, and this is followed by a
chapter upon the operative technique f.nd its dangers. The
authors seem to prefer the trephine to the chisel in opening
the skull.
The second part of the book is devoted to a study of the
various diseases in which operative interference is warranted.
These are taken up in the following order: the traumatic
lesions, primary and secondary; the intracranial complica-
tions of otitis media; meningitis; phlebitis of the sinuses and
abscess; intracranial tumors; hemorrhage and meningitis;
hydrocephalus, microcephalus; various functional troubles,
including epilepsy, psyclios?s, and headache ; encephalo-
cele. Each of these subjects is discussed with great care and
thoroughness, and all the facts at present accessible are put
clearly before the reader.
The book is to be especially commended for its full refer-
ences to modern literature, including both English and Ameri-
can authors, who are usually entirely neglected by the
French writers. The references alone demonstrate how
much more interest has been taken in cerebral surgery in
England and America than on the continent of Europe. It
is to be hoped that this work, like that of Chipault, will suc-
c-_ed in convincing our continental confreres of the utility of
this form of surgical interference. The standpoint of the
authors is not optimistic, and yet the propriety of surgical in-
terference in certain cases of brain disease is forcibly pre-
sented. The work can be highly commended, as it is a re-
liable presentation of the facts up to date.
A M.ANUALOF Medical Jurisprudf.xce and Toxicol-
ogy. By Henry C. Chapman, M.D. With 55 illus-
trations and 3 plates in colors. Philadelphia: \V. B.
Saunders. 1 896.
This little volume has reached a second edidon in three years.
With the e.xcepdon of a brief bibliography, the present edi-
tion is the same as the first. The contents of the volume
are divided into two parts, the first being devoted to medical
jurisprudence, the second to to.xicology. In the first part
the chapters devoted to the signs of death and the examina-
tion of blood stams are particularly lucid and helpful, consid-
ering the short space which the author has given himself for
their discussion. The chapters on rape, signs of pregnancy,
foeticide, and infandcide contain nothing new, they reflect
with accuracy the universal teachings on these subjects. The
chapter on feigned bodily disease, hypnotism, etc. , is incom-
plete and does not add materialiy to the knowledge of these
subjects. The two chapters devoted to toxicology are the
embodiment of discriminate and careful statement.
Syphilis in the Middle Ages and in Modern Times.
By Ur. F. Buret. Translated by Dr. A. H. Ohmann-
Dumesnil. Philadelphia: The K. A. Uavis Company.
1896.
This is the second part of Buret's well-known historical
■work. It consists of two Volumes, the first 'dealing with
syphi 's in the Middle Ages, the other with syphilis in modem
times. The first Chapters of Volume 1. are taken up with a
discussion of syphilis in Europe in the first fifteen centuries
of our era, while the last discusses the pretended American
origin of the syphilitic virus. Buret's pronounced views on
this question are too well known to need repetition ; a simple
examination of facts shows how fragile was the evidence on
which the supposition of the American origin of syphilis was
made. The little volume is well translated and is a handy
u'ork of reference.
Dame Fortune Smiled: The Doctor's .Siorv. By
Willis Barnes. Boston: .-Vrena Publishing Company.
J 896.
" Dame Fortune smilcil,
.\nd never did a dame smile more."
It may be a true story and it may have lia])pened to the au-
thor's hero, but such luck never came to any mortal doctor
before, nor will it come again.
Such a work is simply an irritation t ) a struggling practi-
tioner, thinking where his next small f;e is to come from.
( ierman medical students may be attracted ;o th.s coun-
try by the glowing, glittering accounts of the s ring of finan-
cial and other good fortunes which overtook this adventurer
abroad. May they bear their disappointments with the same
fortitude as >Ir. Barnes' hero displays in bearing his fortunes.
As a novel of absorbing interest, not much can be said in its
favor.
Clinical Lectures on Abdominal Surgery and
Other Subjects. By Charles T. Parkes, A.M.,
M.D., Late Professor of Surgery, Rush Medical College,
Surgeon to the Presbyterian Hospital, Surgeon in Charge
of St. Joseph's Hospital. Surgeon in Chief of Augustana
Hospital, Consulting Surgeon of the Hospital for Women
and Children, etc. Edited by Dr. A. J. OcHSNER. Chi-
cago : The W. T. Keener Company. 1 896.
These lectures have been prepared for publication and edited
by a former pupil and clinical assistant of the late Dr. Parkes.
They are reproduced from the stenographic notes taken dur-
ing the past few years ; the form of language in which the
original lectures were delivered being retained, thus lending an
especial force and charm to the work for all those who were
formerly students and friends of the author.
Chapter I. deals with abdominal tumors. Chapter II.,
gun-shot wounds of the stomach and of the small intestines,
including numerous experiments upon dogs, and gun-shot
wounds of the abdomen. Chapter III. is upon renal calcu-
lus and surgery of the kidney. Chapter I\'. includes tuber-
culosis, malignant growths, hernia, tumors, fractures, and
many other subjects of minor surgery.
The work is not systematized, nor does it have the finish
we might have expected had the author personally prepared
and supervised the .sheets for publication.
Some of the chapters contain matter which has already ap-
peared as contributions to scientific societies.
Deaf-Mutism. A Clinical and Pathological
Study. By James Kerr Love, M.D., Aural Surgeon
to the (ilasgow Royal Infirmar)-, Honorary Aurist to the
Glasgow Deaf and Dumb Institution. With Chapters on
the Education and Training of Deaf-Mutes, by W. H.
Addison, Principal of the Glasgow Deaf and Dumb In-
stitution. Pp. 369. Published by James MacLehose &
Sons. Glasgow. 1896.
The writer treats the subject exhaustively and scientifically.
He considers deaf-mutism in general, the character of deaf-
mutes, congenital and acquired deaf-mutism, the defects
and maladies of the ears. He takes issue with Hart-
mann and Toynbee in the matter of total deafness of deaf-
mutes. These writers found most of their patients totally
deaf, while he believes that total deafness is not common
among them. The chapter on congenital deafness, which
deals with its relation to heredity and consanguineous mar-
riages, claims the thoughtful attention of the reader. He
says that in calculating the chances of deafness in offspring the
family antecedents of both sides as well as of the father and
the mother should be considered. Much has been written
on the relation between consanguineous marriages and deaf-
mutism, and the author reviews the literature on this sub-
ject in an instructive manner.
He says that the study of census returns shows that there is
a steady stream of deaf-mutism, flowing through decade
after decade in spite of all efforts to check it. It should be
combated by all means which can prevent deafness follow-
ing disease, and by the discouraging of marriage between
those afflicted and those near akin.
The chapters on " Education of Deaf- .Mutes " will be of
special value to those whose work is in this direction.
Text-Book of General Pathology and Pathologi-
cal Anatomy. By Richard Thoma, Professor of
General Pathology and Pathological Anatomy in the Uni-
versity of Dorpat.' Translated by Alexander Bruce,
M.A.', .M.D.. F.R.C.P.E., F.R.C.S.E. Vol. I., with
436 illustrations. London : Adam and Charles Black.
1896.
This work, though entitled a text-book, is far from elemen-
tary. The physician as well as the student will read with
interest and profit the result of Professor Thoma's researches
in the ever widening domain of pathology-. The chapters
var\- in interest and importance, showing an inequality in the
presentation of various subjects. The chapter on infec-
July
1896]
MEDICAL RECORD.
i.'^i
tions and parasites, which includes the recent researches in
micro-organisms, is full and interesting and brings the sub-
ject up to date. The chapter on malformations, including
monstrosities and other embryonic deformities, is especially
elaborate and will be consulted as a valuable reference on
' that subject. The chapter on tumors is disappointing. The
copious illustrations are finely done and contribute markedly
to the success of the volume.
The translator is to be congratulated upon the thorough and
conscientious manner in which he has performed his difficult
task.
A Text-Book ok Bacteriology. By George M.
Sterxberg, M.D., LL.D., Surgeon-General, U. S.
Army ; Ex-President American Public Health .Association ;
Honorar)- Member of the Epidemiological Society of Lon-
don, of the Royal Academy of Medicine of Rome, of the
Academy of Medicine of Rio de Janeiro, of the Societe
Fran^aise d'Hygiene, etc., etc. Illustrated by Heliotype
and Chromo-Lithographic Plates and Two Hundred En-
gravings. New York: William A\'ood and Companv.
"1896.
Those who are acquainted with the author's "Manual of
Bacteriology-," published a few years ago, and which won for
itself at once the position of an acknowledged authoritv in
this comparatively recent science, need no description of the
present work. It is based upon the Manual, but is of smaller
proportions, the description of non-pathogenic bacteria and
the bibliography contained in the larger work being here
omitted in the endeavor to bring the book within the com-
pass of one suited to the needs of the general practitioner
and the student. But to one who has not seen the Manual
this description is most inadequate. In the first place a com-
parison of the two works shows that the later one is far from
being a simple condensation or a reprint of certain portions
of the former one. The science of bacteriology is constantly
progressing, but the author has kept abreast of it and has
embodied all the advances of the past three years in the
" Te.xt-Book, " which in this respect might be regarded as
supplementary to the " Manual."
The first part deals with classification, morphology-, and
general bacteriological technology-; in the second the general
biological characters of bacteria are considered; the third
section, occupying about half of the work, is devoted to a
description of the pathogenic bacteria; and in the fourth
part the saprophytes are briefly described. The book is
well written in the author's lucid and pleasing style, and the
illustrations leave nothing to be desired in point of execution
and of fulfilment of their object. Altogether the work is one
which cannot fail to become the standard text-book for
students of bacteriologv-, as well as an authoritative work of
reference for the practitioner.
Atlas of the Dlseases of the Skix. By H. Rad-
CLIKFE Crocker, M.D., F.R.C.P., Physician to the
Department for Diseases of the Skin, University College
Hospital, Formerly Physician to the East London Hos-
pital for Children, Examiner in Medicine at Apotheca-
ries' Hall, London. Edinburgh and London: Young J.
Pentland. New York : }ilacmillan & Co.
Fasciculus XV. of this series of plates, to which we have
on several occasions already referred, opens with a considera-
tion of that so prevalent, so interesting, and still so little un-
derstood condition — eczema. Four figures are given in the
first plate. Two are of eczema seborrhoicum ; neither is
remarkably typical ; one looking like lupus er)-thematosus,
the other like lupus vulgaris. Eczema verrucosum of the leg
is more characteristic, but not just the picture one sees in life
as these cases present themselves for treatment.
At first glance one would diagnosticate pityriasis rubra or
dermatitis exfoliativa from the picture to which the name
eczema squamosum is affixed. It is probably more instruc-
tive to include such a picture than one more commonplace,
in order to demonstrate how much care must be exercised in
distinguishing these conditions.
Hydroa is the next subject, to which four figures are like-
wise given, but Fig. 3 might have been omitted, as it is but
a slightly enlarged counterpart of the ear of Fig. 2, which
shows the sun effects in hydroa xstivale. The next plate is
one devoted to lupus vulgaris, showing the several forms,
scrofulosus, verrucosus, and papillomatosus. in a clear and
instructive manner. The hair and dress in Fig. i are painted
in so truly inartistic a manner that it would be preferable to
show the parts affected alone, as in Fig. 2.
Lupus erythematosus of the hands and nape of neck is il-
lustrated by some striking and rare examples. One instance
is familiar to .American readers of the Dermatological Asso-
ciation's Transactions, it having been described by the author
upon a recent \nsit to this countn,- and before the meeting of
the .Association. Figs. 3 and 4 bear a striking resemblance to
lichen planus. Chromidrosis, or seborrhoea nigricans, a ver)'
rare condition, is indicated by a drawing which shows a de-
posit of pign-ientcd sebum, or sweat, or both, upon the orbital
and cheek regions.
Acne rosacea and rhinoph)-ma form the subject of the
last plate, the latter being the better of the two figures.
Here again Fig. 3. a side view of Fig. 2, seems superfluous,
and the space might have been utilized for illustrating some
other condition. The letter-press is instructive, giving vafh-
able hints as to treatment in addition to a clear and concise
description of the cases themselves.
The Practice of Medicine. By William C. Goodxo,
.M.D., Professor of Practice of Medicine in the Hahne-
mann Medical College of Philadelphia, Physician to the
Hahnemann Hospital, etc. With Sections on Diseases of
the Nervous .System, by Cl.\rexce B.^rilett, ^Sl.D.,
Lecturer on Nervous and JMental Diseases in the Hahne-
mann Medical College of Philadelphia, Senior Neurologist
to the Hahnemann Hospital, etc. \'ol. II. Philadelphia;
Hahnemann Press. 1895.
-A. YEAR ago almost it was that we called attention to the
first volume of Dr. Goodno's work, pointing out the rather
broad manner in whidi, for a homoeopathic production, the
various subjects were treated. In \olume II., which treats
of diseases of the circulator)-, respirator)-, urinary, and diges-
tive systems, diseases of the blood, and constitutional and
parasitic diseases, the same conservative manner of \\riting
and the same breadth of thought is noted which caused one to
feel, in reading the first volume, that the border line which
separates the schools was being grazed. The therapeutical
side indicates that true homoeopathy is not considered the
only guide to the administration of remedies. Much atten-
tion is paid to hygienic rules, diet, bathing, and the use of
many of the newer drugs, especially in full dose. In readmg
this w-ork the old-school physician w ill not find much of that
which he is so apt to condemn in homoeopathic works, and
still the new-school man can scarcely find fault with any of
its teachings, since the indication for the remedies recom-
mended is usually set forth with distinctness. The value of
modern methods of research, the benefits arising from bac-
teriological investigations, the worth of laboraton- experi-
mentation are all duly appreciated by the wT^ters and have
added their influence to the making of a modem expose of
the homoeopathic practice of the day. The work seems in
every way creditable and commendable.
A Text-Book of the Pathogexic Bacteria, for Stu-
dents OF Medicine and Physicians. By Joseph
McFarland, .M.D. Philadelphia: W. B. Saunders.
1896.
Dividing his subject into several chapters, the author
gives a clear understanding of what a bacteriological work-
shop is — how to w-ork and what to find.
Part II. deals with specific diseases and their bacteria, and
these again are subdivided into, a. The Phlogistic Diseases,
fi. The Toxic Diseases. A very good elucidation of how to
cultivate any given specific organism, as, for example, that of
tuberculosis, leprosy, or glanders, or again the to.xic disease
germs like those of tetanus, diphtheria, cholera, pneumonia,
etc. , is carefully gi\-en.
Obstetric Accidents. Emergencies, and Oper.\-
noNS. By L. Ch. Boisliniere, .A..\L. M.D., LL.D.,
late Emeritus Professor, St. Louis Medical College.
Philadelphia: W. B. Saunders. 1896.
T HIS is a well-arranged work and treats of the usual and un-
usual physical complications and accidents of the puerperal
state. It is essentially a little treatise on emergencies, and
can be consulted and studied with great profit by -young and
old. The accidents of parturition are particularly well pre-
sented and will appeal to ever)- physician who is taught with
a perplexing case.
132
MEDICAL RECORD.
[Jul
1896
J^ociety ^ejjorts,
THE PRACTITIONERS' SOCIETY OF NEW
YORK.
Stated Meeting, Alay 13, i8g6.
.Andrew H. Smith, M.D., President, in the Chair.
Volvuluc Ten Days after Operation for Appendi-
citis.— Dr. Charles McBirney presented a boy elev-
en years of age, who had come under his care in the
hospital on the last day of February of this year, with
symptoms of appendicitis for forty-eight hours. The
pain and tenderness had been marked, but the temper-
ature was only 99° F. and the pulse 100. Still, the
tenderness extended over a wide area, and the general
look of the boy was that of one suffering from a grave
illness. The operation was done the same day, and
he found extensive lesion of tlie appendix, which was
perforated at two points and partly gangrenous. Two
concretions were found lying still in it. Pus and gen-
eral peritonitis were found in every part of the abdom-
inal cavity except the extreme left hypochondrium. At
least, the sponge thrust over to that side did not bring
out fluid. The whole cavity was washed out very gen-
erously with normal salt solution ; it was dried out, and
a large glass tube was put down into the pelvis, drain-
ing from that point and packing above. Everything
went along very satisfactorily, indeed, until ten days
after the operation, wlien the boy began to complain of
occasional and scattering pain in the abdomen. This
complaint was made with rather increasing frequency
for a week, when the symptoms became alarming.
There were continuous severe pain, vomiting, and im-
pending collapse. On the surface of the abdomen
dilatation of some coils of intestine could plainly be
made out, making it sure that there was bowel obstruc-
tion from some cause.
Dr. McBurney opened the abdomen a little to the
right of the median line, the .seat of greatest pain, on
March i6th. The intestines were free from adhesions
or signs of inflammation, and it was only after consid-
erable search that he found the cause of the obstruc-
tion and local distention, consisting of a coil of small
intestine held in a position half twisted upon itself by
adhesion of the omentum. It was very easy to pull
out the intestine, give it half a twist back, and then on
closing the wound the boy made a prompt and coii-
plete recovery.
The speaker thought that one of the most singular
features of these cases of general septic peritonitis
with lymph scattered over the entire abdomen, was the
fact that when they got well they did not have adhe-
sions, as one might expect, for when occasion arose to
open the abdomen again the adhesions were likely to
have all disappeared. To have an omental band form
of the kind found in this case was unusual..
Appendicitis ; Secondary Operation for Extensive
Adhesions. — Dr. McBurney presented a second pa-
tient, a boy, aged six years, who had entered the hos-
pital apparently with an attack of appsndicitis of three
days' duration, on February i ith. He was a very sick
boy, and was operated upon on the day of admission,
the incision being made in tka usual place. The only
peculiar feature found was that the tip of the appendix
was the portion which had suppurated, and it lay way
over, even to the left of the median line, and was very
difticult to find without making a hideously large inci-
sion. There was no general peritonitis, simply a lo-
calized though rather wide inflammatorv' process. For
two or three days after the operation the boy seemed
quite well, except that he occasionally complained of
sudden pain. Dr. McBurney watched him with some
anxiety, but after ten days thought it was a temporary
affair. On March loth the boy had continuous pain
and began to vomit. There was general tympanites.
An incision was made a little farther in than the old
one, and most extensive adhesions of the intestines
were found. These vi-ere finally all separated, and,
while he regarded the case as a most hazardous one,
the boy from that time had had no trouble.
Tuberculous Leprosy — Dr. F. P. Kinnicutt pre-
sented photographs of a case of tuberculous leprosy
in a man who had never been outside the United
States. He was born in New Orleans, came to New
York tv.enty-five years ago, and had not been more
than fifty miles away since. His occupation was that
of cook, and he had been employed in various restau-
rants in the city; nevertheless, his disease had not
been recognized until he presented himself at the lios-
pital, supposing he had some throat and rather un-
pleasant skin trouble. On entering the ward his ap-
pearance was so characteristic of leprosy that he was
soon turned over to the board of health and was sent to
North Brother Island. There was no peripheral neuritis
and there were no anaesthetic areas, which Dr. Kinnicutt
thought was rather unusual for a case of as long dura-
tion as this one would seem to be, judging by the le-
sions, although the man claimed that the symptoms
dated back only a year or eighteen months. There
were large ulcers on the tongue, ulcers of the pharynx,
of the epiglottis, of the larynx, tuberculous nodules
at many points on the upper extremities, particularly
the hands and certain parts of the arms, and on the
feet. There had been loss of toenails and necrotic
spots of the skin covering the toes. He was a lamen-
table sight.
Dr. Biggs asked where the man had received his in-
fection.
Dr. Kinnicutt said that was a most interesting
point. He believed authorities were agreed that the
usual source of infection was sexual connection with
a leper. The colony in Canada, the oldest one in
this country (forty or fifty years), was in charge of
Sisters of Mercv, none of whom had ever contracted
leprosy.
Electrode for Severing Ligatures in Vaginal
Hysterectomy. — Dr. Clement Cleveland showed
some small electrodes which he was in the habit of
placing in the loop of the ligature on the uterine and
otiier arteries in the operation of vaginal hysterec-
tomy. One electrode was placed on each ligature,
and after the lapse of the required number of hours,
when there was no longer danger from hemorrhage, the
current was passed and the ligature severed. He al-
w^ays ligated the arteries instead of using clamps, and
had given up catgut as unreliable, employing C hinese
braided silk. It was to meet the objection to silk,
that it did not come away soon enough, that he had de-
vised and used the electrodes. The portion of the
electrode tied into the ligature loop was fine platinum.
Tvo weeks ago he had removed as many as eight of
these electrodes, after severing the ligatures at the end
of thirt)'-six hours, in a single case of vaginal hyster-
ectomy for a fibroid of rather large size. There was
less likely to be sloughing of the stump than where
the ligatures were allowed to remain. The electrodes
were easily sterilized. Their use had never been at-
tended by hemorrhage. An objection to forceps in-
stead of ligatures was that they caused the patient a
great deal of distress by their weight.
Chronic Strychnine Poisonng. — Dr. Charles L.
Dana reported a case of chronic strychnine poisoning
producecl by a proprietary compound containing among
other ingredients tincture of nux vomica. The patient
was a woman who had begun taking the compound
about a year before for nervousness following an at-
tack of melancholia. The symptoms which he sup-
July 25, 1896]
MEDICAL RECORD.
133
posed might be attributed to chronic strychnine poi-
soning were stiffening of the legs and curling under
of the toes while walking, nervousness, and exagger-
ated reflexes. There were no objective symptoms
whatever. There was so great flexion of the toes that
at times she walked on the back of them. Dr. Dana
had thought that the symptoms might not be depend-
ent upon the medicine, but learned that when this was
left off the symptoms disappeared, although she did
not feel so well.
Dr. Peabody remarked that some persons were very
sensitive to strychnine. Some years ago a doctor had
related to him a case of strychnine poisoning from
taking homoeopathic granules of nux vomica.
Dr. Kinnicutt remarked that, on the other hand,
some patients bore large doses without apparent effects.
He had known house physicians in our hospitals to
rapidly increase the amount in weak heart of pneu-
monia, etc., to one-fifth and one-fourth of a grain in
twenty-four hours.
Dr. C. S. Bull had a patient who was taking half
a grain of strychnine a day, but she had begun with
doses of one-one-hundredth of a grain.
Dr. Dana said that at the meeting of the Associa-
tion of American Physicians last week he had de-
scribed a treatment of tic douloureux, which included
giving hypodermic injections of strychnine, running
the dose up within about eight days to one-fifth, some-
times one-fourth, of a grain. There had been no un-
toward results.
Dr. Pull mentioned the case of a man with atrophy
of the optic nerve who when he went away from the
hospital was to take tablets of strychnine three times
a day. He improved so rapidly that he decided on
his own responsibility to increase the dosage, expect-
ing to improve that much faster. One afternoon he
was led into the infirmary by two men, with every
muscle in his body in a quiver, including the muscles
of the face, of the extremities, and of the abdomen.
It was learned that he had been taking nearly one-
third of a grain of strychnine three times a day for
nearly a week. It was three to five days before his
symptoms subsided.
Dr. Kinnicutt said it had been his experience
that the physiological symptoms of strychnine sub-
sided quickly, say in twenty-four or forty-eight hours.
But he had not seen it given to the extent of produc-
ing such marked toxic effects. He asked Dr. Dana
what effect one-fifth of a grain had on tic.
Dr. Dana replied that the treatment had given the
best results of any which he had ever employed.
Sometimes it had stopped the tic for a year and a half,
sometimes for only six or ten months, when the course
of treatment had to be repeated. In these doses, one-
fifth of a grain hypodermically once a day, the strych-
nine had an anodyne effect, the patient going off into
a sort of stupor.
MEDICAL SOCIETY OF DELAWARE.
One Hiiniired aiiJ Sf7'cnf/i Annual Meeting, Held in
Ne7i.'ark, Tuesday, June g, i8g6.
The President, Dr. James T. Ma.ssey, occupied the
chair, and there were about fifty members present.
Dr. H. G. M. Kellock made the address of wel-
come and called the attention of those present to the
many important discoveries of medical interest during
the past year. He referred especially to the Roent-
gen ravs, and stated he hoped this would be but the
beginning of a practical svstem which would enable
us to view all the organs of the body.
Contagious Diseases of the Lower Animals and
Their Relation to the Human Family. — Dr. .A. T.
Xeai.e read a paper with this title. He referred to the
fact that under the revised code of the Delaware laws
the governor has the power to proclaim an epidemic
of disease among cattle, to kill live stock, and to take
every precaution to protect the lives and property of
the public, without doing anything to recompense the
individual loser. Continuing, Dr. Neale said, severe
as this legislation appears to be, it is in fact almost
inoperative, for the live-stock owner, recognizing that
the majority will pay no heed to the individual loser
and tliat quarantine will add materially to his loss,
quietly removes his dead from sight, and before he or
his neighbors are awake to the fact, sometimes has a
fully-established epidemic upon his own and upon the
adjoining farms. There should be amendment of the
present laws, giving permission to the governor to em-
ploy State funds in the purchase and use of protective
vaccines, whether they be those of anthrax, of rabies,
or of any similar disease — permission to use funds in
the interests of the individual, just as he is now em-
powered to use them in the employment of the sheriff'.
Dr. Black said he entirely agreed with Dr. Neale
as to what should be done in this matter. In his opin-
ion about twenty per cent, of milk cows are tuber-
culous, and he believed that many of the summer
complaints of children were due to this cause. He ad-
vocated the sterilization of milk and stated it should
always be brought to the boiling-point a second time.
Discussion on Malaria. — Dr. James H. V\'ilson
read a paper on "The Source and Cause of the Ir-
regular Form of Malaria." He thought that the term
malaria is synonymous with swamp or ague poison,
and that the intermittent and remittent forms of the
disease are due to the same cause, the difference in
type being generally supposed to be only a difference
in degree. Thayer and Hueston, in the course of their
studies, reached the conclusion that the tertian type of
fever depends on the presence in the blood of a para-
site that passes through its cycle of existence in
about forty-eight hours, and the segmentation of this
organism at intervals of about forty-eight hours is al-
ways associated with a febrile paroxysm. In regard to
the ffistivo-autumnal fever, the same authors conclude
that it is due to the organism described by Marchia-
fava and Celli, but that the cycle of existence of this
parasite has not yet been followed out in an entirely
satisfactory manner. The main seats of infection are
the spleen, bone marrow, and internal organs. In the
opinion of Dr. Wilson the mode of infection of irreg-
ular forms of malaria is doubtless identical with that
of the regular forms; that is to say, the method of
admission into the system is similar.
The typho-malaria referred to by Dr. Woodward
during the late rebellion was typhoid fever with ma-
larial complications and the clinical thermometer has
placed this affection where it properly belongs.
Dr. Judson Daland stated that while it was doubt-
less true that many ca.ses of malaria were acquired
through the drinking-water, yet unquestionably many
cases were acquired through the atmosphere. Out of
sixty or seventy cases studied by the speaker, eighty
per cent, were of the tertian variety and, therefore, the
few irregular cases could be easily explained. The
remittent fonn is unquestionably due to the same
cause as the intermittent.
In the opinion of the speaker many cases of malaria
were instances of double infection; that is to say, at
the time the malarial intoxication was acquired an-
other parasite, the amoeba coli, was also taken.
Dr. William C. Pierce, of Wilmington, read an-
other paper on malaria. He spoke of the geographi-
cal distribution of malaria in the I'nited States and
Europe. He referred to the effects of the soil in pro-
ducing malaria and stated that several species of the
Plasmodium may coexist and produce the most vary-
ing types of the disease. He then referred at some
134
MEDICAL RECORD.
[July 25, 1896
length to two cases of malaria which recurred many
years after they were supposed to have been cured,
and one case was especially interesting from the fact
that it recurred five days after the termination of
labor, the woman having had no symptoms of malaria
for some years previous.
Dr. C. M. Ellis referred to one fact which in his
opinion has been almost entirely overlooked by the
profession, and that is that the malarial poison passes
through cycles the same as many other diseases. He
gave a practical demonstration of this by mentioning
localities and periods of time of the recurrence of ma-
laria. He stated he had never seen a case of true re-
mittent malaria as described in the books during fifteen
years of practice.
Dr. Judson Daland, in discussing this paper,
referred to the comparatively few cases seen in Penn-
sylvania as compared with the number seen in Mary-
land and the surrounding country. Concerning the
question of malarial cycles, Dr. Alfred Stilie, of Phil-
adelphia, used to say that a similar condition existed
along the banks of the Schuylkill River years ago.
Dr. John B. Butler, of Newark, asked how one
would make a diagnosis between continued fever and
typhoid fever.
Dr. Vallaxdigham gave the details of an interest-
ing case of malaria which had come under his notice
some time since and which continued to recur imme-
diately the administration of quinine was stopped.
The patient was a man about fifty years of age, a
paper hanger, and presented the appearance of a case
of typhoid. The malaria was finally cured by the
continued administraton of large doses of quinine.
Dr. R. G. Ellegood stated that many years ago re-
mittent fever was quite prevalent and he had seen as
many as eight or ten persons suffering from this affec-
tion at the same time out of a family of fifteen. None
of these cases would present any typhoid symptoms
whatever, but would be typical cases of remittent ma-
laria.
Dr. R. B. Hopkins read a paper on the '" Treat-
ment of Malaria."
The author mentioned various remedies which he
found efficacious in the treatment of different forms of
malaria, and stated that in his opinion the reasons that
this disease is not so prevalent as it used to be are to
be found in atmospheric changes, improved condition
of the soil, better drainage, and better water supply.
Referring to the diagnosis of malaria. Dr. Daland
stated that the one pathognomonic sign of this disease
was the presence of the malarial parasite. In forty-
eight hours this parasite completely changes its ap-
pearance, during which time it will enter a red blood
cell, feed upon the contents of the cell, and increase in
size at the expense of the stroma of the red blood cell.
Nothing resembles this appearance in health or dis-
ease, and the diagnosis of malaria is complete as soon
as this parasite is discovered.
The speaker then passed around a number of photo-
graphs illustrating the process described and referred
to the theory which has been advanced that the rup-
ture and disintegration of the mature malarial body is
coincident with the occurrence of the chill.
Pernicious Anaemia. — Dr. Marshall reported a
case of pernicious ananiia in which the diagnosis was
difficult to determine between leukannia, Addison's
disease, and pernicious anaemia. The patient was a
bank teller, thirty-three years of age, who had a pulse
of 12 and a temperature of 102° F. when Dr. Marshall
was called to see him. The blood count at this time
showed I white to 235 red, the red then numbering
about 1,300,000. The diagnosis of pernicious anaimia
being thus confirmed, the patient was placed upon red
bone marrow and arsenic and in a few weeks the red
blood corpuscles numbered 2.500.000. Two weeks
later the count showed 3,500,000 and in another two
weeks 3,800,000. Three months thereafter the count
showed 4,400,000. The patient continued to improve
and was able to return to his duties.
Obstetrical Complications Dr. C. M. Ellis read
a paper with this title.
The author especially emphasized the great danger
of the convulsions of pregnancy before term and the
urgent necessity for artificial delivery when they occur.
His own experience included eight cases occurring in
the seventh, eighth, and ninth months of pregnancy,
and showed clearly that when a convulsion occurs be-
fore term, unless it is of systemic origin, the rule for
immediate delivery should be imperative, and without
regard to the presence or absence of uterine contrac-
tions or the condition of the os as to dilatation. The
earlier the convulsion begins, the greater the need of
emptying the uterus by the most expeditious methods,
all palliative medicinal treatment being secondary to
this one great object. This procedure is necessary be-
cause of the great fatality of eclampsia before term,
which is fully fifty per cent, of all cases. This high
death rate is greatly exceeded when the delivery is
not accomplished or if it is delayed until several con-
vulsions have occurred or until uterine contraction and
dilatations have supervened.
Dr. Ellis stated that he had never seen a death oc-
cur before delivery after the operation had been ini-
tiated and in his opinion there should be no delay in
evacuating the uterus after the first convulsion. The
earlier albumin appears in the urine the more immi-
nent is the danger of eclampsia, and if this accident
threatens it may be incumbent on the attendant to
hasten delivery without waiting for the actual convul-
sive seizure. In concluding his remarks the speaker
denounced the indiscriminate use of morphine hypo-
dermically in these cases.
Dr. Ellis stated that in bleeding hi.s patients he al-
ways took into consideration as of primary importance
the patient's physical condition.
Dr. George M. Boyd, of Philadelphia, entirely
agreed with Dr. Ellis and advised in addition, as
medicinal treatment, chloral by the rectum. In his
opinion the mortality depends to a great degree on the
extent of the kidney lesion, as in many cases of inter-
stitial nephritis existing before pregnancy eclampsia
develops during labor.
Dr. p. W. Tomlinsox, of Wilmington, mentioned
a case in point, in which twenty-four ounces of blood
were drawn and decided improvement followed. The
patient was delivered of an eight months' child twenty-
four hours after the operation and entirely recovered.
Cardiac Diseases as Encountered in Central Dela-
ware.— Dr. E. S. Dwight read the paper. He re-
ferred to the curious circumstance that frequently
commencing heart lesions were evidenth- due to the
absorption of some morbid product through the
abraded surface of the bladder. He believed that ul-
cerative endocarditis had been the cause of death in
one of his cases of eclampsia, in which the patient's
debility would not permit of bleeding. When ulcera-
tive endocarditis can be recognized before embolisms
have occurred, it is of paramount importance that the
patient should be kept in a recumbent position and
all movements avoided as much as possible.
A Pin in the Appendix.— Dr. H. J. Stvbbs, of
Wilmington, read a paper entitled "Three Cases of
Appendicitis, One of Unusual and Fatal Complica-
tion." He related the details of the three cases and
the remarkable fact about one w-as the presence of a
pin within the appendix. He strongly urged the im-
portance of early diagnosis and prompt medical and
surgical treatment of all cases of appendicitis.
Officers. — Dr. William P. Orr, of Lewes, Del., was
elected J'n-siileiit Dr. Willard Springer, of Wilming-
July 25. 1896]
MEDICAL RECORD.
135
ton, Vice-President; Dr. P. W. Tomlinson, of Wilming-
ton, Secretary, and Dr. William C. Pierce, of Wil-
mington, Treasurer for the ensuing year.
The societj' adjourned to meet in Rehoboth in
June, 1S97.
©Unical department.
A CASE OF HERJMAPHRODISM (?).
By carl beck, M.D.,
PROFESSOR OF SITRCERV, NEW YORK SCHOOL OF CLIMC.\L MEDICINE ; VISIT-
ING SURGEON TO ST. MARK's HOSPITAL, GERMAN POLIKLINIK. WEST
SIDE GERMAN DISPENSARY ; CONSULTING SURGEON H. S. G. S. ORPHAN
ASYLUM, ETC.
True hermaphrodism {Eoix^^ = Hermes = Mercur)-,
and ' AifiiuSi-r^ = Aphrodite = Venus), that is, the pres-
ence of both sexes in one individual, is still doubted,
though many apparent cases are reported. Undoubt-
edly there are varying degrees of hypospadias, while
rudimentar}- analogous organs of the other se.x coexist.
In view of the similarity of the male and female
sexual organs during the first two months of embryon-
ic life, it is readily comprehensible how a slight intra-
uterine disturbance may prevent union of the halves
of the uro-genital sinus, or how further development
of the tubular prolongation anteriorly may be inter-
fered with by the change of the external organs.
In some cases the sex can be differentiated only
with dititiculty. A hypospadiac showing cleft scro-
tum, a miniature penis, and retained testicles, resem-
bles a female so much that it may be baptized as a
female, and years later, to the great terror of the pa-
rents, its male character manifests itself by the de-
scensus testiculorum as well as by the development of
masculine inclinations.
Two weeks ago, through the kindness of Drs. Ferd.
C. Valentine and William S. Gottheil, a case of this
type was referred to me,
L, M , twenty-one years of age, born in the
State of New York, admitted to the surgical depart-
ment of St. Mark's Hospital, June 9th, 1896, gave the
following histor)': He was baptized as a girl, but a
few years later he was again baptized as a boy.
He had children's diseases, but never suffered from
;sf
Fk;. I.
any serious sickness until eighteen months ago, when
he acquired an ulcer on his rudimentary penis, which
he termed a hard chancre, and which healed under the
use of an antiseptic. He also claimed that several
weeks thereafter an eruption over the whole body fol-
lowed. One year ago the submaxillary glands on his
right side swelled to considerable size. They were
extirpated in a hospital of this city, where antispecific
treatment was also given. A few weeks ago he lost
his appetite, had chills, and gradually became weaker.
At the same time he noticed a hard mass below his
umbilicus, which at first was not painful, but troubled
him later.
When I first saw him this very poorly nourished indi-
vidual had a pulse of 124 and a temperature of 101.8°
F. He was apparently a man, had a beardless face, and
a feminine voice and form. Height, five feet eight
inches. Weight, eighty-six pounds. Mammae slightly
enlarged. The penis, two and one-third inches long,
was perfect so far as the glans and corpora cavernosa
were concerned, but the urethra was represented by a
mere depression. In the centre of this groove two
prominences, consisting of skin tissue, were present.
'■??»■
Fig. 2.
one about one inch distant from the glandular end of
the penis and the other one an inch farther downward.
They indicated where the penis was formerly attached
to the infundibulum below, whence it was dissected
one year ago (Figs, i and 2).
Instead of the scrotum there were two well-developed
labia majora of equal size. They contained no testes
and were not sensitive to the touch.
Beneath the arch of the pubis was a red-lined infun-
dibulum, which resembled an introitus vagina; most
markedly and which showed four orifices.
The largest orifice was at the lower end of the infun-
dibulum and permitted only of the introduction of a
metal sound (22 F.). On pressing my little finger
against this meatus, a thin semilunar membrane (rudi-
mentary hymen [?|) yielded. Now I could introduce
my middle finger easily into a canal, four inches in
length (undoubtedly the vagina), at the end of which
a well developed uterus could be felt. The rupture of
the membrane was followed by a slight hemorrhage.
On the upper edge of the infundibulum the orifice
of the urethra was plainly visible. On each margin of
the infundibulum, about one-half inch above its lower
end, was a small orifice, admitting only a very thin
probe for a distance of one-third inch. The patient
claimed that ejaculation of sperma took place through
these orifices. He maintained that since he was fifteen
years old he had connection with women at least three
times a week. He also claimed that he had erections,
his penis enlarging to double size then. Only three
or four drops, as he stated, were ejaculated at a time.
There was never any trace of menstruation.
The inguinal glands were slightly enlarged. The
abdomen showed nothing abnormal, except a slight
bulging above the symphysis. Upon palpation a
136
MEDICAL RECORD.
[July 25, 1896
mass, filling up the space between the right iliac fossa
and the umbilicus, was detected. This mass could not
l)e displaced, was painful on touch, and of an irregular,
nodular shape. At some points slight fluctuation could
be elicited. Aspiration of the tumor yielded blood.
Harpooning of the tumor tissue revealed round cells
under the microscope.
On June 13th I performed laparotomy at St. Mark's
Hospital. After the incision in the linea alba was
made, about one pint of a thin, serous, colorless fluid
escaped from the abdominal cavity. The tumor was
found tigiitly adherent to the peritoneum. On two
portions the peritoneal tissue had disappeared entirely,
hiG. 3.
and iiisiead of it a mass of the same structure as that
of the tumor, being of the size of a dove's egg, was
noticed on either portion. They were extirpated.
After the many adhesions to the intestine and to the
parietal peritoneum w ere separated the tumor could be
drawn outside of the abdominal cavity, and was recog-
nized as the right testicle, hanging to a thick pedicle,
which was found to be the cord. This, however, re-
sembled a tube much more closely in shape, and was
attached to the parietal peritoneum about one and one-
half inches laterally from the symphysis and about
one-half inch below the upper margin of the os pubis.
After the pedicle was tied and the tumor dissected
from it, another tumor of the same consistence and of
much smaller size was detected on the left side far
down in the pelvis. It was of the same renal-like
shape as its fellow, and was attached to the perito-
neum in the same manner, the pedicle being much
smaller. Its removal was undertaken in the same
manner. No adhesions were found (Figs. 3 and 4).
V.^
I. . J
Fig. 4-
Further inspection of the abdominal organs revealed
nothing abnormal, except the presence of a considera-
ble number of small, hard nodules, ranging from the
size of a head of a ])in to that of a pea, in the serosa
of that portion of the small intestine which had been
adherent to the right testicle.
There was considerable shock at the end of the ope-
ration, which fortunately could be done rapidly, but
by severing the adhesions considerable loss of blood
occurred. Nevertheless, the patient made a good re-
covery.
The larger one of the tumors weighs three pounds,
the smaller one eight ounces. The fibrous structure
of the larger tumor is interspersed with small cysts,
which contain a light yellowish fluid of a gelatinous
consistence. Microscopical examination showed it to
be a soft, round-celled sarcoma.
As soon as the patient's condition permits I shall
jDerform a plastic operation for the fonnation of a
penile urethra, according to Thiersch's method.
The patient was examined by Drs. H. J. Garrigues,
L. B. Bangs, J. G. W'allach, Irwin, Sprague, Dowling,
Johnston, Little, Schoeneberger, Cavanagh, and others.
TWO CASES OF DELIVERY AT FULL TERM
FOLLOWING CUL-DE-SAC OPERATION.S.
By HEN|.\MIN TORREXS, M.D.,
NEW VOKK.
In view of the important field opened up by the cul-
de-fac as an avenue for operative procedures in the
treatment of pelvic lesions, a report of the following
cases may be of interest, for they are, as far as I can
ascertain, the first two cases of pregnancy following
cul-de-sac operations for the treatment of adherent
retroposed uteri reported in this country.
These two patients, whom I attended during their
pregnancy and confinement, were operated on by Dr.
W. R. Pryor for adherent retroverted uteri by a new
method, described by him in the Medical Recorp,
July 20, 1895. Their histories aie briefly as follows:
C.ASE I. — Mrs. K , aged twenty-two, married
three years. Pelvic and general condition at the time
of marriage was normal. One month later she became
pregnant. At the eighth month she was delivered of a
fourteen-pound child. The woman was attended by a
midwife. Labor was difficult, lasting twenty hours;
the perineum was lacerated; the child was still-botn.
Infection evidently occurred, as the woman had an at-
tack of pelvic peritonitis, accompanied by fever, pelvic
pain, and severe hemorrhages, which continued for a
month, followed by profuse leucorrhcea, abdominal
pain, and backache.
Eight months later she again became pregnant, car-
ried the child three months, and miscarried. She
had another attack of pelvic peritonitis, and up to the
time of operation, two months later, suft'ered from con-
tinuous flooding and constant pelvic pain.
The cul-de-sac was opened and the adhesions be-
tween the uterus and pelvic floor were broken up.
Both tubes being occluded, their fimbriated extremities
were dilated, the ovaries and tubes were set free from
their adhesions and replaced, the uterus was curetted
and replaced; after which there was a cessation of all
the previous symptoms. The uterus remained in per-
fect position, and pregnancy took place four months
later. For the first six weeks of pregnancy there was
some slight gastric disturbance, after which time it
ceased. Throughout the remainder of her pregnancy
the digestive functions were normal, and there was at
no time the slightest attempt at abortion. The woman
came to full term and had a perfectly normal labor.
On May 21, 1896, at 8 p.m., true labor pains began.
On examination the cervix was small and soft. The
internal os admitted two fingers. Position of child,
vertex L. O. A. L'terine contractions were regular
and of good force. Duration of first stage, two
hours and forty minutes.
At 10:40 P.M. the cervix was fully dilated; the
membranes were ruptured, the patient had several
strong pains, the head descended rapidly and pre-
sented at the vulva. Flexion of the head was main-
tained by pressure through the rectum against the na-
sal eminence of the frontal bone, and the head was
July 25, 1896]
MEDICAL RECORD.
delivered during an inter\-al bet^veen the pains. Tiie
siioulders were rotated and delivered in the same way.
Duration of second stage, twenty minutes.
The third stage lasted fifteen minutes. The pla-
centa and membranes came away intact. The uterus
contracted firmly and hemorrhage was very slight.
Duration of labor, three hours and fifteen minutes.
The puerperium was normal, the uterus remained
firmly contracted, there were no after pains, the lochia
ceased on the si.xth day. The only complication was
a slightly caked breast, which was easily overcome by
hot stupes and massage. Lactation was normal and
the woman nursed her child. A rapid and perfect in-
volution took place, and the uterus when last examined
was in normal position.
Case II. — Mrs. G , aged twenty-seven, married
six years. Became pregnant one month after mar-
riage, went to full term, and was delivered of a healthy
child. After labor she had an attack of pelvic peri-
tonitis, accompanied by fever, Hooding, pelvic pain,
and tympanites. Two years later she was again preg-
nant and aborted at the seventh month. One year
later she became pregnant and again aborted at the
seventh month.
On April 21, 1895, the patient was operated on. In
addition to the same pelvic conditions as were found
in the previous case, namely, adherent retroverted
uterus and occlusion of both tubes, there was also
found a large cyst of the left ovary, which was punc-
tured, and the same method of treatment was adopted
for the other conditions. The operation was followed
by a complete relief of pelvic symptoms. The uterus
remained in perfect position and pregnancy occurred
about September 15, 1895, five months after the ope-
ration. During pregnancy there was absolutely no
gastric disturbance nor any attempt at abortion: the
woman, in fact, going somewhat beyond full term.
Labor pains began July 1, 1896, at 4 P.ir. On ex-
amination, the cervix, which had been large and hy-
pertrophied, was found somewhat softened : the inter-
nal OS admitted one finger. Position of the vertex, R.
O. A. The pains were of good force and regular, but
dilatation of cervix was slow, on account of its hyper-
trophied condition. Duration of first stage, twelve
hours.
After complete dilatation of the cervix was estab-
lished, the membranes were ruptured artificially, and
the second stage was completed in thirty minutes.
After waiting the customary fifteen minutes to allow
the uterus to contract, the placenta was expelled by
Crede''s method. Duration of labor, twelve hours
and fort\--five minutes.
The puerperium was normal and uncomplicated.
The uterus remained well contracted. The lochia
ceased on the seventh day. Involution is progressing
rapidly, but it is as yet too early to speak of the ulti-
mate position of the uterus after involution is com-
plete.
The special point of interest in the above cases was
the entire absence of any attempt at abortion in uteri
which had previously miscarried twice consecutively.
Though there was a perineal laceration in each case,
no plastic work had been done. In neither case did
the scar in the cul-de-sac give rise to any trouble, the
scar tissue having so completely disappeared as to be
undetected.
435 Pleasant A\-eni"e,
TREATMENT OF LARYNGEAL CROUP.
Bv A. LLEWKLLVX HALL, M.D.,
FAIK HAVEN, N. V.
Ix my experience I have found no remedy so thor-
oughly effectual for the relief of simple laryngeal
croup as quinina; sulphas. As a prophylactic for laryn-
geal spasm it has no therapeutic rival and in this
respect it is a blessing to every croup-afflicled house-
hold. I have repeatedly tested the efficacy of the
agent during the past fifteen years without noting a sin-
gle failure. I am aware that such sweeping statements
tend to incite disbelief rather than to inspire faith ; but if
the drug be given with due regard to appropriate dosage
and timely administration the success attending its use
will, I believe, amply demonstrate its value.
The following method of administration gives excel-
lent results : For a child from two to five years of age
the dose is from one-half to one grain given at inter-
vals of two to four hours. Usually the first three or
four doses should be administered at the shorter inter-
val mentioned and then uninterruptedly continued at
the longer interval for two or three days, or until the
disease is at an end. Frequently the first two or three
doses are rejected on account of the bitterness of the
remedy, but tolerance is quickly established and a
croupy child under gentle discipline readily learns to
take quinine without special repugnance.
Tliyroid in Lupus.— Malcolm Morris cites (Brit-
ish /iiiinidl of Dcrnuitology) a case of lupus of long
standing with extensive destruction of nose, cheeks,
and neck. By the use of thyroid, one to five tabloids
daily, the ulcers healed and the disease progressed sat-
isfactorily.
CHILDBIRTH WITH UNRUPTURED MEM-
BRANES.
By J. \V. KALES, M.D.,
FRANKLINVILLE, N. Y.
If unruptured membranes at birth are of such rare oc-
currence as the medical journals say they are, perhaps
the following is worthy of record.
Twelve years ago I was called to see Miss W ,
a strong, robust girl aged about sixteen. She was in
active labor and had been for some hours. Full nine
months had elapsed since the date of conception.
Vaginal examination showed that the whole vagina
was filled with protruding membranes, which ap-
peared stronger and thicker than usual. As labor
seemed to progress favorably and no indications for
interference with nature's process were apparent, I
concluded to await results. The natural labor pains
continued about one-half hour, when the foetus, com-
pletely enveloped in the unruptured membranes, was ex-
pelled. Absolutely no assistance had been rendered.
The labor at full term was in all respects normal. I
carefully e.xamined the membranes while intact.
They presented an ovoid about twelve inches long and
eight inches in diameter. The child could be plainly
seen through the translucent membranes. It was in
a state of complete repose, chin flexed upon the chest,
arms crossed upon the chest, legs flexed upon the
thighs, and thighs flexed upon the abdomen. Not
the slightest motion or sign of life was visible through
the membranes in the dim lamplight. The child
seemed to be of the same specific gravity as the am-
niotic fluid, for it floated in the centre of the fluid and
was retained by the funis, which resembled a slack
cable attached to a buo)'. Several blood-vessels were
seen ramifying over the membranes. The least touch
caused the m^ss to fluctuate like a closed bladder
nearly filled with water. Having completed the ex-
amination, I ruptured the membranes. .As soon as the
air struck the child it gasped once or twice and then
screamed. Further examination revealed a heallliy
male child weighing about eight pounds. I have in
my possession a specimen of a foetus enveloped in its
membranes which was expelled without external agency
during the third month. These are not uncommon.
138
MEDICAL RECORD.
[July 25, 1896
^Ixcrapeutic gtints.
Method of von Troltsch.^Take a portion — say a
tablespoonful — of the gargle in the mouth, hold it in
the back of the throat with the head thrown back;
then, closing the nose with the finger and thumb to
prevent entrance of air, open the mouth and make the
movements of swallowing without letting the liquid go
down the throat.
Summer Diarrhoea of Children. — Astringents
which were formerly so extensively used have very
properly been relegated to the waste dump as useless.
I. Summer diarrhoea is caused largely by improper
and unclean feeding, and is usually preventable. 2.
Bacteria play a very important part in its develop-
ment 3. Hot weather has to do only in an indirect
manner, as it promotes the growth and development of
bacteria in the food supply. 4. Treatment consists,
first, in eliminating all decomposing food from the
bowels by cathartics, lavage, and colonic irrigation.
5. Drugs judiciously administered are of great value,
but are secondary in importance to prevention and
management. — Dr. Rardin (Cincinnati Lancet-Clinic).
Excoriations in Children. — Dr. Pritchard pre-
scribes the following;
IJ Acid, salicyl gr. viij.
Bismuth, subnit 3 ij.
.'\myli 3 iss.
Ung. aq. ros;x^ 3 i.
Treatment of Phagedenic Soft Chancres. — Bathe
the affected parts for ten minutes several times daily
with water at a temperature of 105° F. The pus loses
its virulence at that temperature. The phagedaena
subsides and the general health improves. — Thera-
peutic Gazette, December, 1895.
Gall Stones.—
a, 01. terebinthinae HI v.
Syrupi acaciie 3 ss.
Sodii sulpho-carbolat gr. xx.
Spirit, aetheris conip HI xv.
Aqu.t menthje piperitte q.s. r i.
M. .S. To be taken twice or thrice daily.
Hot poultices should also be applied to the hepatic
area. — Therapeutic Gazette, January 16, 1896.
New Treatment for Tapeworm. — Dr. Newington
{Mcc/icat Times and Hospital Gazette, December 2 1 ,
1895) gave the following for another disorder and
found that the patient passed a dead tapeworm eleven
feet long, of whose presence he, as well as the physi-
cian, was ignorant:
I^ Potass, hydriodat gr. xxxvi.
lodi gr. xij.
Aqux 3 i.
Ten drops in water three times daily.
The same combination was then tried in three cases
in which the parasite was known to be present and in
each case it acted equally well. In still another
case, which had resisted all previous attempts, the pa-
tient passed a mass of dead tapeworm and for a year
had no return.
Ergot. — Dr. Franklin H. Martin (Journal of the
American Medical Association, March 21, 1896) says
the physiological action of ergot is accounted for by
its effect upon unstriped muscular fibre. It contracts
blood-vessels and hence increases blood tension. It
acts upon the uterus in four ways: i. It decreases the
bulk of the organ by producing a steady tonic contrac-
tion of all its muscular fibres. 2. It decreases the
whole bulk of the organ by decreasing the amount of
blood in its walls. 3. By decreasing the amount of
blood in the uterus it modifies materially its nutrition
and decreases the amount of the menstrual flow of
blood. 4. Given in large doses it produces tonic con-
tractions of the muscular fibres, and by instituting
clonic contraction of its fibres causes expulsion of
bodies from its walls and cavity.
lodoformed Vaseline in Bubo.— Rul Her (Arch.
Med. Afil.) writes that the idea of treating buboes in
this manner was inspired by the recommendation of
Laub to incise the swelling and inject nitrate of silver.
He employs a ten-per-cent. solution of iodoform in
vaseline melted by heat, which he injects after mak-
ing a small opening and evacuating the pus. Fail-
ure happens only when the skin is lacking in sufficient
vitality.
Thjnroid Gland in Severe Syphilis — The patient,
twenty-five years of age, had lost the ala; nasi and the
upper portion of one ear by ulceration, and the general
condition was very bad. The beginning dose was two
grams, increased to fourteen after a time, of the fresh
gland chopped up and eaten with bread, butter, and
salt. Every second day the treatment was interrupted
for twenty-four hours. After five days there was
marked improvement and a cure in five months. —
GouLADSE (Med. Mod., October 5. 1895.)
Psoriasis. — Iodide of potassium in gradually in-
creasing and large doses, or oleoresin copaiba, five
minims three times a day.
Digitalis Poultices for suppression of urine.
Endocarditis. — As soon as the heart .sounds in acute
articular rheumatism begin to grow muflled or a bruit
is detected, give, in addition to the salicylate, iodide
of potassium, 0.60 centigrams three times daily. Also
flying blisters over the apex and along the course of the
fourth, fifth, and sixth intercostal nerves. — Canton
Clin. Med.
Constipation Many aiTected wiih constipation do
not drink enough water, whether hot or cold. There
is not enough fluid in the body for the normal secre-
tions and eliminative fluids, a condition which should
be remedied.— Cutter.
Polymyositis Acuta Dr. Herrick (American Jour-
nal Med. Sciences) concludes as follows: i. There is a
definite disease primarily affecting many muscles of
the human body and described as polymyositis acuta,
pseudo-trichinosis, or dermato-myositis. 2. Inflamma-
tory swelling of muscles, exanthema, splenic tumor, ex-
tension to the muscles of deglutition and of respira-
tion, death, characterize the most typical cases. 3.
Atypical and milder cases indicate that either the dis-
ease may run a benign course or that in the absence
of definite means of diff^erential diagnosis forms etio-
logicallv dilTering are confused. 4. Trichinosis and
polyneuritis must always be excluded. 5. Syphilis
mav attack many muscles and, resembling acute poly-
myositis, must be excluded. 6. The etiology is still
unknown. 7. Three hypotheses can be advanced as
to its cause: (a) That it is due to a specific micro-
organism (vegetable parasite). (/') That it is due to
a chemical poison (toxin), (c) That it is due to an
animal parasite (gregarina). 8. In doubtful cases the
excised piece of muscle should be examined not alone
for trichinx- and bacteria, but, as well, by special
methods for protozoa. 9. Failure to find trichina; in
all areas showing inflammatory reaction, or even in
the majority of such areas, does not exclude trichi-
nosis as the primary cause of the myositis. Only re-
peated failure to find trichinae after thorough exami-
nation enables one positively to assert that the case is
not one of trichinosis. (Compare examination of spu-
July 25, 1896] MEDICAL
.turn or tissue for tubercle bacilli.) 10. Syphilitic my-
ositis occurs in three forms — the gummous, the diffuse,
the combined. 11. The diffuse syphilitic myositis is
usually a late manifestation of syphilis; appears with-
out definite e.xciting cause; affects no particular mus-
cle by preference; often involves more than one mus-
cle; may resemble acute polymyositis.
Gastralgia. —
I^ Kl. ext. cocae J i.
Syr. aurant. flor 3 v.
Aqua; 1 ij.
M. S. A teaspoonful every hour until relieved.
— D'Aniemie's Dominion Monthly.
Vaginitis —
If Pulv. aluminis,
Zinci sulphatis,
Sodii biboratis,
Acidi carbolici aa J i.
Aq Ivi.
M. S. A tablespoonful to a quart of lukewarm water as a
-vaginal injection twice daily.
— Vanderbilt Clinic.
Bronchitis. —
(.\cute.)
1} Syr. terebinthin.-e,
Syr. tolu aa loo (oz. 3^)
Sodii benzoat. ,
Aquae lauro-cerasi aa 8 (dr. 2)
M. S. Tablespoonful every four hours.
(Chronic.)
1} Ext. eucalypt : . 25 (dr. 6 V)
Ammon. muriat.
Ext. glycyrrh aa 10 (dr. 2J^)
Syr. tolu 100 (oz. 3^)
JI. S. One teaspoonful every two hours.
Medical World, March, 1896.
Hyperidrosis. —
R Balsam peru i gm.
Formic acid 5 gms.
Chloral hydrate 5 gms.
Alcohol 100 gms.
— L. Heusxer (American Medico-Surgical Bulletin).
Chronic Bronchitis with Asthmatical Condition. —
I? .Ammonium chloride 3 iij.
Huid extract grindelia.
Fluid extract quebracho,
Fluid extract lobelia aa 3 ss.
Comp licorice mixture 5 iss.
M. .S. The mixture is to be well shaken and a teaspoonful
.administered every three hours.
— Dr. Eshner (Philadelphia Polyclinic).
Hay Fever —
IJ Zinci valerianat gr. i.
Pil. asafoetidre co gr. ij.
Make pills No. i. S. Two or three times a day.
— McKenzie.
Dysmenorrhoea
If L'upri arseniatis gr. -^
Tinct. pulsatilUt ni xv.
Tinct. nucis vom ti^ viij.
Aq. dest 3 iiiss.
M. S. One teaspoonful every hour, or half-hour, until the
pain is relieved.
— Lancet.
Artificial Feeding of Infants
If Milk,
Cream aa 3 i.
Water,
Lime water aa 3 ij.
Malt sugar 3 ss.
— Hirst.
Syphilitic Affections of the Eye Galezowski
considers all severe syphilitic affections of the eve as
tertiary. Iodide of potassium is of little value; in-
unctions of mercury should be used.
RECORD. 139
Psoriasis. —
If Ichthyoli 3 i.
.\cidi salicylici 3 i.
Zinci o.xidi 3 ij.
Amyli 3 iv.
Petrolati 3 i.
M. S. Apply locally twice a day.
— ScHMiTZ (Medico-Surg. Bulletin).
Seasickness. — Dr. M. Charteris (Practitioner) thinks
that as a rule passengers commence their voyages un-
der conditions unfavorable to e.xemption from seasick-
ness. They eat heartily, and when the steamer gets
under way their stomachs rebel. The irritated gastric
state is communicated to the vomiting-centre in the
cerebellum, and when vomiting has ceased retching
begins. In a long voyage the diet for the first two
days should be spare and dry. A full meal should not
be eaten. Soups and pastries should be avoided. The
same injunction applies to short voyages. Diet,
though a very important prophylactic, will not guar-
antee e.xemption from seasickness. The following
means have been found successful: (1) A clearing out
of the prima via;, not by saline, but by a liver-acting
aperient, as calomel or blue pill, taken on the night
before embarkation. It should be followed in the
morning by a saline purgative, as citrate of magne-
sium. (2) When on board the steamer, if the passage
be by night, a full dose of the solution of chloral-
amide and bromide of potassium (chlorobrom) should
be taken and the passenger should retire. If the pas-
sage be by day a minimum dose should be taken and
the passenger should remain on deck. Only in rare
instances is a second dose necessary.
Supraorbital neuralgia and asthenopia are fre-
quently due to nasal irritation.
Chilblains. — In the intense form of chilblains with-
out ulceration the parts should be enveloped in aseptic
compresses wet with a decoction of walnut leaves,
using from one and a half drachms to one-half an
ounce of leaves to one quart of water. The whole
should be covered with an impermeable dressing.
.\fter the irritation has somewhat subsided apply the
ointment or powder:
If Boric acid gr. xv.
Tannic acid gr. v.
Vaseline 3 iiss.
M.
If Starch,
Lycopodium aa 3 iiss.
Tannic acid gr. v.
The decoction of walnut leaves may be applied morning
and night and during the day the ointment or powder
may be used, gloves being worn. When ulceration
exists the wound should be washed with a solution of
mercuric chloride, i to 1,000, and the compresses wet
with a solution of i to 2,000. The ulcerated part may
be touched with tincture of iodine or camphorated
naphthol, and then covered with aseptic gauze im-
pregnated with borated vaseline or glycerole of starch.
If granulations have formed, the stick of silver nitrate
may be applied. If these measures fail, ointment of
zinc oxide may be used. Cod-liver oil or iron iodide
may be administered if required. .■\s a prophylactic
those susceptible to chilblains should keep active when
exposed to cold and should avoid long exposure and
violent changes of temperature. A pill constituted as
follows may be taken internally from two to four
times daily:
If Quinine sulphate.
Ergot 55 gr. J
Powdered digitalis leaves gr. -^^
Extract of belladonna gr. j
— La Presse Mt'dicale, 1895, No. 70.
I40
MEDICAL RECORD.
[July 25, 1S96
OUR LONDOxNT LETTER.
(From our Special Correspondent.)
THE WELSH UNIVERSITY — PRI^XE OF WALES INSTALLED
AS CHAN'CELLOR — MIDDLESEX HOSPITAL CONVALES-
CENT HOME THE "queen's NURSES" RECEPTION
AT WINDSOR— LADY DUFFERIN's MEDICAL FUND —
PRIZES AT THE UNIVERSITY COLLEGE CIVIL RIGHTS
AND THE MEDICAL COUNCIL THE BOWMAN LEC-
TURE— PROFESSOR CURNOW THE LATE DR. CHOLME-
LEY.
LuNDON, July 3, j8g6.
I'his day a week the Prince and Princess of Wales
went to Aberjstwytli, wliere they were received with
the utmost enthusiasm by all classes of society. Mr.
and Mrs. Gladstone also went and their reception was
almost if not quite as enthusiastic. The event which
drew them to the principality was the installation of
ihe Prince as chancellor of the University of Wales,
an institution which promises to be of great value to
science as well as other academic faculties. The in-
auguration was celebrated with all the pomp and cir-
cumstance of the new seat of learning. As soon as
the Prince was installed and received the degree of
D.C.L., he proceeded to confer the honorary degrees,
the first recipient being the Princess, who was duly
made a doctor of music amidst what is described as
the wildest enthusiasm. The next recipient was Mr.
Gladstone, who was made LL.D., as also were Lords
Spenser and Herschell, the chancellors of the univer-
sities of Victoria and London. After the ceremony a
visit to the college was made and after that there was
a luncheon. Three toasts only were given — the
Queen, the Prince and Princess, and the university
and its colleges. The chancellor was proposed by
Mr. Gladstone in one of those felicitous speeches in
wliich the aged statesman so much excels. And the
reply of the Prince was equally happy in thanking the
proposer for coming to Aberystwyth at his advanced
age, and giving him the flattering opportunity of con-
ferring an academic distinction upon one who had
attained the highest position of a statesman as well as
a great reputation in literature and scholarship.
On Wednesday their Royal Highnesses the Duke
and Duchess of York opened a grand fete in aid of
the new convalescent home which has been estab-
lished in connection with the Middlesex Hospital at
Clacton-on-Sea. The Middlesex is one of the oldest
of the London hospitals, and, though now situated in
a densely crowded part of the metropolis, was built in
Marylebone Fields nearly one hundred and fifty years
ago.
Yesterday was a grand day for the " Queen's
nurses." About four hundred went to Windsor and
were received at the castle by Her Majesty. The
•'Queen's nurses" have all been trained and are in
connection with the Jubilee Institute which was
founded by the Queen and endowed with some ,^70,-
000, the amount raised as the "women's offering" on
the completion of the fiftieth year of Her Majesty's
reign. JBesides an array of royalties in attendance,
the council of the institute was present, including Sir
James Paget, who is a trustee of the fund. The nurses
were drawn up in a square open on one side and re-
ceived their sovereign with a low courtesy in unison.
The Queen then addressed them, saying: "I am very
much pleased to see my nurses here to-day and to
hear of the good work that they are doing, and I am
sure they will continue to do it." The nurses then
sang a verse of the national anthem and filed before
the royal carriage in pairs. Luncheon was provided
on arrival and tea later in the afternoon. The nurses
visited St. George's Chapel and the State apartments,
and returned to town to be further entertained in the
evening by the Duke of Westminster.
Another event yesterday was the opening of a gar-
den fete by the Marchioness of Dufterin on behalf of
the fund associated with her name for supplying
medical aid to the women of India. The treasurer
said that during the ten years that have passed since
Lady Dufferin began the work ^,'400,000 has been
given by native princes, seventy hospitals have been
established, and three millions of women medically
treated. In a grateful little speech Lady Dufferin
said the fund d2alt with a whole system of hospitals,
dispensaries, medical education, and nurse training,
and was destined to bring medical aid within the
reach of all women in the Indian Empire. It has al-
ready enlisted the support of all the creeds and all the
races in that vast empire.
Yet another function of yesterday may be named.
Sir J. Erichsen distributed the prizes in the faculties
of arts, science, and law at University College. Sir
John urged the claims of culture and science on this
somewhat " huckstering" age.
The Civil Rights Defence Committee is making a
good fight respecting the case of Dr. Anderson. They
appealed to the Medical Council to receive a deputa-
tion, but the executive committee did not ofl'er facili-
ties. The president, Sir R. Quain, has, therefore,
been addressed by the chairman, Mr. Timothy Holmes,
in a letter which sets out the case with great clear-
ness and shows why the council should take some part
in defending the rights of a registered practitioner.
The Apothecaries' Society has also been approached,
and it is hoped will assist in defending one of its
licentiates and perhaps obtain the co-operation of
other city guilds in the protection of chartered rights.
The Bowman lecture established by the Ophthalmo-
logical Society in memory of the late Sir William
Bowman was this year delivered by Professor Snelling,
of Utrecht. After an eloquent tribute to Bowman's
memory and a reference to the demands made by the
state on the ophthalmic surgeons of the present day,
the learned professor described the results of some of
his own investigations on vision and retinal percep-
tion. He pointed out that the act of vision is not
confined to the perception of stationary retinal images,
as the mo\^ements of the eye bring every part of the
image over the centre of the fovea. He had investi-
gated the dependence of acuteness of vision on the
amount of illumination. When this reaches a certain
degree of intensity the unprotected eye is not con-
scious of a further increase of luminosity. The acute-
ness of binocular vision is higher than monocular
with every degree of illumination, but not to the ex-
tent some have stated, as equalling double the light.
In the new hospital at Utrecht special arrangements
have been made for lighting the operating-room. As
visual power is heightened by adaptation of the eye
for a weaker light than that on the observed object,
the walls, ceiling, and floor have been painted black,
light being admitted only through a window directly
on the patient, so that the operator may employ the
maximum of his vision. This plan excludes also
troublesome reflexions from the cornea and the pa-
tient's gaze can be fixed in any direction by the flame
of a candle, which can be well seen against the dark
walls. The adaptation of the eye to light was the
ne,\t point. The sensibility of the retina changes
under the influences of light and darkness, the time
required for this corresponding with that of the forma-
tion and disappearance of the visual purple. Obser-
vations with a small screen and electric spark showed
that the moment the spark flashed out there appeared
on the screen a bright light rapidly increasing in in-
July 25, 1896]
MEDICAL RECORD.
141
tensity and then fading away in about the same time.
While increasing the light had the same color as the
screen, but while decreasing the opposite color. A
third phase followed, of much longer duration, when
the light was reddish-brown, and while this lasted
there was anaesthesia for objective light, such as that
given off by luminous paint. This third phase corre-
sponds with the after-images which arise by long-con-
tinued looking at a bright object and its projection
on a white surface. This succession of light and dark
in after-images is also seen on looking at a feeble
light in a darkened room when the light slowly fades
and disappears, but with die slightest movement of the
eye it reappears as the light then falls on a fresh part
of the retina; but if all movement of the eye be
avoided the light after disappearing returns slowly to
its former brightness, then again fades, so that a con-
tinual slow succession of light and darkness can be
observed. This is regarded as due to a reciprocal
effect of adjoining parts of the retina on each other,
through a modification of the visual substance which
undergoes an alternate assimilation and dissimila-
tion.
Several candidates have already declared themselves
for the vacancies in the Medical Council. Dr. Glover
will again come forward and will doubtless be re-
elected, so that two new members have to be chosen.
Professor Curnow, on retiring from the office of
dean of the Medical Faculty after thirteen years' ser-
vice, has been presented by his old pupils with a hand-
some testimonial.
Dr. William Cholmeley died on the i8th ult., aged
seventy-three. He was editor of the extinct Medical
Times and Gazette from 1873 to 1883, but his chief
work was at the Great Northern Central Hospital, of
which he was one of the founders and one of its most
ardent supporters for the last thirty-eight years, during
which time he enjoyed the respect and esteem of all
his colleagues. Last year the Ladies' Association of
the hospital endowed a bed, " In loving appreciation
of many years' devoted and unselfish labor rendered
by Dr. Cholmeley to the sick and suffering, both as
physician to the hospital, of which he was one of the
founders, and as honorary treasurer to the Ladies' As-
sociation."'
METHODS OF ESTIMATING THE HEIGHT
FROM PARTS OF THE SKELETON— A COR-
RECTION.
To THE Editor of the Medical Record.
Sir: A paper with the above title which I had previ-
ously read before the Association of Anatomists was
printed in the Medical Record of Septembers, 1894.
In looking it over to-day for a special purpose I found
a serious blunder that I feel it my duty to correct at
once, though it is sufiiciently evident to the careful
reader. In treating of cases in which certain parts
may be wanting, as for instance the pelvis, I gave a
method of estimating the height of the promontoiy
from the top of the great trochanter. I had previously
stated that from my observations the height of the
promontory above the symphysis is about 9.5 cm. in
man and 10.5 cm. in woman. I then continued: "I
find from measurements before dissection from one
hundred and eighteen male and thirty-seven female
white bodies, that in the males the trochanter is on
the average i.i cm. higher than the symphysis, and
3 mm. in females. Having in view the greater height
of the promontor}' above the symphysis in women, wc
may without serious error reckon that the promontory
is 10.5 cm. above the trochanter in either sex." It is
perfectly plain that if the symphysis and the promon-
tory are nearer in man, and if also the trochanter is
higher in relation to the j:ubes, the distance from the
trochanter to the promontory must be less in man than
in woman, the difference being on the average nearly
2 cm.
It is needless probably to add that such methods are
to be used with great discretion.
Tho.vias Dwight, M.D.
Harvard Medical School, July lo. 1S96,
35CUT Justinimcuts.
A FOLDING OPHTHALMOMETER.
By J. EDW.A.KD GILES, M.D.,
NEW YORK,
A DEFECT in the ophthalmometer of Javal is that in its
present form it is not portable and therefore cannot
easily be used away from the office. To remedy this
defect certain modifications of the Javal instrument
were designed by Dr. E. A. Chapman and myself, and
the mechanical execution of the work was carried out
by Messrs. Fox & Stendicke, of New York, some of
whose ideas are also embodied.
The instrument when set up appears like the Javal-
instrument in all points, except that the disc is cut out
below the telescope sufficiently to allow it to be raised
and lifted off by loosening a screw. The disc is cut
vertically and hinged so that it can be folded and
placed in the cover of the case, as shown in the en-
graving. The arc with the wires is removed by loos-
ening a thumbscrew ; the telescope is removed from
the standard by unscrewing, and the standard and
^^^_
headrest are each removed from the base by thumb-
screws. After being taken apart the whole, with the
arc and burners and reflectors, packs in a case the size
of a large dress-suit case.
This instrument is provided with a gas burner, with
the idea that it may have to be used where electric
lights are unavailable. The Welsbach burner may
be used, as this gives a light almost as good as the
electric light.
The instrument is somewhat heavy, but the weight
could be reduced by dispensing with the heavy disc
and substituting a black cloth upon a wire frame as a
background for the mires, and using a wooden base in
place of the heavy brass and iron base. This modifi-
cation of the instrument will be appreciated by those
who for any reason have to examine patients away from
the office, even though the occasion for such use may
not frequently occur.
105 East Twent%'-Second Street.
142
MEDICAL RECORD.
[July 25, 1896
NEW SNARES FOR POST-NASAL AND IN-
TRA-NASAL SURGICAL OPERATIONS.
By J. E. SCMADLE, M.D.,
ST. PAUL, MINN.
Fig. I is a snare designed for post-nasal operations,
and represents a modification of the Dr. Jonathan
Wright snare. The ratchet mechanism is practically
the same as in the Wright snare, but has much stronger
A NEW STONE SEARCHER.
i;v LUCIEN LOFTON, M.D.
ATLANTA, GA.
In presenting to the medical profession an instru-
ment which I consider to fill a long-felt want in
genito-urinary work, I would most respectfully ask
a careful trial in order to determine its practica-
bility, its simplicity, and its usefulness. As shown
by the cut, which has been kindly
furnished by Messrs. Tiemann &
Co., of New York, the searcher
can readily be attached to any
of the newer forms of stetho-
scopes. The searcher consists of
a hollow sound, having two eyes
or openings in the curve and an
outlet with plug near the handle,
a hollow corrugated metal handle
terminating in a solid screw re-
ceiving the Hard-rubber metal-
lined connecting piece, to the twO'
cappings (/ and s) to work the ratchet. In fact, the
whole instrument is much stronger and heavier, and
for this reason is adapted to snaring fibroids of the
naso-pharynx, for which purpose it has been devised.
Either No. 5 or No. 7 piano wire can be used with
this instrument. The wire fastener (d) consists of a
screw cap (t- , the articulating surface of which is
traversed by deep longitudinal grooves which fit into
counter grooves in the end of the shaft when the cap
is screwed down, the ends of the wire to be fastened
passing between and at right angles to these grooves.
The instrument is also armed with a tempered steel
lance (j) with a curved end. This runs through
bands on top of the wire carrier, for the purpose of
transfi.xing the growth if so desired, and is shot into
place by means of a thumb lever (;//), worked by the
same hand that is holding the snare. It has also a
windlass arrangement Q^) just in front of the wire fas-
tener, which is adapted to help out the ratchet and
facilitate either a fast or a slow snaring. After re-
peated trials and alterations the post-nasal curve, as
seen in the figure, was perfected.
This modification is also particularly adapted to the
removal of adenoid vegetations. There can be but
little doubt, in spite of
what has been written,
that the snare is much
more satisfactory in
these cases than the
curette or post-nasal
cutting forceps, when the lymphoid mass is of any size.
Fig. 2 represents a snare constructed for intranasal
work. The wire carrier is made a double cannula that
will carry the transfixion dart or wire in either cham-
ber, so that a right- or left-handed snaring can be
done with the same instrument. The wire carrier is
of a size that can be passed with ease, being but little
larger in calibre than an ordinary Eustachian catheter.
The wire fastener works on the same principle as the
one described above, only it is at the side rather than
the end of the tube. Ey means of the movable cannula
at the proximal end to which the wire is fa.stened, and
of the windlass, this snare adapts itself to slow or rapid
snaring.
Through the courtesy and skilful workmanship of
George Tiemann & Co., New York City, it was made
possible to bring the construction of these instruments
to the present degree of perfection.
branches of which the soft-rubber tubes of the stetho-
scope are attached.
Foreign bodies introduced into the bladder are-
liable to take on dead epithelium, mucus, and other
debris, and in consequence thereby become envel-
oped in a coat of material which is next to im-
possible to recognize from the mucosa by the old
method of sounding. This searcher is simple in its
construction and is sensitive to any impression made
upon it, be it in direct contact with or sliding over
a foreign body. The slightest metallic vibration,
whether shielded or not, will be transmitted with
unwavering evidence through the instrument. The
searcher will not transmit the blow made by striking
the lining membrane of the bladder during manipu-
lation.
-Should a foreign body be encountered in any
portion of the urethral tract, the motion made in
sliding the sound back and forth will give a distinct
metallic, scraping noise. It is therefore advised that
the searcher should be adjusted to the ears prior to
passing it into the urethra. It matters not how small
stones may be, or whether they lie in the urethral
a TiCMANM
Lofton's New Stone Searcher.
tract or in the bladder, contact with this searcher
will reveal at once their presence.
Strictures of a sufficient calibre to allow the sound
to pass will give a soft grating noise. It is a peculiar
vibration and will not be mistaken for the noise cau.sed
by contact with any true foreign substance.
Two sizes of the searcher are made — one for adults,
and one for infants and children, the same ear attach-
ment, however, answering for both.
Upon the same principle, with oesophageal bougies
penetrated by a steel wire with a metallic bulb at the
distal end and the ear attachment at the other fastened
with a screw head, the stomach may be searched for
foreign bodies. The bullet probe may be utilized
in a similar manner, the distinction being, as a rule,
easily made between bone and bullet.
July 25, 1896]
MEDICAL RECORD.
143
SAFETY ATTACHMKN'T FOR THERMOiME-
TERS.
By ORRIX C. ANDRE,
WAVERLV, O.
There is perhaps nothing more calculated to cause
the average physician to utter exclamations that would
be hardly proper under certain surroundings than to
have his clinical thermometer drop from his pocket with
the usual result. To obviate
this difficulty I would call your
attention to a little device
which has proven both conven-
ient and efficient. As shown
in the accompanying cut, it
consists of a piece of soft rub-
ber of good quality, with an
opening of the proper size to
admit the usual hard - rubber
thermometer case; attached to
one side is a small eyelet, by
which it may be either sewed
or fastened with a small safety
pin, just at the upper and in-
ner corner of the vest pocket.
After placing the thermometer in the pocket it requires
but a second to pull the loop over the top, where it is
secure until again needed. These " thermometer
safety attachments " are made by Messrs. George Tie-
mann & Co., New York.
l^etUcal Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending July 18, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-po.K
Cases.
Deaths.
176
106
20
4
38
6
3
•+
145
19
214
23
0
0
"SKIASCOPIC RACK.
Bv FRANK D. SKEEI., M.D.,
NEW YORK,
The rack here shown was designed to take the place
of a more e.xpensive apparatus. It is so constructed
that any lenses from the trial case may be inserted in
the clips, and a sliding clip is provided to carry an
additional lens for combinations. In use it is held
-<t-a
by the patient in front of the eye, the examiner di-
recting the patient to move it upward or downward as
the case may require. In this manner a very rapid
retinoscopic examination can be made.
This instrument was made for me by Messrs. Fox &
Stendicke, New York Cit}-.
14 East Twentv-Thikd Street,
Abscess of the Breast. — It is now known that ab-
scess of the breast is the result of an infection, gener-
ally through a fissure or abrasion of the nipple or
areola. The staphylococcus, especially the staphylo-
coccus aureus, is the most common agent. The vascu-
larity of the breast during lactation and the presence
of an animal fluid afford favorable conditions, and
any breach of the surface about the nipples gives the
microbe ready access. The infection is. through the
lymphatic channels. Dr. Shields {Lancet) alludes to
the possibility of organisms entering along the milk
ducts themselves. Organisms may enter the seba-
ceous glands of the skin and produce boils or pustules,
and as the breast is only a highly developed sebaceous
gland there is no reason why infection might not oc-
cur through the nipple and milk ducts. — Boston
Medical and Surgical Journal, June 11, 1896.
The Physiology and Function of Hair.— At a late
meeting of the Aledical Society of Vienna, writes the
correspondent of the Medical Press, Professor Exner
gave a lengthy review of the different opinions enter-
tained by historic authors on the growth of hair.
Many volumes had, he said, been written on this mo-
mentous subject, yet the function of this integumentary
structure is not to be found in one single text-book.
Schein, of this city, has advanced the idea of hair
being the outcome of stunted growth of the tissues and
that where activit}- abounds hair always disappears
on the surface. Within the last twenty years the sub-
ject has been much discussed in connection with the
presumed transformation of man from monkey. Cli-
mate and sunshine have been deduced by Darwin.
Even taste by selection has not been without its de-
votees in ascribing the cause of depilation to the hu-
man race, while Maurer has more recently assigned
hair to be the outcome of more sentient structures, as
testified to in fish and reptiles, in which Lairs connected
with sensitive papillae of nerve structure are found. In
animals higher in the scale we find the rudiments of
these appendages, which have become obsolete through
disuse. The hair appears yet on the head of the hu-
man foetus, which would show that the time was too
short for denuding the body, or
that it yet serves some useful
end. Exner is in favor of a
sensory function, which Mieses
has undertaken to demonstrate
histologically by the nerve
apparatus of the cilia, which
sensory connection Jaubert, of Paris, has confirmed as
a protection for the eye. The hair of the eyebrows, as
well as the fine hair over the whole body, acts in a sim-
ilar manner. The hair of the armpits and genitals is
evidently to prevent chafing as described by the Gre-
cian writers. The thick coat on animals of hair
or wool has an electrical property beside the cover-
ing it provides for inclement weather, the hair being
positive, while the fine wool is negative. Both are bad
conductors of heat, and thus moderate the heat of the
body by retaining the physiological product of com-
bustion, at the same time moderating the transmission
of cold or hot rays from the existing climate. The
ornamental function of Danvin was no unimportant
feature, as the beard of man and the long hair of wo-
man have still an adorning influence.
Sexual Hygiene. — From an article on this subject
by Dr. Thompson, published in the Alcdical Century,
June I, 1896, we take the following: " The tendency
of our time, particularly the prevalent contempt for re-
ligion, makes chastity more difficult for every one, and
the invert suffers far more from this than others. In-
stead of debasing the honorable invert by making him
run after prostitutes and subsequently become the un-
fortunate husband of a less fortunate wife, and the-
144
MEDICAL RECORD.
[July 25, 1896
father of children who suffer as much as he or more,
the attempt should be made to occupy and interest
him, to show him the horizons he can attain by dint
of will. If chastity were a virtue in better favor, I
should recommend it to physicians as a more effective
remedy than to send the invert to 'puella' to prepare
him for marriage and paternity. It would be better
not to increase the number of husbands and fathers
who are inverts or perverts. As for the invert who
wishes to marry in order to have children his desire
is almost criminal. If he marries for social conven-
ience, to reinstate himself or to please his family, he
should marry a woman older than himself, a woman
of the world, who understands everything and accepts
the situation. Those familiar with the confessions of
inverts, and a marvellous lot are correlated in the
works of Krafft-Ebing, will see that in the same ratio
as their se.xual feelings are distorted so is their concep-
tion of themselves, their surroundings, and everything
else in the world. The superior invert has no right
to think he is born out of his epoch or his country.
Even the orient to-day (where pederasty is practised
witliout difficulty) would not offer him the intellectual
pleasures to which he is accustomed, music, the thea-
tre, etc. He would see with a smile that most of the
new Greeks would have been considered too sickly or
too generally malformed to be reared by the Spartans.
He will see with more or less courage that the satis-
faction of the sexual appetite is not, and cannot be,
the sine qua iion of existence to a modern man. Too
long has the general practitioner given this subject
over into the hands of a few specialists who see almost
entirely the extreme cases, so that there is a great
dearth of literature relative to its development and
prophylaxis. To quote Nordau, specialists have failed
to understand their duty. It is time for them to come
to the front ; it is no doubt meritorious to indurate
sections of the spinal cord in chromic acid, and tint
them in neutrophylic solution, but this should not ex-
haust them. Neither is it sufficient that they should
give a few lectures to jurists, and publish observations
in technical journals. Let them speak to the masses
of cultured persons who are neither physicians nor
learned in law. Let them enlighten them in general
publications and accessible conferences, concernin'g
the leading facts in mental therapeutics. If civic au-
thorities deem it necessary to consult us with reference
to bodily hygiene and sanitation, should we not have
some jurisdiction over that more important and far-
reaching field, the sanitation of the mind.' Then the
baleful influences of the Ibsens, Zolas, and Rousseaus
mii^ht be curtailed. Then ' Heavenly Twins,' 'Jude
the^Obscure,' ' Trilby,' and the ' Woman Who Did ' will
cease to be the centre of a gushing, hysterical, psycho-
neuropathic circle and its followers, the faddists who
follow becau.se they have not tlie ability for indepen-
dent thought."
Light Cures Some one in one of the lower prov-
inces of Austria has evolved the idea that light is the
great health-giving and life-preserving agent, and that
all that is necessary to cure most diseases is to expose
the body to its action. He has accordingly founded
an establishment where this remedy can be applied
without contravening the rules of society. The insti-
tute is open during the summer months. There are two
large enclosures, divided by a high wall, so as to sep-
arate the sexes. The method involves the exposure of
the absolutely naked body to sunlight and air, irre-
spective of atmospheric vicissitudes. The patients
are enjoined to pass the greater part of the day in a
state of nudity, and little by little they are expected
to develop such a measure of resistance as will ena-
ble them to withstand all changes of temperature and
humidity. When the sun is high the patients lie
around on the Axy turf or on planks exposed to the
full force of the summer sun for periods \arying from
fifteen minutes to an hour. One effect of the expos-
ure is to provoke profuse perspiration, but in newcom-
ers more or less superficial inflammation of the skin
not infrequently follows. It is not only the sunlight
that is employed, for the treatment involves exposure
to rain and wind as well.
Observations on the Exhalation of Carbonic Acid
Prof. Ugolino Mosso, of Turin, has tested the breath-
ing of soldiers during an expedition up Monte Rosa,
and found that the quantity of carbonic acid exhaled
by a man at a height of twenty thousand feet or so
differs very slightly from what it is at the sea level or
near it. The professor has also subjected himself to
a rarefied atmosphere in the Physiological Institution
at Turin, and found that when the pressure in the air
was still thirty-four centimetres (about seven inches;
of mercury, he felt no inconvenience, but when it was
reduced to thirty centimetres (about six inches) he
felt a great want of breath, and became unfit to make
observations.
While Ike Medical Record is pleased to receive all new publi-
cations which may he sent to it, and an acknowledgment will be
promptly made of their receipt under this heading, it must he with
the distinct understanding that its necessities are such tluit it can-
not he considered under obligation to notice or review any publica-
tion received by it which in the Judgment of its editor will not be
of interest to its readers.
Elementary Anatomy and Surgery for Nirses. Bj-
AV. Mc.\dam Eccles. l2mo, 158 pages. Illustrated. The
Scie^itilic I'ress, London, England. Price, 2s. 6d.
Hemorrhoids and Other Xox-malignant Rectal Dis-
eases. By \V. P. Agnew, M.D. Third edition. 8vo, 214
pages. Illustrated. Pacific Press Publishing Company, San
Francisco, Cal.
Qiain's Elements of An.\tomy. Appendix. 8vo, 76
pages. Illustrated. Longmans, Green & Co., New York.
Price, $2.00.
How TO Feed Children: K Manial for Mothers,
Nurses, and Physicians. By Louise E. Hogan. i2mo, 236
pages. Illustrated. I. B. Lippincott Company, Philadelphia,
Pa.
A Manual OF Anato.my. By Iriing S. Haynes, M.D. 8vo,
6S0 pages. Illustrated. W. B. Saunders, Philadelphia, Pa.
Price, $2.50.
Physics for Students of Medicine. By .Mfred Daniell.
l2mo, 469 pages. Illustrated. Macmillan & Co., New York.
Price, $1.25.
The Three Ethical Codes. i2mo, 54 pages. The Il-
lustrated -Medical Journal Company, Detroit, Mich. Price, 50
cents.
The National Formulary of Unofficinal Prepara-
tions. Revised Edition. Svo, 195 pages. American Pharma-
ceutical Association.
Transactions of the Chicago Pathological Society.
From October, 1894, to November, 1895. Vol. I. i2mo, 2S0
pages.
The Fundus Oculi, with an Ophthalmoscopic Atlas.
4to, 228 pages. Illustrated. Macmillan & Co., New York.
A Text-Book of Bacteriology. By George M. Sternberg,
M.D. Svo, G93 pages. Illustrated. Wm. Wood & Co., New
York. Price, muslin, S5.50; leather, $6. 50.
The Diagnosis and Treatment of Diseases of the Rec-
tus. By William Allingham and Herbert W. Allingham.
Sixth edition. Svo, 485 pages. Illustrated. Wm. Wood & Co.
Price, $4.00.
Transactions of the Southern Surgical and Gyneco-
logical Association. Vol. VIII. Eighth session, 1875. Svo.
303 pages.
Proceedings of the .-Vmerican Medico-Psychological
Association. Fifty-first annual meeting. 1895. 8vo, 25S
pages.
Blind Leaders of the Blind. The Romance of a Blind
Lawyer. By Dr. James R. Cocke. 487 pages. Lee & Shep-
ard, Boston, Mass.
The Student's Medical Dictionary. By George M.
Gould, M.D. Tenth edition. Svo. 701 pages. P. Blakiston,
Son & Co., Philadelphia, Pa. Price, $3.25.
Medical Record
A I^Veekly yournal of Medicine and Surgery
Vol. 50, No. 5.
Whole No. 1343.
New York, August i,
1896.
$5.00 Per Annum.
Single Copies, loc.
(Dvifiiiual Articles.
USES OF THE STOMACH.'
By GEORGE D. BLEVTHING, .M.D.,
NEW YORK.
The influence of the stomach upon the history of
the world is incalculable. What military heroes and
explorers have accomplished must have been left un-
done if their fiery zeal and deeds of high emprise had
been quenched by dyspepsia.
Perhaps one person out of each five thousand human
beings has an intelligent idea of the fact of a stomach
and also puts it to its proper use.
Healthy mind in a healthy body must mean prima-
rily a stomach performing its functions of transforma-
tion and supply to the body — of sustenance — and this
excludes gastrectasis, auto-intoxication, changed mu-
cosa, diminished secretion of gastric juice, atrophied
or hypertrophied muscular coat — all of which are in-
imical to sustentation of body.
Unintelligent parents of high and low degree, some-
times of their own and sometimes by their medical
man's culpability, take the option of destroying the
health and comfort and maiming the powers of the
future manor woman; while in other cases the man
and woman with a stomach well used in early life take
the onus of destruction upon themselves.
The mother who will not suckle her infant has the
first opportunity of deciding if that individual stomach
shall be put to its normal use or if it shall be con-
demned to a series of experiments with concoctions.
The experimental uses are various, as our profession
has a habit of insistence upon its successive schemes,
each being as it is reached the ultimate, and no favor
is shown to the unfortunate who has not the last fash-
ion.
The seriousness with which we all take up contra-
dictions and agree to them suggests the successive
mimicries of children — as if we had said ''Let's play
school," or, " Let's play bears," and at once we are
hypnotized into the belief in our transformations.
The fashion rages for milk uncooked, milk cooked,
milk sterilized, milk pasteurized, milk modified, and
we don't laugh while we play the games, nor yet when
all are set aside for the manufacturing chemists' pro-
ducts, W'hich it were a weariness to the flesh to enumer-
ate.
Still through it all go on the unwearied laborers
who with patience have brought us to many verities,
which will be passed only as stepping stones in our
advance.
In 1875 Ewald's flexible tube, in 1883 (I think)
Oser's lavage and experimental meal were definite and
good — and, while permitting new discussions of the
diagnostic value of lactic and hydrochloric acids, fur-
nished improved implements for exploration. In the
use of the stomach we may consider what may be done
in our present state of knowledge to save the gastric
sinner from judgment to come. No doubt many a life
is signed away, as already intimated, by the misuse of
' Read before the Leno.x. Medical Society.
•the stomach in infancy. The child that should be
suckled is given as a substitute for the natural foun-
tain a bottle with a rubber nipple, and as much of as-
sorted bacteria as environment furnishes, together with
such chemicals as he can get by suction from the nip-
ple and more or less of a supply of the products of
milk degeneration not washed from the rubber nipple
and bottle after use. Then of the nutritive fluid itself :
we know that while many children exist through their
probation and seem indeed to thrive, many succumb or
are insured an after-life of indigestion, malnutrition,
and, as sequela;, anaemia, neura;mia, neurasthenia,
arthritis, or tuberculosis.
The viscus under discussion when in possession of
childhood advanced beyond dentition has, in addition
to mistakes of treatment by parents and nurses, the
abuse that its own carnal desires can confer. Among
children of the so-called working classes with few ex-
ceptions the choice is rarely of any diet but that which
the children elect. The mentor has no judgment to
exercise. In a large number of families who would
resent being classed with persons lacking judgment,
and who are of the plutocratic if not the aristocratic
circle, no more competent authority than a child's ap-
petite is recognized in choice of food.
Many a deserving doctor's revenue would be cur-
tailed by a reform. I recollect the late Dr. Agnew
asking me to sit down at his side at his Manhattan In-
firmary eye class years ago, and listen to the answers
given by the mothers of the children with different
forms of eye disorder — ulcers of the cornea, tarsal
and kindred disturbances of nutrition — when interro-
gated as to ■■ what do you feed the child?" The answer
was invariably: '"Oh, whatever is on the table." We
all have had the range of disorders of malnutrition to
treat of which perverted abuse of the stomach was the
ultimate cause. I remember an only son of a rich
family who had a most obstinate eczema, which I
found to yield readily to treatment when the nine-
year-old patient gave up coffee and his claret for din-
ner. When a certain class of parents aims to be logi-
cal in a child's feeding, they reason that the food fit
for a laboring man or the sumptuous fare of a gour-
mand is what the child needs to give him the muscle
of the one or the fat of the other.
When the child reaches the stage of bolting meals,
green apples, etc., he usually takes so much exercise
and gets such an amount of fresh air, that his condi-
tion is ameliorated up to the time when cigarettes
and cocktails come into the field.
In these days a boy of sixteen not fully con-
scious of his ability to direct his affairs better than
his parents could advise him to do is a milksop and
out of the count, and so there is taken up the abuse of
the stomach, as a settled plan of action. A hastily
bolted breakfast with coffee, a cigarette or two on the
way to school, pie or sandwich and beer for midday
meal, and anything bad that the fertile ingenuity of a
French, Irish, or African cook can produce for a seven
o'clock dinner, are the rule with the boy and very likely
the girl varies her menu only by taking her cigarette
in her bedroom.
We must agree that adults do not apply their matured
wisdom to produce for themselves a better use of stom-
146
MEDICAL RECORD.
[August I, 1896
ach. If any meal is fit for physiological uses in our
day, it is breakfast, at which we are more or less peni-
tential and prepared by last night's dinner for a simple
meal.
Fruits, a cereal, an egg or fish, and bread constitute
perhaps a typical American breakfast and should be
digested and discharged from the stomach in two and
a half hours, and a man or woman not exhausted by a
dinner that was almost a debauch eats it; but how
many patients say to us: "I never take anything at
breakfast but a cup of coffee'* ? Especially is this true
of women and young girls. I always order for such, ■
corset loosened and forced feeding — an egg beaten in
a glass of milk for breakfast until the victim will take
a chop in place of it.
The only purpose in reviewing all this is to present
as strongly as possible that as a rule we are engaged
one and all in ignoring the physiological uses of the
stomach and making it a receptacle for whatever tickles
the palate on the way. Hot, cold, sweet, acid, pep-
pery, oily, in varied succession shock the poor organ
into a state which the newly discovered Roentgen rays
may some time picture for us. Think of a man in
training for a contest in which physical well-being is
important, eating almost any of those pathological pre-
parations which a proper dinner menu holds forth.
Think of pickles, salads, sauces, pasties and pastries,
pate dc foie gras and ices, with a lot of wines and
liquor poured over, in a viscus lined with most delicate
secreting membrane and the illogical e.xpectation of
health, strength, and long life ensuing. The athlete
in training who indulged in our usual diet would be
mobbed by the men who had backed him for a match
of strength and endurance.
We have to do professionally with the state of stom-
ach that this misuse brings about, but of course we
have likewise to do w-ith its prevention. Prophylactics
is equally with therapeutics our province.
In the normal use of the stomach we have to obsene
albumin and starch from ingestion to dismissal thus:
Mastication breaks up the albuminous body for the
action of digestive ferment, pepsin. The more impor-
tant varieties are egg, plant albumin, fibrin, casein,
and these become propeptone and peptone. Interme-
diate are the albumoses, of which syntonin is conspicu-
ous as the product of neutralization.
If gastric juice containing pepsin and hydrochloric
acid be allowed to act on albumin these modifications
of albumin result^the more or less perfect result indi-
cating the intensity of the digestive processes. When
removed and tested by heat the stomach contents co-
agulate if albumin or syntonin be present, or both.
If not shown to be present by coagulation, we may find
peptone.
Boas says propeptone is absent in the digestion of
meat, and we do not know if it be a necessary^ prelimi-
nary to peptone, only it is a very frequent transforma-
tion product in digestion of albumin by pepsin and
hydrochloric acid.
The amount present in the digestion of a mixed diet
bears a relation to the energy of digestion. The strik-
ing feature of the pepsin and acid digestion of solid
albumin is the rapidity of liquefaction.
Starch digestion is accomplished rapidly in the
mouth largely by the salivary ferment ptyalin, and is
then continued in the stomach. This is checked in
acid Huids of course, the starch going through inter-
mediate forms, dextrose and maltose, but is continued
in the intestines.
Some portion of these prepared substances are ab-
sorbed by the stomach. That the organ has absorptive
powers Ewald shows by iodide-of-polassium test, iodine
showing in the saliva in ten or fifteen minutes if the
digestion and absorption are normal. Still the func-
tion of the stomach is not absorption, this being inci-
dental, and upon the muscular power of the stomach
to discharge its contents depends the continuance of
healthful digestion and of a normal stomach. Ac-
cumulation of food promotes fermentation, putrefac-
tion, and distention of the stomach. In turn a dis-
tended stomach becomes a hypertrophied stomach, or
its walls lose motility and the contents still further
accumulate and breed ptomains.
Bouchard names among poisons generated by decom-
position of food butyric, acetic, and lactic acids, leu-
cin, tyrosin, phenol, indol, skatol, etc., and Emile Boix
has written a work on the acid poisons in liver dys-
pepsia. These poisons are not to be confounded with
the ptomains and bacteria necessary to digestion.
Pasteur advanced the hypothesis that vitality depends
upon bacteria for its continuance, but did not refer to
the organic acids of fermentation.
Boix places the liver in charge of these poisonous
substances and considers the action of the liver cells
in their destruction as parallel to the action of white
blood corpuscles as phagocytes.
Hepatic congestion is caused by too large an influx
of the products of indigestion, alcohol being also
named among these chief — and Bouchard associates
tumefaction of the liver with gastrectasis or dilated
stomach.
Now it is stated by Bouchard and others that a
marked cause of hypertrophy and hardness of the
liver is the presence of these acids of fermentation.
Likewise Bouchard and Boix give arthrilism as a
hereditary precursor of sclerogenous liver. Of five of
his reported cases four had a history of arthritic he-
redity-.
Hares fed with bran saturated with food-fermenta-
tion acids developed hepatic cirrhosis. A hare fed for
two months with butyric acid died emaciated, and
post-mortem examination shewed cirrhosis. Acetic
acid gave still more marked results.
Likewise Boix's experiments with cultures of colon
bacillus and toxins resulted in sclerosis of portal
spaces.
Dr. Alexander Haig has made the most exhaustive
study of the excretion of uric acid and of its relation
to urea, and whether it establishes his theory of rheu-
matism and its uric-acid origin or not, the great number
of facts with their logical presentation is a work to
distinguish a scientist even in these clays of brilliant
developments.
The gentlemen of the Lenox may have espoused Ur.
Haig's uric-acid theory or the at present highly popu-
lar bacterial theory. I desire to be in harmony with
all parties, and believe the acid may in some way be
proven a ptomain or result of ba terial toxin. We
have Fraenkel as authority that some of the substances
recognized as bacterial products are chemical bodies
well known and exactly defined as to composition. I
confess to having no logic to present with my hypo-
thesis, but let it stand under that name. Haig proves
that uric acid bears always a definite relation to urea,
1-35, and when in excess of this proportion arterial
tension is increased and the discharge of urine di-
minished. In his experience sodium salicylate as-
sists in reducing that excess, and this accounts for its
efficacy in treatment of rheumatism. This has its
bearing upon stomach digestion, as acid urine bears
a relation to stomach disturbances and there is a con-
nection between the acid of the gastric juice and that
of the urine. The proportion should be lower after
taking food. Lavage or whatever reduces acid of
stomach reduces acid of urine. Ingestion of milk
raises acid of urine, by reason of lactic acid.
Haig has studied the variations of pulse tension
under different drugs, at different hours and different
pathological conditions, with sphygmograph and steth-
oscope, has recorded the curves of uric-acid excretion
August I, 1896]
MEDICAL
under .idniinistration of salic\- kites and other drugs
and has run a parallel between the excretion of uric-
acid and the exacerbations or remissions of rheuma-
tism; indeed his work in this direction has been so
thorough that nothing but admiration and gratitude
can be felt for his reports. He says: "If uric acid
really influences the circulation to the extent which
I have been led to believe it does, it follows that
uric acid really dominates the function of nutrition
and structure of the human body to an extent which
has not been dreamed of in our philosophy, and may
direct the development and life history of ever}' tissue."
This sounds very extravagant, and will much more
than cover the claim of Bouchard and Boix of an
arthritic diathesis, associated with a cirrhotic liver
and a stomach with impaired muscular motility, as a
chain of consecutive links.
Alcohol produces, according to the demonstrations
of Frerichs and others, the effect upon the liver that
the fermentation acids do. Haig declares the inges-
tion of meat to more than predispose by its digestive
products to a uric-acid diathesis and recommends for
safety a vegetable diet to all.
In my own practice it is my habit with dyspeptics
and also with victims of more serious stomach dis-
orders and habitually constipated subjects, to insist
upon the taking of two quarts of water free from putre-
factive matters daily, whether hot or cold depends
upon circumstances.
I have felt satisfied with the result of this regimen
in migraine of long standing and I rely upon pure
water as the chief remedy for dysenter}'. It seems to
me logical that a people who employ their stomachs
as catch-alls of substances capable of putrefaction, till
the stomach is distended, in a state of atony, and al-
most never empty because of loss of motility, must
need a flushing of the stomach and intestinal track
and a removal from the bowels as well of the breed-
ing-matter of bacilli and toxins, and this can be more
certainly effected in a semi-liquid state. Likewise,
if the cause of migraine, epilepsy, and arthritis is, as
Haig believes, uric acid, or if other products of fer-
mentation, lactic and acetic acid, cause irritation of
the stomach and liver, and a cirrhosis as readily as
does alcohol, it is better that the acids be well diluted
with w-ater, as in this condition they are better fitted
for excretion.
The examination of the abdomen by percussion gives
no outlines of the normal stomach, as all is covered by
the border of the ribs. Distended with water or gas,
the splash and clapote are inferior to percussion in
locating the organ, but tell if the viscus is empty.
The value of the experiments is in measuring the
motility of the organ, which is usually diminished in
ratio to its dilatation.
This function of motility is to the last degree essen-
tial to comfort and benefit to indigestion. The work
done in the stomach not being final, when this stage is
accomplished the power of propulsion should be equal
to sending the chyme through the pylorus to complete
metabolism and to give the stomach rest.
Dr. Van Pelt, of Boston, has reported some cases
followed out upon the line of Haig, making the
same analysis tests for urea, uric acid, and acidity,
together with observation of arterial tension.
As not all of these cases were frankly rheumatism,
it is to be supposed that Dr. Van Pelt agreed with
Haig upon the universality of effect of uric acid and
its consequent arterial disturbance, and followed the
cases with treatment to establish alkalinity of the
blood and thereby the solution and excretion of uric
acid.
The first reported case was of curious attacks in the
early part of the day, w hich began by a sense of pressure
at the top of the head, drowsiness, and a semi-conscious
RECORD. 147
state lasting three or four hours. Upon recovery the
eyelids were swollen, the face was ashen. Since the
attacks memory had failed, there was mental and
physical depression, nervousness, and insomnia. She
was troubled with acne. She had had malaria as a
child, but examination for plasmodium had no result.
Examination of urine showed:
Amount in cubic centimetres 1,000
Specific gravity 1.015
Acidity, in grains of hydrochloric acid 1.70
Urea, in grains 10
Uric acid, in grains .90
Relation between two latter, 1-21.
Sodium salicylate, twenty grains every four hours,
resulted in magical relief.
She had before slept only with large doses of trio-
nal. After twenty-four hours' treatment she slept
without a hypnotic and the urinalysis showed in that
time a drop in the relation of uric acid and urea to
1-16.
Although pinning my faith to the uric-acid theory, I
have but two cases to report in which I can vindicate
my belief.
The first is a case of neurasthenia which I have had
for twelve years under surveillance. When I first saw
the lady she came as a patient and her history was of
neurotic inheritance. Her grandfather was a distin-
guished architect, her father a literary man of over-
strung, emotional nature.
The daughter was of slender physique, poetical tem-
perament, and a writer by vocation. At this time she
was quite broken down with overwork. She suffered
always with headache and at irregular inter\'als with
exacerbations of blinding intensity, for a day with
sick stomach and then with a day of prostration. I
made an effort at the outset to put the patient in a
better state of stomach, but she was so sensitive to
criticism that a prohibitory diet resulted in her eating
nothing. In those days I was alarmed by this and let
her eat what she would, and though the quantit)' eaten
was not large, with restrictions removed it was of
most substantial diet, including meat three times a dav.
I next had the eyes examined by an oculist, who found
astigmatism and that the focus of two eyes differed in
distance. This was remedied by glasses and some
improvement of headache ensued, but I was com-
pelled to change habits, occupation, prescribe travel,
etc., and also ran the round of the whole pharmaco-
poeia, tr}'ing finally, with other things, Taylor's passive-
movement cure.
In the course of six years of attendance I had sym-
pathy and patience sorely tried. I had decided that
independently of the eye strain her general malaise
of neurasthenia often was called headache and that
the paro.xysms of intense pain had ceased.
Overfatigue, however, brought on severe ner\-ous
disturbance, sometimes upsetting the stomach. This
made it impossible for me to induce the patient to try
exercise, except in a martyr spirit of obediently walk-
ing to the stake, which insured a failure. Massage
she refused because it was repugnant, and the first es-
cape from this difficulty was by Taylor's mechanical
movement, to which she always went with streaming
eyes. In spite of this repugnance, however, the pa-
tient could sleep without hypnotics for the first time
with this treatment, and, having paved the way and
gradually led up during years of attendance, I arrived
at the subject of meat easing without causing shock
and accomplished a diminution to one meat meal
daily. I found by being called when later the crisis
of headaches and malaise recurred that, though she
was a person of the daintiest tastes and personal
habits, there was at this time an explosion, so to speak,
of bad-smelling sweat, with nervous hypersensitive-
ness, headache, and often vomiting. Of course in
148
MEDICAL RECORD.
[August I, 1896
ten years' attendance I had informed myself upon the
state of the kidneys and had found no organic dis-
order. The urine was at some times loaded with
I'l ■ :s, sometimes with phosphates, but never showed
a ■ >amin and casts.
I came two years ago to the conclusion that some
gradual accumulation blew off at these crises and that
uric acid might be the offense. Various alkalies
failed of anything but upsetting the stomach, when I
stumbled upon salicylate of sodium, with the idea of
there being a rheumatic element in the headache. To
my amazement, after two days the symptoms were
alleviated in every regard, so that the patient spoke
of feeling so light without the headache. General
improvement continued and the patient, while not of
course robust, can now do all that a woman of her
physique usually can, and we are discussing the pro-
priety of her appearance on a wheel.
I regret that my case makes so bad a showing be-
side the others noticed in which scientific data are
given. I reached my conclusion in a stumbling man-
ner, and my cure was empirical ; but 1 am in posses-
sion of the knowledge that it brought me and it veri-
fies to me more concrete work and theories and gives
encouragement for the future. Only a doctor with a
neurotic patient who sticks to him for twelve years
knows what the mental state is that follows such de-
nouement.
I have had cases of migraine which have not been
so complicated but have been troublesome, and they
have been improved or else the patients have got tired
of me and have gone to some one else, or settled down
to endurance. I have one patient, a business man of
thirty-five, who, though a stoutly-built muscular man,
has from childhood suffered periodical attacks of mi-
graine. I gave him two years ago the benefit of my
aqueous-solution treatment and reduced his meat
eating.
He has since had the attacks at longer intervals
and in a modified form. I did not see him for a num-
ber of months, until about three months ago, when he
returned from abroad. I found he so far believed in
the relief of the water drinking that he usually kept
up to near his two quarts, and I then ordered ten
grains of salicylate of sodium. Curiously, it gave him
a headache. Following Haig's advice for rheumatism,
I gave him iodide of potassium for a week and then
ret.:"ned to a double dose of the salicylate of sodium
(gr. XX., t. i. d.), and .so far he has had no migraine.
We come back to the stomach as the source of diffi-
culty: its misuse and its retaliation. Indeed, no old
•case of dilatation, atony, and retention of putrefactive
substances for hours in an almost never empty stomach
can be lived with at peace.
looS M.\DISON AvE.NL'E, May, 1896.
Management of Cases Immediately Following
Operations. — Sir Thornley Stoper {British Medical
Journal) writes as follows: "If I may reduce to for-
mulae the matters I have referred to, I would put them
thus: (i) That the tendency to prolong operations
must be carefully guarded against, as it is a grave
cause of danger. (2) That in the treatment of shock
and vomiting following operation we get no help from
the stomach, and must rely on the rectum as its sub-
stitute. (3) That heat, alcohol, and opiates are our
best remedies; and that the latter are well borne, and
must be intelligently used to their full effect. (4)
That drugs of the class ordinarily used to check vom-
iting are of little or no use in the cases under consid-
eration. (5) That ice does not relieve thirst, and does
barm by introducing water into the stomach and so
provoking vomiting."
THE CLINICAL HISTORY AND POST-MOR-
TEM APPEARANCE OF A CASE OF COR-
TICAL EMBOLUS (RED SOFTENING).
L!v H. A. TOMLIXSOX, M.D., Sci'Ekintexdent.
G. .\. CHILGREN", M.D., Assistant Superintendent,
ST. PETER STATE HOSPITAL, ST. PRTEK, MINN.
The following case is of especial interest because in
our e.xperience among the insane this is the first op-
portunity that has presented itself for the careful study
of the clinical features and post-mortem appearance
of a case of embolus with resulting thrombosis, in
which death has occurred sufficiently early to prevent
the obscuration of the distinctive degenerative changes
in the cortical cell by the products of general disinte-
gration.
We also think it worthy of note that the changes
shown verify Berkeley's statement that degeneration is
the same, no matter what the cause of it may be; be-
sides, this being a natural instead of an artificially
produced change, adds that much to the value of the
case as illustrating cell degeneration. Another and
perhaps the most important point illustrated by this
case is the apparent proof furnished that degeneration
in the cell really results from failure of nutrition, and
that the so-called cau.ses are practically only antece-
dents, having a common effect.
M. B , widow, natixe of Sweden, aged si.xty-five
years, was admitted to this hospital, July 31, 1895,
with the following history: Two weeks before she be-
came much depressed and complained of having a
headache continually. She said she could get nothing
to eat and was starving, and that she had committed a
great crime and had something on her mind that she
wished to tell. She always refused any food offered
her, and did not succeed in telling what she appar-
ently wished to.
She had a history of having been insane about
twenty years ago, and of always having had a violent
temper. No family history could be obtained. When
admitted her temperature was 100.2° F. ; pulse,
90, of fair volume and regular; respiration, 18 a min-
ute. She was well nourished and appeared to be
strong. Kxamination of the heart and lungs showed
nothing abnormal. Her urine had a specific gravity
of 1.039, ^^'^s acid, of a dark yellow color, and con-
tained two per cent, of sugar and some granular casts.
There was slight asymmetry of the face; the pupils
were equal in size, four millimetres, and reacted read-
ily to light but not to accommodation. There was no
evidence of paresis in the limbs. The knee jerk was
equal on the two sides and about normal. Clonus
was absent. There was marked coarse tremor of the
tongue, her speech was slow and indistinct, and she
appeared to have considerable difliculty in speaking.
During the first week she was very restless and at times
noisy, making various inarticulate sounds. She slept
poorly and generally was restless at night. A marked
intention tremor developed in the right upper and
lower e.xtremity. This was more marked in the up-
per extremity.
Second week: She is very stupid and is filthy in her
habits. She does not attempt to feed herself, but eats
fairly well when fed by the nurse. She is res*'ess and
often attempts to get up. She at times tries to bite
the nurses. The right arm and leg are in a partially
spastic condition, and she has but little control over
them. When up she tries to walk by holding on to
chairs, etc., but often falls.
Third week: The spastic condition of the right side
continues and there is marked involvement of the left
side, as shown by choreiform movements when motion
is attempted. The pupils are unequal in size, the left
being the larger. Both pupils react slighty to light.
Aufjust I, 1896]
MEDICAL RECORD.
149
Fourth week: She makes no effort to swallow when
fed by the nurse, and when fed by means of stomach
or nasal tube vomits immediately after the feeding.
She lies in a semi-stuporous condition, eyes closed,
mouth open, tongue dry, pulse regular, 80 beats per
minute. She perspires profusely. The extremities
are spastic. Convulsive movements occur. Some-
times they are general, and then again they are con-
fined to one limb or to one group of muscles. The
pupils are equal in size, three millimetres, and do not
react to light.
During the last three days of life the convulsive
movements gradually disappeared, respiration became
more labored, and the pulse weaker. The temperature
did not rise above 102.6° F., and the highest pulse rate
was 117.
Necropsy, made three hours after death: The skin
was uncolored except in dependent parts, and there
was no post-mortem staining. The head was well cov-
ered with light hair, not yet gray. The eyes were
blue, the pupils moderately dilated and equal. The
eyeballs were sunken and the lids fully closed over
them. The superior central incisor teeth were ex-
posed and protruded beyond the lips. The mammary
glands were not atrophied, the linea albicantiae numer-
ous, and there was a brown pigmentation of the skin
of the lower abdomen and of the iliac regions. Rigor
mortis was present.
The general nutrition of the body was good, with
large deposits of fat in the mammary region and in
the abdominal walls. Muscular development was fair
and the deposit of fat was not so pronounced in the
limbs. There was atrophy of the dorsal interosseous
muscles in both hands. There were areas of redness
over each buttock and an area of extravasation over
the upper and anterior portion, of the right thigh, irreg-
ularly circular and about five centimetres in diameter:
also extravasation showing finger marks on both arms.
The scalp externally was free from scars; internally
it was adherent, especially at the vertex, and there was
considerable deposit of fat.
The skull externally was free from scars, but there
was a shallow depression corresponding to the sagit-
tal suture. Internally the groove for the longitudinal
sinus was shallow and sigmoid in shape, but the
grooves for the vessels, even the most minute, were
quite deeply excavated. The external table was thick-
ened and .there was a marked development of the dip-
loe, especially in the frontal and occipital regions.
There were numerous small Pacchionian depressions
on either side of the median groove in the frontal and
parietal bones. The dura was roughened anteriorly
and adherent to the bone, shredding on removal, but
its internal surface was smooth. The thickness of the
membrane was increased, and its sinuses and vessels
were partially filled with fluid blood.
There were one hundred and twenty cubic centi-
metres of cerebro-spinal fluid.
The pia-arachnoid was not adherent, its vessels
were moderately injected, and, although there was no
opacity, the membrane was gelatinous in appearance
on its external surface, and there was deep staining in
the sulci, especially in the frontal and motor region.
Th; brain weighed twelve hundred and twenty-one
grams. At the base the blood-vessels were not thick-
ened or hardened, but there was a small aneurismal
distention at the bifurcation of the basilar artery. The
cranial nerves w-ere shrunken and tough. The island
of Reil was shrunken in both hemispheres, and the
convolutions surrounding it were retracted so that the
insular and gray matter in the bottom of the fissure of
Sylvius were exposed.
The corpus callosum was very short, and along its
superior surface, in the median line, ran a fibrous
cord, two millimetres in diameter, and apparently con-
tinuous with the pial covering of the corpus callosum.
Over the convexity the convolutions were shrunken
and the sulci gaped. The convolutions were simple in
character over the whole convexity, the simplicity
being most marked in the frontal and motor regions.
On the right side the pre- and post-central as well as
the Rolandic fissures were straight and well defined,
but the Rolandic did not reach to the median fissure.
On the left side the Rolandic fissure extended to the
median fissure, but the pre-central was not so well de-
fined, so that the ascending frontal and second frontal
convolutions were confluent. The cortex over the mo-
tor region, in the fissure of Sylvius, and in the ante-
rior portion of the parietal region on both sides was
pinkish-red in color, quite in contrast to the rest of
the brain. The substance of the centrum ovale was
pale and slightly shrunken, but the puncta were well
marked and dark blood oozed from them on section.
The corpus callosum was shrunken from before back-
ward, as was the fornix, and their substance was tough.
The fifth ventricle was almost obliterated.
The lateral ventricles were reduced in size, and
through the iter there was a membranous raphe, ap-
parently continuous with the ependyma of the third,
ventricle, one millimetre in height and the same in
thickness. There was no thickening or roughening of
the ependyma in any part of the ventricles aside from
this.
The gray substance of the cerebellum was pale and
softened. The dentate bodies were well defined, and
the white substance was not so shrunken as in the
cerebrum.
The anterior mediastinum contained fat in layers in
its lower portion; posteriorly the mediastinum was
normal. There was no fluid in the pleural cavities,,
nor were there any adhesions.
The left lung weighed four hundred and thirty-nine
grams, and there were slight adhes'ons between its
lobes at their roots. There was a small area of hypo-
static congestion in the external and superior portion
of the lower lobe, and a small nodule, partially calca-
reous and measuring two millimetres, in the same re-
gion. Otherwise the lung was crepitant throughout.
The right lung weighed five hundred and eighty
grams, and there were adhesions between its lobes,
most resistant between the middle and upper lobes.
In the superior portion of the lower lobe posteriorly"
there was an old fibrous scar, three centimetres wide,
nine centimetres long. In this fibrous mass the out-
line of the lobules was partially retained. There was
a considerable area of congestion in the apex, with
free exudation of fluid on section of the smaller bron-
chi. The rest of the lung was crepitant.
The heart weighed three hundred and ninety-si.x
grams, and its surface was thickly covered with fat,
especially over the right side. There were calcareous
crescents at the bases of two leaflets of the aortic
valve, and a nodule of similar material in the other
leaflet. The heart muscle was flabby, its cavities,
empty; the valves were competent.
The omentum was normal in length and position,
but contained considerable fat, especially in its lower
portion. The stomach showed no sign of disease, nor
did the intestines, except that the colon contained scy-
bala throughout its length.
The spleen weighed one hundred and thirteen grams.
Its capsule was free, and the pulp was soft and friable.
The liver wighed thirteen hundred and eighty-five
grams. Its capsule was adherent except over the left
lobe, and there was adhesion of the right lobe to the
peritoneum, posteriorly and superiorly, over a space
eight -centimetres in diameter. The lower border of
the liver reached only to the margin of the seventh rib
anteriorly. The substance of the right lobe was soft
and friable, this condition starting from the point of
I50
MEDICAL RECORD.
[August I, 1896
adhesion and spreading throughout almost the entire
lobe. The gall bladder was full, contained two stones,
each as large as a filbert, and its duct was patulous.
The right kidney weighed one hundred and forty-
two grams, and its capsule was free. The pyramids
were distorted; the substance of the kidney was soft
and hyperplastic. The left kidney weighed one hun-
dred and twenty-seven grams, and its physical charac-
teristics were the same as those of the right.
The uterus was enlarged and contained numerous
fibroid growths, both extra- and intra-mural, and they
varied in consistence from ordinary fibrous material to
calcareous formation. The uterus and adnexa weighed
one hundred and fifty-six grams. There was a small
haematoma on the surface of the left ovary, but the
right presented the ordinary appearance of senility.
There was no pelvic adhesion.
The bladder was small, partially relaxed, and con-
tained a small quantity of urine.
Microscopical examination of the brain, sections
stained by the Golgi method, shows the dendrons to
be tortuous in a majority of instances and the seat of
moniliform enlargement, but not interrupted ; the den-
drites show the same condition, and the gemmules have
disappeared. The bodies of the cells are partially
mencement of the degenerative process is well shown
in a fine horizontal dendrite.
Fig. 2 shows a neuron, the apex of whose dendron
has been lost through degeneration, and some of the
Fig. I,— Section of Cerebral Cortex Showing Moniliform Degeneration of
Dendra. X 250. Photomicrograph by Dr. W. C. Horden. U. S. Army
disintegrated and vacuolated; especially is this the
case with the pyramidal cells.
Sections stained by Nissl's method show a granular
degeneration of many cells, and the nuclei have a ten-
dency to color as well as the bodies of the cells, the
nucleoli being pale, enlarged, and irregular in outline,
or else entirely absent. A thrombotic condition of
the arteries and veins of the cortex existed throughout,
the blood-vessels appearing straightened and stiffened,
and obliterating the lymph sacs in some places. There
was no effusion in the lymph sacs. Many nerve cells
were vacuolated, the cell degeneration in some cases
consisting in a sort of sacculation of the nucleus,
which projected in the form of half a dozen expan-
sions, reaching nearly as far as the outer border of
the cells.
C.'ulturesfrom the brain cortex and from the cerebro-
spinal fluid gave Friinkel's pneumococcus.
Description of Microscopic Sections.— In Fig. i two
neurodendra are shown on slightly different levels, so
that the second is less well defined than the first;
they show several large moniliform swellings. Not
only the gemmulai but half of the dendrites have dis-
appeared; and on the right of the picture the com-
FlG. 2. — Seams of Liquefaction in Corpus of a Pyramidal Cell.
Photomicrograph by Dr. W. C. Borden, tJ. S. Army.
moniliform swellings of two of the dendrites is all that
is left of them ; but the afferent nerve fibres in the vi-
cinity are left almost intact. The corpus of the cell
shows two seams of liquefaction running almost verti-
cally through it, while the neuraxon is not markedly
affected.
In Fig. 3 the cell in Fig. 2 is reproduced on a
slightly different plane, and the tangential afferent
fibres near the top show head-like swellings which
exist in health, though possibly somewhat enlarged in
this case. On the left of the picture is shown a cell
corpus in which the degeneration took the form of
Fig. 3. — Granular Degeneration of Corpus of a Pyramidal Cell on the Left,
and Part of Fig. 2 on the Right. X 200. Photomicrograph by Dr. W.
C. Borden, U. S. Army,
granular masses, only about one-third of this cell tak-
ing the impregnation normally. The dendron is
denuded and there is slight moniliform degeneration
of the processes at the base.
August I, 1896]
MEDICAL RECORD.
i=;i
A faint but distinct view of the blood-vessels and
of the glia cells is given in the original photographs,
which were taken by Dr. \V. C. Borden, U. S. A., from
gold-stained sections (Golgi-Obregia) nride in the St.
Peter State Hospital pathological laboratory, from
the corte.\ of the motor area on the left side.
DISEASES OF THE TRACHEA, BRONCHI,
AND LUNGS, TREATED BY INTRATRA-
CHEAL INJECTION.
By JOSHUA LIXDLEV B.\RTON, M.D.,
NEW YORK,
ATTENDING PHYSICIAN TO THE DEPARTMENT OF OUT-DOOR POOR, BELLEVL'E
HOSPITAL ; PHYSICIAN TO THE LL'NG DEPARTMENT OF THE NEW YORK
THROAT AND NOSE HOSPITAL.
Standard authorities upon diseases of the nose and
throat make almost no allusion to the trachea, nor to
the frequency with which cough and changes in the
voice, for which the laryngologist is so often con-
sulted, originate in this organ.
The consensus of opinion seems to be that diseases
of the trachea should be classed with diseases of the
chest.
A study of the subject has, however, convinced me
that the diseases of the trachea present so many anal-
ogies and are so closely related to those of the larynx,
that the separation of tracheal fronV laryngeal diseases
is not altogether practicable.
On the other hand, the intimate connection between
the trachea and bronchi and the pulmonary paren-
chyma renders it difficult to separate them wholly from
diseases of the lungs. We are therefore forced to the
conclusion that the laryngologist should also be a
pneumologist and be an expert in diseases of the
whole respiratory tract.
The special physiology of the trachea was elabo-
rately studied by Mr. Nicaise in 1889, and a resume of
his work presented to the Paris Academy of Sciences.
He showed that " in the state of normal calm respira-
tion the trachea remains slightly contracted and does
not change its volume appreciably. The posterior ex-
tremities of the annular cartilages are almost in con-
tact and the membranous portion lies in a linear fold.
During strong respiration, in crying, groaning, sing-
ing, etc., the trachea is dilated and lengthened while
the larynx rises; in inspiration the trachea shortens
and contracts again."
There occurs therefore a rhythmical change in the
calibre of this tube, the exact degree of which can be
measured. The dilatation is in proportion to the
force of the expiration, and is greatest in the upper
part. The dilated trachea acts as an elastic tube,
compressing the contained air. By virtue of this
property it serves an important use in the production
of the voice, modifications of which may be caused by
pathological changes in this organ.
The tracheal nerves are derived from the great sym-
pathetic and from the pneumogastric and its recurrent
branches, filaments of which extend into the mucous
membrane of both the trachea and the bronchi.
Experimental, physiological investigation seems to
have definitely decided that cough may be produced
by direct irritation of either of these nerves or of their
branches, or of the mucus membrane supplied by them.
Clinical experience proves that the converse is also
true, viz. : That cough may be alleviated if not entirely
prevented by appropriate medication applied directly
to the irritated mucous surface.
To the late Dr. Horace Green, of this city, must he
awarded the honor of being the first to advocate intra-
tracheal medication.
In 183S he succeeded in passing a small sponge
saturated with a solution of nitrate of silver through
the glottis into the trachea. In 1840 he brought the
subject before the New York Medical and Surgical
Society, and reported fifteen cases of severe laryngeal
and bronchial diseases which had been cured by this
means. In October, 1854, he adopted the plan of
passing an elastic tube through the larynx into the
bronchi in a patient suffering with phthisis, and of in-
jecting from one and a half to two drachms of strong
nitrate-of-silver solution into the lungs. " This process
he repeated seven times in fifteen days, with the result
that the patient's cough and expectoration were greatly
diminished, she grew stronger, breathed with more
freedom, and increased in weight."
In Feburary, 1855, he read a paper on the subject
before the New York Academy of Medicine. His
statements were received with incredulity and by many
he was branded a charlatan and his practice a hum-
bug. The paper was referred to a special committee
of seven, who were to investigate Dr. Green's method
and report their conclusions to the academy. This
committee took six months to consider the subject
and then sent in a majority report unfavorable to Dr.
Green and a minority report fully sustaining him.
Through it all Dr. Green never lost his faith, but re-
iterated his belief that this practice was but the ini-
tiatory step to a plan of treatment that would ulti-
mately result in positive good to suffering humanity.
From October, 1S54, to February, 1856, he had treated
one hundred and six cases. Of these seventy-one were
classed as cases of tuberculosis. Of these tubercu-
losis cases thirty-two were considered as cases of ad-
vanced tuberculosis and thirty-nine as cases of early
tuberculosis. Of the cases of advanced tuberculosis
twenty-five were more or less improved, their lives
being apparently prolonged by this means of medica-
tion. Seven only were not improved by the injec-
tions.
Of the thirty-nine cases of incipient tuberculosis
twelve had apparently recovered at the time the report
was written and five more were nearly well. Of the
remaining twenty-two cases seventeen were greatly
improved, three were moderately benefited, and three
failed to receive any benefit whatever. Of the twenty-
eight cases of bronchitis sixteen were cured and all of
the others greatly benefited. In six cases of asthma
treated by this means, in all except one the disease
was entirely removed by the use of intrabronchial
injection.
December 22, 1859, four years after the reading of
his first paper upon this subject before the Academy
of Medicine, Dr. Green read a paper " On the Difficul-
ties and Advantages of Catheterism of the Air Pas-
sages " before the Medico - Chirurgical College, in
which he pointed out some of the errors of his early
practice and advised that for intrabronchial injection
milder solutions should be used. He further adds:
■■ Such has been the amount of success which has con-
tinued to attend this plan of treatment, that I am now-
ready to affirm, after an experience of man)' years in
a field of observation unusually large, that, if I were
required to relinquish all other known therapeutic
measures or topical medication, in the treatment of
thoracic diseases, I should choose the latter with hy-
gienic means alone, in preference to the entire class
of remedies ordinarily employed in the treatment
of these diseases. During tlie three or four years
since my report of one hundred and six cases, I have
treated large numbers of patients afflicted with chronic
laryngeal and bronchial diseases, with asthma, and
with tuberculosis, and the success which continues to
attend this practice has sened to increase greatly my
confidence in this measure as a therapeutic agent."'
In addition to the testimony of Dr. Green, eminent
152
MEDICAL RECORD.
[August I, 1896
medical authorities ' in France, Germany, and Great
Britain agreed that as a therapeutic means intrabron-
chial injection merited more serious atter.tion.
Dr. Green asserted that the patient should be prop-
erly prepared before intratracheal or intrabronchial
medication should be attempted, and with this end in
view he painted the pharynx, epiglottis, and larynx
with a strong solution of nitrate of silver for several
successive days or weeks, in order to numb the sensi-
bility of the mucous membrane before attempting to
introduce either the sponge or the tube.
There is little wonder that this method seemed too
heroic, or that many eminent physicians looked upon
it with disfavor, or that with the introduction of power-
ful spray apparatus it fell into disuse. It must be
conceded that the use of the spray, the nebulizer, and
the pulmonary inspirator, is productive under certain
conditions of good results, but it is impossible by
their use to project into either the trachea, bronchi,
or lungs a sufficient quantity of the medication to ma-
terially alleviate the cough, to soften the secretions,
or to protect the irritated mucous membrane.
A revival of intratracheal and of intrabronchial
injection in a modified form is therefore exceedingly
desirable, and this has been rendered possible by
laryngoscopy and the discovery of cocaine, facilitat-
ing as they do the easy insertion into the trachea of
the endolaryngeal tube, while the great advances
made in materia medica and therapeutics during the
last forty years have placed in our hands a large num-
ber of remedies well suited to the purpose.
Recent scientific research has fully confirmed the
observations of Dr. Green, and proved beyond a doubt
that substances injected into the trachea are not only
borne but are rapidly absorbed.
In the Medical Record of December i, 1883, it is
stated: "At a recent session of the French Associa-
tion for the Advancement of Sciences held in Rouen,
Dr. Bergeron presented a memoir on the subject of the
injection of medicated substances into the trachea, in
which he asserted that the injection of medicated
liquids into the respiratory passages below the larynx
was very well borne by cows, horses, and dogs.'' •
In the Medical Record of October 10, 1885, it is
stated that "some experiments made by Dr. Pernice
show that liquids injected to the trachea run down the
posterior surface and are thence evenly distributed
through all the bronchial twigs. They are absorbed
by the pulmonary veins or by the lymphatic vessels
and thus exert both a local and a systemic action.
When the animal was placed in the supine position,
with the head elevated a little, no cough was e.xcited
by the operation."
Dr. Pernice used in his experiments distilled water,
milk, and defibrinated blood. Absorption was com-
plete and no respiratory trouble of any sort resulted.
He also used solutions of tannin, borax, benzoate of so-
dium, quinine, morphine, nux vomica, and lime water.^
Kirke's "Physiology," page 380, ed. 1892, states:
" It is a remarkable fact that not only is the epithe-
lium of the pulmonary mucous membrane able to allow
the passage through it of gases and volatile sub-
stances, but that under certain conditions fluids such
as water may also be absorbed, and besides this the
presence of carbon particles in the bronchial glands
and alveoli in connection with the lungs must point
to the pulmonary epithelium as the only possible
channel of absorption."
Again quoting from the Medical Record of Feb-
' Bennett, of Edinburgh; Watson, of Glasgow: Gallon. Has-
tings, .\lison, andMackness, of London ; Trousseau, of Paris, and
the French .\cademv of Medicine ; Rokitanskv, of Vienna. B.
P., 125 ; B. P., vol.'52.
■ Lyon Medical. October 7, 1SS3.
^11 Movimento, No. 12, 1885.
ruary 8, 1896, Dr. C. G. Coakley, in a series of experi-
ments conducted at the Loomis Laboratory, made a
solution of India ink, filtered it, and then injected ten
cubic centimetres of the filtered solution into the
trachea of rabbits, and the animals were killed in
from fifteen minutes to two hours. It was found in
every case (whether fifteen minutes or two hours had
elapsed) that not a trace of the pigment could be
found in the trachea, bronchi, or alveoli, but all had
been absorbed. Fjccept where a few lymph cells had
ruptured there was no free pigment in the lymph chan-
nels, but was all contained within the lymph cells or
phagocytes, which were scattered through the lymph
channels of the lung, underneath the pleura, and in
bronchial glands.
Dr. Joseph Muir, of this city, who has perhaps had
the largest experience in recent years of any American
physician in this method of treatment, in a paper read
before the Medico-Surgical Society, January 6, 1896,
and since published in pamphlet form, claims that "A
process analogous to that of pneumo-koniosis is in-
duced. Substances are taken up by the lymphatics,
transported downward and inward to be deposited in
tissues more or less remote, even sometimes as far as
the thicker connective tissues of the lungs."
It follows therefore that if absorption of injected
liquids by the lymphatics of the tracheal, bronchial,
and pulmonary mucous membrane has been fully
demonstrated by competent observers who have also
added their testimony to the ease with which such
injections are borne, we are justified in resorting to
intratracheal and intrabronchial medication both as
a palliative and as a curative measure.
'l"he technique is simple. A syringe with an endo-
laryngeal tube, de\ised by Dr. Muir and manufactured
by Ermold, holding four drachms answers the pur-
pose perfectly. The larynx having been sprayed with
a two-per-cent. solution of cocaine, the patient is in-
structed to grasp the tongue with the right hand, to
draw it forward, at the same time throwing back the
head and opening the mouth as widely as possible.
The operator, with the laryngeal mirror in one hand
and the syringe in the other, then proceeds as though
he were about to make a laryngeal application. As
soon as the tube enters the cavity of the larynx the
epiglottis is pulled slightly forward, the patient is in-
structed to breathe, the cords separate, the lube enters
the trachea, and the syringe is emptied of its contents.
By pointing tlie instrument to either side the bulk of
the medication may be made to enter either the left or
the right bronchus.
If care is taken when inserting the tube to avoid
touching the glosso-epiglottic or the aryteno-epi-
glottic folds or the inter-arytenoid space, each one of
which seems to act as a cough centre, the irritation
caused by this procedure will be found to be surpris-
ingly slight. It is in fact so non-irritating that after
a little preliminary training the cocaine spray may be
discontinued.
The remedies employed should be soothing and the
vehicle non-irritating. For this purpose olive oil, cod-
liver oil, glycerin, mucilage, or any one of the petro-
leum oils may be used. Of the latter the one sold
under the name of benzoinol is probably the best. It
is tasteless, non-irritating, and is said to contain an
ounce of benzoin to the pint of oil. Solutions con-
taining benzoinol, europhen, and menthol, or benzo-
inol, guaiacol. and menthol, have proved veiy effica-
cious in my hands.
From one per cent, to two and one-half per cent, of
europhen and from one per cent, to fifteen per cent, of
menthol, or two per cent, of guaiacol in place of the
europhen, will be found to be quite strong enough.
The strength may, however, be increased or dimin-
ished to suit each individual case, or other remedies,
Aufjust I,
1896]
MEDICAL RECORD.
153
such as ichthyol, may be substituted. From one-half
a drachm to one drachm may be injected at each in-
sertion of the tube. And this may be repeated at one
sitting until from two to four drachms have been used.
This method of medication has many advantages,
viz. :
1. The remedy is applied directly to the irritated
mucous surface.
2. It immediately alleviates the most distressing
symptoms, adding at once to the comfort of the pa-
tient.
3. In a certain number of cases the antiseptic effect
of the medicine is very pronounced, as shown by the
longer internal between the febrile attacks and by
their lessened intensity when they do occur.
4. The tracheal and bronchial mucous membrane
rapidly absorbs the medication, so that we may expect
a general as well as a local effect.
5. We avoid disturbing the patient's stomach with
nauseating doses and the shattering of his nervous
system with opiates.
6. This method of alleviating the most distressing
and annoying symptoms does not interfere in the
slightest degree witli any other line of general treat-
ment which may be deemed advisable.
7. In cases characterized by an atrophic condition
of the tracheal mucous membrane or of pulmonary
disease with cavitation leading to retention and de-
composition of the secretions, intrabronchial injec-
tion will remove the disgusting fetor of the breath
consequent upon this condition.
I have treated during the past winter twenty-five
cases by intratracheal injection, including cases of
severe laryngo-tracheitis, bronchitis, and tuberculosis,
and one case of asthma.
The cases of laryngo-tracheitis and of bronchitis
were rapidly restored to health ; the case of asthma
was greatly improved, while every case of tuberculosis
has been markedly Ijenefited.
Report of Ten Cases — Fred. \V , aged thirty-
five, cabinet-maker. Ill since November, 1895. Began
to cough about December 15, 1895. Had lost twenty-
five pounds in weight. He presented himself at my
clinic at Bellevue Hospital, Out-door Poor Depart-
ment, January 31, i8g6. Marked anamia of larynx,
with great irritability of pharynx. Severe cough.
Expectoration profuse. E.xamination of chest showed
well-marked pulmonary disease. Gave intratracheal
injection of benzoinol, europhen, and menthol. The
alleviation of the cough was almost immediate. The
injections were repeated upon February 7th, loth,
14th, and 19th, when the patient reported that his
most distressing symptoms had been relieved, and
that he could eat and sleep and enjoy himself. And like
many another clinical patient he ceased his visits.
Charles J. M , aged forty-two, waiter. General
health good. Laryngo-tracheitis with bronchitis last-
ing four weeks. Had been under treatment for the
cough, which was severe, for nearly one month with no
relief. January 15, i8g6, I began to treat him by
intratracheal injection, using benzoinol, europhen, two
and one-half per cent., and menthol, seven and one-
half per cent. These were repeated five times in
seven days, when the patient reported that liis cough
was entirely well.
George M , baker, aged twenty-five. General
health good. Had had attacks of astiima every winter.
I saw this patient first February igth. He was suffer-
ing from an asthmatic attack of very great severity.
I gave him an intratracheal injection of benzoinol,
europhen, and menthol. The relief afforded was
marked. Within ten minutes he could breathe freely
and felt perfectly comfortable. This patient was
under treatment for about ten days and was greatly
improved.
February i6th, Mrs. R , aged forty-five. Had
la grippe about one year ago. Had not been well
since. She stated that she had night sweats, had lost
flesh, coughed a great deal, and expectorated freely.
An examination of the sputum showed the presence of
tubercle bacilli. This patient has been treated by in-
tratracheal injections, receiving them three times a
week: her appetite has improved, the night sweats
have ceased, the severity of the cough has been re-
lieved, and she has gained ten pounds in weight. She
is still under treatment.
George S , policeman, aged forty-five. Laryngo-
tracheitis with cough lasting four months. During all
of this time he was treated by sprays, inhalers, and
expectorant mixtures, with slight relief. February
15th I began to treat him by intratracheal injection.
He began to improve at once; the injections were re-
peated from three to four times a week for about three
weeks, with the result that the patient's health is fully
restored.
Thomas K , aged thirty-seven, janitor. Had la
grippe one year ago. Severe cough since July, 1895.
Had lost flesh. Expectoration profuse and tinged with
blood. Evening temperature 102" F., with copious
perspiration at night. Physical examination revealed
extensive pulmonary disease upon the right side, while
the microscope showed the presence of tubercle ba-
cilli. Notwithstanding the fact that this patient had
been constantly under treatment for months, and had
been three weeks in the hospital, his cough was with-
out exception of the most distressing and persistent
character. February 22d I began to treat him by
intratracheal injection: benzoinol, europhen, and
menthol were used. The relief was immediate. The
cough became soft and less persistent, expectoration
easy. The fetor of the breath disapijeared. The ap-
petite improved. The night sweats have ceased, and
the temperature in the evening is normal. This pa-
tient is still under treatment.
February 21st, Miss Mary W , aged twenty-one,
domestic. Atrophic rhinitis, with severe cough and
huskiness of the voice, lasting for weeks and resisting
the ordinary methods of treatment. Diagnosis, la-
ryngo-tracheitis. February 21st I treated her by intra-
tracheal injection. The relief was immediate, the
good effect of the first injection lasting for two days.
Three injections removed the symptoms of which this
patient complained.
Mrs. W , aged fifty-five. Subacute tracheitis
with feeling of tightness across the upper part of
chest. Voice hoarse and cough persistent. March
14th she received an intratracheal injection. The
relief in this case was simply magical. Within ten
minutes the hoarseness in her voice had disappeared.
The sense of constriction across the upper part of
chest had vanished, and the desire to cough was gone.
The injections were continued for one week and then
three times a week until the present time. Result,
tlie patient is practically well.
John W , aged twenty-eight. Has coughed for
one year. Has night sweats. Recently he has lost
in weight, at the rate of two pounds weekly. Cough
\ery persistent and severe. February 17th he received
an intratracheal injection and that night for the first
time in months he slept well. There has been a rapid
alleviation of all the most distressing symptoms in
this case. The patient is still under treatment.
John S , aged thirty-five, laborer. Bronchitis
with occasional attacks of asthma. Had taken ex-
lx;ctorant mixtures and cod-liver oil without benefit.
March ist he received his first intratracheal injection.
This treatment was continued several times a week
for three weeks, when the patient reported that he felt
like a new man. all of the symptoms of which he com-
plained having disappeared.
154
MEDICAL RECORD.
[August I, 1S96
THE KNIFE FOR COCCYGODVMA A FAIL-
URE.
Bv LUDWKj liREMER. M.D.,
ST LOIIS. MO.
As a deterrent example of meddlesome and noxious
surgery, I will briefly cite this case: A woman about
forty years of age slips on the pavement and lands
with no ver}- great violence on the buttocks. Barring
a nervous and excitable temperament, she has up to
the time of the accident enjoyed uninterrupted good
health, has healthy children, and is of a cheerful dis-
position. Immediately following the accident a pain-
ful sensation manifests itself at the end of the spine,
a coccygodynia has suddenly developed, which per-
sists to the present day, over three years after the
accident.
These three years have been a continued martyrdom
with the following phases, which may be said to be
typical of cases of this kind. In due course of time,
after having exhausted all kinds of local applications,
the pain becoming more severe as time wears on, she
consults a surgeon of repute, a professor in one of the
leading colleges of the country, who tells her that the
coccyx must be removed and that such an operation,
which is a comparatively simple one, cures the aflfec-
tion nine times out of ten. The operation is per-
formed by a local surgeon, with the result that the
pain becomes more intense than ever. In addition to
a sore and a sensitive coccyx there now exists an ir-
ritable and painful scar. A second operation is
advised; for it is claimed the first one has not been
thorough enough. Before submitting to this she
resolves to try electricity, which is recommended to
her as being very effectual in relieving such con-
ditions. The faradic current of medium strength is
used, one electrode being placed in the rectum, the
other over the sacrum. The result of this single ap-
plication is a cramping of the rectum, which is added
to the already existing pain and which has not left her
up to the present day. Stretching of the sphincter
ani, which is now resorted to by her physician, in-
stead of affording relief, increases the painful contrac-
tions. She becomes unfit for the discharge of her
domestic and social duties until her physician pre-
scribes morphine to be given by the rectum. From
this day on she knows that, to lead an existence which
can at least be tolerated, she has to resort to mor-
phine. Half a grain suffices to render her condition
tolerable. It enables her to follow without serious
inconvenience her customary pursuits. But her fam-
ily look upon her as a morphine fiend and she herself
smarts under the stigma and self-reproach on account
of the habit which, she is told, is worse than the liquor
addiction. This constitutes another factor in ren-
dering her existence miserable.
Consequently at the solicitations of her family and
friends she makes up her mind to enter a sanatorium
to cure her of the morphine habit. For three months
the withdrawal of the drug is tried systematically.
She becomes sleepless, loses weight and strength to
such an alarming degree that the attempt of weaning
her from the drug has to be abandoned. Neither
massage, hydrotherapy, electricity, nor the other de-
vices in vogue at sanatoriums have had the slightest
effect upon her. It takes another three months to re-
gain the strength she had on entering the institution.
Since then she has tried all sorts of doctors and
methods, has travelled extensively, sojourning at a
variety of health resorts and watering-places, all to no
purpose. In order to relieve an otherwise unbearable
existence she has to resort to the morphine in doses
of from one-quarter to one-half a grain a day.
On presenting herself to me for examination and
consultation, this patient has the appearance of a
healthy, well-preser\-ed matron, whose looks do not be-
tray the slightest trace of the Iliad of woes which she
relates in a graphic manner. Knowing by experience
with other cases that coccygodynia is almost always
one of tlie symptoms of hysteria, sometimes appar-
ently monosymptomatic, all the other manifestations
of the disease being overshadowed or rendered dor-
mant or insignificant by the overtowering dominance
of one — the excruciating pain, I make the preliminary
diagnosis of hysteria.
Of course I look for hysterical stigmata, but there
are none; above all, there is an absence of anjEsthesia
of any kind anywhere, nor is there the slightest indi-
cation of a history pointing to hysterical attacks.
This woman has been exceptionally healthy all her
life. But on close examination I find that travelling
and change of scenery lessen the pain, that at times
she is slightly aphasic, that there is a tendency to a
pulling back of the head, and that often she has "a
lump in the throat." I add to this that she is of a
gay temperament, and that in spite of the overwhelm-
ing pain she has at all times, but which is particu-
larly aggravating in the sitting posture, she does not
present the aspect of a sufferer after having sat in
my office for a number of hours, and I come to the con-
clusion that in the present case the coccygodynia is of
an hysteric nature.
The text-books on medicine, and those on neurology
in particular, describe the affection spoken of as being
neuralgic or rheumatic in character. Probably there
exist such cases, although among the dozen that dur-
ing the last twenty-five years have come under my ob-
ser\-ation not a single one was of such nature. They
were all symptomatic of hysteria, some of them ap-
parently but not in reality monosymptomatic. For
it is a striking fact that most women thus afllicted
positively declare that there is nothing else the matter
with them, though closer inquiry brings out the fact
that a number of minor complaints exist or have ex-
isted, which, however, are ignored or have been for-
gotten. Hysteria is noted for the tendency to oblivion
of ills that have passed.
In all cases of coccygodynia that I have seen, a his-
torj- could be elicited, if not of hysteria proper or
some allied neurosis in the ascendants, at all events
of the existence of the hysterical temperament. In
all of them an immediate or provoking cause, a pro-
voking agent (itgt'i't provoiatciir of Charcot-Guinon)
could be demonstrated. A trauma, severe and pro-
longed emotional and intellectual strain, infectious
diseases, convalescence, parturition and lactation,
chronic intoxication (alcoholism, saturnism, etc.) can
generally be shown to have exi.sted before or at the
time of the cropping out of the trouble. The case
briefly reported above is one of traumatic (monosymp-
tomatic) hysteria. The several therapeutic proced-
ures (insignificant in the healthy) acted like so many
distinct shocks and provoking agents. The adminis-
tration of the anasthetic (in some predisposed indi-
viduals this alone suffices to bring about hysteria,
transient or lasting) in conjunction with the wound,
and later on the irritation set up by the introduction
of the electrode into the rectum, sufficed to aggravate a
condition which, if left to itself, would probably have
remained within the bounds of toleration.
But it is just at this point where a fatal idiosyn-
crasy of hysteric patients plays such a baleful part.
If it is true that there is such a thing as the Juror
operandi among surgeons, it is equally true that there
is a class of women who actually itch for an opera-
tion, the bloodier the better. This is one phase of
hysteria. The desperate monotony of an excessively
painful and annoying affection engenders a craving for
something phenomenal. They look upon their suffer-
ing as unique in atrociousness and unexampled in
August 1, i8g6]
MEDICAL RECORD.
155
medicine, and nothing short of an extraordinary meas-
ure will, in their opinion, be of any avail. As a rule,
nothing short of an operation will satisfy them, and
generally they do not meet with any ditificulty in find-
ing a surgeon who is willing to operate. It is need-
less to add that he is convinced of the appropriateness
of surgical interference in cases of this kind, only he
is mistaken as to indication and disappointed as to
outcome.
The following case will furnisii additional proof of
this proposition and help to elucidate the subject more
fully.
A woman of about thirty-five, whose mother is still
living and is suffering from hysterical hemiplegia, and
whose father died of apoplexy at the age of thirty-
five, presents herself with this history: Up to about
two years ago she has been healthy. She always has
been of a hopeful, mercurial disposition. For a num-
ber of years she has nursed an invalid husband who
died with consumption. After his death she has
taught school and worked very hard. While thus
engaged in work with which she never has been fa-
miliar, a pain constantly increasing in severity grad-
ually develops at the sacrum and in the coccygeal
region. In due course of time she is operated upon.
The coccyx, which the surgeon says points inward to
an unusual degree, is excised. Then the trouble gets
worse. To the deep-seated pain a hypersensitive
cicatrix is added. A specialist for rectal diseases
now examines her to see whether any rectal trouble
exists that may account for the pain. Nothing is
found; but from the time of the examination an addi-
tional painful spastic condition of the rectum devel-
ops. There is also a drawing and gnawing sensation
in the skin over the hips. She is in a deplorable con-
dition, not only physically but mentally. The exacer-
bation of the pain affects in an indescribable manner
her mind, so she claims.
In this case there are also a tendency to retraction of
the head and an alleged impairment of memory, which
on closer examination proves to be partial aphasia.
She craves sympathy and thinks nobody understands
her case or has any idea of her sufferings. With any
and everybody she discusses her strange malady,
though she is a woman of tact and refinement. There
£.re no positive hysterical stigmata; only one side of
the body, the left, gets numb at times and is weaker
than the other side.
In this case there is well-established heredity,
which by grief, anxiety, and hard work is developed
into hysterical coccygodynia of a grave form.
The symptoms on which the diagnosis hysteria is
made in these cases may seem to some to be insuffi-
cient, but they are fully conclusive to the neurologist,
when properly grouped and interpreted in the light of
Charcot's teachings. What Charcot and his school
have not mentioned in their classic delineations of the
syndromes of hysteria are the spastic tendency of the
retractors of the head and a trace more or less notice-
able of aphasia. I consider them as stigmata of a
subtle character, the antesthesias being of a coarser
kind. They are very common in hysterical females
and sometimes the only obvious ones in a chaos of
indistinct and undefinable malaise.
To use a knife on such patients is a grave mistake.
To cut off a painful coccyx is as irrational as the re-
moval of the ovaries in hysterical ovarialgia. The
time will come when another generation of medical
men will look upon such operations as one of the
most remarkable aberrations of the science of medi-
cine. The trouble is in the brain, but not at the peri-
phery, neither bone nor skin. It is projected from the
centre to the periphery, as an irritation of the ulnar
nerve at the "crazy bone" is to the little and fourth
fingers.
Some cases of hysterical coccygodynia get well by
the most divergent and heterogeneous remedies, such as
hydropathy, faith cure, hypnotism, etc. Others never
recover under any treatment. In such cases there is
only one course left to render life tolerable, that is the
use of opium. The substitution of a lesser evil for a
greater one is the last refuge for the unfortunate suf-
ferer. Many will, through a physician's prescription or
by their own doing, resort to this drug. If they do not
take more than half a grain a day, preferably by the
rectum, they may live in comparative comfort. But
generally hysteric people have a morbid dread of
opiates. The fear of becoming a morphine fiend and
the unpleasant untoward effects of morphine in custo-
mary doses, say one-quarter of a grain, has a deterring
effect which on the whole is very wholesome. But
there are cases in which moderate morphinism is
preferable to a life of constant agony, not only to the
patient herself but also to her family.
That even severe cases of coccygodynia may get
well I have witnessed in the instance of a woman of
thirty-seven. The operation had been decided upon,
when her husband, who was well-to-do, failed in busi-
ness. The operation was postponed and never per-
formed. The necessity of hard work brought about
a cure. The change from an idle, fashionable exist-
ence to the cares and responsibilities of running a
restaurant effected a gradual but permanent cure.
She herself considers her husband's failure a wind-
fall. I know of another case of medium severity
which was cured by the bicycle.
Excision of the coccyx is also practised to some
extent on hypochondriacs. Here the diagnosis gen-
erally reads: "The coccyx points strongly inward, is
partially detached, and probably necrosed." What a
revelation in pathology!
I do not mean to say that never and under no cir-
cumstances has the removal of the coccyx been suc-
cessful in curing the pain. Perhaps there are cases in
which the operation has been beneficial. Personally
I do not know of any. Even in cases of success the
question is legitimate : Would not other and simpler
means have been equally effective? Generally speak-
ing, the results of coccygodectomy are as hopeless as
neurectomy in facial neuralgia.
Will there be any fewer operations performed for
hysterical coccygodynia on the strength of the fore-
going remarks.' I do not believe it. Like osteopathy
and faith cure, the knife will continue to have its
sway in the treatment of hysterical ailments. An age
that has given rise to that crowning glory of surgical
fakes, orificial surgery, proudly termed by its advo-
cates the American operation, will continue to hunt at
the periphery for that which lies in the centre. But a
protest is always in order. Besides, I know that con-
sen'ative surgeons repudiate the reckless and uncalled-
for use of the knife.
In spite of this, the indiscriminate extirpation of
w^ombs and ovaries, the slitting and enlarging of ori-
fices of the male urethra, the excision of imaginary
strictures, the clipping of the eye muscles, the cutting
out of pockets of the rectum, circumcision, and the
removal of the coccyx will go on with unabated vigor
— all of which is the outcome of an exaggeration and
misinterpretation of the import and meaning of the
law of the reflexes. In the name of the reflexes a
multitude of surgical misdemeanors are constantly
committed.
Tuberculous Glands in the neck can be removed
w ithout visible scar through an incision within the hair
line extending from behind the ear clownward and
inward. The glands are pressed toward this opening
and caught with a hook or long narrow forceps and enu-
cleated. DOI.LINCER.
156
MEDICAL RECORD.
[August 1, 1896
A CONTRIBUTION TO THE STUDY OF
ACUTE DELIRIUM, WITH ESPECIAL REF-
ERENCE TO ITS BACTERIOLOGY - RE-
PORT OF A CASE.
By AVARKEX L. LABCOCK, M.D..
OCDENSBURG, N. V.,
AS5ISTA.NT PHYSICIAN, ST. LAWRENCE STATE HOSPITAL.
Acute delirium, according to our present conception
of the disorder, is a peri-encephalitis which has a
varied etiology. A review of the articles on the sub-
ject in the latest editions of our standard text-books
reveals the fact that a total of forty-two alleged excit-
ing and predisposing causes are responsible for this
disease. It is a matter of much significance that such
a. diverse etiology should be ascribed to a condition
which usually runs a definite, uniform course, ending
in death in about three weeks. To the critical ob-
server this contradiction of statements signifies that
our knowledge of the exact nature of acute delirium is
very meagre. Not only is the etiology an unknown
quality, but its differentiation from allied conditions,
such as hyperacute mania, toxic delirium, meningitis,
and the delirium of the specific infectious fevers, re-
solves itself into a problem difficult of satisfactory
solution. Particularly often is it confounded with
hyperacute mania. This is illustrated by a study
of the insane hospital reports for the past few years.
Some hospitals and asylums are without a single casfe
for months ; others are never w ithout one or more.
The writer has prepared a table, showing the number
of cases of acute delirium among the admissions of
the last few years of about twenty insane hospitals in
various parts of the country. The most surprising
variation in the total number of cases of delirium to
the total number of admissions is thus set forth. It
ranges from thirteen cases of acute delirium out of a
total of eighty-nine hundred and eighty admissions,'
to seventy-one cases out of fifteen hundred and twenty-
two admissions," extending over a somewhat shorter
period of time. As the two hospitals from which
these statistics are taken are less than three hundred
miles apart, climatic and other similar influences do
not account for the variation. In the opinion of the
writer it is wholly a matter of diagnosis, and cases of
hyperacute mania were evidently included in the lat-
ter figures.
A valuable pathological contribution to the subject
of acute delirium has recently been made by H. C.
Wood,^ who makes the following divisions: "First,
acute peri-encephalitis; second, in acute affection,
primarily centred in the ganglionic cells, but without
lesions that can be demonstrated by our present pro-
cess.'' He then subdivides acute peri-encephalitis
into septic and idiopathic peri-encephalitis, the
former due to the action of septic organisms on the
brain, the latter depending on emotional strain or
functional excitement. He also states that if the ob-
servations of Rasori be correct, there must be a third
peri-encephalitis, due to the presence of a special or-
ganism. Rasori found post-mortem in the cerebro-
spinal fluid a small bacillus which he believed to be
peculiar to the disease and which caused death to rab-
bits, with symptoms of acute septicaemia.
The studies of the writer in acute delirium have
been confined to an effort to determine the alleged
bacterial nature of the disease. Upon looking up the
literature of this part of the subject, the array of evi-
dence in favor of a germ origin for any form of the
disease is very meagre, and, on first reflection, hope-
' 1895 Report, Cleveland (Ohio) Hospital for Insane.
* 1895 Report, Clarinda (Iowa) Hospital for Insane.
'Wood: " .\n E.xpiscation on .Acute Delirium." American
Journal of the .Medical .Sciences, vol. ci.x., g, 361.
lessly conflicting. A number of germs have been
found in the cerebro-spinal fluid of these cases post
mortem, but no one germ can be said to be at all con-
stant. The fluid from the case reported by Vv'ood '
was examined bacteriologically without finding germs
of any kind. This case, however, does not offer any
evidence against the bacterial nature of peri-encepha-
litis, as it evidently belongs to tlie idiopathic subdi-
vision of the disease. The most important bacterial
studies in addition to those of Rasori, mentioned
above, are those of Potts and Berlet," who cultured
cerebro-spinal fluid obtained post mortem, and found
the pneumococcus and the staphylococcus pyogenes
aureus and albus. In another case, reported by Hunt
(quoted by \\'ood>, the bacillus pyocyaneus was ob-
tained by culture from fluid found in the lateral ven-
tricles. This case was found to have a nephritic
abscess and the delirium apparently depended on a
septic peri-encephalitis. Caruthers ' reports a similar
case resulting from pelvic abscess, but unfortunately
no bacteriological studies were made in this instance.
Jackman ' reports finding the micrococcus pneumonia;
crouposK in the cerebro-spinal fluid (post mortem) of
a case of puerperal mania, which rapidly proved fatal.
The clinical history of his case and its short duration
(three weeks) leads to the belief that it was a true
case of acute delirium following parturition. Of all
germs found in the cerebro-spinal fluid of acute peri-
encephalitis (post mortem) this germ occurs the most
frequently. It has also been found in allied condi-
tions of the membranes, such as simple and purulent
meningitis, infectious cerebro-spinal meningitis, and
acute cerebral abscesses following the infectious fe-
vers. In a series of twenty-five cases of purulent
meningitis examined by Netter (quoted by Sternberg)
it was present in sixteen. In four of tlie sixteen the
streptococcus pyogenes was also present. Monti '
and others have detected the germ in cerebro-spinal
meningitis. It is, therefore, apparent that the micro-
coccus pneumonia; crouposa; has a special predilection
for the cerebro-spinal membranes, occurring in both
primary and secondary affections of the meninges.
Heretofore, the germ study of the cerebro-spinal fluid
in acute delirium has been confined to fluid obtained
post mortem. The bacterial investigations of the
writer in this disease have been limited to the study
of the cerebro-spinal fluid obtained during life.
The following case of .icute peri-encephalitis was
under my care throughout its entire course in the acute
receiving-wards of the St. Lawrence State Hospital.
On the tw'enty-ninth day lumbar puncture was per-
formed for the relief of intracranial pressure symp-
toms, and the fluid was sa\ed for clinical and bacte-
riological analysis. The micrococcus pneumonia;
crouposa; and the streptococcus pyogenes were found
on examination. Death occurred on the forty-sixth
day and an autopsy was fortunately procured, which is
reported in full. The following clinical notes are
abbreviated from the clinical records of the case, com-
menced on admission of patient:
C.\SE No. 2,465. — Male, aged forty-six years, paint-
er, native of New York, .\dmitted to St. Lawrence
State Hospital, May 13, 1896. "On admission was
rambling and incoherent in speech, confused, and sub-
ject to slight motor restlessness. Attention attracted
with difficulty. Physical health fair." The history
accompaiiying the patient states that "patient has
no insane or neurotic relatives; uses alcohol and to-
bacco to e.\cess, and had la grippe in March. First
' Op. cit.
'' Medical News. June 20. 1S94.
' Report, Maryland Hospital for Insane, 1S93.
^Jackman: lournal of N'ervous and Mental Disease, .\pril,
1 896.
^ Monci. Riforma Medica, 1SS9, Xos. ;S and 59.
August I, 1896]
MEDICAL RECORD.
157
mental symptoms noted May 3CI, when he became rest-
less and talkative. During the past ten days he has
slept scarcely any and his appetite has been poor. At
times recently he has been so disturbed that it took
four men to control him."
Examination twelve hours after admission : " Patient
talks almost continuously in an incoherent, rambling
jargon. Impossible to attract his attention or get him
to answer questions. Hands and head in constant
motion, as if gesticulating or emphasizing his remarks.
Eyes injected, pupils contracted and do not react to
light. Temperature, 99.6" F. ; pulse, 80, high tension ;
patellar retle.xes lost. Bowels sluggish, tongue dry
and slightly coated. Urine limpid and pale, specific
gravity 1.012, urea diminished, amorphous urates, no
albumin or sugar, chlorides increased. Too disturbed
to permit satisfactory e.xamination of heart and lungs.''
Sulphonal, twenty grains, in hot milk, was given and
patient slept seven hours. Delirium returned on
awakening, but temperature fell to normal.
On the day following admission (twelfth day of de-
lirium): '"Above symptoms continue: temperature
normal."
Fourteenth day: '"Patient continues delirious and
disturbed. Confusion of ideas great; special senses
do not respond to any kind of objective stimuli; sleep
obtained by means of sulphonal and bowels kept solu-
ble with o.\-gall enemata. Pulse, 84, high tension:
temperature normal. Urine unchanged; takes nour-
ishment readily; general condition comfortable."
Seventeenth day: " Delirium and motor restlessness
continues unabated. Temperature, 99.4° F. ; pulse,
96, irregular and weaker. Less influenced by sulpho-
nal. Steadilv losing weight and strength."
Twentieth day: " Little change in mental symptoms,
except that motor restlessness has increased. Tem-
perature, 98.8^ F. : pulse, 88, weak. Heart's apex
impaction feeble. Urine contains trace of albumin.
Stimulants ordered."
Twenty-second day: "Delirium increased and now
entirely oblivious of surroundings. Temperature,
100.2° F. ; pulse, 100, low tension. Tongue dry,
parched, and heavily coated; teeth covered with
sordes and febrile symptoms prominent. Sulphonal
fails to produce sleep; hyoscine substituted with good
results. Takes liquid nourishment with slight resis-
tance."
Twenty-sixth day: "No change in mental symp-
toms. Temperature ranges from 99.4' to 101.6" F. ;
pulse from 102 to 118. Strength declining. Stimu-
lants increased. L'rine contains increased amount of
albumin."
Twenty-ninth day: "No subsidence of delirium.
By means of moderate doses of hyoscine patient sleeps
seven to ten hours daily. Resistive about taking
nourishment. P'ebrile symptoms prominent and
closely resembling typhoid fever. Head slightly re-
tracted; pupils greatly contracted, and patient stupid
and dull, although he still continues talkative and in-
coherent. Symptoms point to increased intracranial
pressure, and operation of lumbar puncture was de-
cided upon.' Morphine sulphate, one-fourth grain,
and hyoscine hydrobromate, one-fiftieth grain, were
given hypodermically, and patient fell asleep in a few
minutes. Two or three drops of a four-per-cent. solu-
tion of cocaine were injected beneath skin of lumbar
region and an aspirating needle inserted into subdural
space without awakening patient. Needle was in-
serted one-half inch to the right of first lumbar spine
and directed slightly upward and inward between first
and second lumbar vertebra?. Flow of fluid was im-
mediate and evinced a high degree of cerebral press-
' For full description of this operation and its use in general
paralysis, locomotor ataxia, and other cerebro-spinal diseases, sec
State Hospitals Bulletin, July, 1S96, vol. i.. No. 3.
ure, the rate of flow averaging at start forty-four
drops per minute, whereas it has been determined by
previous experiments with lumbar puncture that the
normal rate of flow approximates six to ten drops per
minute. The fluid drained away in drops for one
hour, at the end of which time seventy-three cubic
centimetres of clear exudate had been collected and
entire amount reserved for examination. No shock
followed operation and patient slept four hours."
On the following day the patient's condition was
greatly improved. '" Delirium partially subsided, at-
tention could be attracted without much elTort, and
restlessness materially lessened. Temperature fell to ■
normal, pulse tension lowered, and facial expression
improved."
Thirty-second day : '" Mild delirium continues. In-
coherence well marked but attention can be attracted.
Temperature normal, and pulse fair volume."
On the following day temperature rose to 99.6° F.,,
and condition approached that which preceded punc-
ture. Examination of urine revealed albumin and
urea increased in amount and a few pus cells.
Thirty-sixth day: ""Delirium gradually assuming
a low, muttering form and patient's strength rapidly
failing. Albumin, pus cells, and granular casts
abundant in urine. Stimulants increased to one-half
ounce of spiritus frumenti every two hours."
Forty-first day : " Very weak and greatly emaciated.
Delirium muttering and low, like that of typhoid.
Tongue dry, cracked, and brown; mouth very foul,
and teeth covered with sordes. Temperature, 100' F. ;
pulse, 94, weak and irregular. Resistive about taking
nourishment. .Albuminous salt solution injected into
buttocks and hypodermics of strychnine and digitalis
given every four hours. After nutrient injection pa-
tient rallied and seemed much improved for twenty-
four hours, at the end of which time he relapsed.
Twelve hours after relapse nutrient injection repeated
without further improvement."
Forty-sixth day: '"Patient died at 2 p.m., after hav-
ing been in a condition of coma for thirty-six hours.
Eight minutes after death lumbar puncture was again
performed and sixty-six cubic centimetres of turbid
fluid quickly collected."
Autopsy (sixteen hours after death). — The follow-
ing notes are abstracted from the autopsy record :
'" Body greatly emaciated. Brain found bulging and
membranes tense, but only a moderate amount of fluid
drained oft". Tension due to the swollen condition of
the cortex. Pia and arachnoid iirflamed ; frontal half
of membranes cloudy and opaque, presenting evidence
of extension of the inflammation from the frontal to
the temporo-sphenoidal and tlience to the occipital
lobes, the inflamed area of the latter being apparently
of very recent origin. The vessels of the pia were
highly injected and the pia over the cerebellum was
mildly inflamed. The entire cerebrum was soft and
swollen, and the cortex was infiltrated with inflamma-
tory products, thus presenting evidence of acute en-
cephalitis. Minute punctate hemorrhages apiaeared
on the surface of the convolutions from which the pia
was stripped. The superficial layer of the cortex tore
up in flakes on removal of the pia. The temporo-
sphenoidal lobes were softened and the frontal lobes
were adherent to each other for a short distance ante-
rior to the corpus callosum. The olfactory bulbs
were soft and atrophic; the choroid plexus was cystic;
the ventricles were greatly dilated, and their walls
were softened and infiltrated with serum. The me-
ninges of the cord and nen-e sheaths of both anterior
and posterior roots were inflamed throughout.
The lungs were large, white, anainic, and emphy-
sematous; contained much frothy mucus. The lobules
contained a cloudy, semi-fluid, gelatinous exudate,
smears of which were saved for microscopical exam-
158
MEDICAL RECORD.
[August
1896
ination. An ante-mortem clot was found in the pul-
monary arteries, extending into the vessels of both
lungs.
The heart was soft, flabby, and dilated. The left
ventricle contained a small ante-mortem clot e.xtend-
ing into the aorta. The valves were competent
throughout. The right ventricle contained a large,
fibrous clot, intimately blended with the muscular
columns, e.vtending through the tricuspid orifice into
the right auricle. The pericardium, aorta, and heart
wall were normal in appearance.
The liver was large, congested, and studded with
friable, soft areas. It resembled the liver of acute al-
coholism.
The spleen was congested and friable; normal in
size. Blood smears were saved for microscopical ex-
amination.
The kidneys were both highly congested. The
right contained a small abscess at the upper angle.
The intestines were normal. The Gasserian, semi-
lunar, and Meckel's ganglia, retina, cochlea, and sec-
tions from all the organs w-ere saved for microscopical
examination.
Microscopical Examination. — Smears from the
lungs showed broken-down epithelial cells, shreds of
lung tissue, red blood corpuscles, and much granular
matter. Blood smears from the spleen, stained by
Gram's method, revealed the micrococci pneumonia;
in great numbers. They occurred singly and in
pairs, and were not accompanied by the streptococci
which were found in such abundance in the cerebro-
spinal fluid from the second puncture. The red cells
were granular and in various conditions of transitional
change. The leucocytes were normal in contour, in-
creased in number, and some contained within them-
selves one or more cocci.
Microscopical examination of sections from the in-
flamed areas of the cortex revealed the usual appear-
ance of acute inflammation. Nissl's stain showed
that the perivascular and lymph spaces were crowded
with white blood cells in various stages of degenera-
tion. The vessel walls were swollen and the lumen
of the arteries was crowded with corpuscles. Around
some of the larger arterioles the lymphatic engorge-
ment was very great; the cells were densely crowded
together and evidences of granular degeneration were
very apparent. The perigangl ionic spaces were occu-
pied by a serous infiltration, which in some places
gave way to an enormous crowding together of lym-
phocytes. The cortical cells in close proximity to the
ialood-vessels were swollen; the nucleus was distinct
and the protoplasm was vacuolated in some instances.
The condition of the nerve cells varied greatly in dif-
ferent fields examined.
Chemical Examination. — Briefly, the chemical
analysis of the cerebro-spinal fluid resulted as follows:
First puncture : amount, seventy-three cubic centi-
metres, clear; reaction, neutral; specific gravity,
1. 010; albumin, 2.25 per cent.; chlorides, 4 per cent.;
urea, o.i per cent.; sugar, negative: traces of phos-
phates, sulphates, and globulin. Frotagon was also
tested for and found. Second puncture: amount,
sixty-six cubic centimetres, cloudy and opaque; reac-
tion, neutral; specific gravity, i.oog: albumin, 3.5
per cent. ; chlorides, 4.5 per cent. ; urea, o. i per cent. ;
phosphates, 0.75 per cent.; sulphates, 0.25 per cent.;
sugar, negative. White and red blood corpuscles,
pus corpuscles, and hamatin crystals were also
present.
The large amount of albumin present suggests an
intense inflammatory condition of the membranes,
which evidently steadily progressed, as the albumin
increased from 2.25 per cent, in the first specimen to
3.5 per cent, in the specimen of fluid obtained imme-
diately after death. The chlorides and other salts,
traces only of which are present in normal fluid, were
found to be greatly in excess, particularly in the speci-
men from the last puncture.
Bacteriological Examination. — Many precautions
were taken in collecting the fluid during both lumbar
punctures so as to exclude all possibility of contami-
nating it with e.xtraneous germs. The needle, tube,
and glass receptacle were previously sterilized by
steam; the fluid was kept at the body temperature by
means of hot moist packing about the tube and gradu-
ate, and the latter was kept covered with .sterilized
gauze. As soon as tw-elve cubic centimetres were
collected, that amount was transferred to a sterilized
precipitating tube and the latter was plugged with
sterilized cotton. The liquid, after standing twelve
hours, was placed in a centrifugal machine and its
suspended solids were precipitated. Aiier precipita-
tion the supernatant fluid was drained off and the floc-
culent precipitate was stained by Gram's method and
mounted in balsam. This method of precipitation
and staining, with the exception of keeping the tem-
perature of the fluid at 100° F., was carried out after
the second puncture. On examination of the slides
prepared from the fluid of the first puncture, large
numbers of the micrococcus pneumonia; crouposa;
were found, together with an occasional streptococcus
pyogenes. Slides from the fluid of the second punc-
ture revealed an increased number of both germs,
particularly the streptococcus. Pus cells were numer-
ous in each field examined from the fluid of the sec-
ond puncture.
As the writer had no facilities for making cultures
of the germ, an attempt was made to demonstrate its
specific nature by the inoculation of rabbits. Two
were inoculated from fluid of the first puncture, as
follows: The aseptic precautions described above were
supplemented by the use of a sterilized hypodermic
needle, and the fluid was kept at a temperature of
100° F. until injected subcutaneously into buttocks of
rabbit. Two cubic centimetres were injected into
each rabbit. .\t the end of twenty-four hours both
had an elevation of temperature of little more than a
degree, and manifested symptoms of a mild .septica;-
mic infection. At the end of forty-eight hours their
temperature was still elevated and they were eating
poorly. Twenty-four hours later they seemed to have
regained their usual condition.
Three rabbits w-ere inoculated with fluid from the
second puncture in the manner described above. At
the end of twenty-four hours two of them gave evidence
of an intense infection, while the third gave birth to
eight young, evidently premature. Of the young two
died, while the mother manifested no further evidence
of infection. The two remaining rabbits were greatly
prostrated; their temperature ranged from 103.8° to
105.2" F. (normal rabbit temperature, 103.1° F.);
they refused to eat and lost weight rapidly. At the
end of forty-eight hours one appeared to be dying, but
both recovered after a few days. An examination of
the blood of these rabbits revealed the same germ that
was found in the spinal exudate, which here occurred
both singly and in pairs.
The microscopical appearance of the germ found in
the spinal fluid and the blood of the inoculated rab-
bits exactly corresponds to that of the micrococcus
pneumonia; crouposa; or micrococcus Pasteuri (Stern-
berg). Its virulence upon the rabbits, however, ap-
peared much less than that of germs from pneumonic
sputum, as the animals usually die when inoculated
with the latter. It is assumed, therefore, that the
germs injected had from some cause or other become
attenuated. Tlie subject needs further investigation
by reinoculation and culture experiments with the
fluid obtained by puncture before the identity of the
germ can be established. The above notes are only
August I,
1896]
MEDICAL RECORD.
159
offered as an incentive to more thorougli work in sus-
pected cases of bacterial peri-encephalitis.
The features of particular interest presented in this
case are:
First, the temporary relief of the cerebral symp-
toms and improvement in the patient's condition fol-
lowing lumbar puncture.
Second, the finding of a germ, probably the micro-
coccus pneumonia' crouposa; in the cerebro-spinal
fluid obtained during life.
Third, the protraction of the delirium and the un-
usual length of the disease (forty-six days).
RUPTURE OF THE UTERUS.'
Hv JOil.V C. MacEVITT, M.D.,
BROOKLV.N, N. Y.
One of the most formidable, dangerous, and unex-
pected accidents to the parturient woman with which
the obstetrician has to contend is rupture of the ute-
rus. Without the slightest premonition the attendant
is carried from a peaceful contemplation of a natural
process to a most direful result. In the literature of
the subject it is the exceptional author who outlines
any premonitory symptoms, and they are so vague and
difficult to appreciate that until time and experience
designate more tangible evidence we will still rest in
fancied security by the patient's bedside until in the
presence of the disaster. The frequency of rupture of
the uterus is hard to determine, owing not only to the
failure of physicians to report their fatal cases, but to
the fact that the greater majority of the cases are not
recognized. Baudeloque in his thesis states that in
his post-mortem examinations, after craniotomies, he ■
usually found a ruptured or contused condition of the
organ. Sudden deaths during labor reported as due
to concealed hemorrhage, shock, embolism, heart fail-
ure, etc., are probably due to this cause. Statistics
by foreign and American obstetricians of note, based
upon personal and collected cases, range from one in
four hundred to one in five thousand. This appar-
ently great difference is undoubtedly due to the classi-
fication of the injur)', some recognizing a tear of lim-
ited extent in the cervix or body, whereas others
recognize only those whose grave symptoms indicate
laceration into the peritoneal cavit)'. Tears in which
the whole extent of the cervix is involved, according
to the theory of Kaltenbach, are of a non-traumatic
origin. To cure a diseased condition remove the
cause, is an axiom in practice. In these cases, in
most instances, the cause is unrecognizable until the
harm is accomplished. Cases presenting a history of
Casarean section, previous ruptures, or operation in-
volving the uterus for carcinoma or fibroid neoplasm
should put the attendant upon his guard to be in
readiness to operate upon a moment's notice, or, bet-
ter still, he should advise such a patient to seek treat-
ment in some hospital where adequate skill and con-
venience for operating under proper precautions exist.
A successful operation, one of the very few, in which
both mother and child were saved after a rupture with
protrusion of the child into the abdominal cavity, was
performed by Dr. Tucker, of Bay City, Mich., he for-
tunately recognizing the rupture at the moment of its
occurrence and performing without delay cceliotomy,
his only instrument being a small penknife.
Many factors enter into the etiology of this acci-
dent. Eighty per cent, of these cases occurs in multi-
pariE, due to a thinning and weakening of the uterine
muscular fibres in previous labors. It is asserted and
disputed that a healthy uterus can rupture itself
' Kead at the fourth annual meeting of the .•Association of
Alumni of St. Mary's Hospital.
through the force of its own muscular contractions.
External violence, such as falls, blows, traumatisms in
which the uterine tissue is injured, oftentimes pro-
duces rupture. Freund relates a case in which labor
appeared two days after the patient had fallen, strik-
ing the enlarged abdomen against a curbstone, and
in which the uterus ruptured shortly after the onset of
labor. Disproportion between the size of the child
and the maternal soft parts, as exemplified by statis-
tics, shows a great preponderance of male children in
these cases. Hydrocephalus was an early recognized
cause ; also previous operation upon the womb, already
referred to, laceration of the cervix, narrow pelves
and pelves presenting abnormal bony prominences,
the symphysis pubis and enlarged ileo - pectineal
eminence being often at fault in this respect, and mal-
presentations presenting irregular surface to the con-
tracting uterine muscles: but above all I believe the
greater number of ruptures is produced by bad man-
agement and a failure to recognize imperative inter-
ference early enough. Vou can easily understand
how the administration of ergot during the second
stage of labor, so often indulged in by midwives and
criminally incompetent practitioners, notwithstanding
the well-known action of the drug, the untimely and
unskilful use of the forceps, the condition of malpres-
entation after the liquor amnii has escaped, when
the woman has been in labor for hours, without pre-
paring her for the ordeal by the administration of an
ancesthetic, will lead to this accident. The following
two cases will serve to illustrate gross incompetency
in management.
Case 1. — A poor, ill nourished Polish woman, the
mother of two children, without any history of pre-
vious difficult labor, was taken with labor pains on
the morning of January 6th. In the afternoon a mid-
wife was sent for, and, according to her evidence be-
fore a coroner's jur}-. she found the woman suffering
from pains every four or five minutes, with the os
slightly dilated. Without waiting for complete dila-
tation she ruptured the membrane. This was about
two o'clock in the afternoon. At eleven she left the
woman with advice to the husband to send for a doc-
tor. The doctor arrived at 3 a.m. The woman was
in hard labor, head presenting at brim. Failing to
deliver with forceps, the aid of a second physician
was sought. A second application of the forceps was
likewise futile. .\t 7 a.m. of the second day both
these doctors took their departure, promising to return
later. They failing to do this, a third practitioner was
called in, who, not deeming the pains of the now ex-
hausted woman strong enough, ordered regular doses
of ergot and left the patient to nature and the drug.
He returned at eleven o'clock that night to find the
woman vomiting and in a state of collapse. He sent
for a consultant, upon whose arrival the bladder was
catheterized and bloody urine withdrawn. It was
then decided to send for an ambulance to remove her
to a hospital. The ambulance surgeon arrived at the
house at about 5 a..m. the tliird day of the woman's
labor. She then presented marked pallor of the face
and lips, wrist pulse weak and rapid, with every evi-
dence of complete exhaustion with entire absence of
pains. On examination the surgeon found a pro-
lapsed, pulseless cord, with head presenting at brim
but not wedged in. Having been informed of the
fruitless eft'orts of the four physicians who had pre-
ceded him to deliver with the forceps, he proceeded
to do an internal podalic version, which he states he
accomplished with comparative ease. He experienced
but little difficulty in delivering the body and extremi-
tities, but the head remained fast. After vainly tr}ing
to deliver this he severed the body from the head and
brought the woman to St. Mary's Hospital, where I
was sent for to complete the attendance. As you can
i6o
MEDICAL RECORD.
[August I, 1896
well imagine, the woman presented all the appearance
of approaching dissolution from collapse. 'I'he abdo-
men was greatly distended, tense, and painful, show-
ing the presence of general peritonitis, and in conse-
quence of this condition nothing could be determined
by abdominal palpation.
Upon the introduction of my hand into the uterine
cavity I found it filled with intestines. The decapi-
tated head I could feel between them, receding before
my fingers into the peritoneal ca\ity. I found it
somewhat difficult to gain possession of this, owing to
its moist, rounded form, but finally, getting my inde.x
finger into the mouth, I gently worked it back through
the widely torn rent into the uterine cavity and down
to the pelvic brim. I retained my purchase and an
assistant was able to grasp with a strong pair of for-
ceps the remaining portion of the neck, which he held
until I applied a pair of obstetrical forceps and deliv-
ered the head, the placenta following directly. I was
desirous of doing a cctliotomy, cleaning out the ab-
dominal cavity, and stitching the torn womb, but on
consulting with the medical gentlemen present it was
deemed unwise, owing to the patient's condition. I
then endeavored to produce an inversion with the in-
tention of amputating the womb, but my efforts, to-
gether with the stimulants the patient was constantly
receiving, brought on contractions, which rendered my
efTorts of no avail. The uterus was then crowded
down into the pelvis and held there by abdominal
compresses and bandages. After douching out the cav-
ity with a weak solution of carbolic acid, an iodofomi
drain was inserted into the rent, and the patient re-
moved to the ward where she died five hours after-
ward. I will leave comment upon this case to the
members of the association.
C".\SE II. — .\ strong, healthy German woman, mother
of seven children, upon the appearance of labor pains
sent for the doctor she had engaged to attend her. On
his arrival he stated he was in a great hurry, made an
examination, ruptured the membrane, applied the for-
ceps, and delivered. One week afterward she was
brought to St. Mary's Hospital. On an e.xamination
by Dr. John Byrne, the bladder, vagina, and uterus
made but one cavity. Fortunately, in this case the
uterine rupture did not extend into the peritoneal
cavity. After waiting for proper involution. Dr. Byrne,
at one sitting, made a thorough and successful resto-
ration of the parts. A few days ago 1 learned from
the doctor that the woman was again pregnant.
The position of the ruptures in these cases is not so
much a matter of moment as their extent. Sometimes
the cervical portion is torn from their body. The ma-
jority of the tears have their origin in the thin obstet-
rical neck and extend transversely and longitudinally.
This portion of the uterus is passive during a pain,
and, it being also the thinnest, you can understand
how the force of the contracting fundus, pressing the
fatus against the bony brim, can destroy the integrity
of the inter\'ening wall. Rarely there may be an ex-
ternal rent in the walls of the uterus without injury to
the peritoneum and conversely.
I believe it to be a difficult matter to detect any but
a rupture of so grave a character that there can be no
mistaking the objective symptoms. Some ruptures are
progressive and cannot be recognized until completion
of the disaster. But there can be no mistaking the
following symptoms: During the acme of a pain the
woman experiences a sensation of something tearing
or giving away, followed by vomiting, faint, pallor,
shallow respiration, coldness of the extremities, in
fact all the symptoms of shock; cessation of the pains
generally, but not always; for if the arch of the fun-
dus is not destroyed contractions can continue. If the
child has entered the jjeritoneal cavit)" it can be felt
through the abdominal walls, and an examination per
vaginam will show a recession of the presenting parts.
Palpation of the abdominal walls will not only show
the presence of the child, but the uterus can be felt
as a separate body as well. Hemorrhage from the
vagina also often takes place. Emphysema at the
level of the hypogastric region caused by air in the
connective tissue is a symptom not always present.
When found it indicates a fatal termination. In my
reading on this subject I have not met with the men-
tion of a single case in which a woman with a previously
ruptured uterus was afterward delivered without a re-
currence of the same, an item of considerable impor-
tance in the elective treatment of these patients.
Preventive treatment resolves itself into a matter of
individual judgment. Treatment after rupture de-
pends entirely upon the position of the child. If the
head presents apply forceps and deliver, having an
assistant steady the uterus by pressure. Failing to
deliver, craniotomy is advised, but morally and scien-
tifically cctliotomy would be the better procedure, pro-
viding the child is still alive; in other than vertex
presentations with a dead child embrjotomv; incase
of a living child podalic version may expedite delivery,
but the greatest care is necessary in order not to en-
large the tear.
In a third class of cases, in which the child is partly
within the peritoneal cavity, try and deliver through
the vagina. But when the child is wholly within the
cavity, cctliotomy is the only justifiable operation.
The old treatment of passing the hand through the
uterine tear and withdrawing the child will only
jeopardize the woman's chance for recovery. The
old-fashioned expectant plan is not to be thought of
in this enlightened era. After the removal of the
child and placenta through the abdominal opening, the
rent in the uterus is to be sutured, the peritoneal cav-
ity cleansed in accordance with the rules of aseptic
surgery, and the wound closed. The uterus is then
to be douched out with a weak solution of carbolic
acid. In cases in which the child has been delivered
through the natural passage and the mother after-
ward develops symptoms of septicemia, it would be
proper to perform cceliotomy for the purpose of re-
moving the septic material. In other than cceliotomy
cases daily irrigations and drainage are requisite. It
is a disputed question whether it would not be better
in all cases of rupture in which the amniotic fiuid and
blood have entered the peritoneal cavity to remove it
through abdominal section, as it is well-nigh impos-
sible to secure proper aseptic conditions without; but
statistics of reported cases up to the present time
show a less mortality when drainage and irrigation
have been given the preference over cceliotomy. In
cases of cceliotomy, where the edges of a uterine rent
are so irregular and injured that they cannot be prop-
erly brought together, amputation of the uterus is re-
sorted to. The mortality resulting from this proceed-
ing has been so great that drainage is preferable. The
placenta should be removed manually and not ex-
pressed.
Phimosis — Dr. Martin (Medual News) says this is
a frequent agent in causing or aggravating diseases in
children. The indirect disturbances by reflex are
often puzzling and by no means infrequent; it affects
digestion very seriously at times. Prolapsus ani ac-
companies preputial inflannnation, which will also
give rise to symptoms resembling those of stone in the
bladder. Phimosis will aggravate the symptoms ot
any coexisting disease and be the cause of slow recover)'
in many cases. The reflex disturbances from it are
of sufliciently frequent occurrence to justify a physi-
cian in making an examination of every male child for
this condition.
August I, 1896]
MEDICAL RECORD.
161
Medical Record:
A VVefk/y Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, August i, 1896.
THE SIN OF SUBSTITLITION.
On several occasions previously we have condemned
the practice of substituting one preparation for anotlier
in the compounding of prescriptions. The evil is a
well-recognized one and, we have good reasons for be-
lieving, is more prevalent than would at first sight ap-
jjear. To such as take the requisite pains to examine
the question the damaging testimony against the un-
principled pharmacist is overwhelmingly evident.
The difficulty of finding some efficient remedy for this
gross abuse has always been great, and it is with a
feeling of congratulation that we notice the action of
a leading manufacturing firm of this city in placing
the responsibility where it rightly belongs. The firm
in question, whose products have gained for themselves
a well-deserved reputation for uniformity of strength
and surety of action, has directly attacked the evil in
the very practical manner as set forth in the follow-
ing circular to physicians throughout the country :
"Dear Sir: We beg to call your attention to the
following statement of facts, which we believe will be
of great interest to you as a practising physician re-
lying upon the pharmacist for dispensing the medi-
cines which you prescribe:
"On a recent date a prescription of a physi-
cian ordering was sent to — drug store. The
bottle dispensed upon this prescription was immedi-
ately sealed in the presence of a witness and expressed
to us. A copy of the prescription was asked for and
obtained, which proved to be an accurate transcript of
the prescription, bearing date and number correspond-
ing to those upon the label of the bottle dispensed.
Upon examination the content of said bottle was
found to be a fluid differing materially from , so
as to be obviously recognizable as a plain violation of
the physician's prescription.
" Another written order for was sent to Drug-
gist . Upon examination this proved likewise to
have been filled w-ith a different and inferior fluid.
" Subsequently, the same day, a messenger was sent
to and asked verbally for four ounces of .
He received a wrapped vial, for which he paid fifty
cents. This bottle was found without label, and the
messenger returned and asked to have the bottle la-
belled. The druggist then simply labelled it with
the name of the firm's preparation. Thereupon, the
messenger requested the druggist to put 'all the name
on the bottle.' The druggist told the messenger that
he 'would not dare to put the firm's name on the label,
although it was all the same.' The druggist finally
admitted to the messenger that he was 'out of" the
particular article and then returned the fifty cents.
•■ There is one significant fact that should also be
mentioned: the price charged in these cases (as in
every instance coming to our knowledge) is the same
as the patient would be charged by pharmacists who
dispense the genuine medicine ordered. Comment is
unnecessary.
" In defence of our own rights, and in order that
you may take such means as you deem best to protect
yourself and your patients, we advise you of these
facts. We further respectfully request that in pre-
scribing you will kindly send the prescription to
pharmacists, of whom there are many, who will faith-
fully respect their legal and professional obligations
to physicians and to the public."
The Pharmamitical Era, in commenting upon this
miserable business, makes the following sensible re-
marks :
'"We fail to comprehend what a druggist is think-
ing of when he permits such practices behind his pre-
scription counter. Where is the profession of phar-
macy drifting to if it has gotten to that point that a
physician cannot depend upon a druggist filling his
prescriptions with what is ordered.' We should dis-
credit these reports if they came from a less responsi-
ble source. Such practice if continued will work un-
told injury to the credit and standing of the entire
pharmaceutical profession. Physicians are constantl)-
claiming that one of the principal reasons why they
handle their own medicines is that they are then sure
of what they are administering. Any such wholesale
accusation against the integrity of druggists is as un-
just as it is untrue. There are thousands of consci-
entious, upright, honorable pharmacists, who would no
more think of substituting in a prescription than they
would of trying to pass a counterfeit bill. It is unfor-
tunate that reflection must be cast upon these honest
druggists by the acts of their unscrupulous brothers,
but all of this hue and cry on the part of manufactur-
ers about substituting cannot be ignored. Where
there is so much smoke there must be some fire.
" Every honest druggist owes it to himself and his
profession to speak plainly on this subject. He should
adopt the most strict rules for his own establishment,
improve every opportunity to condemn the practice of
substituting, and see that resolutions to this effect are
passed by his local. State, and national associations.
Each druggist should make it a point to give his phy-
sicians and his customers to understand that when a
prescription comes into his establishment it is filled
with exactly what it calls for. There can be no mid-
dle ground, no compromise, no question on this point.
Physicians who pre.scribe them and the manufacturers
who make the goods must have no good cause for such
complaints. The honor of the drug trade demands
that this stigma be removed. It is not a question of
dollars and cents alone, but professional honor is at
stake, and we know that every honest pharmacist will
join with us in the statement that the druggist who
l62
MEDICAL RECORD.
[AuOrUSt I, 1896
substitutes in his prescriptions is a disgrace to his
profession."
Aside from the question of fair dealing between
man and man, of ordinary justice in trade, and com-
mon honor in protecting the consumer, this outrageous
practice of substitution not only tends to distrust of
the one in whom every confidence should be placed,
but is a direct menace to the skill of the physician and
the faith he may have in well-tried drugs. Further
than this, the very life of the patient may hang upon
the culpable waste of time that a substitution may en-
tail or the substitution may eventually cheat the in-
nocent sufferer of the only chance of ultimate recovery.
Thus the physician becomes more than interested in
the exposure of such nefarious practices. Every re-
spectable pharmacist in any community owes it to
himself by word and deed to frown on the culprits and
to lend his efforts in exposing their fraudulent pro-
ceedings. When the latter have been discovered no
pains should be spared to make the facts known, either
by disciplinary action on the part of boards of phar-
macy or by suits at law. The advice to patronize
only such as are known to be honest is perfectly sound.
In the end we must narrow ourselves to this. There
is nothing to prevent every physician who wishes to
claim his rights in the premises from advising his pa-
tients to patronize such pharmacists as he has good
reasons for believing are above the usual temptations
of fraudulent dealings. There are plenty such and
these only should be encouraged. When a .substitutor
is discovered he should be blacklisted once and for
all. His very act, being deliberate, cold-blooded,
and inexcusably dishonest, places him beyond the
pale of possible repentance. He is the spotted leop-
ard who cannot live without his skin.
FRAGILITAS OS.SIUM IN THE INSANE.
A FAVORITE theme for the sensational newspaper
writer is the abuse of the insane by asylum attendants.
It is assumed as unnecessary of demonstration that
the latter are brutal by nature and still further hard-
ened through contact with lunatics and observation of
the many wiles and treacheries of these -poor suffer-
ers. The specific charges of cruelty are often based
upon the occurrence of fractures or of ecchymoses dur-
ing the struggles of a patient to escape from his keep-
ers for the purpose of committing some act of vio-
lence. It is assumed as matter of course that no such
accidents can occur except as the result of unjustifia-
l)le violence. But the facts are the oih^^r way, for
daily obser\ation shows that it requires but a slight
traumatism to produce ecchymoses in the insane, and
a pressure on the skin no greater than that associated
with the force necessary to prevent the escape of the
patient may result in covering him with black and
blue spots. From the same cause, the lowered nutri-
tion in the insane, the bones may become exceedingly
brittle and liable to fracture, as the result of almost
inappreciable factors or even spontaneously.
At the meeting of the .\merican Medico-Psycholog-
ical Association, held last year in Denver, Dr. H. f.
Eyman, of Toledo, reported a case of this nature
which barely escaped being made the subject of a
newspaper scandal. The case was that of a strong
man, about sixty years of age, who had been admitted
to the hospital suffering from delusional melancholia.
He slept in a dormitory with twenty other patients.
One night he became restless and wandered about the
ward, finally stopping by the bed of another patient.
The latter awoke suddenly and was alarmed at seeing
a man so near him. He put his foot against the pa-
tient's chest and pushed him away with some vio-
lence, but not with sufficient force to throw him down.
The man went back to bed, whence he arose the fol-
lowing morning with the other patients and dressed
himself quietly. During the day he became restless
and suddenly attacked the attendant, a smaller man
than himself, who was obliged to use some though no
undue force in subduing him. While being conducted
to the disturbed ward he broke away and ran a consid-
erable distance before being overtaken, showing at
that time no evidences of soreness or illness. A few
hours after being placed in the ward, however, he
complained of being ill, and examination showed sev-
eral fractures of the ribs. He was at once removed to
the hospital, where he sank rapidly and died in a few
days. At the autopsy nineteen fractures of the ribs
were found, and the bones were as brittle as pipe-
stems. The coroner made a thorough examination of
the case and exonerated the attendants from all blame.
The man's son took the body home and then consulted
some physicians who were not disposed to agree with
the coroner. The case was taken to the newspapers,
but although it was in the very middle of the silly
summer season, they did not care to make a sensation
of it and .so it was dropped.
This case, had it not been for the searching inves-
tigations of the coroner and his exonerating verdict,
might readily have been taken up by some scandal-
mongering paper, and the physicians and hospital at-
tendants would have been subjected to infinite worry
and unpleasant notoriety.
THE P.VRASITES OF WHOOPING-COUGH.
The recognized contagiousness of whooping-cough
at once places this disease in the category of the in-
fectious processes; but although a considerable num-
ber of studies have been made to determine the causa-
tive organisms, it cannot be said that this end has been
.satisfactorily attained. Of all those that have been
isolated from the sputum the greatest significance has
been attached to the bacillus described in 1887 by
.\fanasiew, but the pathogenicity of this also has been
disputed. In a recent communication upon this sub-
ject, Kurloff {Ccntralhlatt fur Bakteriologie, vol. xix.,
Nos. 14 and 15) details the results of a .study of the
fresh, unstained sputum in a series of cases of whoop-
ing-cough. This observer found an amoeba charac-
terized by a finely granular protoplasm and great
capability of movement, which he believes to be
the infecting agent of the disease. As this organism
grows it attains considerable size, large bright granular
August I, 1896]
MEDICAL RECORD.
163
spores appearing in its body, arranging themselves
in concentric layers. Upon rupture of the cell the
spores escape and proceed to increase in size, until
finally, and partly within the body of the patient,
through rupture of the capsule young ama-bae are set
free. These are provided with cilia and are capable
of active movement. Other ciliated amoeboid bodies
were also found, but their relation to those described
was not perfectly clear. No specific significance was
attached to the many bacteria present in the sputum,
although the importance of these with regard to the
secondary phenomena and complications of the disease
must be conceded.
A SPECTACLE FOR THE SILLY SEASON.
Much astonishment as well as indignation has been
aroused in medical circles over the curious actions
of our new charity commissioners. They have had a
ward set apart in Bellevue Hospital, in which they are
testing a secret specific for inebriety-. This is being
done without the counsel or supervision of the medi-
cal board. The spectacle of the e.vecutive officers of
a great and historic hospital grappling with the hard
problems of experimental therapeutics ought to add
much to the gaiety as it does to the silliness of the
season.
2|aus of me ^mcck.
Obituary Notes — Surgeon C. S. D. Fessende.v.
L'nited States Marine Hospital service, died at Salem.
Mass., July 23d, at the age of si.\ty-eight years. He
was appointed to the Marine Hospital service in 1861.
On November 22, 1895, he was placed on waiting
orders on account of physical disability. — Dr. Edw.ard
GuTMANN died in this cit)' on July 21st. He had been
ill for almost a year. He was born at Halle, Ger-
many, in 1828. He studied medicine at the Univer-
sity of Berlin, and came to this countr}' to begin the
practice of his profession in 1854. — Dr. John H.
McGivERN died at Plympton, N. S., on July 2rst,
after an illness of several months. He was thirty-
nine years old, and was bom in St. John, N. B. He
received his degree from the medical school of the
University of New York in 1883, and at once began
to practise in Harlem. — Dr. Samuel Swift, of Yon-
kers, died in this city on July 29th. He had an apo-
plectic attack while in a theatre on Saturday evening,
and was taken to Flower Hospital. He was fifty-three
years old. He was a graduate of the College of Phy-
sicians and Surgeons of this city in 1872. — Dr. M. M.
Weil, a recent graduate of the College of Physicians
and Surgeons of this city, died from poisoning by
carbolic acid, taken with suicidal intent on Saturday
last.
A Rejected Paper. — Mr. Lawson Tait, who is
polemical, not to say belligerent, gave notice to the
chairman of the section on ethics of the British
Medical .Association that he proposed to read a paper
on "The Ethics of .Advertising, Illustrated by ih;;
Manners and Customs of the Editor of the Brit.ih
Medical Journal'' but received word in reply that no
attack on the editor of the British Medical Journal
would be permitted. So now Mr. Tait proposes to
publish the paper elsewhere, '' where Mr. Hart may
have his brittle nature less sedulously and unscrupu-
lously protected."
The American Microscopical Society will hold its
nineteenth annual meeting in the new Carnegie library
building, Pittsburg, Pa., Tuesday, Wednesday, Thurs-
day, and Friday, .August 18, 19, 20, and 21, 1896.
The British Medical Association at its meeting in
Carlisle this wt-ek was in\ited bv the local profession
to meet in 1898 in Portsmouth.
A New Board of Health Building. — A new three-
story brick building, to be used as a stable and a
laboratory by the board of health of New York, is to
be erected by the city on the south side of Seventeenth
Street, east of Avenue C.
The Canadian Medical Association will hold its
annual meeting in Montreal on .August 26th, 27th. and
28th, under the presidency of Dr. James Thorbum, of
Toronto.
An Alleged Case of Cholera in London.— The
cable reported a week ago that a physician had found
a supposed case of cholera in Walworth Road, South
London, and that the officials were examining into
the case. As nothing further has been cabled, it is
presumable that the disease was not Asiatic cholera.
Peace in Peekskill. — For a number of years there
has been trouble in the Peekskill Hospital owing to
the usual difTerences between the lay managers and the
medical staflf, and all efforts to reconcile these difTer-
ences and woo back the physicians who had resigned
from the staff proved futile. Recently, however, the
rules of the hospital were so modified that the doctors
felt they could accept the invitation to return, and they
have accordingly done so.
The Third French Medical Congress will be held
this year at Nancy, on .August 6th- 12th. There will
be three set discussions: "The .Application of Blood
Serums to the Treatment of Diseases," " Intravascular
Coagvilation of Blood," and "The Prognosis of Al-
buminuria.'"
The New Jersey State Dental Society held its
twenty-si.xth annual meeting during the past week, at
-Asbury Park.
A Protest against the System of Appointments
to the Public Hospitals. — A committee of five physi-
cians from the County Medical Association called on
the commissioners of charities a few days ago, to file
a statement protesting against the present system of
appointing physicians to the staffs of the various pub-
lic hospitals and institutions in the city.
A Police Census of Physicians — The police re-
cently took a census of physicians and surgeons in
this city, at the request of the County Medical Soci-
ety, in order that there may be a complete and accu-
rate list of the members of the profession, which is to
be the basis of some investigation of the standing of
certain supposed illegal practitioners.
164
MEDICAL RECORD.
[August I, 1896
Order of Military Surgeons of New Jersey. — At
the annual session of the Order of Military Surgeons
of New Jersey, held in connection with the annual
encampment at Sea Girt, the following officers were
elected: President, Maj. D. L. Wallace, First Regi-
ment; First Vice-President, Maj. W. J. Parker, Fourth
Regiment; Second Vice-President, Lieut. Leslie F.
Ward, First Troop; Secretary, Maj. D. Strock, Sixth
Regiment; Treasurer, H. C. H. Herald, retired. A
resolution was adopted petitioning the governor to
have the uniform of the medical department of the
United States army adopted as the uniform for the
medical department of the national guard of the
State of New Jersey.
The American Public Health Association will
iiold its twenty-fourth annual meeting at Buffalo, Sep-
tember 15th to 1 8th. The following are the subjects
proposed for discussion : the pollution of water sup-
plies; the disposal of garbage and refuse; animal dis-
eases and animal food; the nomenclature of diseases
and forms of statistics; protective inoculations in in-
fectious diseases; national health legislation; the
cause and prevention of diphtheria; causes and pre-
vention of infant mortality; car sanitation; the pre-
vention of the spread of yellow fever; steamship and
steamboat sanitation ; the transportation and disposal
of the dead; the use of alcoholic drinks from a sani-
tary standpoint; the centennial of vaccination; the
relation of forestry to public health; transportation of
diseased tissues by mail; river conservancy boards of
suf)ervision. This is a rather wide range of subjects
to be disposed of in four days.
"Climate and Health," a publication of the
weather bureau of the United States department of
agriculture, has been discontinued, owing to the
failure of Congress to make the necessary appropria-
tions.
The Convalescent Dinner Society is a London as-
sociation which undertakes the duty of granting in
well-authenticated cases in which sickness has re-
duced the strength necessary to return to work, an
order for fourteen daily dinners. Such orders have
been granted to nearly one thousand convalescents
during the last year.
The Perils of Militia Duty. — The Second and
Seventh regiments of the Illinois militia made a
trial march and bivouac last week with disastrous re-
sults. On going into camp at night the men pulled
down vines from walls and trees to make beds of.
These being of the rhus venenata, the night's sleep
resulted in some three hundred active cases of ivy
poisoning the next morning for the surgeons to attend.
Moral: All green leaves are not laurels of war. —
Boston Medical and Surgical Journal.
The Iowa Cigarette Law, which prohibited abso-
lutely the manufacture or sale of cigarettes or cigarette
paper within the State, or their importation into the
State, has been declared unconstitutional by Judge
Sanborn, of the United States Circuit Court. His
decision followed that of the Supreme Court in the
prohibition case some years ago, which was to the
effect that, the federal constitution having delegated to
Congress the power to regulate commerce between the
several States, the legislature has no power to prohibit
the importation of liquors into the State or their sale
in the original packages by the importer.
The Green Cross Society has been organized in
Vienna, its object being to render medical aid to Al-
pine climbers and to instruct the guides in the prin-
ciples of first aid.
A Memorial to Keats. — It is proposed to endow a
bed at Cuy's Hospital to bear the name of the poet
Keats, who was for a short time a medical student
there. Guy's is in great financial straits and the in-
genuity now being displayed in devising means to re-
plenish its exchequer is worthy of admiration.
A New Local Anaesthetic is called eucaine; it is
a synthetic product. It is said to cause anaesthesia of
the conjunctiva without affecting in any way the
normal rerte.xes of the pupil.
To Prevent the Introduction of Small-Pox from
Cuba. — In answer to an appeal from (Governor
Mitchell, of Florida, to the navy department, for
help in protecting his State against the introduction of
small-pox from Cuba, Secretary' Herbert has tele-
graphed instructions to Captain Crowninshield, of the
Maine, now at Key West, to aid the local health au-
thorities in the work of boarding steamers and passing
upon bills of health.
Health in Buffalo The mortality in Buffalo for
the last six months has been at the wonderfully low
rate of 1 1.67 per thousand. Among the causes which
it is claimed have resulted in this reduction of the
death rate are frequent examinations of all lodging and
tenement houses, the maintenance of a bacteriological
laboratory-, the sanitary inspection of schools, and
especially a strict supervision of the milk supply in
order to prevent the sale of milk from tuberculous cows.
The Medical Society of Virginia will hold its
twenty-seventh annual session at Rockbridge .41 um
Springs, on September 8th, 9th, and loth.
Vital Statistics of Philadelphia — For the week
ending July i8th, there occurred in the city of Phila-
delphia 595 deaths, of which number more than one-
half (315) were among children under five years of age.
The most conspicuous causes of death were as follows:
Cholera infantum, 121 (20.3 per cent.); pulmonary
tuberculosis, 49 (8.2 per cent.); marasmus, 43 (7.2
per cent.); inflammation of stomach and bowels. 39
(6.5 per cent.) ; convulsions, 26 (4.4 per cent.); apo-
plexy, 21 (3.5 per cent.); pneumonia, 21 (3.5 per
cent.) ; inflammation of the brain, 20 (3.3 per cent.)
There were reported during the week 39 cases of
diphtheria, 34 of typhoid fever, and 12 of scarlet fever;
and II, 5, and 2 deaths from the same diseases re-
spectively.
Medical Students in Italy. — In all the universi-
ties of Italy, and their name is legion, there are about
seven thousand medical students. At the beginning
of the summer over two thousand received diplomas
with the right to practise medicine.
Auo-ust
o
1896]
MEDICAL RECORD.
165
Ijleutcws and Notices
A Pictorial Atlas of Skin Diseases and Syphilitic
Affections. In Photolithoehromes from Models in the
Museum of the Saint Louis Hospital, Paris, with Explana-
tory- Woodcuts and Text. By Ernest Besnier, A.
FOURNIER, Tenneson, Hallopeau, De Castel.
Feulard, and Jacqcet. Edited and annoted by J. J.
Pkingle, M.B., F.R.C.P. London: The Rebman Pub-
lishing Co. , Ltd. Philadelphia: W. B. Saunders. 1896.
When completed this set of plates will be in twelve parts.
The third ])art is now out. We have already given our read-
ers the high opinion we hold of this production. The pres-
ent fasciculus tends in nowise to diminish the views previously
expressed. A good reproduction of the tongue, pathologi-
cally altered or otherwise, is beset with difficulties which few
have wholly overcome. The frontispiece contains four fig-
ures of syphilitic tongues, which are not nearly so faulty in
coloring as tongue pictures usually are.
The three remaining plates represent, first, the rather un-
usual conditions of concentric-ringed eruption of dermatitis
herpetiformis, very suggestive of herpes iris lesions, the
cockade-like form presented being very striking. Then
comes a peculiar-looking gumma of the thigh, the syphilis in
which is spoken of as "unknown and unrecognized." The
history of this case, which is filled with interest and carries
with it an important lesson, is written by Henri Feulard, in
whose service the patient was observed.
The last subject (Plate Xfl.) is discussed by E. Besnier.
It represents an old man showing, in separate figures, the two
sides of the face, each of which is covered with disseminated
lesions of epithelioma of the sebaceous type. One has ul-
cerated, and the side of the nose is destroyed by a slowly ex-
tending and penetrating cancer. This collection is simply
one of interesting and instructive cases, with descriptive text
written by the physician whose case is depicted. No attempt
is made at a systematic treatise on the subject.
Popular Ess.ws ox the Care of the Mouth and
Teeth. By Victor C. Bell, A.B., D.D.S.
The second edition of this book has appeared so soon that
it indeed endorses the contents. The author states that the
book has been accepted for instruction by the New York
board of education for use in the public schools. No
greater compliment could be paid, and we commend the book
for its practicability to the profession.
La SerothSrapie de la FifevRE Tvphoide, Etudk
Experi.MEXTALE. Par le Dr. M. Fuxck. Bruxelles.
1896.
Ix this very interesting and valuable monograph is contained
a large number of experimental investigations with regard to
the effect of " sero-therapy " in typhoid fever. Notwith-
standing the beneficial results which were undoubtedly ob-
tained by this specific treatment in experimentation on ani-
mals, Funck says that this mode of treatment should not as
yet be applied or even tried in man.
The Methodical Examinatiox of the Eye. By
William Lang, F. R.C.S. Eng. London and New
York: Longmans, Green & Co.
This is an excellent work for the beginner and contains all
the necessary directions to enable the student to master this
difficult procedure.
A Treatise on the Medical and Surgical Diseases
OF IXFAXCV .\XD CHILDHOOD. By J. LEWIS S.MITH,
M. D. Eighth Edition. Thoroughly Revised and Greatly
Enlarged. Lea Brothers & Co. 1896.
This volume is dedicated veni- fittingly to Dr. Frederick M.
Warner, who was a colaborer in its preparation and died
before its publication. ■
The book comprises nearly a thousand pages and is the
outcome of almost a life's experience in hospital and private
clinical work, besides having valuable chapters on the surgi-
cal diseases in children by Prof. Stephen Smith.
The value of the book is greatly enhanced by such contri-
butions as that of Dr. Joseph O'Dwyer on "Intubation,"
Professor Robinson has several dermatological chapters and
many good illustrations.
In a text-book of this size we miss a chapter on influenza,
and the importance of urinary examination is not even men-
tioned. The book is quite modem, gives a great many
points, and certainly deser\-es a large sale. The type is clear
and the illustrations are very good.
Electricity ix Electro-Therapeutics. By Edwix
J. Houston, Ph.D., and A. E. Kexnellv, Sc.D. New
York: The W. J. Johnston Company. 1896.
This work is, for the most part, devoted to the explanation
of the modus operandi of the various apparatus intended for
the transmission of electro-motor force to the human body. It
is necessarily rather too technical to be understood by the ordi-
nary reader. The therapeutical side of the subject is treated
somewhat scantily, which may be regarded as commend-
able rather than otherwise, since comparatively little is known
of this subject, excepting as regards the heating power of the
electric current as applied to cauterizing pui-poses. The
laity has great confidence in the mysterious curative virtues
ascribed to electricity, and hence in no other method of
treatment is greater fraud daily practised. The high Scien-
tific reputation enjoyed by the authors is an assurance of the
accuracy of their statements. The book has one hundred
and twenty-eight good illustrations.
Tr.-\.nsactions of the American Surgical Associa-
tion. Vol. XIII. Philadelphia. 1895.
This volume, containing the proceedings of the meeting held
last year in New York, is full of interesting and practical ma-
terial. Among the articles of special value are those bear-
ing on the operative treatment of malignant diseases and the
use of anaesthetics.
Transactions of the New York State Medical
Association for the Year 1895. Vol. XII. Edited
for the Association by E. J. Ferguson, M.D.
The present volume contains an unusual variety of articles,
medical and surgical, pro\'ing the well-earned position of the
Association as a thoroughly progressive and actively working
body.
The National Dispensatory Formulary. New and
Revised Edition. Lea Brothers & Co. Philadelphia and
New York.
This is a supplement to the National Dispensator)' and is a
formular\- of unofficinai preparations. It contains four hun-
dred and fifty-four formula; for the preparation of various
remedies, ranging from acetum aromaticum to vinum rhei, and
furnishes a very useful addition to the dispensator)'. It is
bound in pasteboard.
CoxsuMPTioN : Its Nature, Cause, axd Prevention.
With an Outline of the Principles of Treatment, for all
Classes of Readers. By Edward Playter, M.D.
fand medallist, Toronto University), M.C.P.S. Ont.,
Author of Playter's Physiology and Hygiene. Editor of
the Canada Health Jourttal. Toronto : William Briggs.
1895.
The object of the work is indicated in the title. It is in-
tended for non-scientific rather than for medical readers, and
still the latter will find much to interest them. Consumption
is discussed by the author from the many sides which the
subject presents, and the social problems it involves are well
brought out.
The work is for sale in the States by E. B. Treat & Co.,
of New York.
The Diseases and Tre.\tmext of the Diseases of
the Rectum. By William Allixgham, F. R.C.S.
Eng., and Herbert Allingham, F. R.C.S. Eng.
Sixth edition. New York: Wm. Wood & Co. 1896.
This very popular treatise, after being for some time out of
print, appears much improved and elaborated in a sixth edition.
The different forms of rectal diseases are discussed in an e.x-
haustive and intelligent manner, and many illustrations of
typical conditions are scattered throughout the text. The
reader will be struck wiili tlie thoroughly practical character
of the contents, and the verj- reasonable arguments for the
choice of tlie different operative procedures. This will be
noticed more particularly in reference to the commoner dis-
eases of the rectum ; for example, hemorrhoids, prolapsus.
1 66
MEDICAL RECORD.
[August I, 1896
and fistula. The criticism of Whitehead's operation is well
presented and the objections to its widespread use are well
taken. The various operations for hemorrhoids are given in
an intelligent manner and will be of great service to the gen-
eral practitioner, who so often treats these cases. The same
may be said of fistula, the true pathological condition of which
is so little understood and which is often so injudiciously
treated. The importance of a single and proper division of
the sphincter is forcibly insisted upon and the after-effect of
the neglect of proper precautions in the treatment of the re-
sultant wound and of a proper method of dilatation are very
well put. The relative merits of inguinal and lumbar colot-
omy are practically considered, and tend to enforce the neces-
sity of a proper discrimination in given cases. The radical
method of the author in preventing prolapse after the former
operation is in our opinion hardly advisable and more ex-
perience than that already presented is necessar\' before the
measure can meet with any extended adoption. As a whole,
the work is peculiarly adapted to the necessities of the gen-
eral practitioner as well as the practical surgeon, and will
amply repay a careful study.
DiET.s FOR Infants and Children in Health and
IN Disea.se. By Louis Starr. M.D., Editor "Ameri-
can Text-Book of the Diseases of Children. " Philadelphia :
W. B. Saunders. 1896.
This is a bound block of diet sheets, with ingredients for
infant feeding indicated and the quantities left blank to be
filled in for each case. There are seven forms of blanks for
the different ages. Owing to the " compact binding " it has
been found necessary to insert instructions as to how to tear
out the leaves without tearing them across. Since the main
object of the book is to have these readily removable, the
binders might have done their work in a less "compact"
manner. The scheme is a good one, but it has been ren-
dered almost impracticable in the present edition by too
much binding. The paper tears less readily along the per-
forated lines than elsewhere.
The Trained Nurses' Directory, May, 1896. Com-
piled and Edited by M. Louise Longewav, C.raduate of
the New York Training School, Bellevue Hospital. Pub-
lished semi-annually.
This is a collection of names carefully selected by promi-
nent physicians of New York and vicinity from their private
lists, and has been endorsed by many well-known practi-
tioners.
Being of vest-pocket size and with flexible cover, it is well
suited for the physician to have with him when he needs to
refer to the list. It is arranged by schools and by streets,
and has blank sheets for memoranda. Many excellent nurses
are omitted from the first issue, but the next promises to be
more complete. The venture has a worthy object and
should succeed.
CEUVRES DE LfioN Le Fort, Professeur df. Clinique
Chirurgicale a la Faculty de Medectne de
Paris, etc. Publiees par le Dr. Felix Lejars, Pro-
fesseur Agrege i la Faculte de Medecine, etc. Tome
Deu.xieme, " Chirurgie Militaire; Enseignenient," avec
une preface de M. le Medecin Inspecteur-Gencral Dujar-
din-Beaumetz. Felix Alcan, Editeur. Paris. 1896.
This second volume of Professor Le Fort's extensive work
makes a book of nearly a thousand pages. It is devoted
chiefly to a consideration of military surgery, though the sub-
ject of instruction occupies an appropriate space. In a pre-
face Dujardin-Beaumetz renders the author worthy homage.
The volume is marked by the same proofs of profound study
and devotion to the cause which has always characterized the
numerous writings of this distinguished author.
The third volume, which will complete the work, is shortly
to be issued and will be devoted to surgerv- proper.
The Treatment of Phthisis. By Arthur Ransome,
M.D., M.A. Cantab., F.R.S. London: Smith, Elder
&Co. 1896.
This volume will be found to be a very practical addition to
the literature of this very common disease and will be appre-
ciated by eveiv student anxious to analyze facts, draw de-
ductions, and enlarge his personal resources in the treatment
of the various complications and conditions of this dreaded
disorder. No specific is -given, but the whole subject is
treated from a broad and rational standpoint.
J^ociety Reports.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meetings Fthntary 12, i8g6.
John Slade Ely, M.D., President.
Dr. Ira Van Gieson presented a preliminary re-
port on some studies he had made on
The Explanation of True Heterotopia of the
Spinal Cord. — He said that by heterotopia of the
spinal cord was meant a dislodgment of portions of
the gray matter situated outside of the outlines of the
posterior or anterior horns. Pick, in 1878, had first
drawn attention to this condition, and had published
a case in which he had found exceedingly minute
masses of gray matter which had become displaced
and were situated near the middle of the posterior
columns. In a second case published a year or two
afterward he found the same condition, to which he
gave the name " heterotopia." After these cases had
been placed on record a number of others had been
published in which all sorts of displacements had
been described, but many of these were afterward
found to be really due to bruising of the spinal cord.
The speaker said that he had reported two genuine
cases, and that up to the present time there were only
about six cases on record. The displaced portion was
usually situated about the middle of the posterior col-
umns. To understand what he considered to be the
true nature of this condition, reference must be made
to what are known as "outlying cells.'' In 1873,
Beisso, an Italian, had shown that in the spinal cord
of some of the lower animals, particularly in oxen, the
ganglion cells were not confined to the gray matter.
Sherrington had carefully studied these outlying cells
in the human spinal cord. He found that they oc-
curred in three regions, viz. : (i, and most frequently)
on the internal surface of the posterior horn; (2) on
the outside limb of the posterior horn ; and (3) just
at the junction of the anterior and posterior horns,
where thev join the lateral columns. Dr. Van Gieson
said that he had found them in a fourth region — in
the region of the anterior commissure. In his opin-
ion heterotopia was simply a clustering together of
these outlying ganglion cells. A study of the devel-
opment of the nervous system showed that this whole
system originated from the outer of the three germ
layers — the ectoblast. The first stage of development
consisted in a thickening of the dorsal aspect of the
embryo, the cells of the ectoblast becoming a little
thicker. Next, there was a dipping in of the ecto-
blast, forming what was called the jirimitive furrow.
This was followed by a slight division between the
ectoblast and the primitive furrow. To this the name
of '"neural crest" had been given, because from these
crests arose the spinal ganglia. In the next stage of
development the primitive furrow became deepened
and cup-shaped, and the edges of the cup tended to
approach each other. A continuation of this process
resulted in the formation of a tube — the future canal
of the spinal cord. Then the neural crest became
spread over the spinal cord, and subsequently divided
in two, these halves being situated on the sides of the
spinal cord. These lateral halves then spread until
they almost reached the anterior portion of the spinal
cord. The cells which originally came from the
spinal ganglia sent their processes into the spinal
cord. As the cells of the primitive medullary canal
migrate outward to the periphery of the spinal cord
they become pear-shaped, forming the neuroblast, the
future ganglion cells. It should be particularly noted
that the development of these ganglion cells was in
August I, 1896]
MEDICAL RECORD.
167
a radial direction. From the radial growth of the
Eansrlion cells and the constant encroachment on the
gray matter of the posterior root collaterals and other
fibres, some of these cells are thrust out beyond the
■confines of the gray matter and become the outlying
cells; hence these displaced masses of gray matter are
simply a grouping together of the outlying ganglion
cells — in other words, an exaggeration of a normal
condition. Heterotopia is observed, the speaker said,
to the greatest e.xtent in those regions in which were
to be found the greatest number of outlying cells.
The chances of these heterotopic masses forming a
nidus for tumors seemed to him extremely small.
Ur. J.\.mes Ewixg remarked that it was pleasant to
learn that three out of the si.x genuine cases of hetero-
topia on record had been discovered by Americans.
Tumors of the Brain. — Dr. J. S. Thacher made
some remarks on this subject, illustrating them by
lantern slides. He said that tumors of epithelial
■origin appeared in medical literature much less fre-
quently than formerly. A considerable number of
these epitheliomatous tumors had been shown to be
sarcomata or endotheliomata. It was natural that
true epithelial tumors should not be frequently met
with in the brain, because the cells of the nervous
system, although originally derived from the epiblast,
had so far lost their resemblance to ordinary epithe-
lium that only those growths starting from the lining
epithelium of the central canal would show in neo-
plasms a structure which was distinctly epithelial.
Very few cancers of the brain had been reported in
recent years. Knapp had collected forty cases com-
ing under his personal observation, and of the thirty
in which the nature of the growth was recorded not
one was cancerous. Dr. M. Allen .Starr, in a collec-
tion of two hundred and sixty-nine tumors of the brain
occurring in persons under twenty years of age, and
in which the nature of the growth was recorded, found
only ten to be cancerous, and most of these were sec-
ondary. The speaker then illustrated by lantern
slides the nature of the growths found in four cases
of primary carcinoma of the brain. These all con-
tained cylindrical cells. Two of them were secondary
to tumors elsewhere in all probability; one was in a
stage of what could be called properly only epithe-
lioma; and one was a tumor which had apparently
begun in the brain and had gone on to multiple meta-
static deposits.
The first slide exhibited was from a tumor of the
brain secondary to a growth in the stomach. It had
been taken from a man, fifty-five years of age, who
had come into Dr. Murray's service at St. Luke's
Hospital, complaining of pain in the shoulder. A
tumor was found in the scapula which on examination
proved to be an adeno-carcinoma. Dr. Thacher said
that, thinking it appeared to be secondary to a tumor
of the alimentary canal, he had asked if there had
been any symptoms pointing in this direction, but he
had received a negative reply. During the last two
weeks of life the man had complained of pain in his
head; the right pupil had been contracted, and there
had been incomplete left hemiplegia. There were no
symptoms of gastric trouble. The autopsy revealed a
large tumor of the stomach to the left of the cardiac
orifice; several smaller tumors in the right lung; a
large tumor in\olving a portion of the scapula, and
two tumors in the brain — one in the frontal lobe, one
and a quarter inches in diameter, and one in the pos-
terior part of the parietal lobe, one-half inch in diam-
eter.
The second specimen was from a woman, forty-five
years of age, in Dr. Northrup's service at the Presby-
terian Hospital. Six months previously she had fallen
and had had convulsions, followed by some difficulty of
speech and complete loss of power in the left arm and
leg. She had recovered speech and the paralysis had
improved. About two days before her death there had
been some rigidirv^ of the neck. She had then passed
into coma. At the autopsy a tumor was found in the
right parietal lobe just behind the fissure of Rolando.
It measured two inches in diameter and involved the
cortex, but did not reach the ventricle. It contained
viscid material. In the lung was a tumor about half
an inch in diameter. No other tumors were found.
From its alveolar structure, the fact that the alveoli
contained much mucin, that they were lined with cylin-
drical epithelium, that the tumor did not communicate
with the ventricles, that it was apparently not con-
nected with the membranes of the brain, and that there
was a small tumor in the lung, he felt justified in con-
cluding that this tumor was secondary to the nodule in
the lung.
The third specimen was from a girl, sixteen years
of age, who entered Dr. Ball's service at St. Luke's
Hospital, complaining of vomiting and headache.
She suffered from these attacks for two months or
more before death. There were no other prominent
cerebral symptoms, and she was supposed to be sufl'er-
ing from gastritis and hy,steria. The vomiting occurred
several times a day, and did not appear to depend
upon the taking of food. About seven hours before
death she complained of pain in the head being ex-
tremely severe, and she was more than usually ir-
ritable and noisy. Then there was a general rigidity
lasting about an hour, and finally general tonic con-
vulsions with cyanosis. At the autopsy, along the
upper and inner edge of the right temporal lobe and
along the floor of the descending horn of the lateral
ventricle and invading the brain tissues in the imme-
diate neighborhood, was a new growth measuring two
inches by one by one inch. Its consistency was like that
of the brain. It involved the right optic thalamus and
corpora quadrigemina. There were no other tumors.
The growth consisted of very regular cylindrical cells
covering the papilla;. From the fact that there was
no other tumor, from its distinctly papillary character,
from the regular cylindrical cells, and from its situation
at the border of one of the ventricles, the conclusion
seemed inevitable that this was a primary papilloma
of the choroid plexus and the descending horn of the
lateral ventricle.
The fourth specimen was from a man, forty-five
years of age, who came into Dr. Thompson's service
at the Presbyterian Hospital about eight months be-
fore his death. He stated that four months before ad-
mission he had begun to sufter from lumbar pain, and
three months later from prickling and numbness in the
legs and thighs quickly followed by weakness. Then
a marked '" girdle" sensation had been felt about the
waist. Over the trunk and legs was a marked reduc-
tion to sensibility, pain, and temperature. During the
last month of life he became very dull. The autopsy
showed a tumor encircling the cord and invading the
eighth and ninth dorsal segments, and destroying all
of the cord at that level except a little anteriorly.
There was a small nodule in the lung, and in the
brain were eleven tumors varying from half an inch to
one and a half inches in diameter. These tumors were
very vascular and papillary, the papilla; being covered
with cylindrical epithelium. The tumor in the spinal
cord had given rise to the clinical picture observed.
It was conceivable that these numerous tumors in the
brain and the one in the spinal cord might have been
secondary to the tumor in the lung, which was about
three-fourths of an inch in diameter. Clinically it
would appear that the tumor of the spinal cord was
not the primary one, yet in the four cases reported it
had been shown that a considerable neoplasm might
exist in the brain without clinical symptoms. From
the fact that the largest tumor in the bodv was in the
1 68
MEDICAL RECORD.
[August I, 1896
brain, and was in the descending horn of the hiteral
ventricle, wiiere two or three tumors had been re-
corded, and from the vascularity arid papillary char-
acter of the tumors, he thought it was safe to conclude
that the tumor began as a papilloma of the choroid
plexus of the descending horn of the lateral venrricle,
and afterward passed into the category of carcino-
mata.
Dr. a. Jacobi asked why Dr. Thacher had sus-
pected in the case of the adeno-carcinoma of the
scapula that there was also a tumor of the alimentary
canal.
Dr. Thacher replied that the regularity of the cy-
lindrical cells and the mucous contents of the alveoli
were probably the most striking features which had
led him to think there might be a tumor in the ali-
mentary canal.
The President said that he thought a metastatic
tumor often preserved a suggestion of the structure
from which it had developed. He had noticed this
particularly in adenomata of the breast and of the
stomach. In the former there was very frequently a
distinct suggestion of a compound tubular gland pre-
served, although the growth might be extremely irreg-
ular in other respects and abundant. In the stomach
he had noticed a preservation of the type of a simple
cryptic gland.
Dr. Wood e.xhibited under the microscope sections
from a
Tumor of the Cerebellum. — These sections had
been taken from a patient who had been admitted to
the St. Luke's Hospital to Dr. Kinnicutt's service
about two weeks before death. There had been
cough and pain in the left side before admission, and
on entering the hospital bloody fluid had been found
in the pleura from which nearly a pure culture of tu-
bercle bacilli had been obtained. About one week later
the man had become comatose, and this condition had
been associated with rigidity of the muscles of the arm
and some hyperaesthesia. .\t the autopsy the pleura was
found to be very much thickened, there were a few old
cicatrices in the lungs, and a number of pale yellowish
nodules scattered through the brain — two or three in
the cerebellum, two or three in the cerebrum, and one
in the optic thalamus. There was no new growth in
the alimentary canal. The tumor of the cerebellum
was thought to be an endothelioma, (i) because the
cells were developed in the perivascular lymph spaces,
and (2) because the growth had a distinctly tubular
character.
Dr. Thacher said that at the autop.sy he had felt
positive that these were masses of tubercle, but the
structure seen under the microscope certainly resem-
bled carcinoma. As only one nodule had been exam-
ined microscopically he could not say whether the
growth was endothelial or epithelial.
The society then went into executive session.
S/ii/i-i/ AfL-ciiiig, February 26, lSg6.
Lesions of the Heart and Blood-Vessels.— Dr.
George P. Biggs presented four specimens illus-
trating sudden death due to occlusion of the coronary
arteries. The first one was from a man, twenty-five
years of age, a cooper by occupation. Alcoholism and
syphilis were denied. The patient after going up a
flight of stairs walked into a friend's room and sat
down. After talking for a few minutes his head sud-
denly fell upon his chest, the breathing became rapid,
and the face cyanotic. He was speechless and could
not be aroused. The ambulance arrived about fifteen
minutes later, and then the breathing was slow, irreg-
ular, and shallow, and there was no perceptible radial
pulse. On admission to the hospital his breathing
was shallow and irregular, he was cyanotic, and the
pulse could not be felt. After free stimulation he re-
vived sufficiently to answer a few questions. He stated
that he had not been drinking for a year past, that he
had no pain, and that he was extremely thirsty. In
spite of the cyanosis there was no feeling of suff'oca-
tion. He soon relapsed into unconsciousness, and
oedema of the lungs developed very rapidly. He died
about an hour and a half after the development of the
first symptoms. At the autopsy rigor mortis was well
marked; there was no oedema; the diaphragm was at
the level of the fifth space on the right side and the
sixth space on the left. The heart was found very
greatly distended with blood, which was dark in color
and largely fluid. The cavities of the heart were di-
lated and the walls correspondingly thin. The heart
muscle was rather soft but of normal color. The
valves were normal except for slight thickening at
the bases of the mitral and aortic cusps. There were
several elevated, yellowish areas of atheroma in the
aorta, two to five millimetres in diameter. Attached
to two of these areas in the anterior portion of the
aorta just above the aortic valve were two thrombi.
The larger one of these was attached near the opening
of the left coronary artery by three small finger-like
projections onlv, and was irregularlv cylindrical in
shape, measuring one and a half by one-half centi-
metres. It was found lying in the most anterior sinus
of Valsalva, completely filling it, and causing the
aortic cusps, back of which it lay, to remain in the
close position. More careful examination revealed
that the left coronary artery, which arose from this
sinus of Valsalva, was completely closed over by the
thrombus. The second thrombus was half a centi-
metre in diameter, and was attached loosely a little
above the first one. The coronary arteries were mod-
erately atheromatous. The kidneys showed slight
chronic diffuse nephritis.
The speaker said that the case was interesting as
showing how easily the cause of death in such a case
might be overlooked. The smaller thrombus had
fallen off, notwithstanding the care taken in the re-
moval of the heart, and was found only after careful
search of the blood left in the pericardial sac. The
larger thrombus, the one obstructing the coronary ar-
tery, was so loosely attached that it dropped off during
the incision of the heart, and if the aorta had not been
inspected from above before making the incision the
position of the thrombus would have been entirely
overlooked. Apparently the thrombi had been in ex-
istence for a considerable time, but had caused no
trouble, as they had been regularly washed upward by
the blood current. For some reason the larger one
had suddenlv fallen backward and occluded the left
coronary arterv, tlius causing the sudden cardiac fail-
ure.
The second specimen was from an autopsy made
some time ago for Dr. Robert Milbank. The pa-
tient, a male of thirty-one years, gave no histor)' of
syphilis, rheumatism, or malaria, and had enjoyed
good health with the exception of attacks of what
were described as '" painful dyspepsia." He had re-
cently taken a good deal of violent exercise. At 2
P.M. on the day of his death he had taken a hearty
lunch with a friend at the club, and at 4 p.m. had been
seized with severe epigastric pain. When seen by Dr.
Milbank he was suffering inten.sely and was only
temporarily relieved by the hypodermic injection of
large doses of morphine. .After an hour or two some
water)- mucus was vomited. The pulse was small and
rapid — no to 124. The patient w-as conscious almost
to the last, and walked across the room shortly before
death. He died about six hours after the first symp-
toms. The autopsy re\ealed an embolus of consider-
able size, lodged in the left coronary artery. In the
.aorta were two small thrombi, one attached just at the
August I,
1896]
MEDICAL RECORD.
169
The other organs of the
mouth of tiie left coronary artery, the other attached a
little higher up. A considerable portion of the throm-
bus at the mouth of the left coronary arter)' was miss-
ing, and was undoubtedly the source of the embolus in
that vessel. There were no dirombi in the heart cavi-
ties. The organ was of normal size, and its valves
were normal. There was an endarteritis of the aorta,
apparently rather acute in character. The sub-peri-
cardial adipose tissue was rather thick, particularly
over the right ventricle
body showed no important lesions.
The third specimen was from a sailor, forty-eight
years of age. Two days before admission to the hos-
pital, while lifting a heavy weight, he had been sud-
denly seized with severe pain referred to the left
hypochondriac region. This was soon followed by
dyspncea, and both pain and dyspncea had been con-
stant since tliat time. The pulse was found to be
very irregular and feeble, the face extremely con-
gested, and the feet were slightly cedematous. No
cardiac murmur was audible. The respirations were
rapid and feeble, and moist rales were heard over
both sides of the chest, anteriorly and posteriorly.
His temperature was 101.4" F., respirations 56, and
pulse loo. Notwithstanding free stimulation he died
a few hours after admission and two days after the
onset of the symptoms. At the autopsy the body was
found to be very obese; rigor mortis was very marked:
the diaphragm was at the si.xth rib on the right side
and the sixth space on the left side. Each pleural
cavity contained six hundred cubic centimetres of
serous Huid, and the pericardium seventy-five cubic
centimetres of serous liuid. The heart was very
greatly enlarged; its cavities were all verj' much di-
lated and distended with partially clotted blood.
There was slight hypertrophy of the left ventricle.
The valves of tlie left side were very slightly thick-
ened, but no incompetence could be detected. An
ante-mortem thrombus completely filled the left auri-
cular appendix, and a second thrombus, measuring
two centimetres bv one centimetre was attached in the
apex of the left ventricle. The most anterior sinus of
Valsalva was completely filled with an ante-mortem
thrombus, which held the cusp completely closed.
This thrombus covered over the opening of the left
coronary arterv', and was continuous w-ith a similar
clot which filled the coronary artery almost completely
for three centimetres. The primary site of the devel-
opment of this thrombus was apparently in tlie aorta
very near the opening of the coronary artery. The
aorta and coronary arteries were moderately atheroma-
tous. The muscular substance of the heart was soft,
pale, and friable throughout. The lungs were ex-
tremely cedematous. The spleen was normal. The
kidneys showed a moderate amount of chronic diftuse
nephritis. The right one contained a recent infarction,
one centimetre in diameter. The vessels at the base
of the brain were moderately atheromatous. The
other organs were practically normal.
The speaker said that it was probable that the dysp-
noea and feeble irregular heart action which sud-
denly developed shortly before death were due to a
more complete closure of the left coronary arter)-.
This obstruction was probably developed rather slowly,
so that the disturbance of the heart action was not so
marked as in the other cases.
Rupture of the Heart with Myomalacia. — For
the fourth specimen Dr. Biggs said he was indebted
to Deputy Coroner O'Hanlon, who performed the au-
topsy. It had been removed from a man of sixty
years who, for a year or more, had been troubled with
indefinite precordial oppression and occasional at-
tacks of angina. On tlie day of his death he went out
feeling as well as usual, but was suddenlv seized with
a severe attack of angina just as he reached his desti-
nation. He succeeded in mounting a flight of stairs,
but died almost instantly after doing so. At the au-
topsy the pericardial sac was found distended with
blood. The heart was of normal size and was cov-
ered with considerable adipose tissue. Just at the
junction of the outer wall of the left ventricle with
the inter-ventricular septum was a large, ragged tear,
about two centimetres in length. The cardiac muscle
around this area was softened and torn. From this
point of rupture the course of the blood was traced al-
most directly outward to the visceral layer of the peri-
cardium. It then dissected its way upward to the
base of the ventricle, lifting up the pericardium and
forming a large hamatoma over the entire base of the
left ventricle. The final rupture was shown by a
linear ragged tear of the pericardium, about two cen-
timetres long. The valves and the coronary arteries
were ver}' atheromatous. About one centimetre from
the origin of the right coronary artery the lumen of
the vessel was very materially encroached upon by
atheromatous deposit, and finally completely occluded
by a recent thrombus. The rupture occurred in the
particular area supplied by this artery and was the
result of myomalacia following its obstruction. Dr.
Biggs referred to a recent article in the Journal oj
Experimental Medicine, in which Porter described
some experiments he had made on dogs by ligating
or partially occluding the coronarj- vessels. This ex-
perimenter's conclusions in part were: (i) That the
frequency of the arrest of the heart as a result of this
occlusion depended upon the size of the vessel ligated:
(2) that the rapid closure of a coronary artery was
invariably followed by death of the part it supplied,
and tliat the process was a typical coagulation ne-
crosis; (3) the disturbed action of the heart and final
arrest he attributed to the disturbance of the co-ordi-
nation of the heart, due to the anamia of a consider-
able portion of the heart muscle. On the passage of
a glass tube down through the innominate into the
coronary artery he noted invariably an almost imme-
diate development of irregular heart action widr a
weakening of the contraction and lowering of the ar-
terial pressure. If this occlusion were allowed to con-
tinue, the heart very soon became arrested. If the
glass tube were soon removed, the symptoms disap-
peared and the heart's action returned to its normal
state, showing that it was the ana;mia of the part sup-
plied which had disturbed the mechanism. By con-
necting the end of the glass tube w ith a supply of
defibrinated blood diluted with salt solution, and sup-
plying in this way nutrition to the area thus obstructed,
he was able to keep up the normal action of the heart
for a long time, thus demonstrating that the presence
of the foreign body was not itself responsible for these
symptoms. Cases of complete coronary obstruction,
the speaker said, were rarely obser\-ed clinically, and
still more rarelv diagnosticated, owing partly to the
suddenness of death and the variability of the symp-
toms. The clinical picture usually presented is
briefly as follows: Rapid, irregular, feeble heart;
dyspncea and pulmonary ctdema, with or without pre-
cordial pain. The absence of pain was a character-
istic feature of the first case presented, while in the
second case the pain was described as " intense," and
in the third and fourth cases as " severe." An inter-
esting feature of the first two cases was the compara-
tively early age, twenty-five and thirty-one years, a
period of life when coronary lesions are not usually
expected.
The next specimen exhibited was one showing ex-
tensive replacement of the muscular tissue of the left
ventricle by fibrous tissue. This was due to a grad-
ual occlusion of the left coronar}- arterj- by atheroma-
tous and calcareous changes. As the specimen had
been previously presented to the society, it was shown
I/O
MEDICAL RECORD.
[August I, 1896
only as an illustration of the possible remote effect of
coronary obstruction.
Ulcerative Endocarditis. — The last specimen in
this series was one from a case of ulcerative endocar-
ditis. It had been removed from a man, thirty-seven
years of age, who had been well up to nine days be-
fore his admission to the New York Hospital, when he
had had a chill. On the second day of his illness he
was feverish, and suffered from shortness of breath
and pain in the left side. He then developed also
cough with mucous expectoration. A second chill oc-
curred on the si.xth day. On admission his tempera-
ture was 104° F., respirations 40, and pulse 120.
Physical examination showed an area of dulness with
bronchial voice and breathing on the left side oppo-
site the angle of the scapula and near the spinal col-
umn. The heart action was regular, rapid, and
strong. The urine contained a trace of albumin with
granular casts. The patient improved under stimula-
tion and tonic treatment up to the twenty-first day of
his illness, when the temperature suddenly rose to
105.3' F. For some da}-s previously it had been be-
low 100° F., and his pulse had been between 72 and
80. The temperature soon subsided, was lower for
four days, when another chill occurred, with a tem-
perature of 104° F., followed by profuse perspiration.
The blood was examined for malarial plasmodium,
but none was found. After this time chills were of
frequent occurrence, and were associated with profuse
perspiration and a septic type of fe\-er, the tempera-
ture frequently rising to 106' or 107^ F., and often
falling to normal. Prostration rapidly increased, and
he died during the tenth week of his illness, and in
the si.xth week after the development of symptoms of
general sepsis. The autopsy revealed abundant adhe-
sions over the left lung, and a few over the right lung.
The heart was about normal in size; its cavities were
dilated and greatly distended with blood: the muscu-
lar substance was pale and soft; the mitral and pul-
monary valves were normal. Two of the aortic cusps
were normal, while the third had attached to the lower
two-thirds of its inferior surface a large amount of
grayish coagula. Three ragged perforations, the
largest four millimetres in diameter, through this
aortic cusp were found in the area with which the
thrombi were connected. Examination of the cusps
from above showed no vegetations, but there was con-
clusive evidence of the development of a large aneu-
rism of the valve prior to the rupture. The tricuspid
orifice was almost completely filled with firm, whitish
thrombi, which were attached to the superior surface
of the valve. The largest thrombus measured two and
a half centimetres in diameter. All the thrombi were
solid throughout. Examination in the fresh state and
by cultures showed large numbers of capsule diplo-
cocci. A large part of the lower left lobe of the lung
was still consolidated. There were a few areas of in-
farction in the upper lobe, and thrombi were present
in many of the pulmonary vessels. The right lung
contained infarctions, and the vessels leading to those
areas were occluded by thrombi. The spleen was
slightly enlarged and soft, but contained no infarctions.
Both kidneys showed moderate parenchymatous degen-
eration; the right one contained an infarction.
The President said that only a short time ago he
had seen a review of a German article which stated
that experiments like those described had been tried
on dogs and rabbits. In this article it had been as-
serted that total occlusion of the coronary arteries
caused complete arrest of the heart in about two min-
utes, and that if the occlusion were complete for a
short time only and the blood then readmitted to the
vessels the heart would recover. The specimen of
interstitial myocarditis was of extreme interest in con-
nection with the subject of aneurism of the heart.
Double Aorta and Dissecting Aneurism — Dr.
\\'iLi,l.\MS, of lluffalo, presented a specimen of double
aorta and dissecting aneurism. The patient, a man
of fifty -eight years, had been under the care of Dr.
Charles G. .Stockton, who had first seen him on Sep-
tember 27, 1894. The patient said he had never been
sick up to eight years before, when he had had a se-
vere attack of pneumonia. The previous winter he
had had some shortness of breath and tumultuous
heart action, and since then more or less dyspncca on
exercise or excitement. His height was five feet nine
inches, and his weight two hundred and sixteen
pounds. He presented a distinctly livid appearance:
the pulse was weak and irregular; the capillary circu-
lation was poor; there were dry cough and scanty
mucous expectoration. Physical examination showed
emphysema of both lungs with congestion at the
bases. There was a systolic bruit at the apex of the
heart, conveyed far to the left. The impulse was dif-
fused and scarcely perceptible. When lying down the
patient's face became greatly congested. One month-
before this time this man had successfully passed an
examination for life insurance. It was found that he
voided eighteen hundred and twenty-four cubic centi-
metres of urine in the twenty-four hours, which con-
tained 17.8 grams of urea, that the specific gravity
of the urine was i.oio, and that it was free from
sugar and indican. Under treatment with digitalis,
hot-air baths, and faradization, his general con-
dition improved considerably. One morning he was
found dead in bed without having made any complaint
during the niglit. The autopsy was made about twelve
hours after death. Rigor mortis was finn. The sub-
cutaneous fat was three-fourths of an inch thick over
the thorax and two inches thick over the abdomen.
There was a quantity of bloody serum in the left
pleural cavity, and a large firm blood clot. The left
pleural cavity was full of clotted blood; the right
pleural cavitv was emptv. The heart was very large,
its muscle thick and firm, and there was hypertrophy
and dilatation, especially of the left ventricle. The
mitral orifice admitted two fingers. The valves were
stretched, but not thickened. There was moderate
atheroma of the ascending aorta. The left kidney was
large, finn, and contained several small cysts. The
capsule was somewhat adherent, and the surface be-
neath granular. The right kidney presented a similar
condition. The kidney showed under the microscope
the changes of chronic diftuse nephritis. The spleen
and liver were normal; the stomach was small; the
large intestine and vermiform appendix were normal.
The upper and posterior wall of the aorta exhibited
an opening one-fourth of an inch in diameter and
nearly round. It was supposed at first to communi-
cate with the descending aorta, which had ruptured
into the pleural cavity. The aneurismal dissection in
the thoracic aorta appeared to the left and in front,
extending behind beyond the middle line to the right.
Between the tenth and eleventh intercostal arteries it
was far over to the right and behind. At the level of
the renal arteries it had travelled still farther around,
and a little below this point it entirely encircled the
pair of aortic trunks to be subsequently described. It
reached to the bifucration of the aorta, and on the
right common iliac to its bifurcation into the external
and internal iliacs. The opening below the left sub-
clavian arter}^ did not communicate directly with the
aneurism, but with a vessel which was continuous
with the left common iliac. What had been supposed
to be the only aorta was continuous with the right
common iliac. The dissecting aneurism surrounded
both vessels more or less completely. The aneurism
had its origin in a rupture, not of the main artery
but in a channel to the left of it. It had stripped
off the pleura on the left side and had broken
August I, 1896]
MEDICAL RECORD.
171
through this, causing the fatal hemorrhage into that
cavity.
A careful examination .showed that there was a du-
plication of the aorta from the left subclavian down,
the two portions being separated b)- a complete septum.
The right was the larger and was in line with the de-
scending limb of the arch. The left branch did not
exhibit arterio-sclerosis. The principal vessels arose
from the right branch, except the anterior mesenteric,
which was given off from the left and behind. The
coeliac axis, superior mesenteric, and both renal ar-
teries arose from the right or principal branch. There
were ten pairs of intercostal arteries arranged along
the right aorta, most of them patulous. Many of the
intercostals opened from the right aorta into the left,
and went no farther.
Dr. Williams said that this condition was very rare.
Krause cited five examples of double aorta. In view of
the fact that in the development of the human embryo
the right and left systems of arterial arches fuse together
at a very early period, it was astonishing that the man
should ha\e lived to a good age in health and comfort.
Rupture of the Aorta. — Dr. J.\mes Ewing pre-
sented a specimen of rupture of the aorta removed
from a woman twenty-six years of age. She presented
no personal or family history of importance. The ill-
ness had begun three years before death with the ordi-
nary symptoms of acute nephritis developing after ex-
posure to cold. It was characterized at the onset by
oedema and dyspnoea. These symptoms continued ir-
regularly for about one year, after which ura;mic symp-
toms were added. She entered the hospital on Jan-
uary 27th and was then pale and cyanosed. There
was a paralysis of the right side of the face which had
appeared three months before. The pulse was 100,
somewhat irregular, and showed remarkably high ten-
sion. There was severe and constant headache, and a
constant feeling of sinking and choking about the
heart. She was given the usual remedies for reducing
arterial tension without much effect, and they were
finally stopped. Within two hours after discontinu-
ing the use of arterial dilators, she complained of se-
vere pain in the chest and became greatly prostrated.
The house physician then found in addition to the
loud systolic murmur, heard all over the precordiuni,
a remarkably harsh double murmur, heard loudest over
the aortic valve. The patient went into collapse, and
died within an hour. At the autopsy the kidneys were
found to be of about the normal size, the surface was
coarsely granular, the capsules non-adherent, the cor-
tex irregular in thickness, the markings obliterated,
and the kidney tissue in part replaced by uric-acid in-
farcts. There was very little congestion of the kidney.
The heart was moderately enlarged. The wall of the
left ventricle was very considerably hypertrophied
without dilatation. There was no roughening of any
of the valves, and there was only very slight athe-
roma. On opening the pericardium a large amount of
fresh bloody serum was evacuated. The heart was
surrounded by a thick dark clot. Some difficulty was
experienced in finding the origin of the blood, so the
abdominal viscera were removed and the aorta
stripped up. On reaching the aortic valve the finger
was passed into a peculiar pouch. About one inch
above the aortic cusps was a clean linear rupture of
the whole aortic wall, and through this rupture the
blood had infiltrated the tissues around the aorta, and,
rupturing into the pericardium, had infiltrated the tis-
sues of the aorta to the middle of the transverse arch.
At the origin of the left subclavian artery could be
seen a healed partial rupture of the subclavian vein,
about three-quarters of an inch in length, which ap-
fieared as if the intima and media had been slightly
displaced on the adventitia. The remainder of the
aorta showed very little atheroma.
The speaker remarked that at least two such cases
had been reported to the society within tlie past few-
years.
Dr. Geori;e P. Biocs said that about a year and
a half ago Dr. Ferguson had presented to the society
a specimen showing a vertical linear rupture in the
aorta, situated just a short distance above the aortic
valve. In this case the blood, after having dissected
along the aorta nearly its entire length, had finally
broken through into the pericardium, causing sudden
death.
Dr. Van Horne Norrie recalled a case of rupture
of the aorta, seen about two years ago in a male pa-
tient in St. Luke's Hospital. This man was suffering
from phtiiisis and nothing unusual had been noticed
until about half an hour before his death, when, after
a sudden attack of pain around the heart he went into
collapse and died. The autopsy showed complete
transverse rupture of the aorta about one inch above
the aortic orifice, and a large amount of blood in the
pericardial sac. The gross appearance of the aorta
was normal.
Dr. Ewing said that Dr. Delafield thought that the
primary cause of the rupture in the case he had just
reported had been the high tension of the arteries.
From the gross and microscopical appearances of the
specimen presented, it was evident that the rupture
had not been due to the giving way of a cicatrix of
syphilitic origin.
The society then adjourned.
(CUiiical department
A CASE OF FATAL TRAUMATIC MYO-
CARDITIS (?).
Bv R. V.VX SAXTVOORl), M.D.,
.NEW YORK.
The following case presented from the standpoint of
pathology so many points of interest upon which little
light is shed by recent literature, in addition to its
medico-legal importance, that it seems worth reporting,
although, in the absence of an autopsy, it is unfortu-
nately incomplete.
L. Z , aged twenty-four, an engineer by occupa-
tion, had consulted his physician, Dr. G. W. Oakes,
of Williamsbridge, a few days before the accident
about to be narrated, for a trifling derangement of di-
gestion. He was otherwise well and able to attend to
his work. On June i, 1894, a wagon in which he was
riding was struck by a trolley car and he was thrown
violently to the pavement. Just how he fell I was not
able to ascertain. He was taken to a hospital and ten
days later to his home, where he was attended by his
own physician. On July 2d I saw him in consultation
and found the following: He was seated with his
elbows resting on a table in front of him, suffering
from great dyspncta. There were old ecchymoses
about the right side of the head and face. The pulse
was feeble, regular, beating 136 per minute. The
heart was not appreciably enlarged or dilated. Its
sounds were weak but normal. There were a few
moist rales over the lower lobes of both lungs. The
legs and feet were very cedematous. There were no
fractures of ribs or evidences of intracranial injury.
I was informed by his physician that the symptoms
had been the same, thougli at fir.st not so intense, dur-
ing the period of his attendance since the accident and
the patient was saitl to have sutTered similarly in the
hospital, though of this part of the history I could get
no satisfactory account. On July 5th death occurred
from cardiac exhaustion.
172
MEDICAL RECORD.
[August I, 1896
We have here a case of fatal cardiac lesions, the
exact nature of which was not self-evident, resulting
from traumatism, but without any penetrating wound.
An erroneous statement that a diagnosis of fracture
of the base of the skull had been made at the hospi-
tal led me to consider first the possibilit}- of some
nerve lesion. Rapid heart action has been observed
in cases of lesions of the medulla, presumably from
paralysis of the pneumogastric or by pressure upon the
latter by tumors in the thorax. Neither in the one
case ' nor in the other" does the rapid heart action im-
peril life. In Bouveret's article on paroxysmal tachy-
cardia' several fatal cases of this disease are recorded
and the theory is advanced that the disease is due to
the exhaustion of the cells of the bulbar centres of the
vagus. In the only case among those which Bouveret
regards as typical of this malady, that of Bristow,'
death did not occur during a paroxysm and no lesion of
the nervous system was found, but the heart was much
dilated. In view of the facts that in cases of demon-
strated lesions of the medulla and of the pneumogas-
trics, the heart's action has not been so rapid as to
imperil life, and that the only case in which an au-
topsy has been recorded in a case of paroxysmal
tachycardia a lesion of the myocardium was found,
the statement that there may be a lesion of the vagus
centre or of any other ner\-e centre which betrays
itself by dangerously rapid cardiac action seems at
least unproved. In such cases a lesion of the myocar-
dium seems much more probable, in the light of our
present knowledge. These considerations led me to
think of the probability of the existence of a lesion of
the myocardium in my case.
A considerable number of cases of injury to the
heart due to non-penetrating injuries have been col-
lected by Fischer' and Schuster." More or less ex-
tensive lacerations and ecchymoses of the heart mus-
cle with or without injuries to the aorta and other
organs are related, death being caused by shock,
hemorrhage, traumatic aneurism, or secondary inllam-
mations. In only eleven of eighty-two cases collected
by Schuster did the patient survive more than twenty-
four hours.
Two highly suggestive cases are recorded by Hoch-
haus.' The first was that of an adult, forty-three
years old, previously healthy, who fell from a wagon,
breaking some ribs, though not in a locality involving
injury to the heart. His heart later was found to be
somewhat dilated, pulse 100-120, small and soft. He
became premanently disabled on account of his car-
diac malady. The second was a similar though more
complicated case resulting from a fall on the back.
Both were regarded as cases of chronic myocarditis of
traumatic origin.
It is to this class of cases of injur)' to the heart
muscle due to non-penetrating injury that the case
above narrated probably belongs. The lesion is sup-
posed by Schuster to be caused by concussion or bv
the direct crushing of the heart between the sternum
and the vertebra-, the latter springing back into place.
It seems not impossible that cardiac laceration may be
produced by spasmodic contraction excited by the
shock of the accident, as occurs not infrequently in
the case of the voluntary muscles.
In looking over the recent literature of this subject
I could find very little about the matter. It is not
probable that such cases are extremely rare. It is not
improbable that traumatism has a larger share than is
generally recognized in chronic diseases of the myo-
' Jacoby: X. Y. Med. Journal, 1S93, 373.
' Prodsting : Deutsch. Archiv f. klin. Med., x.\xi. , p. 349.
' Rev. de Med., i88g, p. 755.
* Brain, Vol. 4.
' Langenbeck's .Vrchiv, Bd. ix.
' Zeitschr. fiir Fleilkunde, 18S0-S1. p. 417.
■ Deutsches .\rchiv f. klin. Med., ii., p. i, 1S92.
cardium, as exemplified by the two cases related bv
Hochhaus above referred to. The effect of trauma-
tism on the cardiac valves has long been recognized.
I publish this case in the hope that it may attract at-
tention to the less readily recognized lesions of the
myocardium due to injury and lead to the publication
of illustrative cases.
106 West 0.\-e Hlndkeu and Twentv-Second Street.
A CASE OF GLOSSITIS.
Bv W. WASHBURN, M.D.,
NEW YORK.
J. M. H , aged forty-five, commercial traveller, had
generally enjoyed good health, but had been subject
to what had been termed malarial attacks, for which
he had been treated by quinine. About December
I St the patient discovered a small ulcer on the inside
of the left cheek, which after washing with witchhazel
disappeared. He had not had syphilis.
On December 5th the patient presented himself at
my office for treatment for sore throat and pain down
the left side of the neck. He was well nourished,
rather fleshy. The skin was of good color and the
eyes were clear. The pulse was 90, temperature 100^
F., respiration 22. The left tonsil was enlarged
slightly, with marked redness, localized on the an-
terior inferior surface. I ordered a gargle of tannic
acid and potassium chlorate. Early the following
morning I was summoned in haste, the messenger
saying that the patient was choking to death. When
I reached the patient he was in bed, conscious
but unable to speak, and had a feeling as though he
could not breathe. The nose was, however, free and
with a little encouragement he soon learned that he
could not only breathe properly but also swallow
without any great difficulty. The mouth was forcibly
open and the tongue filled the whole opening, the
teeth being embedded in the tongue. Closer exam-
ination showed that the left side of the tongue was
extremely thickened — nearly three inches thick — and
that the right side was very little affected. Cracked
ice was immediately applied to that portion of the
tongue that could be reached. Diagnosis: Left hemi-
glossitis. The sublingual veins were opened as soon
as a knife could be procured, some fifteen minutes
later. The patient could articulate (very thickly)
immediately after liie blood began to flow, and his
mental condition improved at once. Ice was ordered
now for external application, as the left cheek and left
side of the neck were beginning to swell rapidly. An
hour later more blood was drawn from under the left
side of the tongue, with relief (for the patient had again
become unable to articulate. The bleeding was re-
peated each hour thereafter until about noon, after
which the swelling did not again increase on that side of
the tongue, but began on tiie right side and rapidly in-
creased, so as to make articulation again very difficult.
The same treatment was applied on the right side of
the tongue that had been given to the left, and in the
mean while three leeches were applied to the lower
angle of the left jaw. At i p..m. the pulse was 108;
temperature, 101 ' F. : respiration 18 and pretty full.
The leeches were still on the left side, and the right
side of the face and right side of the neck were swelling
but under control by blood-letting from the under sur-
face of the tongue. Here a different course had to be
adopted in bleeding, for the veins could be seen, there
having been so mucli rolling over of the tongue to the
right side, and longitudinal cuts were therefore made
as near the under side as possible. The bleeding was
at first not very free, but a little later the veins were
reached and the improvement was as rapid as it had
August I, 1896]
MEDICAL RECORD.
173
been on the left side. A catheter was left with the
nurse, with instructions how to use it in case of oedema
giottidis. Solution of acetanilid in fifteen-drop doses,
about one grain, was given every hour. Swelling of
the right side of the tongue began to go down rapidly
about 2 P.M., but the glands of the neck on that side
remained swollen.
The mouth was now douched with ice water, as pa-
tient could control the water from going down the throat.
This was continued for ten minutes and repeated each
hour. Mustard leaves were applied to the feet and
removed when these became very red. Hot applica-
tions to the abdomen were also made.
The subsequent incisions in the tongue showed
white lines of tenacious pseudo-membrane (the knife
and hands were thoroughly aseptic). The mouth was
sprayed every hour with a solution of the perman-
ganate of potassium. Patient left the city on Decem-
ber loth and has not been heard from since.
The case presents some peculiar features. No cause
could be found for the glossitis —there were no sharp
edges of any of the teeth. The patient had never had
syphilis and no other known poison had been absorbed
or injected; recovery took place without the forma-
tion of pus. The case is reported as interesting be-
cause of these features and the probability, so far as
can be seen, of the glossitis being the direct result of
cold, as is claimed by some authors, among whom
Cohen, in " Pepper's System of Medicine," may be
quoted.
One other feature deserves mention — the fact that
first one side of the tongue only was affected and then
the other, and to this may be attributed the further
fact that there was no protrusion of the tongue, as is
usually the case, but rather a rolling over and point-
ing downward of the tip, which was caught behind
the lower teeth and during the time it was swollen
could not be dislodged from that position, except
partiallv.
BIL.\TERAL ORCHIDECTOMV, SUPRAPUBIC
CYSTOTOMY. FOLLOWED BY ,\(;;UTE MA-
XLV AND DEATH.
Bv WILLIAM WARREX TOAVXSENH, M.D.,
RUTLA-ND, VT.,
CEKITO-L"RINAi;V SLRL.EON, \ERMONT STATE HOl'SE OF CORRECTION.
Re.alizixg that the advisability of bilateral orchidec-
tomy for prostatic hypertrophy is still under discus-
sion, and believing that it is the duty of every operator
to give a full and detailed history of cases that come
under his observation, I report the following:
S. M. P , aged si.xty-seven, farmer, came to con-
sult me in regard to a bladder trouble which he had
had for the past five years, and gave the following
history: L^p to the beginning of his trouble he had
always enjoyed good health, and had been a hard
worker. He was always very energetic se.xuallv. He
gave a complete history of beginning prostatic hvper-
trophy, namely, frequent and nocturnal micturition,
lack of force to stream, etc. The use of the catheter
began two years before, as voluntary micturition had
become impossible, and .since then he had consulted
a number of physicians, who advised various internal
remedies, vesical irrigations, and suppositories. Since
using the catheter he had been growing worse; intro-
duction of the instrument was getting more painful,
and had to be performed every hour, day and night.
The urine contained a large quantity of pus and
some blood. The prostate was enlarged to about the
size of a goose egg. The passage of a searcher
through the prostatic urethra excited a severe parox-
ysm. The bladder contained 55 c.c. of residual urine
whicli was ammoniacal. Stone was suspected but was
not made out by the examination, as this was quite
painful and the patient would not consent to an anaes-
thetic merely for an examination. Cystoscopy was
not performed for the same reason. As the case
seemed to me to be an ideal one for bilateral orchi-
dectomy, and as the patient was in excellent con-
dition in other respects, I advised operation, which
was assented to. November 3, 1895, I performed the
operation in the presence of a number of my associ-
ates. The first forty-eight hours after operation the
patient was in excellent spirits, and other than pain
from the wound and that occasioned by catheteriza-
tion, which was performed every two or three hours
instead of every hour, as had been done previous to
operation, he suffered little. On the third day the
dressings were removed and the wound was found
to be healed. A collodion and gauze dressing was
put on and from the time of operation up to the fifth
day all went well. Catheterization was performed
every two or three hours and frequently when the beak
passed the cut-oft' muscle urine would flow out along
side the catheter.
Beginning about the fiftii day the patient, after the
bladder had been voided of its contents, experienced
severe pain near where the beak passed into the pros-
tatic urethra, and after the bladder had been voided
of its contents.
?"xamination of the prostate by palpation per rec-
tum showed that there had been atrophy. In passing
the catheter I detected a distinct grating on with-
drawing the instrument, and with the searcher and
various manipulations vesical calculus was made out.
Operation was advised and one week from the day of
orchidectomy I did a suprapubic cystotomy, and re-
moved three calculi weighing in all forty-eight grams.
The patient recovered from the shock of the opera-
lion and on the day following was doing well; the
urine was draining from the bladder and his condi-
tion was good.
The second day following the operation the temper-
ature ran up to 102° P., whereupon the gauze packing
was removed, the bladder washed out, and a drainage
tube inserted; the temperature came down to 101° F.
following the dressing. Pulse and respiration were of
good character up to within a few hours of death. The
next morning he had a normal temperature, but was
somewhat delirious. Thinking that there might be
some septic condition, I removed the tube, irrigated,
and repacked with gauze. He grew more delirious,
was very restless, and insisted upon getting out of bed.
Bromides and suiphonal failed to quiet him, and on the
following morning I found him in a maniacal con-
dition and requiring the services of several attendants
to keep him in bed. I called Dr. L. C. Stillings in
consultation, who advised hypodermatic injections of
liyoscine and feeding with the cesophageal tube intro-
duced through the nares (as the patient refused nour-
ishment, thinking that we were trj-ing to poison him).
This form of treatment was carried out until death
took place from exhaustion, eight days after the supra-
pubic operation and fifteen days after the bilateral
orchidectomy.
What caused this maniacal condition? We can
certainly eliminate the idea of sepsis, as the wound
was perfect in each operation, and so far as urrtmia
is concerned I think that also can be eliminated,
because a very careful examination, both microscopi-
cal and chemical, was made of the urine and no sign
of kidney lesion was discovered. Was it possible for
the mental condition to be due to the severe strain in
undergoing two such serious operations in so short a
time when recovery or rather alleviation from the
painful symptoms was anticipated as a result of the
orchidectom\? This we might expect in an hysterical
subject, but hardly in the patient in question.
'74
MEDICAL RECORD.
[August I, 1896
In reviewing the literature, I find a quotation from
the British Medical Journal, May 18, 1S95: "The au-
thor reports seven cases in which this operation was
performed and in the first hemiplegia occurred, with
death four weeks after the operation. The second
developed signs of acute mania six days after the ope-
jation and died ten days after; the third also devel-
oped mania and died on the twelfth day; the fourth
exhibited the same symptoms with the same result,
death. The fifth had no appreciable mitigation of
the urinary trouble thirty days later. The sixth was
one of single orchidectomy, Ijut the patient died in a
few days in a state of mental aberration; and finally
the seventh, also a single orchidectomy, developed
distinct mental weakness, and death followed."'
It is well known that when oophorectomy was first
teing done, numerous cases of mania were reported
following the same. Should the testicle and brain
not maintain the same relation to each other as the
ovary and brain? I will leave this to the neurologists.
In conclusion I will say that as for the operation
relieving the prostatic hypertrophy it was a success,
as there was a marked decrease in the size of the
gland, determined not only by rectal palpation but by
palpation and ocular demonstration through the supra-
pubic incision. Although unfortunate in not being
able to report a favorable case, I will operate again,
as the favorable cases that have been reported out-
number the unfavorable ones. In the case just re-
ported the prostate did decrease in size and I have
•every reason to believe that, had the patient lived, the
prostate would have been reduced so as to have allowed
the urine to be voided voluntarily /<:■/■ vias naturaks.
NARCOTINE IN MALARIA.
By LOUIS C. AGER, M.D..
ASSISTANT BACTERIOLOGIST TO THE HOAGI-AND LABOKATORV, BROOKLYN.
Ix the Medical Record for September 21, 1895, the
statement was made that the opium alkaloid " narco-
tine" or " anarcotine" was being used ver)' successfully
in India as a substitute for quinine. The drug was
recommended in the acute forms of malaria only, but
it occurred to me that it miglit be useful in hemicrania,
supraorbital neuralgia, and the other chronic forms of
malarial poisoning that are often so difficult to deal
with. After considerable difficulty I got some of the
drug from a wholesale house in New York and put it
up myself in two-grain capsules. The first case in
which I used it was that of a woman about thirty-five
years old. She had had acute malarial fever a few years
before and had been troubled with neuralgia in various
forms ever since. About a month before I saw her
she had a severe attack of hemicrania, which had only
been controlled by the hypodermic use of morphine.
When I saw her she was suffering from a similar at-
tack of a severe character. I gave her three two-grain
doses of narcotine half an hour apart, then two grains
every four hours, till about fourteen grains had been
taken. The patient was much relieved after the third
dose, and has had little or no return of the trouble in
the last three months.
Since that time I have used narcotine in a few simi-
lar cases with very good results. In one case there
was considerable heart depression about two hours
after the third dose, but not so much as sometimes
occurs after full doses of the coal-tar analgesics.
Although my experience with the drug has been far
too limited to furnish any positive knowledge of its
usefulness, I feel encouraged to try it further and to
:suggest it to others.
The Hot Iron. — Before using it render the skin
area ana-sthetic by applying pure synthetic crystallized
guaiacol, in quantity of from twenty to sixty drops.
— PiZE.
Epitheliomata of slight extent often give way to
such mild means as the following solution frequently
applied:
I? Resorcin 2 gm.
Potass, chloral 10 "
Aq. dest 300 "
— Brocq.
Burns of the Second Degree. —
I( Carbonate of lime 10 gm.
Oxide of zinc 5 "
Starch,
Linseed oil,
Lime water aa 10
Ichthyol 1-3 "
M. — Leistikow.
Orchitis. — Apply a few drops of guaiacol over the
scrotum. — Balzek.
Analgesia, without irritation of the skin, is best
obtained by adding an equal part of glycerin, or some
vehicle which can be absorbed by the skin, to guaia-
col, and covering with tissue to prevent evaporation. —
Ferraxd.
Tedious Labor After a case of tedious labor, an
iodoform pessary is to be inserted in the vagina. A
similar pessary is to be used night and morning for
the first three days, and once in twenty-four hours for
the next six days. — Clifton Dispensary Rules for Mid-
7vivcs.
Dr. Cheever, in the Boston Medical and Surgical
Journal, says it is not advisable to operate in glandu-
lar infiltrations so extensive as to preclude entire
removal ; neither is it w ise to operate when you can-
not remove the whole disease, as in a tuberculous or-
gan of which you excise a part, nor in a sarcoma of the
antrum in which you cannot extirpate the splienoid
cells. It is allowable to depart from these rules when
the pain is so agonizing that unless the suffering can
be palliated the patient had better die than live; and
also in a " forlorn hope," so-called, the patient is en-
titled to an operation if he assumes the responsibility.
Even then it is well not to operate unless there is some
slight chance of success.
Deaths from Anaesthetics. — The German Surgical
Society gives the following statistics for the past five
years in regard to mortality from anaesthesia: Chloro-
form was administered 201,224 times, with 88 deaths,
or in the ratio of i in 2,286; ether, 42,141 times, with
7 deaths, or in the ratio of i in 6,020; chloroform
and ether, 10,162 times, with i death; chloroform,
alcohol, and ether, 5,744, with i death; ethyl bromide,
8,967, with 2 deaths.
Spontaneous Straightening in Rickety Curves of
the Legs. — Dr. liruns concludes from observations
in Tiibingen (Beitrdge Cliir., vol. xvi., i) that tlie
greatest niunber of cases undergoes spontaneous cure
in from two to four years. If the curves are unchanged
at the sixth year, spontaneous cure does not occur.
The chief aim of treatment should be to improve the
general health. Of the number of cases under obser-
vation 75 percent, were cured, 15.3 per cent, were
improved, 9.7 per cent, remained unchanged. He
considers that after the acute stage it is not harmful
for children to be on their feet.
August I, 1896]
MEDICAL RECORD.
/o
Epididymitis. — The testicle should be wrapped in
lint Lind moistened frequently with lead water and
opium, or the following:
K Tincture of aconite.
Tincture of opium aa 3 i.
Dilute lead water,
Water aa ; ij.
Osteomyelitis. — Dr. Funkhouser, of St. Louis, says
the chief diagnostic point in osteomyelitis is the
acutely sensitive spot near the junction of the epi-
physes.
Fistula in Ano. — Dr. Gibbs, in the JVew York
JA-i//u!/ /I'/o/ia/, March 21st, gives two reasons for
failure in treating this trouble, i. We are by no
means sure of starting with an aseptic wound, though
it is a simple matter to lay open a small, superficial,
straight tract, and after thorough cleansing obtain im-
mediate union. It is a different matter with an old
fistula running under the skin and up around the in-
testine, with pockets and ramifications difficult to
find, and all surrounded with thickened, new-formed
connective tissue. In the latter condition, 2, the
difficulty of preser\'ing aseptic conditions long enough
to allow of firm union in an organ which has to be
functionally active, and at the same time is eliminat-
ing septic material.
Floating Bodies in Joints. — Dr. Halstead (A/i/nr/s
of Siirgiir, September, 1895) draws the following con-
clusions: I. That the etiology of some of these bod-
ies is not fully understood, but that the condition de-
scribed by Konig under the name of osteochondritis
desiccans explains most that are found in otherwise
healthy joints. 2. Few are the direct result of vio-
lence. 3. The most pronounced symptom is severe
pain in the joint, with locking of the joint, usually
in a nearly extended position, this being followed by
acute inflammatory processes. 4. The lengthening of
the femur when there are movable bodies in the knee
may be the result of irritation produced by the press-
ure of these bodies. 5. The only treatment is the
removal by direct incision, preferably using cocaine
anaesthesia.
Hypertrophy of the Prostate. — Where objection is
made to castration, remove a small portion of the vasa
deferentia and atrophy will follow. It may be done
under local anasthesia. Castration has given eighty
per cent, of cures. — White.
Abortion. — Dr. Jacub [Moiiatschr. f. Geburtsli. 11.
Gyiidk., September, 1895) thinks the right treatment
is rest and opium, with extract of viburnum prunifo-
lium. If there is free flooding with the os closed, the
vagina should be plugged with iodoform gauze or
aseptic wool. If the os is dilated to allow passage of
finger, the ovum should be detached and extracted and
the uterus syringed out once for all with any suitable
disinfectant solution. When dilatation of the os is im-
perfect and flooding grows severe, it is right to press
the finger forcibly through with great care and then
effect extraction. In many cases the e.xpulsion of the
ovum may be left to nature. Ergot should be given
for a week after abortion. Jacub deprecates the em-
ployinent of the curette and vaginal irrigation.
Septic Peritonitis. — Dr. Brown concludes: i. That
septic peritonitis is a surgical condition, and should at
the earliest possible moment be put under surgical
supervision. 2. That all cases of acute diffuse peri-
tonitis are not necessarily fatal, and while the mortality
following operation must be great, many of these cases
■can be cured by prompt resort to the knife. 3. That
;success in these cases will depend on : {a) early ope-
Tation ; [h) careful cleansing of the abdominal cavity
by sponging and irrigation ; [c) by drainage by means
of glass drain, supplemented if necessary by gauze.
4. That all such cases should be operated on. Xo
surgeon should fail to give his patient the benefit of
the chance afforded by operation, no matter how des-
perate the condition may be; they all die without
operation and many desperate cases are cured by
prompt surgical interference. — Medical Afirror, May,
1896.
Tinea Tonsurans — Dr. Harvey thinks that much of
the scalp trouble found in institutions is due to the
careless and too frequent use of hair-clippers. Girls
with long hair seldom have ringworm of the scalp.
Dog-Tail Sutures. — It is said that the tendons
found in the tail of a dog make better sutures than
either catgut or kangaroo tendon, when properly pre-
pared in sublimate. — Peoria Medical Jourtial.
Preservation of the Perineum Dr. Oliver, be-
fore the Ontario Medical Association, June, 1896,
says that his method, when the perineum was rigid,
was to introduce two fingers of the right hand into the
vagina, and with each pain stretch the perineum in
advance of the head. When full expansion is com-
plete two fingers are introduced behind the occiput,
and this part of the head is brought well down under
the pubic arch. This, he claimed, should be a rou-
tine practice. He also advocated the method of ex-
pelling the head in the interval between pains by
means of the thumb or finger in the rectum.
Local Anaesthetics Dr. Loup [Bulle/in Medical,
1896) says that when a fluid is injected under the
skin the ner\e filaments are rendered insensible by
driving away the blood and temporarily preventing its
return, producing an anamia. Dr. Loup, acting on
this principle, has succeeded in producing an ana;s-
thetic area by means of a perfectly neutral substance
— sterilized olive oil.
Shall We Operate for Simple Fracture of the
Cranial Vault? — Dr. Nancrede replies: "Bearing
in mind the immediate risks of encephalitis and the
future ones of epilepsy and insanity, there can be but
one opinion as to the advisability of operating for all
varieties of accessible fractures. An exploratory in-
cision made with strict antiseptic precautions will re-
solve any doubt in cases of head injury, and if no
bone lesion be found will heal promptly, adding noth-
ing to the risks."
Ruptured Urethra Dr. Cabot {Journal of Cuta-
neous and Genito- Urinary Diseases, July, 1896) savs:
I. In every case of ruptured urethra, immediate peri-
neal section, with suture of the urethra, should be
practised. 2. By this procedure not only do we greatly
lessen the danger of urine infiltration and abscess, but
we also, in a large proportion of cases, may hope to
prevent the formation of close, intractable strictures.
3. In the early operation the search for the posterior
end of the urethra is much easier than in the later.
The hemorrhage from the branch of the artery of the
bulb serves as a guide to that end of the canal.
Fibroids. — Dr. Martin says the indications for
vaginal hysterectomy proper for fibroids must of ne-
cessity include only the smallest tumors, or, at best,
fibroid uteri with long slender subperitoneal projec-
tions. The operation is often the ideal method of
treating small multiple fibroids, which are so frequent-
ly the cause of severe uterine pains and excessive hem-
orrhage. Fibroids of considerable size may be
treated by vaginal hysterectomy, when the uterus is
low in the pelvis and the vagina is large and the tissues
are loose. It is easy to turn a vaginal hysterectomy
for fibroids into a morcellement if it be necessarj'.
176
MEDICAL RECORD.
[August I, 1896
Cfovrcspo ntXcnce.
OUR LONDON LETTER.
(From our Special Correspondent.)
ELECTION' OF COUNCILLORS OF COLLEGE OF SURGEONS —
E.XHIBITS IN THE HUNTERIAN MUSEUM — RU.MORS
ABOUT THE BRITISH MEDICAL ASSOCI.\TION — UNI-
VERSITY OF LONDON IN THE LORDS — HOSPITAL
MANAGEMENT QUESTION EDINBURGH INFIR.MARY —
GLOUCESTER EPIDEMIC TESTI.MONIALS — THE LATE
DR. RALFE.
London, July 10, 1896.
The election at the Royal College of Surgeons has
terminated in a way ratiier disappointing to the re-
formers. Mr. Bryant, Mr. Davies-Colley, and Mr.
Pick were elected. There was no e.xcitement what-
ever at the college, partly due, no doubt, to the large
number of voting-papers which were employed, ren-
dering it unnecessary for the voter to appear in per-
son. Mr. Davies-Colley supplants, so to say, Mr.
Cadge, who usually voted in favor of reforms; so that
the fight to secure them will be more arduous, and
this election will be looked back upon as a decided
check. It is not, perhaps, of much consequence, but
the fellows seem determined to stick to all their privi-
leges and deny the members any share in the govern-
ment of their own college.
From July ist to 4th there was, as usual, an e.xhibi-
tion of the additions made to the Hunterian Museum
during the past year. They were placed in the coun-
cil room of the college and examined with considera-
ble interest. There is a very fine specimen of the
gigantic extinct bird, nioa, of the New Zealand South
Island. The bones, I heard, did not all belong
to one bird, but they have been very carefully selected
to match, and some which could not be obtained have
been supplied by accurate casts. It was said, too,
that this skeleton is particularly valuable, as it con-
tains both great toes and both coraco-scapulaj, as
neither of these are to be seen in a specimen in the
British Museum. A collection of cystic and other tu-
mors originating about tlie kidney attracted some at-
tention, as did a skeleton showing the changes of os-
teitis deformans. The dissected legs and feet from a
case of congenital abscess of the tibia were also
shown, as well as other interesting specimens.
It is whispered that there may be a little diversion
at the annual meeting of the British Medical Associa-
tion. I may say it is more than a whisper, to judge
from a letter whicli is circulated in some quarters,
threatening an attack on the yi'/z/v/;?/ and its editor, to
be led by Mr. Lawson Tait. He will probably be
supported by a not inconsiderable number of mem-
bers, provided the managers will give any chance for
discussion; but perhaps they will once more adopt
their usual plan of averting criticism or any unpleas-
ant remarks by staving off this subject until close
upon the announcement of refreshments or some equal
attraction. They may, however, try this game once
too often. Then it is said that probably the editor's
health ma)' not permit him to put in an appearance,
when there would, of course, be no fight, but the usual
loud and emphatic pronunciation by councillor after
councillor of that mighty formula — "Our Great Asso-
ciation."
There are many malcontents among the would-be
contributors of papers, especially to the ethical sec-
tion. Among these is Mr. Laffan, of Castel, who has
spoken out boldly and told his grievance, which is
that the managers plead overcrowding as an excuse for
rejecting his paper. He appealed to Mr. Tait, whom
he seems to have imagined was Ti persona grata — an
error difficult to account for : and he declares that both
Journal and association are in the hands of a clique —
a statement which some think shows him to be a ver-
itable Rip Van U'inkle.
A bill for reconstructing the L^niversity of London
has been introduced in the House of Lords. It adopts
the recommendations of tiie Ro}al Commission, but
in the present state of public business it has no
chance of passing this session.
The question of management of hospitals, to which
I have formerly referred, has caused some trouble in
Edinburgh. Last winter one of the staf? of the in-
firmary, who had been nominated by the College of
Surgeons, resigned in order to gain extension of ser-
vice in the wards, for, although there was no rule on
the subject, the managers did not consider that any of
the staff should be members of their board, and a
new rule has been adopted to this effect. This ar-
rangement is logical enough, as the members of the
staff are in a sense the servants of the board ; or,
to put it more agreeably, officers appointed by and
responsible to the board. As I have informed you,
at some hospitals one or more of the staff have
seats at the board, and in a few all of the staff are
admitted, but in the latter case usually w ithout votes.
On a small board it is easy to imagine that the staff"
migiit virtually obtain the full control of the institu-
tion— a position which the lay members are not often
willing to accept. Some representation of the staff
must often be felt necessary. Perhaps the best plan
is for the staff to hold separate meetings as a medical
committee and connnunicate their resolutions to the
board of management.
The epidemic at Gloucester is not yet over, al-
though more than two thousand persons have been at-
tacked. Last week there seems to have been some
recrudescence. During the last six weeks the cases of
small-pox notified numbered sixteen, twenty-five, fifty-
six, forty-two, forty-seven, and eighty-four respecti\ely.
And yet the opposition to vaccination still continues,
though on a smaller scale than before.
It is proposed at St. Mary's Hospital to get up a
testimonial to Sir\Mlliam Broadbent, and some would
like to extend the subscriptions over a wider area. I
scarcely know why, unless because he has obtained a
baronetcy. It is true he has done his work well at
the hospital, but he has had his reward and enjoys a
large practice. There are so many calls to help poor
doctors that I think the rich ones should decline to
accept gifts from their brethren.
I regret to report the death of Dr. Ralfe, who a
short time ago retired from the physiciancy of the
London Hospital and was appointed consulting physi-
cian. He was a hard-working and exceedingly able
man, and his retirement was caused by failing health.
Your readers will know his book on '"Diseases of the
Kidney," which was perhaps his most important work.
But his great knowledge of chemistry in relation to
physiology and pathology enabled him to add to medi-
cal literature jjapers of permanent value on those sub-
jects, and to give his students accurate and authorita-
tive instruction. The profession loses in him an
industrious and learned exponent of advanced medi-
cine and a genial, upright colleague.
Resection of the Hip for Cozalgia. — i. Conser-
vative treatment must be reserved for the first stage of
coxalgia. 2. Surgical intervention in tuberculosis of
the hip-joint is indicated as soon as pus has formed in
the articulation. 3. In coxalgia v.ithout suppuration
surgical intervention is indicated if the pain or the
deformity resists continuous extension. — La:mbaite,
Journal </<' Medccinc ile Chiriirgie ct cU Fharmacologii',
1895, t. iv., f. 3.
August I,
IS96]
MEDICAL RECORD.
177
BERI-BERI TWELVE THOUSAND FEET
ABOVE SEA LEVEL.
To THE Editor of the Medical Recokd.
Sir : Professor Miura reports a case of beri-beri on top
of Fujiyama in the month of December {Sc'/-/-A'7i'ii
J/c-i/iui/ Jounial, June, 1S96), which is rather a stag-
gerer. The temperature at that altitude is very low
and the velocity of wind great. It is well known
that beri-beri in Japan is a disease of June, July, and
.\ugust, between the spring and fall monsoons, in an
average temperature of 24.1° C. When the cool
northwest monsoon comes in, beri-beri ceases alto-
gether, even on the plains.
Now, if the disease were due to a germ, could it de-
\tlop on Fujiyama when it does not in the plain? If
it is due, as Professor Miura claims in this case, to
insufficient alimentation and constipation, why should
not this same cause operate elsewhere? Perhaps such
a cold and snowy climate as such a mountain must
have in the month of December caused the patient to
use in e.xcess the ordinary mode of heating of the Jap-
anese, that is, the charcoal hibachi.
An individual on the top of Fujiyama in December
must seek continued shelter — on the east side of the
mountain, in an unventilated hut, anchored in some
crannied nook, or in a cave — to escape the perpetual
snowfall and bitter cold northwest winds. In such a
place of refuge, carbonic fumes could accumulate.
All roads lead to Rome, and it seems to me that
"wherever I catch hold of a case of beri-beri I always
somehow discover the carbonic gases.
Albert S. .\shmead, M.D.
^'ew York.
"GERMS -\ND SERU.MS."
To the Editor of the Medical Record.
Sir: In the issue of the Medical Record of July
i8th. Dr. Lincoln Phillips attacks antitoxin in particu-
lar and the serum therapy and germ theory in general.
To use his own words, '" after reading his letter I
cannot refrain from writing a few words in reply."
I agree with the doctor, that if we allow it we may
be made the dupes of some of the chemical manufac-
turing companies; but, fortunately for us, we do not
have to prescribe, nolens rokns, every preparation we
see advertised, or even endorsed by any great gun of
the profession ; so the first paragraph of his letter is
not, strictly speaking, the issue. More especially is
this the case, as neither the germ theory nor serum
therapy originated in the shop of any chemical com-
pany, but through patient and thorough work by con-
scientious investigators, who, most likely, never re-
ceived any monetary return for their labor.
Dr. Phillips says: " What of antitoxin? Time will
demonstrate, as it has almost done already, that it is a
delusion and a snare." This is dogmatic, and I for
one disagree with the writer. Up to the last few
weeks I have been living in a locality where diphthe-
ria is almost unknown — high up in the Alleghany
Mountains in Virginia — and I have not had a case of
true diphtheria in my practice since antitoxin made
its appearance on the field; therefore I claim to be
entirely disinterested and unbiassed. I have read and
studied the subject, weighing each article pro and
con., and my reading has not been with any preformed
opinion in favor of antitoxin, rather the reverse; and
1 have come to the conclusion that in antitoxin we
have a remedy which surpasses any other in its cura-
tive value in diphtheria. It acts in the same manner
that vaccine acts in small-pox, and proves the truth of
si?n!k dissimilc est rather than that similia simi/ibus cu-
rantur.
" Beware of the diagnostic powers of a man who re-
ports from fifty to one hundred consecutive cases of
diphtheria cured without the loss of a single one, an-
titoxin or no antitoxin." To that I say, .Amen.
So far as I am aware, infallible cure has never been
claimed for antitoxin, but statistics, gathered with as
much care as possible, have proved that a mortality of
12.3 per cent, of all cases treated with antitoxin is
such an advance over a mortality of 20.8 per cent,
without its use, that we cannot ignore its curative
value, and to say that it is a delusion and a snare is
misleading.
The old cry of the anti-antitoxinists is. Mistaken di-
agnosis and unreliability of figures. Why a physician
should be more prone to make a false diagnosis of a
case because he intends to pursue one course in treat-
ment in preference to another, I cannot see. If I lass
one case as diphtheria because I use antitoxin, and
call another case presenting the same symptoms fol-
licular tonsillitis because I employ other remedies, I
am wilfully creating an erroneous impression in the
minds of both the laity and the profession. I for one
cannot think that the gentlemen who have been at
such trouble to get figures would lend themselves to
such deception. R.easoning on this basis, what can
false diagnosis have to do with it? If w-e have a mor-
tality of 20.8 per cent, against 12.3 per cent, under the
same conditions of false diagnosis, is not the balance
in favor of the treatment which gives the lesser death
rate ?
The same may apply to " mild cases." We all know
that one epidemic of contagious disease may be very
much more severe and fatal than another; but surely
a method in treatment does not affect the character of
the epidemic, since it can affect only the cases under
treatment. If it does, then Dr. Philips is arguing
against himself, as we have the lesser death rate with
antitoxin, according to statistics. And we must go by
them, as we have nothing else to go by.
I know it may be said that if figures are correct all
the epidemics of diphtheria treated with antitoxin
showing a decreased mortality presented a mild type,
and in the past two years diphtheria has not been such
a malignant disease as heretofore. All I can say is,
may it continue to decrease in severity, as I have no
means of knowing what the severity of the disease
may have been, except the word of the men who '• see
blue through blue glasses."
" We are too enthusiastic over germs and germ the-
ories." Let us consider briefly what is the status of
the germ at present. Literally speaking, a germ is the
original source or cause. Medically speaking, it is
the organism or protozoon which causes disease. We
know that the genu exists, for we see it under the mi-
croscope. We know that it multiplies, for we plant
an almost invisible amount on a suitable Sterilized
medium, and in twenty-four or forty-eight hours we
have a large mass containing, nay, made up of, hun-
dreds of thousands of the same kind of germs which
we planted. We know that in some cases they have
the power of locomotion, as we see them scudding
across the microscopic field like fish in the sea. We
know that they produce disease, because inoculations
in lower animals produce pathological conditions, as
evidenced by post-mortem examinations and death.
We know they produce specific disease, as inoculations
of Klebs-Loeffler bacilli produce diphtheritic depos-
its, inoculation of pneumococcus results in pneumonic
symptoms, tubercle produces tuberculosis, and so on.
What can there be in this to be too enthusiastic
about? .\nd this is as far as the germ theorists claim to
go; when it comes to counteracting the effects of these
bacteria, we enter into tiie domain of therapeusis. If
1/8
MEDICAL RECORD.
[August I, 1896
we have discovered in germs, bacteria, micrococci, ba-
cilli, spirilla — call them what we will — the cause of
disease, have we not made a glorious beginning and
one that may lead to great results in cure? For the
first principle in treatment is to get at the cause.
Can we be too enthusiastic over the germ theory?
If we are too enthusiastic over genns, we have to go
back twenty years and acknowledge our complete ig-
norance of the etiology of many diseases, and espe-
cially of the cause of contagion and infection, as the
only way we can explain these phenomena is in the
presence of these " overestimated" germs.
When I studied medicine the germ theory was in its
infancy and bacteriology was not taught in this coun-
try, but investigation since then has proved conclu-
sively to me that bacteria are not myths, but living,
moving organisms, having the power to produce dis-
ease and dangerous to belittle and ignore.
Asepsis and antisepsis have proved of inestimable
benefit to surgery. Why? By inhibiting the growth
of pyogenic organisms; and here we have tangible re-
sults. So with antitoxin, we have results through the
deteriorated activity and virulence in the special
diphtheritic bacillus, brought about by the influence
of the antitoxin in direct contact with this bacillus
and neutralizing its power in the system.
Dr. Phillips closes his letter by saying: " So that
if we give a remedy and the patient gets well, what
definite reason have we for assuming the patient would
not have recovered without medicine?" I am afraid
the doctor is either a fatalist or a faith curist. I am
glad to say that I, with many others in the profession,
can say that I am convinced that remedies adminis-
tered by me have been instrumental in saving and pro-
longing life, and I regret that any one practising our
noble calling should consider it such a happy-go-lucky
empiricism as the w-riter does.
I pray you to excuse such a dissertation on a well-
nigh worn-out subject, and I hope the doctor will not
take umbrage at anything I may have said here.
W. H. F. Miller, M.D.
Baltimore, Md.
^ciu instruments.
A CERVIX KNIFE FOR DENUDING IN
TRACHELORRHAPHY.
i;y augustin h. goelet, m.d.,
NEW YORK.
The accompanying cut illustrates a knife designed for
facilitating the denudation of the lips of the cervix in
the operation of trachelorrhaphy as described in the
JOHN KL(NUt.h<SH.C0.NEWY3RK.
Medical Record of July 4th. It consists of a two-
edged pointed blade set at an obtuse angle to a firm
shaft and handle. It is made in two sizes. The cer-
vix is transfixed beyond the angle of cicatricial tissue
and the blade cuts as it is drawn downward, denuding
one side at a single stroke. The denudation can be
accomplished with this knife in one-half the time that
is usually consumed when scissors are employed, and
the surface left for coaptation is more even and regu-
lar.
;rtlctlicn:t ^tcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending July 25, 1896 :
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-po.x
Cases.
Deaths.
120
qS
20
7
44
5
5
5
115
6
195
24
0
0
Medical Legislation in New York State by the
Last Legislature. — The amendment of greatest in-
terest to physicians, passed by the last legislature^
was that to section 145 of the public health law, re-
lating to admission to examination. This amendment
provides that admission to examination for the degree
of M.D. must be preceded by the study of medicine
for four full school years of at least nine months each
year, including four satisfactory courses of at least
six months each in four different calendar years.
Under the law as it was the length of a school year
was not stipulated and the former courses in medical
colleges in this State averaged from five to seven
months. The law further provides that New York
medical schools and New York medical students shall
not be discriminated against by the registration of any
medical school out of the State whose minimum grad-
uation standard is less than that fixed for the New
York State schools. Another provision allows medi-
cal schools to matriculate conditionally a student de-
ficient in not more than one year's academic work or
twelve counts of the preliminary education required,
provided the name and deficiency of each student so
matriculated be filed wdth the regents' office within
three months and that the deficiency be made up be-
fore the student begins the second annual medical
course counted toward the degree. Students who had
matriculated in a New York medical school before
June 5, 1890, and students who had matriculated in a
New York medical school before May 13, 1895, as
having entered before June 5, 1890 on the prescribed
three years' study of medicine, shall be exempt from
the preliminary education requirement. It was further
provided that a medical student certificate may be
earned without notice to the regents of the conditioned
matriculation either before the student begins the sec-
ond annual medical course counted toward the degree
or two years before the date of the degree for matricu-
lants in any registered medical school, in the four
cases following: (1) For matriculants prior to May
9, 1893, for any twenty counts, allowing ten for the
preliminaries, not including reading and writing; (2)
for matriculants prior to May 13, 1895, for arithmetic,
elementary English, geography, spelling, United
States history, English composition, and physics, or
any fifty counts, allowing fourteen for the prelimi-
naries; (3) for matriculants prior to January i, 1896,
for any tw^elve academic counts; (4) for matriculants
prior to January i, 1897, for any twenty-four academic
counts. But all matriculants after January i, 1897,
must secure forty-eight academic counts, or their full
equivalent, before beginning the first annual medical
course counted toward the degree, unless admitted
conditionally, as hereinbefore specified, when the de-
ficiency must be made up before the student begins
the second annual medical course counted toward the
degree. This law took effect March 31, 1896, excepit
August
I, I
896]
MEDICAL RECORD.
I ■
that the increase in the required course of medical
study from three to four years does not take effect till
January i, iSgS, and does not apply to students who
matriculated before that date and received the degree
of M.D. before January i, 1902.
Two bills making changes in examinations failed
to pass. -The first provided that the regents shall not
alone conduct preliminaiy examinations prior to ap-
plicants entering upon the study of medicine, but that
colleges may also do it. The second provided that
any citizen of the United States who shall have, after
a regular course of study, received the degree of M.D.
from a regularly incorporated medical college in the
United States, in which the course of study is equal
with the courses of study in medical schools in this
State, and shall have practised medicine for at least
three years, may, upon producing necessary proof of
the above provisions, be licensed to practise medicine
in this State upon the payment of a fee of §25. A
bill requiring the State board of medical examiners to
issue a license to Abraham C. Miller, also failed.
Aside from the main amendment, noted above, the
public health law was amended as follows: relative to
dental examiners; allowing pharmacists who were el-
igible on May 24, 1894, to be licensed at any time;
changing the qualifications for the practice of veter-
inary medicine; allowing the health officer of the port
of New York to receive for fumigation and disinfec-
tion of every vessel from an infected port, or of such
vessel as in his judgment shall require fumigation and
disinfection by reason of exposure to infection or con-
tagion, $50, or such sum not more than S50 or less
than §5, as may in his judgment be deemed reason-
able, during a single quarantine; allowing the medi-
cal schools and colleges in the counties of Onondaga,
Oswego, Madison, Cortland, and also Auburn State
prison to have all unclaimed cadavers in those coun-
ties.
These amendments to the public health law did not
pass : repealing the provision as to vaccination of
school children; providing a fine of $50, or imprison-
ment for six months, or both, for violations of regula-
tions of local boards of health; providing that the
town board of health shall be the village board of
health in villages of under two thousand population ;
requiring a certain standard of test for lager beer, ale,
and porter, and providing that lager beer shall be kept
in storage for six months after it is brewed before it
is sold.
A law was passed providing that every concern em-
ploying a master plumber in New York City shall
register his name and address annually in March at
the office of the department of buildings and receive
a certificate of registration, providing he holds a certi-
ficate of competency from the plumbing board. Here-
after the plumbing and drainage of all buildings, both
public and private, in the city of New York, shall be
executed in accordance with the rules and regulations
adopted by the superintendent of buildings. An ap-
propriation of $6, 000 was made for equipping the
quarantine boat Ripple with disinfecting apparatus.
The health officer of the port of New York was given
S6,ooo for expenses of maintenance and repairs on
Fire Island, and for the salaries of the superintend-
ent, watchmen, and other employees during the year
1896; and the regents of the university $10,000 for
conducting examinations in the preliminary education
of dental students as required by the law of 1895,
chapter 626, and of veterinary students as required by
the law of 1895, chapter 860, and for deficiency in the
general examination appropriation caused by increase
in number of schools and .students.
Efforts were made, without success, to exempt from
jury duty veterinary surgeons and registered dentists;
also to amend the code of civil procedure as to physi-
cal examination of plaintiff by physicians of the' same
sex; also to regulate the employment of medical ex-
pert testimony in criminal proceedings; also, provid-
ing that the term funeral expenses, whenever the same
is used in connection with the settlement of the estates
of decedents, shall hereafter be deemed to include the
reasonable compensation of physicians and surgeons
for services and medicines furnished to the decedent
during the last illness in the lifetime of the decedent.
An appropriation of $3,500 was made for the State
medical library.
A law was passed, making it a misdemeanor if any
person in charge of an ambulance or hospital shall
refuse in answer to a call for an ambulance to take to
the hospital from which the ambulance came, for exam-
ination and yeatment, the person or persons for whom
a call may be made. A charter was given to the Mer-
chant Marine Hospital Service, with William T.
Jenkins, M.D., Carter S. Cole, M.D., A. T. Talmadge,
M.D., C. W. Hogan, and Cornelius Van Cott as the
incorporators. The commissioners of the sinking
fund of New York City were authorized to lease to
the Hospital for Scarlet Fever and Diphtheria Pa-
tients a piece of ground belonging to the city and
situated on the block bounded by Avenue C, East
River, Sixteenth and Seventeenth Streets. The board
of trustees of Faxon Hospital in Utica were required
to grant equal rights and privileges to practitioners of
all schools of medicine.
The New York HomcEopathic College and Hospital
was allowed to charge for board, nursing, and medical
or surgical aid and attention, $1 a day for each needy
and charity patient who occupies a bed in the Flower
.Surgical Hospital, belonging to the New York Homoe-
opathic College and Hospital, such payment not to
exceed $1,200 a year. Another law confirmed the title
of St. Luke's Hospital to certain lands in New York
City by consenting to, ratifying, validating, and con-
firming certain deeds made by the mayor, aldemien,
and commonalty of New York City, and certain deeds
made by the rector, churchwardens, and vestrymen of
the Anglo-American Free Church of Saint George the
Martyr. Houses or homes for the reformation, pro-
tection, or shelter of females day nurseries or corpo-
rations or societies for the care and instruction of poor
babies and needy children, and industrial homes and
any benevolent or charitable corporation owning or
maintaining public baths, for free school societies, or
free circulating libraries, now existing in New York
City, were exempted from the payment of water rates,
under the law of 18S7, providing hospitals, orphan
asylums, and other charitable institutions in the city
with water, and remitting assessments therefor. An
appropriation of $6,000 was made to the Pasteur Insti-
tute of New York City, as a full equivalent for ser-
vices, as provided in chapter 770 of the laws of 1895.
M. J. Dady was given $4,500 to purchase the building
and land situated at and adjoining the Kings County
farm for the use of the hospital, valuation to be fixed
by the board of managers of the hospital.
These hospital bills failed: legalizing certain acts
of the board of supervisors of Erie County, and pro-
viding for the management and maintenance of P>ie
County Hospital as an institution separate from the
almshouse; amending the town law so as to enable
towns to raise money for the support of hospitals;
allowing New York City to appropriate $10,000 an-
nually to the community of Notre Dame de Bon
Secours (Good Help) for its charitable uses and pur-
poses, and to St. Mark's Hospital, for board, nursing,
and medical or surgical aid and attendance, $1 per
day for each needy and charity patient who receives
such care, support, and maintenance from said hospi-
tal, such payments not to e.xceed in the aggregate
$30,000 per annum ; providing for the erection of a
i8o
MEDICAL RECORD.
[August 1, 1896
hospital in Brooklyn for the use of the department of
charities and corrections and under its supervision.
A bill abolishing all the coroners in the State, in
obedience to the new constitution, and with the ap-
proval of the State medical and bar associations, was
introduced but not passed. It did away with all coro-
ners, post-mortem examiners, coroners' physicians, and
coroners' jurors, and conferred upon the appellate
divisions of the Supreme Court power to appoint
their successors. The bill abolishing coroners' juries
also failed. A two-year term was made for the coro-
ners of New York County ; and a four-year term for
the coroners of Kings County. In the former county
the coroners were allow'ed to appoint two assistant
clerks, who shall keep the office open between the
hours of 4 P.M. and 9 a.m., every day in the year, in-
cluding Sundays and legal holidays, one at least of
said clerks being in attendance during said hours;
but an effort to raise the salaries of coroners' physi-
cians from $3,000 to $5,000 failed.
A law was passed protecting the owners of bottles,
boxes, siphons, tins, or kegs used in the sale of soda
waters, mineral or aerated waters, porter, ale, beer,
cider, ginger ale, milk, cream, small beer, lager beer,
weiss beer, white beer, or other beverages, or medi-
cines, medical preparations, perfumery, oils, com-
pounds, or mixtures. The law relating to instructions
as to the bad effects of alcoholic liquors was revised.
The trustees of the Clifton Springs Sanitarium Com-
pany were authorized to issue $150,000 in bonds and
to mortgage the trust property to raise money to pay
the cost of completing the new sanitarium building.
The charter of the Inebriates' Home for Kings County
was amended relating to the appointment of directors.
Among the bills that failed were these: providing
for the medical treatment of persons who have been
convicted of public intoxication; providing for the
treatment of the disease of drunkenness; providing
for the treatment and cure of inebriates and persons
addicted to the excessive use of opium and other nar-
cotics; prohibiting vivisection and dissection in the
public schools; relating to proceedings for the com-
mitment of the insane to State hospitals and other in-
stitutions: charter for the Optical Society of the State
of N>;w York for the purpose of improving and regu-
lating the practice of dispensing and refracting op-
ticians.
Laws local to New York City were passed: author-
izing the sinking fund commissioners, whenever re-
quired to do so by the board of health, to set apart
land on the south side of East Seventeenth Street be-
tween Avenue C and the East River, and adjacent to
the hospitals now under the control and supervision
of the board of health, for the construction thereon of
a building as an ambulance station and vaccine lab-
oratory; for the relief of the Mount Sinai Training
School for Nurses, and legalizing its incorporation.
These bills failed: amending the law regulating the
sale of poisons so that the name of the substance or
substances best known and used as the antidote for
the article contained in the box, bottle, vessel, or
paper shall be given ; forbidding any but a registered
pharmacist to expose or offer for sale at retail any
medicine, medicinal preparation, or poison whatso-
ever; allowing an ofhcer or employee who has served
thirty yeas in the health department of New York
City to draw upon the health department pension
fund; amending the charter of the Deutsche Poli-
klinik; making further provision for the proper main-
tenance, care, and treatment of sick, infirm, and desti-
tute persons in New York City under the jurisdiction
and care of the commissioner of public charities.
An amendment was made to the law enabling the
Kings County Pharmaceutical Society to establish a
college of pharmacy in the city of Brooklyn. These
bills were lost: allowing the commissioner of police
and excise in Brooklyn to appoint not to exceed seven
surgeons, and all surgeons so appointed shall hold
such office at the pleasure of the commissioner; creat-
ing a board of physicians and surgeons for the city of
Brooklyn, defining the duties thereof, and abolishing
all surgeons connected with any of the departments of
said city, except the department of health: amending
the Erie County midwifery law of 1S85, so that the
county judge shall appoint a board of examiners in
midwifery to consist of nine members (each with a
three-year term), who shall have been licensed to
practise physics and surgery in this State, and who
shall have been in active practice tor at least five
years.
An Old -Timer. — A correspondent in Chelsea,
Mass., sends the following: ''Some of us in these
days of tablet triturates and ready-made syrups, elix-
irs, solutions, and what not, are rapidly becoming
rusty in the gentle art of writing the prescription, es-
pecially the one of the shot-gun order. To show that
even our State board of registration has not caused
this to become a lost art in the old Bay State, I beg
to submit the following, taken from the file of one of
our city druggists who has tilled it twice during the
last month. The man had gleet and said this cured
him :
" IJ Calsum hypophos 3 iij-
Potas. hypophos gr. .\xv.
Lithier brom ? i.
1 )ie. phosfor. acid I i^.
Fl. ex. nux vomika | iss.
hyJrasters 3 vi.
" hammemelis J vi.
" cann. indica 3 iss.
" gelseminumi 3 i.
" gentiern 31].
" chira. ophila ? ij.
Oil of morrus 3 iv.
Aq. dastil,
Syr. symplercis aa ad ? xxxij.
" M. Too teaspoonfuls in water one-half hour before meals."
Syphilis from an Insurance Point of View.—
Dr. P. H. Maclaren, of Edinburgh, in considering this
subject without reference to general mortality statis-
tics, from which it is difficult to obtain accurate infor-
mation, states that he is inclined to classify for insur-
ance purposes all syphilitics under the three following
groups: I. If a man has been properly treated, the
probabilities are that, provided he is of good constitu-
tion and habits, no complications will arise, and the
expectation would be that he will go through life with
scarcely more appreciable risk than one who has never
had the disease. 2. If proposer has not undergone a
sufficient course of treatment, and applies for insur-
ance before the expiration of six years, the period at
whichthe disease normally terminates, and yet is not
suffering from any tertiary manifestations, and is
otherwise satisfactory, the chances are that he may
escape the malign fonn, but ten per cent, extra should
be charged until the expiration of the six years,
and the case then reconsidered. 3. When tertiary
symptoms have developed, the proposal should be ab-
solutely declined, because, while treatment may tem-
porarily remove these, it cannot eradicate the tendency
to recurrence; and clinical observation has shown that
those so affected rarely live beyond a term of ten years,
and often much less when palliative treatment is not
carried out. While his personal experience is almost
absolutely favorable regarding the prognosis of the
cases included in Class i, it is questionable when the
cases are looked at, with the interests of the offices
perfectly safeguarded, if they should not practically be
treated in the same way as those in Class 2. — Edin-
burgh Medical Journal, March, 1896.
Medical Record
A IVeekly Journal of Medicine and Surgery
Vol. 50, No. 6.
Whole No. 1344.
New York, August 8, 1896.
$5.00 Per Annum.
Single Copies, loc.
(Dviginal JiX'ticlcs.
THE ANTITOXIN TREATMENT OF DIPH-
THERIA IN THE KAISER AND KAISERIN
FRIEDRICH CHILDREN'S HOSPITAL IN
BERLIN, AND DR. WINTERS' OBSERVA-
TIONS THEREON.
By ADOLF BAGINSKY, M.D.,
EXTRAORDINARY PROFESSOR OF THE DISEASES OF CHILDREN IN THE IM-
VER5ITV OF BERLIN AND DIRECTOR OF THE KAISEK AND KAISEKIN
FRIEDRICH children's HOSPITAL.
The erroneous statements of Dr. Joseph Winters, re-
cently made in the Medical Record, regarding the
statistics of the antitoxin treatment for diphtheria in
the Berlin hospital of which I have the honor to be
the supervising physician, have compelled me to pre-
sent certain facts to my American colleagues which
may be of interest in the pending discussion of the
real merits of the new remedy.
Dr. Winters offers the following so-called observa-
tions from the diphtheria division of the cases treated
in the Poliklinik and Klinik: '
" When I first visited the Empress Frederika Hos-
pital while in Berlin, I was first invited to attend the
Dispensary Clinic for diseases of children, which op-
portunity I availed myself of. Such care in the man-
agement of cases of slight illness I do not think can
be seen anywhere else in the world. The waiting-
room for children is under the charge of a trained
nurse. Every child has its temperature, pulse, and
respiration taken by the nurse and its clothing re-
moved; it is then carefully wrapped and taken before
the physician. There again you see the same minute,
painstaking care in every case. Noticing this great
care and that not in a single instance was the throat
examined, I thought it strange. The doctor told me
that the throat was not examined in this room, because
the throat of every child was examined before being
brought to this room, and if there was any affection of
the throat the child was referred to the diphtheria
polyclinic. A clinic for walking cases of diphtheria
was a revelation to me. The next hour I visited the
room where the diphtheria polyclinic is held, under
the supervision of the same physician. Every child
brought to the dispensary department of the Empress
Frederika Hospital, if it presents any throat lesion, is
placed in an isolation room of the hospital which they
now^ have for these cases; it is immediately injected
with antitoxin, and if Loeffler's bacillus is found, it is
placed in the diphtheria pavilion and receives further
serum treatment. It is in this way that the enormous
number of cases, as compared with previous years, is
taken into this hospital for serum treatment. When
there is a lack of serum or when there is no serum,
these walking cases of throat affection are not detained
in the hospital, as it is not deemed safe to do so when
they cannot be immunized and protected against their
surroundings. It is this method of conducting the
diphtheria department of the Empress Frederika Hos-
pital which accounts for the reported low mortality and
for the difference in mortality during periods when se-
' Medical Record, June 20, 1S96.
rum is used and w hen it is not used. It was this very
feature of the reports from the Empress Frederika
Hospital which made the strong impression on Vir-
chow. But Virchow had not studied the details; he
accepted the percentage mortality without knowing
how such percentages were obtained."
In this portion of Dr. Winters' paper there are so
many false statements, perhaps based partly on faulty
observations, that I find it necessary to preface these
remarks with a plain description of our methods as
they actually exist :
In the Poliklinik (Dispensary) of our hospital we
have two distinct departments, viz., an infectious de-
partment and a non-infectious department.
In the non-infectious department children are treat-
ed in the dispensary as out-door cases or are admitted
to the internal wards of the hospital as medical or surgi-
cal patients. The surgical wards are under the charge
of Professor Gluck, and are restricted to the reception
of patients who have no infectious disease.
In the infectious department only really infectious
cases are treated, in so-called pavilions especially de-
signed for this purpose, and only a few cases and con-
valescents are treated in the poliklinik or dispensarj'.
For this purpose the infectious department has a num-
ber of wards (so-called " Ordinations-Zimmer"), and
these are not, as Dr. Winters says, isolation rooms
" which they now have for these cases," implying that
they have been in existence only since the antitoxin
treatment was introduced. This department has ex-
isted since the opening of the hospital in 1890. In
other words, these isolation wards existed long before
anybody thought of antitoxin. These wards are va-
riously labelled: " For scarlatinal cases," '"for diph-
theria cases," "for pertussis cases," "for measles
cases;" for surgical infectious cases, such as erysipe-
las, phlegmons, vulvo-vaginitis, blennorrhcea neonato-
rum; and, finally, we keep one room reserved for spe-
cial purposes.
The division, or, rather, the distribution of the va-
rious new cases, is managed by one of my assistants,
a physician especially named for the position. His
work consists in examining the cases and sending them
to their various rooms on the strength of the diagnosis
made by him. Naturally, the throat is carefully exam-
ined and each symptom given proper weight. This
physician, furthermore, examines the urine of the chil-
dren, for it is here that we frequently observe those
pathological conditions which are the forerunners of
infections. Although ever)- child is strictly isolated
until we arrive at a proper diagnosis, it is the invaria-
ble rule in our wards to re-examine the throat of every
child before treatment is commenced; so tliat it is un-
true and improper for Dr. Winters to state that he re-
cently observed anything different in spite of our
" painstaking care." The throat of each and every
case is not only examined by niy assistants, but fre-
quently by myself, and, as a rule, every important case
is treated by me personally, and detained by the assis-
tants if a doubtful diagnosis exists until I corroborate
it or otherwise. It is to be taken for granted that I
examine thoroughly all cases before giving my opin-
ion.
To again quote Dr. Winters: ''The throat was not
i8:
MEDICAL RECORD.
[August 8, 1896
examined in this room." This latter is absolutely un-
true, and it is equally evident that Dr. Winters has
misunderstood all our methods.
We could even overlook some of Dr. Winters' re-
marks, were it not for the fact that he distinctly states
that a case of angina in a child " is immediately in-
jected with antitoxin.'' This is such a glaring mis-
statement that I find it difficult to understand how and
why Dr. Winters could be willing to permit such an
assertion to appear in print.
In the special diphtheria room above mentioned all
cases of spurious angina which simulate diphtheria
are carefully e.xamined, not, as Dr. Winters puts it,
"by the same [admitting] physician," but by the spe-
cial diphtheria assistant, one of my assistant physi-
cians, who has charge of the diphtheria pavilion: and
it is he who, as specirl assistant in this disease, is re-
quired by me to separate all cases of catarrhal angina
from those of diphtheria. For this purpose this assis-
tant of mine is required to use all necessary clinical,
microscopical, and bacteriological methods in arriving
at the proper diagnosis.
Children with apparent diphtheria are brought in
the diphtheria pavilion. It is in this separate diph-
theria building that antitoxin treatment is commenced,
and not, as Dr. Winters erroneously puts it, " receives
further serum treatment."
Other cases in which the diagnosis is not clear are
disposed of in two ways; ist. They are admitted to
the quarantine, which is situated on the whole of the
upper part of the poliklinik or dispensarj- building,
and are subjected to careful scrutiny; or, 2d. they
are given out-door treatment, consisting of gargles of
chlorate of potassium, quinine, and ice compresses;
but the mothers are invariably given strict instructions
in regard to isolation, care, diet, and medication.
I should be pleased to have Dr. Winters inform me
how he came to state that a child had been injected
" immediately" with serum in our poliklinik or dis-
pensary. The treatment with antitoxin is given only
in the diphtheria ward or pavilion, in some cases in
the quarantine station, but never otherwise.
But it is proper, also, to state when and why we
have given injections '" immediately" in our poliklinik.
All the brothers and sisters of a patient with diphtheria
whom we admit in our diphtheria pavilion receive
'■ immunizing injections of antitoxin," when we are
positive that a case of diphtheria really exists: and
these injections are given soon after the antitoxin
treatment is commenced in our poliklinik, and are for
the purpose of conferring " immunity.'' And I would
furthermore ask Dr. Winters to inform me '" when and
where" I called cases which were given immunizing
injections of one hundred and fifty and two hundred
antitoxin units "cases which were treated and cured,"
as though they had been ill with diphtheria. The ob-
servations as given by Dr. Winters and all his con-
clusions are incorrect, and are based on such faulty
observations as as to amount almost to misrepresen-
tations.
It is absolutely untrue that at the time when no an-
titoxin could be procured children were sent away.
Dr. Winters was in our hospital, according to our vis-
itors' list, once only, and it is, therefore, quite evident
that we cannot expect him to know our exact mode of
procedure from one superficial inspection; for I re-
peat that our working methods are exactly now as they
have been since the hospital was opened in 1S90.
If, however, he had wished to be thoroughly in-
formed about our working and scientific arrangements,
he could have received such information in New York
City from one of your physicians, Dr. Louis Fischer,
who is thoroughly conversant with our modus operandi,
and has had an abundant opportunity for acquainting
himself with it. Besides, I believe he was one of the
first to introduce and generalize the antitoxin treat-
ment in America after having learned it in our diph-
theria wards.
Therefore, with such flimsy knowledge of our ways,
all of the so-called observations and experience of Dr.
Winters at the Kaiser and Kaiserin Friedrich Chil-
dren's Hospital as regards the antitoxin treatment
amount, a priori, to nothing.
Now, as regards my own experience and my views
concerning the antitoxin treatment of diphtheria in the
Kaiser and Kaiserin Friedrich Children's Hospital,
I can only endorse every word that I have said or
written in its favor, and will stand by it.
I regard it as useless always to go back to statistics
and repeat them, for, by putting together a lot of fig-
ures one will never be able to convince people. In
statistics there are so many things to consider, so
many to discard, and so many facts to analyze that
one cannot only prove every absurdity, but can often
succeed in disproving facts.
I consider it of prime importance to classify each
and every case according to (i) its primary or earliest
clinical manifestations: (2) its course, and (3) its
termination. Under these conditions I am in a posi-
tion to announce some new facts :
ist. Our cases are to-day just as severe as they have
ever been on admission to our hospital. It is abso-
lutely untrue that since the introduction of the serum
treatment we have been dealing with milder forms of
diphtheria. On the contrary, we have had the worst
forms and most malignant cases during all this time
as well as during the last few months. It is therefore
wrong to speak of mild epidemics, for even in my pri-
vate consultation practice I have met the worst forms
of diphtheria.
2d. In spite of the malignant type of our cases we
find that the course of treatment since the introduction
of the so-called healing serum is so much more favor-
able that a comparison with former methods is un-
called for. \\'e can easily compare results of the
former clinical methods by noting the percentage of
mortality. .As an example allow me to offer the fol-
lowing statistics of the first half of the present year:
1S96. January, number discharged cured, 27; died, 2 =; (>.6<)%
February, " " " 25; " 4= idf
March. " " " 25; " 3 = 10.71^
-April. " " " 25; " 0—0^
May. " " " 25; " 3 = 10.71^
June, " " " 20; " 1=5^
This is the percentage of mortality which we can
place opposite former percentages of forty to fifty per
cent. But this would be hardly enough if we did not
consider the course taken by convalescing cases and
the remedy used in the treatment.
3d. When the antitoxin treatment was first intro-
duced opposition was thought to be justified by the
fact that with the greater number of admitted cases
more mild cases were admitted to the hospital, and so
it was asserted that a larger number of milder cases
were treated to swell the favorable statistics. To dis-
prove that I can show that, although the number of
cases admitted has been considerably lessened and
the cases taken were always of the severest kind, the
mortality has diminished and the percentage of dis-
charged cured has considerably increased.
4. I have as yet never noticed, after an injection of
antitoxin, whether the remedy was employed as a cura-
tive agent or was used in prophylactic doses to confer
immunity (excepting in two cases which I shall report
in detail -later), any symptoms which were detrimental
to the health of the patient. In the large amount of
carefully studied material, I have looked at every
factor and watched for harmful results, and cannot
find a single fact which would tend to destroy my con-
fidence in the absolute value of this antitoxin as a
August 8, 1896]
MEDICAL RECORD.
1^5
healing agent in diphtiieria. I therefore cannot un-
derstand the reports of other observers about the
poor results and effects of the serum. Surely it is not
possible in comparison with the great value of anti-
toxin observed in such a large number of cases of
diphtheria in our hospital to diminish this value by
a few reports of unsuccessful or doubtful cases occur-
ring elsewhere.
5th. It is highly important that in the treatment of
diphtheria with antito.xin the physician should first as-
certain the quality of the antito.xin used and not take
the hrst substance he finds labelled in the market.
For it is a well-known fact that some alleged anti-
toxins are absolutely inert. It is therefore advisable
to use, as we are in the habit of using, antitoxin the
preparation of which is under the control of the Ger-
man government. We use in our hospital two kinds
of antitoxin: ist, Aronson's and, 2d, Behring's.
6th. It is also necessary to remember that diphtheria
is a disease attended by many grave complications
and that antitoxin is not our sole reliance in such
emergencies. To be markedly successful in this dis-
ease the physician must be a pathologist and a thera-
peutist and be thoroughly in touch with all the special
indications that mav arise during its course. If he
does not properly understand the leading principles
of treatment the best remedy we have will be a failure
with him. The results to which I refer have been
achieved not only in the hospital, but also in private
practice.
I do not intend to go any further into this subject
at the present time, but think it just to give my Amer-
ican colleagues a proper insight into the true state of
affairs as they e.xist here and the facts as gained from
the material under observation.
It is to be sincerely hoped that should American
observers desire to pass criticism on our methods or
report the affairs of our hospital they will qualify
themselves with better information and study our
workings properly — not as Dr. V\'inters has done or
believes he has done. I am always ready to offer my
hand cheerfully for this purpose.
THE ANTISEPTIC TREATMENT OF TYPHOID
FEVER.'
By WESLEV DAVIS, M.D.,
WORCESTER, MASS.
Ix the time allowed me I can point out only in the
most cursory manner some of the methods employed,
with very little in the way of full illustration.
I wish first to direct your attention to the etiology
of typhoid fever. I suppose we are all agreed and
ready to admit that it is a germ disease; that the
germs may enter the body by the way either of the air
or of the food and drink, and that whichever way they
enter they are carried through the oesophagus to the
canal below, when they find a most favorable culture
medium as they approach the lower portion of the
ileum; then they multiply with great rapidity, all the
conditions being favorable. The ptomains which
they form are absorbed and cause the fever with which
we have to contend; moreover, the germs themselves
are taken up entire and carried through the glands
and lymphatics to many tissues of the body, when, of
course, they may continue with more or less activity
their toxin-producing mission.
But nowhere are they found in such abundance, and
nowhere are the conditions so favorable for their mul-
tiplication, as in the lower portion of the small intes-
tine. This undoubtedly accounts for the greater fre-
' Read before the Worcebter District Medical .Society, .April 15,
i8g6.
quency of the typhoid lesions in this locality. The
glands here take up from the contents of the intestine
a greater number of bacilli than do the glands in
other parts of the canal, simply because this is the
most favorable culture ground, and consequently there
are more bacilli and ptomains here to be absorbed,
as well as more glands to be affected by their absorp-
tion.
It seems to me we must all admit that this fever is
dependent upon the absorption of these poisonous
ptomains into the blood, as is the case in diphtheria
and septica;mia. We should look upon our patient
and endeavor to judge by his condition as to the
amount and severity of the poisoning taking place.
In any other disease than typhoid fever we would
endeavor to cleanse the source of infection with anti-
septics, and the more thoroughly we were able to ac-
complish this the better would be the chance for re-
co\-ery.
Now, as I view the matter, this is precisely the con-
dition of the typhoid patient: the small intestines are
the source of the trouble and the problem for us to
solve is what we can do to overcome or prevent this
poisoning from continuing. If we could stop it at
once we might see as rapid cures as we sometimes do
when septic conditions are removed from other parts
of the body and we should have an aborted typhoid
fever.
Since we cannot reach the site of infection, as is
possible in many unclean surgical cases, the next best
thing is to wash out the intestine with cathartics,
which, if begun early enough and combined with suit-
able antiseptics and copious draughts of sterilized
water, must carry out of the system multitudes of ba-
cilli that otherwise would remain to multiply and gen-
erate their ptomains for continuous poisoning.
If this be true, it naturally follows that we must
continue to flush out the canal with antiseptics just
so long as the bacilli remain and develop the toxin
which keeps up the fever. We have quite an ex-
tended list of antiseptics that have been tried and are
claimed to be useful for this purpose, among which
may be mentioned naphthol, naphthalin, thalline,
salol, resorcin, sulpho-carbolate of zinc, and arsenite
of copper.
I have unwittingly had a little experience with the
zinc, the result of which has interested and I think
instructed me greatly.
Last August I was called to attend a girl who had
become so ill she could not continue her work longer
as a domestic and was taken home by a cousin to be
cared for. I found her with what seemed a very se-
vere attack of cholera morbus, so severe that for a
day or two I feared collapse. At my first visit I put
her upon grain doses of sulpho-carbolate of zinc
every hour in addition to the other treatment. About
the fourth day, the choleraic condition being improved,
she had a temperature of 104° F., and developed a
parotitis which aroused my first suspicion of typhoid
fever. I directed the nurse to disinfect the stools
and be careful, but evidently too late. I saw this
patient eight days, when she was so far recovered that
I did not consider it necessary to put her in other
hands when I left town. The week following the
cousin was attacked with typhoid fever and was illi
nine weeks, my patient becoming the nurse. Her hus-
band came under my care at the City Ho.spital Oc-
tober 19th, having been sick two weeks, and was dis-
charged November i6th. A boarder in the family,
also having been sick two weeks, was admitted to the
hospital September 9th and discharged October 14th.
The men were ill six and seven weeks each and the
woman nine.
Why did my patient recover so rapidly? Is it un-
reasonable to believe that the bacilli were eliminated
MEDICAL RECORD.
[August 8, 1896
by nature in spite of my efforts and that the sulpho-
carbolate of' zinc acted as a disinfectant? Or shall
we consider it as confirming Dr. Chambers' claim
that the fever can be aborted early by emeto-cathar-
sis?
My patient was actually ill not over two weeks, yet
lost her hair as thoroughly as did her cousin, who was
sick nine weeks.
At our annual meeting in May last I called atten-
tion to the Woodbridge treatment and showed the
chart of a case then convalescing. The case made a
rapid recovery, the result being so satisfactory that I
have treated every case coming under my care since
by the same method.
In the City Hospital we had eighteen undoubted
cases of the fever during my service from October 1st
to Januar}'. These cases all recovered, and those un-
complicated pursued what appeared to be an unusually
mild course. It certainly seemed encouraging for the
treatment when we found there were fifty-one cases
reported to the Board of Health outside the hospital
during this period, with twelve deaths, a mortality of
23.5 per cent, against none at the hospital, while dur-
ing the same period of 1894 we lost four out of
eighteen under the regular treatment.
I have treated eight cases in private practice, which
have done well and served to strengthen my faith in
the method.
Dr. Woodbridge has reported another series of fifty
cases, making in all over four hundred, without a
death among those uncomplicated. He also reports
eight hundred cases reported by one hundred and sev-
enteen other physicians, with nine deaths. He states
that "seven certainly, and possibly eight of these
were due to grave complications (developed prior to
the commencement of the treatment) or to the late
stage of the disease at which treatment was begun, or
possibly to faults of preparing or administering the
remedies."
So far as I have been able to learn from the jour-
nals, every one who has had faith and enthusiasm
enough to carry out the treatment faithfully gives a
favorable report.
We will now turn our attention to the treatment
itself. Here are the formulae:
T.\BLET No. I.
H I'odophyllin gr. ^.
Calomel (hydr. chlor. mit.) gr. ^.
Guaiacol carb gr. y'j.
Menthol gr. ^.
Eucalyptol ni i.
T,\BLET No. 2.
IJ PodophyUin gr. ^}^.
Hydrargyri chloridi mitis ". .• gr. -jij.
Guaiacol carb gr. ^.
Menthol gr. ■^.
Thymol gr. Vs-
Eucalyptol 'til i.
No. 3 C.\PSLLE.
'^ Guaiacol carb gr. iij.
Thymol gr. i.
Menthol .' gr. ss.
Eucalyptol ni v.
You will observe the la.xatives do not enter into the
composition of the capsules.
In the use of these. No. 1 is to be given at once
and thereafter ever)' fifteen minutes for the first twenty-
four hours, as directed by Dr. Woodbridge. I have
given them thus, but on attempting to dissolve the
tablets concluded they might as well be given at in-
terwils of half an hour in double the dose, tu:, two
tablets every half-hour.
At the end of the first day if these are well borne,
and the bowels have not moved too freely, two No. 2
tablets are to be given every hour alternately with two
No 1 tablets, so that the medicine is given everv half-
hour.
If five or six free evacuations occur during the sec-
ond twenty-four hours the treatment can be continued,
or the intervals lengthened to three-quarters of an
hour or more, according to the judgment of the physi-
cian. My experience is that patients do best when
the bowels are kept well open.
After three days capsule No. 3 is given, one every
three hours, between which the tablets, mostly No. 2,
are given, according to the effect to be maintained
upon the bowels. The ideal management of a case
would be to have tlie frequency of the dejections di-
minish from six or eight, /tjr/ /iiss/t with the fall of
temperature, until there should be only two or three in
twenty-four hours when it reaches normal.
There is nothing in the treatment that contraindi-
cates the use of baths, turpentine stupes, stimulants,
tonics, or opiates to relieve pain, and I have always
used them when indicated.
Realizing the impossibility of reproducing in the
Medical Record the thirty and more clinical charts
exhibited when the paper was read before the society,
I will give a brief history of some of the cases and
draw a few conclusions which seem warranted from a
study of all the charts:
April 14, 1895. — First saw Mr. C — — , the case al-
ready referred to, who had a temperature of 104° F.,
severe pain in head and back, with general soreness.
He was given acetanilid and quinine without relief.
Bromides also failed and morphine was resorted to on
the 1 6th, his bowels having been previously moved by
calomel, ipecac, and soda, and showing no tendency
to overact.
April 17th. — His head was still aching and he
begged for relief, which was obtained by morphine,
but the pain returned as soon as he awoke.
April i8th. — He continued much the same, with
persistent fever and pain in head and back, which
strengthened my suspicions of typhoid fever, and he
was put upon the No. i tablets, one every fifteen min-
utes, the acetanilid being omitted. The following
morning he had a temperature of 104.5^ F., pulse 108.
The tablets were then given every half-hour in double
doses, as he objected to the frequency. This treat-
ment was followed faithfully until he had eleven de-
jections during the second twenty-four hours, when
the tablets were diminished in frequency and finally
omitted. But for six days the number of dejections
ranged from six to eight every day, when, becoming
anxious as to their frequency, I ordered the milk
scalded for a few days, and about this time the tablets
and capsules were ordered made small as possible
that they might be more easily taken. The charac-
teristic eruption was well marked on the third day
after the treatment was begun, and the ne.xt day, with
a temperature of 104.3° F-) he called for bread and
milk, which was allowed whenever he desired. He
had no delirium or t)'mpany and the tongue was moist
throughout.
Two days after he commenced on the small tablets
and capsules his temperature was 100.5' ^-j but
gradually rose to 102.8 F., when we discovered tab-
lets in the stools. A visit to the druggist revealed the
fact that he had combined the medicines with cal-
cined magnesia in his efforts to make the tablets and
capsules as small as possible, and this had rendered
them insoluble.
We recovered in all over seventy-five tablets and
capsules, and as soon as the medicines were made
soluble his temperature dropped to normal in a night
on the eighteenth day of the treatment. We would
probably have reached a normal temperature several
days earlier if the medicines had been soluble. His
appetite was good and he indulged it quite freely and
August 8,
1896]
MEDICAL RECORD.
185
made a vety rapid recovery, going to Vermont on a
business trip one niontli from the day the tablet treat-
ment was commenced, and having had an evening
temperature of 104" F. for over six days of the time.
If seventy-five and more of these undissolved tab-
lets and capsules can pass through the alimentary
canal of a typhoid patient and not produce a relapse,
what have we to fear from the residuum of a beef-
steak dinner, providing we keep the bowels open, well
flushed out with an antiseptic solution ? My experi-
ence has made me skeptical as to the influence of
easily digested food in producing relapses.
In 1894 we had at the City Hospital three patients
convalescing at the same time. One had passed the
prescribed ten days of normal temperature and was
put upon toast, which seeming to do no harm, he was
given chicken after a day or two and the diet made a
little more libral, when after a day or two his tem-
perature rose and he had a relapse, from which he
ultimately recovered. The second had passed his
period of normal temperature and was put upon toast
only, when he relapsed but finally recovered. The
third got a relapse the seventh day of normal tempera-
ture, having had no food, and died.
These cases impressed me strongly, as they occurred
within a few days in the same ward and we could not
ascertain any cause or learn that the patients had
obtained any forbidden fmit or article of diet.
I am disposed to think relapses may be the result
of late ulceration in Peyer's patches or the separation
of sloughs in patches when ulceration has already oc-
curred, thus liberating bacilli into the canal, which,
occurring in connection with constipation, may give
time for their multiplication and a reinfection of the
system.
Here is a brief report of the last case treated, that
of a lad of seventeen, member of the Classical High
School. I saw him first the sixth day of the disease.
Temperature, 102.5° F. ; it reached 104° F. the eighth
and again the thirteenth day of the disease. There is
nothing especially interesting about the case except
that he became so deaf after a few days that he could
hear no ordinary conversation, and complained of a
feeling of tightness as though a band were drawn about
the forehead. He had no delirium, tympanites, or
sordes; the tongue was clean and moist throughout all
the latter half. He ate stale bread in his milk or broth
whenever he desired, also chewed beefsteak, and usu-
ally drank two eggs a day beaten up in milk. He
had an ice cap to the head, baths occasionally, but
would not tolerate them cold. As he complained of
considerable abdominal tenderness, turpentine stupes
were applied. He had strychnine, but no alcoholic
stimulants were used. A little opiate was given for a
distress in the bowels that troubled him at times, and
toward the last the cathartic effect of the tablets was as-
sisted by one-third of a seidlitz powder each morning.
His hearing returned as the fever subsided and he
made a good recover)-.
On July 27th I was called to a little girl, aged
eight, who had been complaining for a week of pain
in the head, back, and limbs. She had a temperature
of 104.5^ F. I put her at once upon one No. i everj-
half-hour. The next day I found her so much im-
proved that I thought I had made a mistake, the tem-
perature being nearly normal. I omitted the tablets,
but much to my annoyance two days later I found the
temperature 103.5" F., when I put her upon tablets
Nos. I and 2 alternately, three-quarters of an hour
apart. I also ordered capsules of half-size, which
she took without much difficulty. Her temperature
reached normal August 4th, i.e., in eight days, i)ut
treatment was not entirely omitted until nearly a week
later. Her recovery was good.
George C had been feeling poorly for a week
or more, had consulted a physician twice, but continu-
ing to grow worse, went to bed, where I found him.
His temperature was not high, but the history and his
condition impressed me with the feeling that I had
a typhoid fever to treat. The peculiar typhoid facies
was well marked. I put him on the treatment at my
first visit and the result was very gratifying, his tem-
perature reaching normal in eight days. It was some
two weeks before he was able to work.
Miss F , a school teacher. Her mother having
told me how she complained of being so very tired
and exhausted, I was not surprised when called fo
find nearly all the symptoms of typhoid present. I
put her at once upon the treatment and after a few-
doses she vomited excessively. I then stopped the
tablets and gave subnitrate of bismuth for a few hours,
when, the stomach seeming quiet, the tablets were re-
sumed, but again rejected. She was then put upon
the sulpho-carbolate of zinc alternately with guaiacol
carbonate, gr. iv., every four hours. Her bowels were
kept open with calomel. She made a prompt recov-
ery, temperature reaching normal in six days. She was-
out of school between two and three weeks.
I saw Miss G , aged twelve, on Saturday with a
temperature of 104^ F., prescribed for the fever and
gave a cathartic, supposing from the sudden invasion
it would subside soon, and did not see her again.
I was called the following Tuesday to find a tempera-
ture of 105.3' F., iliac gurgling, and splenic dulness
as large as the back of the clenched fist and as dis-
tinct as over the liver. I put her at once upon the
No. I tablet and followed the treatment faithfully.
Thursday morning there had been six dejections and
at 8:30 P.M. the temperature was 105.2° F. Fri-
day morning there had been six more dejections
and the temperature was 101° F. and next morning
98.5° F. ; four days of treatment. The splenic dul-
ness disappeared almost as rapidly as the high tem-
perature and could not be detected on the second day
of normal temperature. She made a steady but rather
slow convalescence.
Mr. E , a rather robust and corpulent travelling
salesman, twenty-eight years of age, was attacked the
day before I saw him with chilliness and severe pain
in the head, back, and limbs, with muscular soreness.
I found him October 5th with a temperature of 102.5°
F., complaining very much of his pains. I gave a
calomel purge and acetanilid in hot water for the
pains, but next day found him with more fever in spite
of the acetanilid. His temperature was 103.5° F. and
he begged for something to relieve the pains in his head
and back. There was no epistaxis and at this time
no special tenderness in the right iliac region, but the
expression of his face w-as that of a typhoid, and the
severity of the pain and his peculiar complaint re-
minded me of the first case so much that I put him at
once upon the tablet treatment and followed it faith-
fully, with the result that his temperature was normal
in five days. I would say that after the first fe-n- days
he developed considerable iliac tenderness and it was
four weeks before he was able to resume his work.
I believe this to have been a case of aborted typhoid
fever, and that, too, in a man in whom ever}-thing fa-
vored the severest form had it taken its regular course.
I will present in this connection one case taken
from the hospital records: \\'. J. T , a young man.
laborer. He consulted me at my office December
14th. Had some fever and general malaise. I did
not feel positive as to the diagnosis.
December 15th I saw him at his boarding-house.
I now found symptoms so suspicious that I put hin>
upon the tablet treatment. Next day when I saw him
the indications were still more marked and I sent him
to the hospital. Here is the record made by the house
officer: "He says ten days ago he had a chill: epis-
1 86
MEDICAL RECORD.
[August 8, 1896
taxis twice last week, again this morning. Has had
diarrhoea, body ached generally, tongue coated, abdo-
men slightly distended, rose spots, gurgling, and
slight tenderness in iliac region of both sides, lips
dry and cracked. Temperature, 102.6° F."
This reads like a typhoid record, more so than any
of my private cases, and yet the result was the most
satisfactory of all, the temperature reaching normal in
three days. He was discharged well January 9th, hav-
ing been in the hospital twenty-four days.
This comprises all the cases I have to present that
I regard as aborted, and I am well aware that you can,
.and probably will, doubt the diagnosis. But I wish
to ask one question. Are we justified at this early
■period of the disease in quietly folding our hands and
allowing the bacilli to thrive and multiply in the ali-
mentary canal until they have so affected the solitary
and agminated glands that ulceration and sloughing
become inevitable, not to mention the profound poi-
soning of the nervous system by the absorption of
their ptomains? Shall we do this, I ask, merely to
establish a diagnosis that cannot be doubted?
I firmly believe that the great majority of these ba-
cilli— the intestines and stools always being found
full of them —can be rendered inert and washed away
at this early stage, and that by so doing the oppor-
tunity for making an accurate diagnosis may be for-
ever lost. Dr. Woodbridge claims that under this
treatment he has never failed to abort a case of ty-
phoid fever seen before the eighth day. But the time
of actual beginning must in many cases be involved
in much uncertainty.
Osier, in speaking of the Brand treatment, says he
gives the patients the benefit of tiie doubt and bathes
them early, even before the diagnosis is established,
though by so doing he has often bathed patients with
other diseases than typhoid.
I can but think the principle involved is correct and
should be applied with even greater freedom in this
antiseptic and eliminating treatment of typhoid fever.
Mr. F had been sick in bed a week. On ad-
mission he had a hemorrhage, again on the fourth
day, and two or three more succeeding it. Five days
later he had a chill with temperature of 106 F., which
was repeated ne.xt day. No complication being dis-
coverable, he was put upon quinine and the chills or
excessive temperature did not return. He had a severe
run of the fever. There was a condition of paresis in
one leg simulating phlebitis, but without swelling,
though there was inability to move the limb. A little
later there was retention of urine from paresis of the
bladder and still later cystitis. He was ultimately
discharged well.
Mrs. R had been sick eleven days, on admis-
sion. To all appearances she W'as a very sick woman.
Temperature, 104^ F. ; diarrhcea, five dejections the
first day. Abdomen swollen and tympanitic. The
house officer remarked it was a good case to test the
treatment, upon which she was placed at once. The
second day she had fifteen movements of the bowels
and the temperature fell two degrees. While she was
a very sick woman, her condition from that time was
better. She had stomatitis, so we had to abandon the
tablets, using the capsules and four grains of guaiacol
carbonate every three hours alternately. We were not
then so thoroughly imbued with the idea that the
bowels should be kept open, and I think we erred in
not using sufficient cathartics. She had a relapse and
was put back upon the same treatment as at first, and
made a good recovery.
Mr. D had been sick five weeks on admission,
and from the history we were given to suppose he had
malaria. We waited three days for the chill, and
when' it did not come and the temperature kept going
higher we put him upon the treatment. He had a
slight recrudescence and a tedious convalescence, and
also a rheumatic condition of one calf, which prevented
his standing upon that leg for a week or more and
when that was better the other was similarly affected.
His recovery was ultimately good.
Mr. Sh had an ordinary attack, except as com-
plicated with stomatitis and parotitis. He made a
good recovery.
Mr. G had an attack of local peritonitis; other
than that his case was uneventful.
The other charts simply showed the course the dis-
ease pursued in the sixteen uncomplicated cases and
why we had the reputation of having mild typhoid.
Among these would have been included the two fol-
lowing cases had not the charts been lost:
Carl admitted October 2d. The record says:
"Temperature, 103.8° F. ; numerous rose spots.
"October 9th. — Temperature dropped from 104.8°
F. last night to 100.5° ^' ^^'^ morning.
"October i ith. — The morning temperature was 98°
F. and the evening temperature was normal the 15th,
/.e., in thirteen days."
Fitz was admitted October 12th with numer-
ous rose spots. He had stomatitis from treatment,
but nevertheless a normal temperature in nine days.
I am indebted to Dr. Greene for valuable charts
from the hospital in this section, also to Dr. Farnham,
too, for illustrating the effect of the treatment in chil-
dren of five and nine years of age.
Before we leave the consideration of the charts I
wish to call your attention to the fact that after the
first few days of treatment in all the uncomplicated
cases the temperature falls steadily and in some cases
rapidly to normal in from eight to twenty days, the
average being thirteen days. Also to the number of
movements of the bowels and to what seems to be a
fact that constipation ushers in relapses.
I wish also to call attention to the effect of the
treatment upon the temperature. Observe how the
temperature changed when the treatment was begun,
becoming less vacillating, and how it resumed the
same character when it was omitted. The same thing
occurred in I) 's case when the treatment was
commenced. Then observe how afterward throughout
the whole course of the disease it did not vacillate
like an ordinary typhoid temperature from morning to
evening, the range Iseing about one-half as great. In
other words, the antiseptic and eliminative treatment
removes much of the septic character of the disease,
as shown in the daily range of temperature and its
more or less rapid fall.
While I am a firm believer in hydrotherapy for the
disease when indicated, I also belie\e that the neces-
sity for its use is greatly diminished by steadily and
persistently wasliing out the alimentary canal with
antiseptics and cathartics, thus removing as far as
possible the most fruitful source of the poisoning
which is maintaining the high temperature that indi-
cates the necessity for a further resort to hydrotherapy.
Another thing that impressed me strongly while ob-
serving the cases under this treatment was the fact
that in a short time after commencing it the dull
apathetic look would give place to one of more intel-
ligence and patients would seem to take more interest
in what was transpiring about them. The tongue be-
came moist early, as a rule, and seemed unusually clean
throughout the course of the disease. We had none
of the red, dry, and cracked tongues that we have been
accustomed to see so frequently. Many seemed to have
a desire for food, even with quite an elevation of tem-
perature, and I have not hesitated to give stale bread,
either toasted or with milk, and other things of similar
character whenever they desired, if the tongue was
tolerably clean and moist. 'lender boiled chicken was
usually allowed as soon as the temperature reached
August 8, 1896]
MEDICAL RECORD.
187
normal. Tympanites has usually disappeared in a few-
days. This I suppose to be owing to the constant
passage through the bowel of an antiseptic Huid which
does not favor decomposition and the liberation of
gases. Also to the fact that the bacilli in the canal
are rendered inactive, washed away or destroyed, thus
preventing the poisoning of the nerve centres by their
toxins, which favors or even produces paralysis of the
muscular coat of the bowel, thereby allowing disten-
tion.
.Stomatitis occurred in quite a number of cases.
When this was well marked the tablets were omitted and
guaiacol carbonate in from three to five grain doses
given alternately with the capsules. This removed
all cathartics from the treatment, and we endeavored
to compensate for it by the use of podophyllin, sul-
phate of magnesia, and the like.
I now think as I study the charts that in some of
the cases we failed to keep the bowels sufficiently
loose, and that probably the results might have been
better if we had substituted in tablet Xo. 2 ^V S^- <^f
podophyllin for the calomel and podophyllin and used
these in place of the guaiacol carbonate and various
cathartics.
Dr. Shields says: '" All cases of ptyalism can be pre-
vented by using a tooth powder of potassium chloride
once daily." If this proves true, it is a matter of much
value, as there is probably nothing so valuable as a
cathartic in the disease as calomel if it can be used
without producing stomatitis. It seems important to
give the cathartic frequently in order to keep up a
steady and constant action, thus changing in a meas-
ure the current of the fluids in the bowel from the mu-
cous membrane to the lumen, thereby lessening the
amount of septic absorption from the canal. One of
Dr. Greene's patients had as many as twenty-two de-
jections in one day and twelve the next. Mrs. R
had fifteen, followed by a fall of two degrees in tem-
perature, and one of my private patients had eleven.
They certainly did not seem to be injured by them.
Nausea was induced by the tablets in a few cases, but
was soon overcome by a short suspension and giving
bismuth for a few hours, when the treatment was usu-
ally well tolerated. Nothing was allowed to interfere
with its continuance, not even hemorrhage, for we
considered that a bowel emptied of its contents, both
fluid and gaseous, would place the ruptured vessel in
the most favorable condition for the hemorrhage to be
arrested. A few cases, either from the irritation of
the antiseptic or the frequency of the stools, developed
a dysenteric condition, which was always relieved by a
few injections of starch and laudanum without discon-
tinuing the treatment. In none of my cases did hem-
orrhage commence later than the fourth day of treat-
ment. To get the best results from the treatment the
medicines must be given faithfully and persistently.
Possibly this may explain why those w-ho are enthusi-
astic in its praise get better results than those who are
skeptical.
I do not wish any one to think that I consider this
treatment perfect in its present form : on the contrary,
I regard it as only in its infancv, and that as the mass
of physicians shall give it a trial and learn what it can
do in its present form, they will gradually have confi-
dence and ability to make variations and observe results
intelligently, until quite likely a more perfect method
may be evolved. I would also enter a most respect-
ful protest against experimenting before having tested
it as it is, since thereby much harm may unintention-
ally be done by bringing discredit upon the method
which it does not merit.
Now, gentlemen, in closing I wish to remind you
that long before diseases were known to have germs it
was thoroughly established that the stools of a typhoid
patient contained a poison or ferment which, placed in
a privy vault, would infect the w-hole community.
From this source, in a variety of ways, the germs are
received into the alimentary canal and pass downward
until they are below the inhibiting properties of the
upper portion and arrive upon their native soil. Here
in the contents of the lower portion of the ileum, al-
ways at a proper temperature for their rapid develop-
ment, they multiply and grow in the greatest profusion.
Their ptomains are absorbed, giving the malaise for
the conmiencing fever and the fever itself as they be-
come sufficiently abundant. The bacilli are taken up
into the glands, both solitary and agminated of the
mucous membrane, and there multiply and cause these
parts to swell and ultimately to ulcerate and slough
from the pressure. This does not occur until near the
tenth day. Osier reports one case that had not ulcer-
ated at ten days, and Phillips, two, one at fourteen
and another at thirty-six days, yet autopsies were made
and it was found that the patients died of typhoid
fever, as shown by the swelling of the glands.
What killed them? Certainly not the extensive ul-
cerative destruction of the canal. Then it must have
been the poisoning from the ptomains, and where
were these developed? Undoubtedly some in the
swollen glands of the mucous membrane, but chiefly
in the contents of the canal itself, where everything in
their history shows that they develop most rapidly and
consequently produce the greatest amount of toxin.
Now, if this is true of the germs of typhoid fever, its
causes are always to a certain extent within our reach
and under our control, and the reason why the treat-
ment should be commenced early and continued faith-
fully throughout the disease must be apparent to every
one.
Without detaining you longer I wish to call your
attention to the frequency with which the bowels
moved and to remind you that nevertheless the patients
all recovered.
THE IMPORTANCE OF AN UNDERSTANDING
OF MIDDLE-EAR DISEASE BY ALL PRAC-
TITIONERS. WITH A REPORT OF SOME
CASES IN WHICH INEXCUSABLE ERRORS
HAVE BEEN MADE.'
By RICHARD FROTHINGHAM, M.D.,
AURAL SrRGEON, METROPOLITAN THROAT HOSPITAL, AND A SENIOR ASSISTANT
SLRGEO.N, THROAT DEPARTMENT, \ANDERBILT CLINIC, COLLEGE OF
PHYSICIANS AND SCRCEONS, NEW YORK.
On account of the anatomical relations of the middle
ear and the gravity of some of the results of middle-
ear disease, as regards not only permanent loss of
hearing but also danger to life, no part of the body is
of more importance to all practitioners; and still
there is no branch of medicine about -.vhich the ma-
jority of physicians know so little.
Besides destroying the organ of hearing and caus-
ing death, ear disease may result in permanent paral-
ysis, disturbances of co-ordination, or it may affect
the organs of sight, taste, and smell.
In most medical schools \ery little attention is paid
to the teaching of diseases of the ear, and students, as
a rule, have verv limited clinical opportunities. Al-
though grave and fatal cases are sure to come into
the hands of all practitioners, there is no examination
in this branch of surgery in most medical schools.
Consequentlv. the average student pays little or no at-
tention to diseases of the ear. Now that a four years'
course has gone into effect in so many medical schools
in this country, all things point to more thorough
teaching and better clinical advantages in all special
departments: and it is to be hoped that the ear will
no longer be so slighted.
' Read before the Harvard .Medical Society of New York, May
25. 1S95.
i88
MEDICAL RECORD.
[August 8, 1896
Most medical men have a better idea of all other
special branches, even including diseases of the e)'e:
but if one of their patients has eye trouble, he is much
less apt to tamper with it than with the middle ear.
With the best intentions, the average physician as-
sumes the responsibility of treating all acute and sup-
purative diseases of the ear, believing himself fully
competent to handle such skilfully.
From childhood he has been taught to consider ear-
ache and running ears as naturally of frequent occur-
rence but of minor importance, and commences his
medical education with but little respect for the dis-
eases of the ear. An examination on this subject not
being compulsorj-, he oftentimes neglects the lectures
and ignores this important branch of his profession,
not even acquiring sufficient knowledge to appreciate
their possible danger.
The correction of this grave evil lies in the hands
of the faculties of the medical schools, who, by requir-
ing all students to pass a rigid examination in aural
diseases, would do much to benefit a long-suffering
public.
The eye being on the surface, patients can see
acute trouble; or, if there is a disturbance of vision,
they realize the gravity of the case and are very apt to
seek the advice of a specialist even without consulting
their family physician. On the other hand, the tym-
panic cavity is situated so deep in the skull that the
patients cannot see for themselves, and do not appre-
ciate the gravity of their case; and if they have an
acute or suppurative ear disease are well satisfied to
place themselves in the hands of their family medical
adviser. Comparatively few cases of acute or suppu-
rative ear disease come into the hands of a specialist
until either the patient's condition has become so se-
rious that they insist on other 'advice, or the family
physician, having exhausted his remedies, gives the
thing up as a bad job — which, by the way, he is very
loth to do. Patients dread becoming blind, but pa-
tients with ear trouble do not realize their danger. In
eye disease there is little or no danger to life; but, in
neglecting proper aural treatment, a patient runs the
risk of death or permanent injury to the organ of
hearing.
Children especially are neglected. Their little
ears may ache ever so hard, but so long as the general
practitioner assures the family that "pain will pass
away or the ear discharge, and "in children discharge
from the ear is harmless and usually takes care of
itself," the parents are satisfied. Adults stand a cer-
tain amount of pain; then, their patience becoming
exhausted, and having obtained no relief, they seek
other advice. Ear disease in infants is often over-
looked.
Anatomy. — To emphasize the importance of dis-
ease of the middle ear, let us briefly consider some of
the anatomical relations of its parts as given by differ-
ent authorities.
So intimately are the middle ear and external audi-
tory meatus associated in their diseases, and as in all
middle-ear disease the condition of the canal must be
considered, I also give its anatomical relations.
The External Auditory Canal. — The external au-
ditory canal is in relation anteriorly and interiorly
with the parotid gland, suppuration of which may dis-
charge through the meatus. Anteriorly it is also in
relation with the posterior wall of the articular fossa
of the inferior maxillary bone.
The posterior wall is made up by the mastoid pro-
cess; and pus from the mastoid may come through
this wall.
Its superior wall forms a portion of the middle
cranial fossa and is covered by the dura mater. This
wall may be ver}' thin, and otitis externa may produce
disease of the brain.
The Middle Ear. — The middle ear consists of the
tympanic cavity, membrana tympani, the ossicles,
Eustachian tube, and mastoid process. The mucous
membrane lining these parts is continuous with that
of the pharynx, and acts as periosteum. This ex-
plains how easily ulceration of the mucous membrane
will cause caries; and a spot of caries the size of a
pin's head will permit of extension to the cranial cav-
ity and fatal consequences.
It is especially the tympanic cavity that concerns all
practitioners.
The Tympanic Cavity. — The tympanum is an ir-
regular prismatic cavity, enclosing the auditory ossi-
cles, and measuring about half an inch from above
downward and from before backward, and from one-
twelfth to three-sixteenths of an inch from without in-
ward. It is situated within the petrous portion of the
temporal bone, immediately above the jugular fossa
and below the cerebral membranes, the carotid canal
lying in front, mastoid cells behind, external meatus
externally, and the labyrinth internally. It is in rela-
tion with more structures of importance than any cav-
ity of equal size in the body.
The fact that there are some twenty communica-
tions with the tympanic cavity readily explains the
numerous channels for invasion of middle-ear disease
to deeply seated and important parts.
The relations and conditions of the different walls
of the tympanic cavity are of sufficient importance to
be considered separately.
The superior wall forms the roof of the mastoid and
Eustachian tube, and is the partition between the cra-
nial and tympanic cavities. Its thickness varies,
sometimes being very thin or entirely wanting, the
mucous membrane of the tympanum being in contact
with the cerebral membranes and forming part of the
cranial cavity. In infants the sutura petro-squamosa
is open, but in adults this is usually closed.
The inferior wall separates the tympanum from the
jugular vein. This wall also varies in thickness,
sometimes being membranous.
The anterior wall lies close to the carotid canal.
At its upper part the Eustachian tube opens into the
tympanic cavity.
The posterior wall has important relations to the
facial nerve, as the eminentia pyramidalis containing
the stapedius muscle is connected with the Fallopian
canal by fissures. Therefore, in caries of this wall,
the facial nerve is exposed to danger. In the upper
part of this wall is the opening between the mastoid
and tympanum.
The membrana tympani is the dividing line between
the middle and external ear. Its function as a pro-
tective to the delicate structures of the middle and in-
ternal ear is not of secondary importance to whatever
part it takes in the transmission of sound.
The inner wall of the tympanic cavity forms the di-
viding line between the tympanum and labyrinth.
Its relations and landmarks are the fenestra ovalis
in the upper posterior part, below and posteriorly the
fenestra rotunda. Between and in front of the two
fenestra is the promontorj-. Vertically above the
promontory is Jacobson's nerve, and above and behind
the fenestra ovalis is a portion of the Fallopian canal
containing the facial nerve.
Caries of the inner wall may cause suppuration in
the labyrinth and extension into the cavity of the skull.
The facial ner\'e, being separated by a thin plate of
bone which may be deficient in places, is easily in-
flamed or destroyed.
The Mastoid. — The relations of the mastoid pro-
cess to the lateral sinus and cranial cavity should
be remembered by all. Sometimes the petroso-mas-
toidean suture is not obliterated, and pus may make
its way through it to the cranial cavity.
August 8, 1896]
MEDICAL RECORD.
189
The Literal fossa or sulcus forms the inner and pos-
terior wall of the greater part of the mastoid cells.
Usually this wall is strong, but it m.iy be very thin or
perforated.
Vessels and Nerves of the Middle Ear.— Owing
to the free anastomosis between the fibres of the sym-
pathetic, trifacial, pneumogastric, and glosso-pharyn-
geal, and the ner\-es of the middle ear, either refle.x
aural symptoms may arise from disease in other parts
of the bodv or reflex symptoms of other organs may
be due to disease of the ear.
The arteries of the tympanic cavity are derived
from the external and internal carotid, middle me-
ningeal, and stylo-mastoid. Of the blood supply little
need be said, except to remind you of the free anas-
tomosis between the vessels of the tympanum with
those of the labyrinth and brain. This is often the
channel for a purulent inflammation.
Many general practitioners are, and all should be,
perfectly familiar with the normal landmarks and
methods of examining the middle ear, and perfectly
able to recognize and treat all cases of acute or sup-
purative disease with credit to themselves and full
justice to their patients. They can do a paracentesis
or mastoid operation if necessary, and know full well
when the case demands such surgical interference. It
does not require any great amount of training or spe-
cial skill for any man to acquire sufficient knowledge
to become familiar enough with the ear to be able to
examine a case and recognize the normal landmarks
of the drum membrane. This is inore than half the
battle. Very soon he would notice any deviations
from the normal, picture in the field, such as foreign
bodies or cerumen in the canal, polypi, granulations,
perforations, congestions, bulging, or retraction of the
drum membrane. When it comes to recognizing the
finer changes within the tympanic cavity, the result of
suppuration or adhesions: changes in the ossicles, the
result of misplacement or caries; and the finer diag-
nostic points between obscure diseases, special skill
and long experience are requisite, and this is not
within the scope of the busy general practitioner.
My experience leads me to believe that most men,
in examining the ear, hold their speculum at the
wrong angle ; and so, instead of seeing the drum mem-
brane, obtain a beautiful view of thg posterior wall of
the meatus.
The cases I report will well illustrate some inex-
cusable mistakes made by general practitioners, many
of them e.xcellent men and graduates of our best
schools.
In the treatment of disease of the ear. treatment of
the nose and throat should go hand in hand, and to-
gether they should be treated as one organ. The
aurist who is not a thorough throat man can obtain
but poor results.
Prognosis of Middle-Ear Diseases — While speak-
ing of the necessity of a more thorough understanding
of middle-ear disease by the average man, a few words
on the prognosis and result of treatment may not be
amiss.
E.xcluding chronic middle-ear catarrh, the results
from treatment in middle-ear disease are most satis-
factory, nay, even brilliant. In no branch of medi-
cine or surgery are they better.
Chroiic middle-ear catarrh usually comes on so
slowly, and the loss of hearing is so gradual, that it is
quite imperceptible to the patient. He becomes
quite deaf before he realizes that the hearing is
affected. In the mean time the disease has been run-
ning on from two to ten or more years before the patient
seeks treatment. The patient is told by his family
and friends that he is getting deaf, but does not believe
it and replies that " people mumble and do not articu-
late distinctly." On finally awaking to the fact that
he is deaf, it is too late to accomplish much by treat-
ment. Usually uU that can be done is to get back
what hearing has recently been lost, and to help the
patient keep what hearing still remains. The more
acute the chronic middle-ear catarrh in its onset, the
better the prognosis in individuals previously healthy.
When chronic middle-ear catarrh is due to disease
of nose or throat and is seen early, we can stop the
disease and restore in large measure what hearing has
already been lost. When acute middle-ear catarrh is
properly treated, we can restore the hearing. It is in
the treatment of acute and chronic middle-ear suppura-
tion with or without granulations, polypi, and other
complications, that we can expect and do get brilliant
results.
Statistics show that about two-thirds of all ear dis-
eases are of the middle ear, and that about thirty per
cent, of all ear diseases are suppurative; also that an
average of about seven-tenths of one per cent, of all
ear cases treated in ear hospitals are affections of the
mastoid.
According to Field, between one and two per cent,
of all cases of aural suppuration are supposed to re-
sult fatally from intracranial complications.
Barker records that out of eight thousand and twenty-
eight deaths from all causes in three large London
hospitals during twelve years, forty-five cases were
due to disease of the temporal bone.
Four factors are to be taken into consideration in
the prognosis of suppurative middle-ear disease :
Prognosis as to life, stopping discharge, closing of
perforation, restoration of hearing.
Acute middle-ear suppuration, properly handled,
rarely causes intracranial complications or results in
death. The danger of septicaemia is slight. Under
proper treatment the discharge stops, perforation
closes, and the hearing usually becomes normal.
In scarlet fever and diphtheria prognosis is more
doubtful. In these cases the amount of destruction
decides the result. L'lceration may be rapid and de-
stroy all of the drum membrane, and extend to the
ossicles, and they may be thrown out with the dis-
charge.
Prognosis in acute mastoid disease, except in spe-
cific and tuberculous individuals, is good.
In healthy individuals with chronic suppuration, we
can stop the discharge. The closing of the perfora-
tion depends on the amount of destruction of the drum
membrane and the condition of the edges of the per-
foration. If the perforation remains open there is al-
ways danger of a recurrent attack. The amount of
hearing remaining depends on the condition of the
drum membrane and ossicles.
Death, as a result of a neglected chronic otorrhcea,
is by no means uncommon. It seems to be pretty
generally 'agreed to by all aurists that as long as a
discharge from the ear exists there is danger to life.
C. H. Burnett says that " so long as a chronic pu-
rulent discharge comes from an ear, the patient's life
and hearing are in danger, and unless the otorrhcea
is cured the disease surely tends to extend to the
brain."
Schwartze says: "As long as purulency exists, even
though it be so slight that no discharge from the canal
is seen, there is danger to life. The symptoms of
fatal disease may appear with unexpected sudden-
ness when the otorrhcea has. perhaps, existed for many
years, with no perceptible detriment to the general
health, and in cases also in which no caries exists."
Urbantschitsch states that "practical experience
teaches that individuals with chronic otorrhcea do not,
as a rule, reach advanced age."
Death may result from meningitis, cerebral abscess,
septicaemia, general pyamia, septic thrombo-phlebitis,
hemorrhage.
I go
MEDICAL RECORD.
[August 8, 1896
Thrombosis and phlebitis are most common in the
lateral sinus, but may occur in the superior or inferior
petrosal sinus.
Ulceration through the anterior wall of the tympanic
cavity may cause erosion of the internal carotid artery.
Fortunately this is rare, about twenty cases having
been reported.
Ulceration through tiie inferior wall of the tympanic
cavity may cause fatal hemorrhage from the internal
jugular vein. Also there may be hemorrhage from
the middle meningeal artery, and lateral and petrosal
sinuses.
The stand taken by most life-insurance companies
shows the respect with whicli they regard otorrhcea as
a factor in causing death. By the best of them it is
agreed that all persons with chronic middle-ear sup-
puration should be rejected. Some companies believe
in assuming the risk at an advanced premium. .Some
companies reject individuals in whom there is a per-
manent dry perforation of the drum membrane, and
other companies accept such a person if there has
been no discharge from the ear for a certain number
of years. Of course, during an acute suppuration, no
person is accepted; and some companies refuse to as-
sume the risk if there is a history of recurrent attacks
of acute suppuration, even though the drum membrane
is intact and other conditions are apparently normal.
Unrecognized Acute Middle -Ear Suppuration
Followed by Meningitis. — In August, 1894, a house
officer in one of our best New York hospitals re-
quested me to examine this case: A woman, aged
thirty, poorly developed and nourished. Her right
ear had been useless since childhood, the result of
suppuration, but had not discharged since that time,
and was found to be perfectly dry-. The left ear had
never troubled her until the present attack. Some ten
days before I first saw her she had pain in the left ear;
since which time the pain had been steadily on the
increase, and for the last few days she had been unable
to sleep, temperature running from loi' to 103' F.
for several days. Physical examination negative.
On examining the left ear, the meatus was found very
much congested and swollen in its upper posterior
portions; the drum membrane only so arouncl the ex-
treme periphery. The rest of the drum membrane was
pale yellowish, with great bulging, and pus was seen
through it in the tympanic ca\ity. So great was the
pressure of this pus that all blood was apparently
squeezed out of the vessels of the drum membrane.
Immediate paracentesis was advised. The house offi-
cer did not have the authority to give me permission
to do even so slight an operation without first consult-
ing his "visiting," a fine and very busy practitioner.
That afternoon the '"visiting" examined the case; and
he, seeing no great inflammation or cause Yor opera-
tion, decided to await further developments. Three
days later he decided to have the ear lanced, and
called in the visiting surgeon to operate. The sur-
geon punctured the ear in two or three places, but got
nothing but blood. Probably forgetting the direction
of the meatus, he neglected to lift the auricle upward
and backward, and, his speculum being at a wrong
angle, his knife went into the posterior wall of the
meatus. This gave the patient no relief. She devel-
oped meningitis and died.
Acute Mastoid Disease, Diagnosed as " Celluli-
tis."— Mary , aged twenty-five, a strong and
healthy woman. Last July, while at a summer resort
on Long Island, she had an attack of erysipelas and
developed an acute ear trouble. The disease extended
into the mastoid, and her sufferings for the four weeks
before I saw her were very great. Her physician, a
New York man, having a summer practice at one of
the fashionable resorts, attributed the great pain, ex-
tending all over the side of the head, the extensive
mastoid oedema, and sensitiveness on pressure, to a
cellulitis resulting from the erysipelas. He allowed
this condition to go on for some four weeks, all the
time the swelling and her sufterings being on the in-
crease. Then he finally suggested a change of air.
She came to New York and consulted another man,
who viewed the case in much the same light as his
predecessor. One week later she fell into my hands.
I found the walls of the left meatus nearly in contact,
from great oedema of the upper posterior wall of the
meatus, and cedema and apparent fluctuation over the
mastoid, the auricle standing out prominently. Un-
der ether I did a paracentesis and mastoid operation.
Some two ounces of pus were found in the tissues
over the mastoid. The external cortex of the mastoid
was solid and no sinus was present, but a spot of in-
flamed, discolored bone was seen. This spot was
very soft, and a drill easily penetrated it. On going
in some one-fourth of an inch, pus welled out of the
bone under great pressure. The opening was enlarged,
and a large drainage tube inserted. There was no
pain after operation, and the patient made an unusu-
ally rapid recover)'.
Furuncle of Canal, Diagnosed as " Mastoid
Disease." — Case I. — Last May I was called upon to
do a mastoid operation in this case: A woman, aged
twenty, had severe pain in and around the ear for
three days. On examination I found the auricle con-
gested and sensitive to the merest touch. The move-
ments of the jaw in mastication caused excruciating
pain, as did also all movements of the auricle. There
was no tenderness over the mastoid except when the
auricle was touched. A large furuncle of the poste-
rior wall of meatus was found. This was incised,
with evacuation of its contents. Relief was immediate,
and in three days the patient was entirely well.
Case II. — A male, aged thirty-five. Hi.story and
condition of ear the same as in above case. Patient
had been to the hospital and was told that he would
have to be admitted, an operation performed, and it
would be two weeks before he could leave the hospital,
as the ear would ha\e to be opened from behind. In-
cision gave the same relief and result as above.
Acute Middle-Ear Suppuration Diagnosed and
Treated as "Neuralgia." — Case I.— Miss ('• ,
aged twenty-six. .Never had ear trouble before. In
May, 1893, during an attack of acute corj'za she first
had pain in right ear four days previous to my first visit.
Pain in the ear steadily increased and extended into
the mastoid and all over the side of the head. For two
nights she had been unable to sleep. When her sister
came for me, she reported that the patient had been
delirious all night. Her physician had several times
examined the ear, and pronounced it "neuralgia," as
the drum membrane was perfectly normal. On my
arrival I found her condition quite serious. Pulse,
160; temperature, 103.4" F. ; and she was excited and
feeble. Great mastoid tenderness, and the chances
were that the case would require a mastoid operation.
Examination showed the deeper part of the meatus
filled with cerumen, no portion of the drum membrane
being visible. On removing the cerumen the drum
membrane was found swollen, congested, and bulging,
with two small bulla; on it. These were inci.sed and
a free paracentesis made, after which there was abun-
dant serous discharge. One hour later temperature
was 100" F. Patient went to sleep soon after the
operation. Her ear trouble yielded nicely to treat-
ment (leeches, ice, and douching), and in one week's
time the ear was entirely well.
Case II. — Miss McG , aged twenty-two. His-
tory and condition about the same as in the last case,
except that there was no cerumen and that her trouble
had been running on some four weeks. She had been
in the hands of two men, both of whom assured her
August 8, 1896]
MEDICAL
RECORD.
191
tliiit " tlic ear had not gathered and wouUl not gather."
Aft^r a paracentesis this case for a week yielded nicely
to treatment, but mastoid inflammation developed and
operative interference became necessar}- and was ad-
vised. The family would not consent to a mastoid
operation, and the last I heard of the case she was
trying the " faith cure."
Otalgia Dentalis Diagnosed as " a Gathering in
Ear." — Case I. — Girl, aged twelve. Bad pains in
the left ear for three weeks. The ear had been sy-
ringed and poulticed for over two weeks. The child
was examined by her medical adviser half an hour be-
fore I first saw her, his verdict being that the "• ear is
nearly ripe:'go on in the same way and the ear will
soon break." My e.xamination revealed a normal
drum membrane. I discovered a very bad tooth. I
advised its removal and promised relief. The tooth
was extracted and her sufferings ended.
Case II. — Mrs. A , aged forty, had pain in her
ear for some weeks. She was examined by a good
general practitioner and her trouble was pronounced
by him " a gathering in the ear," and he insisted on
immediatelv lancing it. The patient did not like the
idea, and, as I had treated one of her children for ear
trouble, she came directly from him to my office. I
again found a normal drum membrane and a bad tooth,
after the removal of which the same result followed as
above.
Acute Middle-Ear Suppuration Right, but Same
Disease on Left Overlooked. — Willie L , four
months old, a very badly nourished and weak child,
was first seen by me in July, 1894. History: The
child did very well until he was about four weeks old,
except that he had " snuffles." Then the child com-
menced to be very fretful and restless, cried a great
deal, and never slept soundly. The child became
very much emaciated. Three weeks before I first saw
the child his right ear commencced to discharge, but
there was no improvement in his general condition.
All this time the family physician was in constant at-
tendance. -At the appearance of discharge from the
ear he said: "Let the ear alone and the child will
soon be w-ell now.*' For all this the child was stead-
ily going down hill. Two weeks later a throat man
who does considerable ear work was consulted. At
this time there was a profuse muco-purulent discharge
from the right ear. As after his having treated the
child for a few days there was no improvement in the
child's restlessness or general condition, he referred
the case to me for an opinion as to the cause of the
baby's apparently continued pain. On examining the
right ear I found a large perforation of the drum mem-
brane, with free discharge and no bulging. The left
drum membrane was very much bulged and pus could
be seen through it in the tympanic cavity. I wrote to
my friend and advised an immediate paracentesis of
the left drum membrane. Three days later the child
was again sent to my ofiice; the doctor, seeing no in-
dications for paracentesis, did not operate. The
child's general condition was much worse, but the con-
dition of his ears remained unchanged. I emphasized
my former advice. Next day I was requested by the
doctor to take charge of the case. I made a cur\ed
incision of the drum membrane, upon which there was
free escape of muco-pus. The child quickly became
quiet and w-ent to sleep before the nurse left my office.
The child rapidly gained his strength. Later I per-
formed an adenoid operation, and to-day the baby is as
healthy a specimen as one would wish to see.
Polypus from Shrapnell's Membrane the Unrec-
ognized Cause of Head Symptoms. — Woman, aged
fifty, suffered from vertigo and dull pain with fulness
all over the left side of head for some two years.
Treated by family physician for head trouble and
change of life. She was assured that she had no ear
trouble, although every few days she noticed a stain
on the towel after cleaning the ear. This was ""soft-
ened wax," the doctor reported. On examining the
ear a polypus the size of an ordinary pea was seen
hanging down from Shrapnell's membrane. This was
removed, and through the perforation of Shrapnell's
membrane the attic was seen to be filled with pus and
desquamated epithelium. The attic was thoroughly
cleansed with a middle-ear syringe, introduced through
the perforation. The woman's vertigo and head symp-
toms were relieved.
Polypus of Ear, Diagnosed as " Chronic Catar-
rhal Disease." — Mrs. M , aged sixty, suft'ered
from tinnitus, fulness, and pain all over the left side
of head some five years, and felt sure that she was go-
ing insane. She had been treated off and on for
chronic catarrhal deafness for several years by one of
the best doctors in a favorite watering-place. He
last treated her by catheterization for her " retracted
drum membrane" two days before I first saw her. On
examination I found a very large glistening polypus
entirely filling the inner half of the external meatus.
This was remo\ed and the drum membrane found to
be almost entirely destroyed. The symptoms were
relieved, and the patient now feels that her head and
brain are as good as anv one's.
Acute Middle-Ear Disease with a Bulla of Drum
Membrane Diagnosed as " a Malignant Gro-wth." —
A woman, aged thirty-six. History of earache for
three weeks without treatment. Referred to me by a
physician who had made a diagnosis of sarcoma frcni
the great pain and its very rapid growth. On exami-
nation I found the right meatus almost filled by a large
bulla. This was incised and large clots were removed,
after which, as there was some bulging of mtmbrana
tympani, a paracentesis was done. Serous discharge.
Relief of pain. Convalescence rapid and uneventful.
Dried White Desquamated Epithelium in Canal.
Diagnosis Made that " Ossicles were Coming Out."
— .\ ner\-ous woman, aged twenty-fi\e, with a history of
deafness with pain in right ear for several months. She
was examined by her physician, and he sent for nie in
a great state of excitement, as he found that the ossicles
of the ear were surely coming out. He had probed
them, and was positive that they were bones of the ear.
On examination I found the inner third of the meatus
filled with a whitish, irregular mass of hard, diy, des-
quamated epithelium. This was removed and the os-
sicles were seen intact. Patient had a small, dry per-
foration of .Shrapnell's membrane, from which no pus
esciped. Pain and deafness were relieved.
Were I to enumerate the number of patients I have
seen with perfectly intact drum membranes, who had
been told by physicians that the ear drums were en-
tirely gone, I would more than tr)' the patience of this
society. Some of the drum membranes were per-
fectly normal, others in various stages of thickening,
retraction, cicatrization, or calcification.
On the other hand, patients without a vestige of
drum membrane or a sign of an ossicle, in whom on
examination the entire inner wall of tympanic cavity
could be seen, have been assured that their drum
membranes were perfectly normal.
19 East ThrRTv-EiGHTH Street, New York.
Inoculation against Rabies in Vienna. — During
the years 1S94-95 the number of patients who under-
went a cour.se of preventive treatment of rabies at the
Rudolf-Stiftung in \"ienna was one hundred and
twenty. The anti-rabic department, where the treat-
ment is the same as that employed at the Pasteur In-
stitute in Paris, is under the care of Professor Pal-
tauf. There were no deaths among those treated by
inoculation.
192
MEDICAL RflCORD.
[August 8, I S96
FORMALIN AS A PRESERVATIVE.'
By H. a. L. RVFKOGEL, M.D.,
SAN FRANCISCO, CAL.,
CI-RATOR OF THE MCSEL'M, MEDICAL DEPARTMENT, UNIVERSITV OF CALIFOR-
NIA, AND ASSISTANT DEMONSTRATOR OF ANATOMY, MEDICAL DEPARTMENT,
INIVERSITV OF CALIFORNIA.
To find an ideal preserving fluid has long been the
aim of those taking an interest in the care of speci-
mens of organic life.
Such a preservative must not alter the preparation
in any way, it should cause no shrinkage nor harden-
ing, the color of the object ought not to change, the
microscopic as well as the macroscopic appearance
must be preserved, the fluid should be non-inflam-
mable and obtainable at but little cost. As yet no
combination has fulfilled all these indications, nor is
it likely that any ever will; for preserving fluids are
usually such by virtue of one of these very objections,
if such it really be, namely the hardening of albumi-
nous material.
Of necessity all preserving fluids must have anti-
septic qualities and many such, as alcohol and glyce-
rin, are hygroscopic as well. This last qualit\- is of
course not an advantage, owing to the great shrinkage
that occurs on the withdrawal of any water from ani-
mal tissues.
It is by the presence of these qualities that we must
judge the value of the diff'erent media in use. Thus,
solutions of boric acid, four per cent., or carbolic acid,
one to two per cent., are simply antiseptic. Any ob-
ject placed in these will indeed not suft'er putrefactive
changes, but after a time will become macerated and
practically worthless. Glycerin is hygroscopic and
slightly antiseptic. It alters by shrinkage and is too
costly for ordinary use. Alcohol is hygroscopic, anti-
septic, and coagulates albumin. It therefore both
hardens and shrinks the specimens. It also alters by
dissolving out many of the organic pigments. Finally,
solutions of formic aldehyde are antiseptic. They
harden albumin, but cause no shrinkage, and effect
animal pigment but slightly.
Of course all fluid preservatives alter the appear-
ance of tissues to a certain degree by the withdrawal
of blood.
The specimens we show you have been kept in
formic-aldehyde solution or formalin, which appears
to overcome many of the objections mentioned above.
Formic aldehyde, a gaseous body discovered in
1863 by Hoffmann, while passing methyl alcohc' and
air over hot platinum, is one of a peculiar series of
chemical compounds which dift'er only in the amount
of o.xygen they contain. The first of these is methane,
or marsh gas, of which the chemical formula is CH,.
The second is methyl alcohol with a formula of CH,0,
and the third, methylenglycol, is represented by the
formula CH,0,,. If we now extract from this last
one molecule of water, we have the formula of formic
aldehyde, CHp.
Formic aldehyde is a gas, colorless and possessing
a very pungent odor. When inhaled it is very irritat-
ing, quickly setting up a coryza or bronchitis. Its
point of saturation in water is forty per cent., and it is
this saturated solution that is sold under the name of
formalin by Schering. We probaby have here a solu-
tion of methylenglycol, for, as shown above, formic
aledhvde plus one molecule of water gives us methvl-
engly'col, thus: CHp -H ,0 = CH o!^.
On account of its antiseptic properties, discovered
by Blum, it has been used in many diseased condi-
tions dependent on pathogenic germs, but it is of its
uses as a preservative and fixing agent that we now
' Read before the .-Mumni Association of the .Medical Depart-
ment of the University of California, April, iSg6.
wish to speak. These, as mentioned above, depend on
its antiseptic powers and ability to harden protoplasm.
Solutions of one-per-cent. strength, /.<•., one volume
of formalin to forty of water, preserve gross specimens
of tissue indefinitely and so thoroughly that micro-
scopic sections may be prepared therefrom at any
time. Solutions of this strength will not, however,
fi.x the cells so as to show fine intracellular structure.
Still it is the architecture of the tissue, as it were, that
most interests the pathologist, and this will be per-
fectly shown.
Solutions of even less strength may be used, but
with less satisfactory results as regards preservation
of color and minute detail. When the object to be
preserved has many delicate colors that must be shown,
a stronger solution, c.^., four per cent, to eight per
cent., had better be employed. Bodies of insects and
reptiles, fruit and flowers should thus be preserved.
You have all noticed that the slime or mucus that
covers the bodies of certain fishes, reptiles, etc., and
some pathologic specimens becomes converted into
white stringv masses when the animal or tissue is
placed in alcohol. This does not occur with formalin
in solutions stronger than one in forty (one per cent.);
so that any slime or mucus that covers specimens
placed therein remains transparent.
Formalin gives beautiful results in the preservation
of the centriil nervous system, showing very distinctly
the white and gray matter. For this purpose, however,
it has two objections. First, it causes a certain
amount of swelling: second, the gray matter becomes
very brittle, so that small pieces are broken off in
handling. These may both be remedied by making
up the one per cent, solution of formalin in fitty per
cent, alcohol, thus :
R Formalin
Alcohol,
Water . . .
I part.
. aa 50 parts.
This at first glance may appear e.xpensive, but it is
not so, for a single immersion will suffice, owing to the
great rapidity of penetration of the formalin. Of
course if alcohol alone were used it would have to be
changed one or more times to obtain a good result.
If a strong solution of formalin be injected into the
digestive tube and carotid arterj- of a small animal,
The specimen may be left hanging in the open air for
many months without undergoing change.
Blanchard has preserved leeches in the fluid and
found no alteration in the delicate coloration of the
animals after a year.
Egg albumen placed in formalin, four per cent., so-
lidifies and becomes slightly opalescent. If it is now
boiled it will not change in appearance.
Formalin has also been of great use to teachers of
bacteriology demonstrating cultures in gelatin. For,
if the vapor of formalin be introduced into a test tube
in which a cidture is growing, it immediately arrests
the growth of bacteria. Moreover, the gelatin which
has been liquefied bv the bacteria is again solidified
without alteration of appearance. Thus a culture may
be kept in any stage of growth desired.
As a fixing agent in solutions of two per cent, to
five per cent, it far surpasses alcohol and almost equals
the more costly fixing agents, such as osmic acid, etc.,
killing as it does the cells before any change can take
place in the finest intr.acellular structure. For exam-
ple, it has been used instead of osmic acid in Ramon
y Cajal's method for nervous tissues with better re-
sults.
Durig has used four-per-cent. formalin as a mordant
instead of aniline-oil water.
Cullen, of Johns Hopkins, has devised a method for
making frozen sections permanent by means of forma-
lin. He places the section in formalin, four percent.,
August S, 1S96]
MEDICAL RECORD.
19J
three to five minutes; alcohol, fifty per cent., three
minutes; alcohol absolute, five minutes. Cullen finds
sections prepared in this manner in twenty minutes
after an operation as definite for diagnostic purposes
as those prepared by the ordinary methods which take
several days.
To recapitulate, the ad\antages of formalin over
alcohol are as follows:
1. Alcohol by withdrawing the water from a speci-
men causes great shrinkage. Formalin, acting only by
changing the protoplasm, causes very little shrink-
age.
2. Alcohol dissolves out most organic pigments and
so greatly alters the appearance of objects. Formalin
does not do this to any extent.
3. The price of alcohol is.nearly $3 a gallon; that
of one-per-cent. formalin solution about 30 cents.
4. Alcohol is very inflammable. Formalin, being
a watery solution of a gas, is not so.
5. Alcohol by changing mucus or slime to white
strings spoils the appearance of objects covered by
this material. Formalin by leaving mucus and slime
transparent is free from this objection.
The objection to formalin is the irritating quality
of its vapor when inhaled. This is, however, not
troublesome in the solutions ordinarily employed.
The specimens shown well illustrated the advan-
tages of formalin. Two were specimens of a pneu-
monic lung, one in alcohol, the other in formalin.
From the external surface of the one in alcohol the
delicate mottling and striping had almost vanished.
On the contrary the specimen in formalin — in this
case one per cent. — was almost unaltered.
In another jar was a uterus from a case dead of
purpura hemorrhagica. This was placed in a four-per-
cent, formalin solution in order thoroughly to harden
the blood clot in the interior of the uterus. After
four weeks the uterus was carefully cut across and the
specimen was ready. Upon examination it was seen
that the blood clot formed a perfect cast of the cavity.
Neither the uterus nor the clot had shrunken to any
appreciable degree.
Colloid material in the Graafian follicles remains
clear and has not decreased in volume; one of them
is filled with a clot whic'i, like that in the uterus, com-
pletely fills the cavity.
Had this specimen been prepared in alcohol every
thing would have been shrunken and distorted. The
clot would not have formed such a perfect cast of the
uterine canal and the contents of the Graafian follicles
would have appeared as opaque balls or strings filling
a small part of their interior.
1546 HuvvAKD Street.
A. DANGER IN
FILTERING URINE WITH
TALC.
Physicians Should Work Less Dr. Kortright, in
the Brooklyn Medical Jounial, says that arterial sclero-
sis is a common cause of death in physicians. The
lesson that we should learn from our deceased col-
leagues, he states, is not to work too long. When you
find your arterial tension increasing, your temporal ar-
tery becoming tortuous, your radial growing hard, es-
pecially if you have a little palpitation and pass an
increased amount of limpid urine, whatever your
years, know that old age is upon you. Henceforth
shape your life like one that is old. Curb your ambi-
tion. Be content with a small practice. Reduce your
expenses. Give up your night work. Decline con-
finements. Take a long vacation in summer. Retire
early. Eat abstemiously. Drink not at all. .Sell
your horse. Take a great deal of moderate exercise
in the open air. Watch the functions of the skin.
Guard against a chill. Cultivate an even disposition.
Study to be quiet.
By BR.\XDRETH SYMONDS, A.M., M.D.,
MEDICAL EXAMINER FOR THE ML'Tt'.^L LIFE INSURAN'CE COMPANY OF NEW
YORK.
The difficulties in testing for albumin in the urine are
too well known to be enumerated here. The fallacies
to which our tests are liable and the means of avoid-
ing and overcoming these are generally well under-
stood. If the albumin is abundant there is no liabil-
ity of error. WJien urine shows a distinct white cloud
on boiling which is not dispelled by the addition of
nitric acid, and when also a distinct white ring is in-
stantaneously formed at the junction of the same urine
and cold nitric acid — the so-called Heller's test — it
is not necessar}- for us to examine further in order to
predicate the presence of albumin in that specimen of
urine, or to seek more delicate tests for this particular
case. The accuracy of combined positive results with
these two tests cannot be questioned. A\'hen, however,
the amount of albumin is less, so small that the cloud
on boiling is a faint one and needs good light and a
dark background in order to discern it, and the con-
tact test with nitric acid shows negative results even
after standing for half an hour, then our tests may give
certain fallacious reactions against which it is neces-
sary to be on our guard. The substance which it is
most difficult to exclude under these circumstances is
mucin. This is present in nearly all urines, even of
men who are apparently healthy. The test for it is
very simple and delicate. If mucinous urine is al-
lowed to overlie acetic acid, a dift'used white ring is
quickly formed at or just above the junction of the
two fluids. This reaction is also produced by means
of citric,' picric," tartaric,'' and dilute mineral acids.
The latter in the slightest excess are said to dissolve
the precipitate. The delicacy of these reactions with
mucin causes Oliver to say: * '"All acid reagents em-
ployed for the detection of albumin in small quanti-
ties by the contact method are open to the fallac)' of
the mucin reaction."
Each writer agrees with all the others in recogniz-
ing this difficulty in testing for albumin with all tests
but his own. As regards his own test, either it does
not react with mucin or there are certain easy modifi-
cations by which this difficulty can be absolutely
avoided, but no other test besides his is to be counte-
nanced, as all the others are inaccurate or not deli-
cate. This is the story that is told by a dozen writers
on this subject, affording thereby much amusement to
that unbiassed physician who reads them all. I have
tried nearly all these contact tests, and must agree w ith
the majority as regards the accuracy of each test. I
consider each of them liable to give a reaction with
mucin which cannot be distinguished from that with
albumin.
About two years ago a method for avoiding these
reactions with mucin was introduced to the profes-
sion by a well-known firm of apothecaries, who also
made a specialty of urinalysis. This method, which
received the endorsement of Grey,' was as follows:
"Clarify the urine by adding about sixty grains of
powdered French chalk, purified for this purpose, to
an ounce of a mixture of two parts of urine and one of
distilled water; shake all thoroughly together and pour
upon a small four-ply filter, which has been previously
wetted with distilled water, throwing away the first
portion of about one drachm, and returning remaining
' Tyson : " Practical F.."camination of Urine," p. 60.
' Roberts : .Medical Chronicle. October, 1844, P- 3-
' Neubauer and Vogel : " Analysis of Urine," p. 177.
■* Oliver on " Urine Testing," p. in.
' American Journal of the Medical Sciences, 1894, vol. cviii..
p. 39&-
194
MEDICAL RECORD.
[August 8, 1896
portions to the filter, until the filtrate is perfectly clear.
This separates the bacteria and the susiDended mucin
from the mucus of the mucous membrane."
I used this method for some time for clarifying
urine which was partly decomposed, before my atten-
tion was drawn to its faculty of separating out also
mucin. This seemed very reasonable, as I had pre-
viously noticed its ability to remove a large part of the
urinary coloring-matter, which is more soluble than
mucin. For a short time this method gave great satis-
faction. Then the unpleasant thought arose that if
talc possessed the power of removing mucin and uri-
nary coloring-matter, why does it not also remove albu-
min? I submit herewith the experiments which were
undertaken to determine this. Esbach's albumino-
meter was used for the quantitative investigations in
all cases. Even if this is only approximately accu-
rate, it is reliable enough for purposes of comparison.
All the tests in each experiment were made on the
same evening and the results were carefully checked
the next evening, thus insuring accuracy for purposes
of comparison. The urine, of course, was not diluted
prior to filtration. In order to avoid the suspicion
that the results might be due to dilution from the wa-
ter contained in the wetted filter-paper, the first two
drachms of the filtrate were in ail cases thrown aside.
I. This specimen unfiltered showed 0.075 P^'' cent,
of albumin. Six drachms of uri^e were mixed with
one teaspoonful of talc' and then filtered. The fil-
trate showed less than 0.025 P^"' cent, of albumin.
II. This specimen unfiltered showed 0.05 per cent,
of albumin. Two ounces were mixed with two tea-
spoonfuls of talc and filtered. The filtrate showed a
precipitate in the albuminometer, but too small to be
measured. One ounce of this filtrate was now mixed
with one teaspoonful of talc and passed through a fresh
filter. This second filtrate showed a slight cloudiness
■with Esbach's reagent, but no precipitate. One-half
ounce of this second filtrate was mixed with one-half
teaspoonful of talc and put through a fresh filter. The
filtrate from this gave no reaction at all with Esbach's
reagent.
III. This specimen was from a case of chronic ne-
phritis associated with valvular cardiac disease.
From the history it seems probable that the renal le-
sion was primary. The unfiltered urine showed 0.225
per cent, of albumin. The first filtrate of two ounces
of urine with two teaspoonfuls of talc reduced this to
0.15 per cent. One ounce of this filtrate was again
mixed with one teaspoonful of talc and passed through
a fresh filter. The amount of albumin was thereby
reduced to 0.075 P^"" cent.
IV. Another specimen was obtained from this same
case a few days later. The unfiltered urine now
showed 0.175 per cent, of albumin. The first filtrate
showed 0.1 per cent., the second filtrate 0.05 per cent.,
and the third filtrate 0.025 per cent. Fresh talc, of
course, was used for each filtration.
V. As the power of talc to remove albumin from the
urine was by this time fully established, the following
experiment was made to prove that if the quantity was
constant this power varied directly almost with the
amount of talc used. The original urine unfiltered
showed 0.175 per cent, of albumin. When one ounce
■was mi.xed with two teaspoonfuls of talc, the filtrate
showed o.i per cent.; when the same quantity was
mixed with three teaspoonfuls of talc, the filtrate
showed 0.05 per cent.; when with four teaspoon-
fuls, it showed 0.025 per cent.; when mixed with five
teaspoonfuls of talc, the filtrate showed an amount too
small to be measured in Esbach's tube. This experi-
ment also removes the suspicion that the comparative
diminution of albumin in the successive filtrations
' One rather heaping teaspoonful of purified talc or French
chalk was found to weigh fifty-four grains.
might be due to the repeated dilutions from the thick,
wetted filters used.
VI. In order to eliminate the possibility of actual
dilution, this experiment was devised. A sample of
urine was taken which showed when unfiltered 0.175
per cent, of albumin. Two ounces of this were then
shaken for some time with three teaspoonfuls of talc.
The mixture was then poured into a precipitating glass
and allowed to stand for twenty-four hours. At the
end of that time practically all the talc had settled to
the bottom, leaving above the clear urine considerably
decolorized. This was then passed through one thick-
ness of unwetted filter-paper, in order to get rid of a
little talc at the top of the fluid. The albumin was
found to be reduced to a trifle less than o.i per cent.
VII. It .might be urged that even if talc does re-
move albumin, these experiments do not show that it
takes all out of a specimen, and there will still be left
enough to respond satisfactorily to our tests. The
urine used in these experiments was intentionally
selected on account of the large amount of albumin
contained therein, so that any loss could be easily
measured. The figures furnished by Esbach's albu-
minometer refer only to dry albumin, and an amount
equivalent to 0.2 per cent, on that instrument would
make one-fifth or one-fourth of the bulk of urine when
estimated in the ordinary wet way by boiling and allow-
ing the urine to stand for a few hours in a test tube. In
fact, a percentage of albumin that furnishes no appre-
ciable deposit in Esbach's tube will yet give perfectly
satisfactory and characteristic reactions with all our
tests and may be of the profoundest clinical signifi-
cance. The dangers of clarifying the urine by this
method are most pronounced in just these cases, which
are encountered every day in ordinary practice. For
example, a specimen of urine on boiling showed a dis-
tinct cloud which was not dispelled on the addition of
nitric acid. On contact with nitric acid it showed in-
stantaneously a delicate white ring at the junction of
the two liquids, thus indicating albumin. On contact
with acetic acid it showed a white ring, indicating mu-
cin. The cjuantitative analysis showed an amount of
albumin too small to be measured in Esbach's tube.
One ounce was filtered with one teaspoonful of talc in
the usual way. The filtrate showed no cloud on boil-
ing; the contact test with nitric acid gave a negative
result, even after half an hour, and likewise the con-
tact test with acetic acid. In order to see if simple
dilution could cause This change in the reactions, the
original urine was diKued one-half with plain water.
All three tests then gave positive results, although a
little fainter than before dilution. The contact test
with nitric acid required about two minutes before the
ring of albumin appeared, but then it was typical.
This loss of albumin has occurred repeatedly in my
analyses, and might readily have led to the most se-
rious mistakes. It is on this account, and not from a
mere academic interest, that these experiments were
undertaken. The results given prove the great danger
of the method, I think conclusively.
VIII. At the suggestion of D. Granville M. White,
two experiments were made to determine the influence
of talc in removing sugar from the urine. The first
experiment showed some reduction in the amount of
sugar, but, unfortunately, my notes on this case have
been lost. The second experiment showed a reduc-
tion from over 0.75 per cent, before filtration to less
than 0.5 per cent, after filtration, one ounce of urine
having been mixed with one teaspoonful of talc.
12a West Fiftv-Nisth Street.
Surgery of the Lay Press. — " Egan was removed
to Kellevue Hospital, where it was found that the ten-
dons and two arteries had been severed and one or
two ner\-es fractured."
August 8,
1896]
MEDICAL RECORD.
195
THE USE OF PEROXIDE OF HYDROGEN IX
DISEASES OF THE NOSE, THROAT, AND
EAR.'
By W. -SCHEPPEGRELL, a.m., M.li.,
NEW ORLEANS, LA.
VICE-PRESIDRNT OF THE AMERICAN L.\RVNGOLOGlCAL, RHlNOLnGICAL, AND
OTOI,OGICAL SOCIETY ; CHAIRMAN^ SECTION ON OTOLOGV. LARVNGOLOG\-.
AND RHINOLOGY, LOUISIANA STATE MEDICAL SOCIETY ; VICE-PRESIDENT,
NEW ORLEANS ELECTRIC SOCIETY, ETC.
Peroxide of hydrogen is one of the most useful agents
•which we have in the treatment of diseases of the nose,
throat, and ear. Its germicidal and antiseptic proper-
ties, and its capacity for destroying pus and decaying
organic matter without injurious effect on healthy tis-
sues, render it almost indispensable in many cases.
It has always been a source of surprise to me that so
little reference to this valuable agent is found in the
foreign periodicals.
Peroxide of hydrogen is a dio.xide or double oxide
of hydrogen (H.,0.,), water being simply a monoxide
of hydrogen (H„0). It derives its name " peroxide"
from the fact that it is the highest oxide of hydrogen
known to chemistry. It was first prepared by The-
nard, about seventy years ago, and was known as ■" oxy-
genated water," a name still retained in France. A
given volume of it, when decomposed, yields four hun-
dred and seventy-five times its own \olume of free
oxygen. In its undiluted state it is a strong cauterant
of animal tissue, and is therefore usually prepared as
a two- or three-per-cent. solution,.the former yielding,
when decomposed, ten and the second fifteen times
the volume of the liquid in gaseous form.
Peroxide of hydrogen is not toxic; in fact, it is used
for internal medication, and the amount which maybe
taken without injurious effect is well illustrated by a
case recently reported, in a course of discussion on
diphtheria, by Dr. Rudolph Matas. In this case, in
which Dr. Matas had occasion to prescribe it for a
man suffering from asthma, the patient, from a misun-
derstanding of the directions, took six or eight four-
ounce bottles of peroxide of hydrogen during one
night, and was not only not injured by this excessive
amount, but actuallv believed that he had been bene-
fited.
In diseases of the nose, peroxide of hydrogen is an
important therapeutic agent. In ozana a wash of a
twenty-five-per-cent. solution is useful ; or, after wash-
ing the nostrils with an alkaline or the normal physi-
ological salt solution, the hydrogen peroxide, pure or
mixed with an equal quantity of glycerin, may be ap-
plied locally by means of an atomizer or applicator
with cotton, to remove or destroy any scabs or secre-
tion which may be left. In this way the nostrils can
be kept clean, and the offensive odor, which is one of
the most unpleasant features of this disease, may be
prevented. In purulent rhinitis a five-per-cent. solu-
tion, to which an alkali has been added, is useful.
It is also said to be serviceable in controlling nasal
and pharyngeal hemorrhage.
In membranous rhinitis, whether due to the Klebs-
Loeffier bacillus or to micrococci, the spraying of the
nostrils with a twenty- to fifty-per-cent. solution is
indicated, and has given me excellent results. My
experience in diphtheritic rhinitis with this agent has
been so satisfactory that I have not deemed it neces-
sary to use the antitoxin in these cases, as this does
not seem to prevent the post-diphtheritic paralysis,
which would be the only reason for my using it in
diphtheritic rhinitis.
In specific necrosis in the nostrils, peroxide of hy-
drogen is an important agent, n<;t only for its disin-
fecting properties, but also for controlling the horrible
odor that is present in these cases. In diseases of the
' Read .It the meeting of tlie Western Society of Eye, Ear,
Throat and Nose Surgeons, April 9, 1896.
accessory sinuses of the nose, peroxide of hydrogen is
so beneficial that I use it in all cases, whether of a
maxillary, frontal, ethmoidal, or sphenoidal sinus. In
my opinion it cleans and disinfects the infractuosities
of these cavities more effectively than any agent that
we have.
In diseases of the throat, peroxide of h\drogen is
used in follicular and other forms of tonsillitis, and in
specific affections, and is a sheet anchor in diphthe-
ritic processes in this region. Long before the intro-
duction of antitoxin, I have had excellent results from
hydrogen peroxide in diphtheria, and even since the
use of this serum I ne\^r fail to use the peroxide as a
valuable adjunct, and I believe it to have had an im-
portant bearing on the results obtained. It attacks
the membrane, disinfects the parts, and has no inju-
rious effects when swallowed, which is more than can
be said of many other antispetics used for this pur-
pose. In a recent case of laryngeal diphtheria, to
which I was called in consultation, the stridor and
dyspncea were so marked that 1 was compelled at once
to introduce an intubation tube. The tube, however,
was repeatedlv coughed out, and I then made use of a
procedure which I had found beneficial in former
cases — the injection of a seventy-five-per-cent. alka-
line solution of peroxide of hydrogen directly into the
larynx, by means of a laryngeal syringe. The relief
given by this injection was so great that I was not
compelled to intubate again, but simply to make these
injections every four hours. The patient also received
three injections of diphtheria antitoxin serum, which
I made at intervals of twenty-four hours, and the child
made a good recovery. Recently a German author
called attention to the irritating effects of peroxide of
hydrogen on the mucous membrane. This effect I
have found in none of my cases, although this may be
due to the fact that in employing this agent I make
use of a small addition of bicarbonate of soda, and
that I adjust the strength of the solution to the require-
ments of the case.
Diseases of the ear offer a good field for the use of
peroxide of hydrogen. As a non-irritating antiseptic
wash it is invaluable, as in the various forms of sup-
puration, especially when they are accompanied with
a disagreeable odor. In diffuse or circumscribed in-
flammation of the external canal, peroxide of hydrogen
is useful after an incision has been made; and in sup-
purative otitis media, especially in neglected cases, a
five- to fifteen-per-cent. solution is of great assistance.
In cases complicated by inflammation of the mastoid
cells, especially in the suppurative form, the indica-
tion for peroxide of hydrogen is clear, although this
does not prevent the use of iodoform, aristol, and
other antiseptic agents.
In acute cases of purulent otitis media, a five-per-
cent, alkaline solution should be used, as strong solu-
tions are not necessary and may be injurious.
-Medical Bltldjm;.
Ectopic Gestation. -Dr. MacMonagle {Siin//i,-?it
Callfm-iiia J'mcfitioucr, May, 1896 1 names the follow-
ing conditions which may be mistaken for ectopic
gestation or for which it may be mistaken : i. Uterine
pregnancy. 2. Retroversion of the gravid uterus. 3.
Ovarian tumors. 4. Cysts of the broad ligament; dis-
tended Fallopian tubes. 5. Fibro-myoma and fibro-
cystic tumors of the uterus. 6. Pelvic harmatocele.
7. Pelvic inflammatory exudations. 8. Malignant dis-
ease in the abdomen or pelvis. 9. Pregnany in tlie
rudimentary horn of a malformed uterus. 10. Preg-
nancy in a well-formed bicornute uterus. 11. Spuri-
ous pregnancy. 12. Perforation of the vermiform
appenaix, with rapid extravasation of fecal matter and
shock.
196
MEDICAL RECORD.
[August 8, 1 896
The Treatment of Inoperable Malignant Tumors
by the Toxins of Coley.— Dr. Henry Matagne, of
Brussels, reports in the Gazette Medicalc lic Liege,
May 14, 1896, a series of fourteen cases of malignant
tumors treated by injections of the mixed to.xins of
erysipelas and bacillus prodigiosus, and states that he
obtained one complete cure. The patient was a man,
sixty-four years of age, of strong constitution. In
January, 1895, he first noticed something abnormal in
the floor of his mouth. In February he consulted a
physician, who made the diagnosis of an epithelioma-
tous tumor and advised operative treatment, to which
the patient refused to submit. He consulted several
other physicians of high authority, who confirmed the
diagnosis and advised operation. In the beginning
of June, 189s, he consulted Dr. Matagne. The patient
at that time presented a tumor consisting of three
lobes occupying the floor of the mouth to the left of
the frenum of the tongue, the largest lobe being about
the size of a nut; the two other lobes extended one to
the right side of the frenum, the other toward the base
of the tongue. In the left subma.xillary region there
was a gland the size of a small nut, and under the
chin were two other glands, respectively the size of a
bean. The tumor was indurated, there was very super-
ficial ulceration without suppuration, and there were
lancinating pains radiating toward the left ear. In
brief there were all the clinical signs of cancer, and
all who had examined the growth agreed that it
was an undoubted case of epithelioma. Histologi-
cal examination of the neoplasm was not made.
The fear of jeopardizing the progress of the treat-
ment in opening a gate to secondary infections was
reason for not removing a piece for examination.
The treatment was begun on the loth of June; sub-
cutaneous injections were given in the subhyoid
region, the initial dose of the toxins being five
centigrams. Two hours later the temperature was
38.5' C. On the i6th of June forty centigrammes
were injected into the tumor; severe rigors fol-
lowed one-half hour later; the tongue was greatly
swollen for two days. The highest temperature
reached during the treatment was 41^ C During the
whole febrile period the tumor diminished to a
marked degree. This diminution continued after the
cessation of the fever, and by the beginning of Sep-
tember no trace of the tumor remained. The second
case was one of recurrent sarcoma of the neck, occur-
ring in a woman seventy-eight years of age. The
tumor was the size of an egg and located in the
sterno-mastoid muscle. There was another tumor the
size of a small nut in the region of the masseter, and
two small, very hard glands were found underneath
the chin. After the treatment had been continued for
three and a half months, the injections being given
every other day, the large tumor had completelv disap-
peared. The tumor in the region of the masseter was
scarcely perceptible. The glands had not entirely
disappeared when the treatment was accidentally in-
terrupted. At present, six months after the cessation
of the injections, there is a slight recurrence of the
trouble; the patient has been advised to renew the in-
jections. In a third case, a recurrent sarcoma of the
neck, the size of a foetal head, the patient was treated
with the toxins for three months and the tumor had
diminished to two-thirds its original size, when the
patient, tired of the long duration of the treatment,
preferred to consult a surgeon. The operation proved
fatal. In a fourth case reported, a recurrent sarcoma
of the arm, the injections only temporarily retarded
the growth. In the fifth case, a sarcoma of the jaw.
there was no result, except a temporary arrest in the
progress of the disease. Case VI. was a deeply ulcer-
ated sarcoma of the neck, occurring in a ver}- feeble man
sixt)--four years of age. The pdtient died after five
weeks of treatment during a reaction which followed
an injection of ten cubic centimetres of the toxins.
The tumor had diminished a little in volume. The
remaining seven cases were all of epithelioma or car-
cinoma and there was very little result, except in two
cases; in one of these, a case of recurrent carcinoma
of the breast, the injections seemed to produce an
arrest in the progress of the growth, the latter remain-
ing stationary for several months. In the other case,
a cancer of the uterus, there was diminution of the
pain and a decrease in the size of the tumor. The
improvement lasted for four months.
Ligature of the Innominate Artery. — In the Bos-
toii Medical and Surgical Journal Dr. Burrell has re-
ported a case of ligation of the innominate artery in
which the patient lived one hundred and four days af-
ter operation. According to the author this case
teaches: i. That a patient with general arterio-sclero-
sis and an enlarged and dilated heart may be kept un-
der ether one hour and a half, subjected to a severe
operation, and recover with little shock. 2. That
while ligation of the innominate artery is not of ne-
cessity fatal, yet it will always be an extraordinary
operation, fraught with danger frcm the cutting off of
an extensive area of circulation. The removal of the
sterno-clavicular articulation, and such a portion of
the sternum as may be necessary, makes the perform-
ance of the operation more practical and one of rela-
tive simplicity and safety. 3. That the absence of
pain or marked discomfort following the operation,
the complete relief of all the patient's symptoms, and
his almost uneventful recovery are remarkable. 4.
That the secondary hemorrhages which have occurred
in almost all of the recorded cases were undoubtedly
due to local sepsis, and that the recoveiy of this case
was due to the accuracy with which it was possible
to place the ligatures and to the asepsis. 5. That if
the innominate is ligated at all, two ligatures are nec-
essary, one to act as a breakwater by obstructing the
constantly recurring waves of blcod coming from the
aorta. 6. That the collateral circulation was princi-
pally established in this case by a downward stream
of blood from the right carotid and vertebral arteries
into the subclavian artery. That while the fusiform
aneurism had shrunken, there was very little clot above
the second ligature. This would lead him in another
case of fusiform aneurism in this situation to ligature
the carotid, if possible the subclavian in its first part,
and, if practical, the vertebral. 7. That the unique
behavior of the first ligature that was applied to the
innominate is perhaps the most interesting fact which
we learn from this case. When the innominate arterj-
was tied something in the wall was felt to give way.
The ligature gradually cut its way through tlie coats
of the vessel, and this was followed by an inflamma-
tion in the organization which prevented a secondary
hemorrhage, and finally rested, organized and prob-
ably covered with a smooth layer of intima, inside the
innominate artery. This places a new factor at our
disposal as regards final disposition of the ligature.
Frost Bites.—
IJ Chloralis X ij.
Zinci o.\idi _. gr. xl.
Pulv. myrrh.,
Pulv. opii aa 3 ss.
Adipis \\.
M.
— J. R. Wood, L' Union Med. du Canada.
August 8, 1 896]
MEDICAL RECORD.
197
Medical Record:
A Weekly Journal of Medicine a?id Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, August 8, 1896.
MfiNlfiRE'S DISEASE AND ITS TREATMENT.
The complex of symptoms which goes under the
name of Meniere's disease often causes the patient a
great deal of distress and the physician much an.xiety,
on account of the painful and obstinate nature of the
symptoms. Me'niere's disease has been written about
to a very great extent, since Me'niere himself pub-
lished his original article in the Gazette Medicalc dc
Paris, in 1861. A recent monograph upon the sub-
ject, by Dr. Frankel-Hochwart, contains nearly six
pages of bibliography. The result of all this research
has been to establish the fact that the vertigo and
other accompanying symptoms in Meniere's disease
are due to an irritation of the vestibular and cochlear
branches of the eighth nerve. This irritation, it has
been shown, is due to very different causes. It may
be a syphilitic exudate or some other inflammatory
process in the internal ear, or, as is more commonly
the case, a chronic inflammatory disease of the middlr>
ear with secondary involvement of the labyrinth.
Apparently there are cases of Meniere's disease also
in which the condition is functional — cases in which
no evidence, at least, of real organic disease can
be found, and in whicli the convulsibility of the epi-
leptic constitution shows itself; or cases of neuras-
thenia, in which the point of least resistance is tlie
eighth nerve. The causes and the pathological
changes underlying the symptoms that go by the name
of " Meniere's disease" are indeed so various that it
is somewhat unfortunate that a specific name has been
given to the condition, since neither the periodicity
of the attacks nor the progressiveness of the disorder,
in fact no symptom aside from the vertigo, may be
considered constant in persons who suffer from this
malady. This fact is abundantly shown by a study of
Hochwart's classification. He tells his readers that
there are four different kinds of Meniere's disease,
with .some nine different subdivisions of these four
classes. Thus, we have the epileptiform, due to a
sudden hemorrhage into the labyrinth; the traumatic
form, in which, perhaps, a fracture or some direct
injury of the ear structure occurs. Then we have the
progressive form, which develops on the basis of a
previous ear disease. This type of Mdnifere's disease
is subdivided in accordance with the location of the
ear trouble and in accordance with its chronicity or
acuteness. Me'niere's disease may develop on the
basis of lesions occurring either in the external ear,
on the one hand, or in degenerative diseases, involv-
ing the nucleus of the nerve, on the other. Still an-
other form of Me'niere's disease is described as oc-
curring as the result of mechanical causes, such as
washing out the ear, catheterizations, seasickness, and
so on. And, finally, there are attacks of Me'niere's
disease which are called pseudo-attacks, and which
are due to hysterical, epileptic, or migrainous neuroses.
The conclusion which one would most naturally
and logically reach, from a survey of the literature on.
this subject, is that the term" Meniere's disease,''
had much better be abolished and the term " aural
vertigo" be used in its place. The physician then,
when a patient presented himself with a history of
severe attacks of vertigo, would have to ascertain only
if the vertigo were of aural origin; if so, in what part
of the ear it was situated, and, finally, what was the
nature of the pathological process. This is really the
problem that is to be solved in every case, and it is
often obscured by the physician feeling anxious to
make out a picture which will correspond \\\X\\ so-
called Meniere's disease. He should be satisfied
with establishing '.he relationship of the symptoms to
the eighth cranial nerve.
These remarks are a somewhat lengthened prelimi-
nary to the notice of a practical communication upon
the subject, made by Dr. Lemariey, in the Anualcs des
Maladies de /' Oreille, du Larynx, dii Ncz, ef dii Pharynx.
The drugs which have been used in this disease vary,
naturally, with the stage and form of the trouble, but
the bromide of potassium, salicylate of sodium, the
sulphate of quinine, iodide of potassium, and, finally,
pilocarpine, have been most frequently recommended.
It is with regard to the efficacy of the last-named
remedy that Dr. Lemariey writes. He reports the
case of a man of thirty-five, who suffered most sererely
from attacks of the symptome de Meniere. The attacks
developed suddenly on the basis of a chronic middle-
ear disease, involving both ears. For a week he was
treated in various ways without success, the attacks
coming on as usual and the continual vertigo annoying
him greatly. At the end of a week, treatment with
pilocarpine w^as begun. He used a solution of ten
centigrams of nitrate of pilocarpine in ten grams of
distilled water. Injections were given every day, the
patient lying in bed during the time, and until after
the "s-weat crisis," that is to say, for about two hours.
The dose at first was four milligrams of the solution,
and was increased by one milligram every two days.
Besides the physiological action of pilocarpine upon
the saliva, the sweating, and the urine, a progressive
amelioration in the state of the patient took place.
Fifteen days after the beginning of treatment he was
able to go about the wards, and in about fifteen days
more he left the ho.spital, practically cured.
Rabies in Pennsylvania — Rabies has broken out
among the cows, dogs, sheep, and hogs in Path Val-
ley, (Jentre County, Fa., and it is feared that the dis-
ease will become general throughout the county.
198
MEDICAL RECORD.
[August 8, 1896
CATHETERIZATION OF THE URETERS.
Surgical treatment of diseases of tjie kidneys has
become so frequent in large hospitals as to make it
extremely important to diagnosticate the exact condi-
tion of the two organs as nearly as possible before the
operation. Such unfortunate occurrences as removal
of an only kidney, the other being congenitally absent,
or extirpation of a diseased organ when its fellow hap-
pened to be in no better condition, had stimulated the
ingenuity of surgeons in their search for a safe and
effectual means of withdrawing urine secreted by one
kidney before it entered the bladder to become mixed
with that secreted by the other. By this means it was
hoped that not only would knowledge be obtained of
the existence of one or both kidneys, but that the
amount and condition of the urine would furnish a
reliable index to the condition of the respective
secreting organ. Obstruction of the ureter by pres-
sure is both difficult of application and uncertain in
its result, for one cannot be assured that the flow from
that side has been entirely checked. Moreover, cys-
titis may exist, and the urine from the other kidney
on passing into the diseased viscus will then contain
morphological elements which may or may not have
been furnished by the kidney. This led to attempts
to catheterize the ureter through a vesico-vaginal fis-
tula, or even through an artificial opening made for
that purpose. The introduction of the incandescent
light, whereby cystoscopy was made practical a few
years since, led to efforts at catheterization of the
ureters tl. rough the badder, and the clinical work of
Casper Meyer, Kelly, and others is sufficient testi-
mc.i, > be success which has crowned those efforts.
The u^e^hra being shorter and larger in women, it
was to be expected that cystoscopy and catheterization
of the ureters would become a practical art in them
sooner than in men, and so it did. In a work recently
published on the diagnostic value of ureteral cathe-
terization' Casper credits Dr. James Brown, of Balti-
more, with having first successfully catheterized the
male urethra (June 9th, 1893), but with an instrument
which was found both uncertain and liable to injure the
ureter. He urges the same objections against the Nitze
ureter-cystoscope. The catheter leaves the cystoscope
at a definite angle, and even if one succeeds in intro-
ducing it into the mouth of the ureter, it is liable, on
account of the fixity of that angle, to damage the lower
ureter, whose course is more or less variable. More-
over, there is difficulty in withdrawing the cystoscope
and leaving the catheter in the ureter. Casper over-
comes these objections, at least in a degree, by caus-
ing the end of the catheter to leave a fenestra whose
length can be increased or diminished by a slide.
Moving the slide forward shortens the opening and
gives the projecting end of the catheter a more acute
angle, whereas retraction of the slide lengthens the
opening so that the catheter assumes a greater curve
and also conforms more readily to the course of the
ureter when introduced. By entirely withdrawing the
slide or sheath, the catheter can be lifted free from
' " Die diagnostische Bedeutung des Katheterismus der lire-
teren," von Dr. Leopold Casper. Berlin ; Oscar Coblentz, 1896.
the cystoscope and allowed to remain while the latter
is withdrawn. The ureter-cystoscope has reached that
degree of perfection, and its application has been made
sufficiently easy in women at least, certainly to render
inexcusable at the present time removal of an only
kidney, or cutting down upon the healthy organ when
it is known that one of the two must be diseased.
But up to the present ureteral catheterization has not
proven to be so innocuous as to justify indiscriminate
application for the purpose either of gaining experi-
ence or of guarding the ureter against a mere possibility
of injury during operations, for the longer the catheter
is allowed to remain in place the more likely it is to
excite inflammation or expose to infection. In man,
even the introduction of a large sound without marked
curve into the bladder is not a trifling procedure, and
it is safe to say that if all surgeons should undertake
ureteral catheterization, the number of patients not re-
quiring, but rather being damaged by, such practice
would exceed the number to whom it could be of
benefit. In other words, it would seem that here, for
the present, is a field for the cultivation of a specialty
within a specialty^
To be of value therapeutically, catheterization of
the ureters would in most cases have to be repeated a
number of times, which fact of itself would indicate
that in this direction its application will be more
limited than in diagnosis, yet it has been resorted to
for flushing the pelvis of the kidney, dilatation of ure-
teral stricture, dislodgment of gravel, etc., with ad-
vantage.
In ureteritis, Mann, Reynolds, Etheridge, Lapthorn
Smith, and others say that constitutional treatment,
particularly free use of water, is more promising than
local applications.
THE SURGICAL TREATMENT OF EXOPH-
THALMIC GOITRE.
Since extirpation of the enlarged thyroid gland was
first practised in 1880 for the relief of the symptoms
of exophthalmic goitre the subject of this operation
has been a matter of considerable discussion. Some
authorities would operate in almost all if not all
cases; others would be as sweeping in the limitation
of surgical intervention; while still others would be
governed by the urgency of the symptoms referable to
the thyroid gland — as a result either of pressure or of
intoxication due to failure of function. According to
the latest dictum the cases most suitable for thy-
roidectomy are those in which psycho-neurotic symp-
toms predominate and which have resisted other thera-
peutic measures. To the not yet large number of
cases operated on Berndt ' adds two more, in one of
which a perfect cure was eft'ected, while in the other
only improvement resulted.
The successful case occurred in an unmarried
woman, sixty-five years old, in whom palpitation of
the heart followed emotional disturbances at the age
of thirty-five years. Shortly afterward a pulsatile
swelling made its appearance on the left side of the
' Archiv fur klinische Chirurgie, No. 4, 1896.
August 8, 1896]
MEDICAL RECORD.
199
neck. Subsequently the diagnosis of exophthalmic
goitre was made by a distinguished clinician, despite
the absence of exophthalmos. Later in the history of
the case the woman suffered from violent attacks of
delirium cordis, characterized by tachycardia, with a
sense of anxiety and of oppression, and followed by
sweating. As time went on, symptoms of melancholia,
with suicidal tendencies, made their appearance.
Varied treatment had been employed at different
times, but without avail. When finally operation was
proposed the woman readily assented. Accordingly,
the enlarged left lobe of the thyroid gland was re-
moved, together with a nodule of considerable size
that was found in the anterior mediastinum. The
right lobe of the gland was not enlarged, nor was the
trachea compressed or softened. Following the opera-
tion the pulse progressively diminished in frequency
to the normal and the other symptoms gradually dis-
appeared.
The second case occurred in a married woman,
fifty-eight years old, in whom palpitation of the heart
developed at the age of twenty-five years in the train
of hard work. The patient had always been irritable.
In the course of two years swelling of the neck made
its appearance. The skin became pigmented and the
eyes protruded. The patient complained of sleepless-
ness, of a sense of fear, of restlessness, of dyspnoea,
and sweating. After ten years of unavailing medical
treatment an operation was readily agreed to. Both
lobes of the thyroid gland were enlarged, the left,
however, in greater degree, but the trachea was not
affected. The left lobe and a retro-sternal nodule that
was found were removed, but failure of the heart
necessitated premature termination of the operation.
The condition of the patient was greatly improved
after the operation, but death resulted a year later
from pneumonia complicating influenza.
Berndt looks upon exophthalmic goitre as a reflex
neurosis originating in the irritation resulting from the
torsion, traction, and compression of the sympathetic
nerve endings in the thyroid gland due to the morbid
changes in its structure. These conditions are re-
moved by thyroidectomy and with the removal of their
cause the symptoms likewise disappear.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
July 25, 1896: July i8th. — Assistant Surgeon L.
Morris, detached from Indian Head proving ground,
ordered home, and granted one month's leave. July
2 I St. — Assistant Surgeon F. C.Cook detached from
treatment at the New York hospital and ordered to
proceed home; Medical Director G. H. Cook de-
tached from special duty at Philadelphia and or-
dered to take charge of hospital there; Medical Di-
rector D. Kindleberger, detached from duty in charge
of hospital at Philadelphia, and ordered home to await
orders; Medical Inspector W. G. Farwell ordered to
special duty at Philadelphia attending officers.
Dr. Edward N. Brush, superintendent of the Shep-
pard Asylum, has been elected professor of psychiatry
in the Woman's Medical College of Baltimore.
The American Electro-Therapeutic Association.
— The sixth annual meeting of this association will
be held on September 29 and 30 and October i,
1896, in Allston Hall, Studio Building, on Clarendon
Street, near St. James Avenue, Boston, Mass.
The American Pharmaceutical Association will
hold its* annual meeting in Montreal, August 12th-
20th. An attendance of between seven hundred and
eight hundred is looked for, and great preparations
have been made for their entertainment.
Extreme Heat in the Southwest. — The tempera-
ture in Little Rock and Oklahoma during the past two
weeks has exceeded that ever known there. At Little
Rock, according to a recently issued bulletin of the
weather bureau, the maximum temperature durilig the
past twelve days was 102' F. on eleven days, and
104° F. on one day.
The Royal College of Surgeons. — By the election
of Sir William MacCormac to the presidency of the
Royal College of Surgeons, a St. Thomas Hospital
man has been honored for the first time in fourteen
years, since the election of Sir Spencer Wells.
Inspection of Charitable Institutions — The New
York State board of charities has appointed Dr. Ste-
phen Smith, of this city, and Enoch V. Stoddard, of
Rochester, a committee to inspect the charitable insti-
tutions of the State. This is one of the duties im-
posed by law upon the board.
Second Pan-American Medical Congress. — Dr.
Francisco Bastillos, No. 7 Calle de Tacuba, Mexico,
is the treasurer of the second Pan-American Medical
Congress, to be held in the City of Mexico during
the week beginning November i6th. All physicians
residing in the United States and Canada who con-
template attending are requested to forward the regis-
tration fee of $5 to him, and at the same time to no-
tify Dr. C. A. L. Reed, of Cincinnati.
Beriberi at Philadelphia. — The Norwegian bark
Carwpiis, which reached Philadelphia on July 29th
from Mauritius, had on board six severe and several
mild cases of beriberi. The former were detained
at the quarantine hospital. The disease made its ap-
pearance as the vessel was crossing the equator.
An International Congress of Medical Ethics is
the latest proposal. According to the Sea //>>■/ oi Eng-
land, a journal of the same name in Belgium proposes
the institution of an International Congress of Deon-
tology and Medical Legislation, and gives the follow-
ing views as to the programme that should be
adopted: "To lay down the fundamental rules of a
code of honor, which shall serve as a guide to all
practitioners in the multiple contingencies appertain-
ing to a medical career; the relations that should ob-
tain between neighbors, between strangers, between
general practitioners and specialists, between tiie rank
200
MEDICAL RECORD.
[August 8, 1896
and file of the profession and the staffs of hospitals,
between physicians and surgeons, consultants and
family attendants, beginners and veterans, men prac-
tising in watering-places and those sending patients
to undergo the cure, etc."
Dr. John H. Packard has resigned from the surgi-
cal staff of the Pennsylvania Hospital, and Dr. Wil-
liam Barton Hopkins has been elected his successor.
Spinal Meningitis among Stock. — Spinal menin-
gitis has broken out among a number of hojses near
Newtown Square, Pa., and five of the animals have
died. The disease has been unusually prevalent
among the stock in Chester County during the pres-
ent summer.
Homoeopathic Representation on Hospital Medi-
cal Boards At a special meeting of the managers of
the Chester (Pa.) Hospital, on July 28th, an amend-
ment to the by-laws admitting homoeopathic physi-
cians to the medical staff was rejected.
The Mississippi Valley Medical Association will
hold its meeting at St. Paul, on September 15th,
i6th, 17th, and i8th, instead of a month later, as was
previously announced. The change is made in order
to give the members and their families an opportunity
for a tour through the Yellowstone Park. Information
concerning this excursion may be obtained by address-
ing Dr. C. .\. Wheaton, St. Paul, Minn.
The American Association of Obstetricians and
Gynecologists will hold its ninth annual session at
the Hotel Jeft'er.son, Richmond, Va., on September
22d, 23d, and 24th. The preliminary programme
contains the titles of thirty-five papers.
The Heat in Europe has been excessive thus far
this summer, and has caused much suffering as well
as many fatalities. Eighteen deaths are reported to
have occurred at Konigsberg on July 30th and 31st as
the result of sunstrokes.
Obituary Notes. — Dr. Williamson, of Greenville,
Pa., was fatally injured, on July 23d, by being struck
by a freight train. — Dr. John Dale Dillon was
killed at Philadelphia, on July 28th, by jumping from
the fourth story of his residence while temporarily in-
sane. He was forty years old. He was graduated
from Jefferson Medical College in 1877, and served
for a term as resident physician in the Philadelphia
Hospital. — Dr. Joseph M. Toner, of Washington,
died on July 31st. He was widely known not only as
a physician but also as a scientist, historian, and phi-
lanthropist. He presented to Congress in 1882 a val-
uable collection of thirty thousand historical and
medical works, and for many years he had been en-
gaged in gathering copies of ever)' original letter and
paper of George Washington. This forms the largest
collection of Washington letters ever put together.
It is permanently deposited in the Congress librar)-.
Dr. Toner was a graduate of the Jefferson Medical
College in the class of 1853. — Sir Willian Robert
Grove, F.R.S., died in London, on Augu.st 2d. He
was educated for the legal profession, but early turned
his attention to tiie physical sciences, and especially
to electricity, in which he made many discoveries, be-
ing the inventor, among other things, of the battery
which bears its name. — Dr. Lawrence B. Cortelyou,
of Brooklyn, was instantly killed by falling from a
third-story window of his house on August 5th. He
had been ill for some time and was delirious at the
time the accident occurred.
The National Association of Dental Faculties
held its annual meeting in Saratoga, on August ist,
under the presidency of Dr. S. H. Guilford, of Phila-
delphia.
Electricity in Diabetes. — M. d'Arsonval, in a re-
cent paper read before the Paris Academy of Sciences,
said that he had been trying on two patients the high-
frequency currents of Tesla for diabetes, and with ex-
cellent results. At the commencement of the treat-
ment, the urine of one patient amounted to twenty-
four pints a day and contained over twenty ounces of
sugar. After si.x weeks of the current the quantity
had fallen to twelve pints and the sugar to about six
ounces.
The Rapacious Plumber. — .\n Edinburgh plumber
recently sued a man for the amount of his bill, one
item of which was a guinea for '" medical rubbings."
The cu.stomer, who had rheumatism, so admired the
dexterity the plumber displayed in rubbing lead joints
in the pipes that he got the man to rub his own joints.
Effective Health Measures in Texas. — A vera-
cious P^nglishman, living in Texas, wrote as follows
to his mother, who lives near Gloucester in England:
" I have been much interested in the accounts of the
small-pox in your neighborhood. In this free and en-
lightened country, when it broke out in a town every
one was ordered to be vaccinated. Those who ob-
jected were held against a wall by one policeman, and
another stood opposite with a loaded revolver while
the operation was being performed. I should much
like to assLst in the same way at the vaccination of
some of tlie Stroud people." The letter was printed
in a local paper, and now the good people of the place
are full of admiration of the way our sanitary laws are
enforced.
The " Revista de Ciencias Medicas" of Havana
announces in the number for June of this year that its
publication must cease. The reason is, of course, the
disturbed condition of the island and the dispersion of
the physicians, many of the best of whom are in the
Cuban anny helping to win their country's freedom.
The Rcrista was founded eleven years ago and has
during that time done much to advance the cause of
medicine in Cuba, its pages having contained many
valuable contributions relating to tropical diseases.
We regret exceedingly the suspension of publication
of this good journal and trust that it will be only for
a short time, and that the Rrvista will rise again and
share in the general prosperity that must follow the
triumph of the right in Cuba.
The Pottstown ( Pa. ) Hospital has been the recip-
ient of >2oo. bequeathed to it by the late Lindley R.
Beecher.
August 8, 1896]
MEDICAL RECORD.
201
glexiiaws ami Notices.
The Stomach: Its Disorders, and How to Cure
Them. By J. H. Kellogg, M.D. Illustrated. Mod-
ern Medicine Publishing Company. Battle Creek, Mieh.
1896.
This book embodies, as we copy from the writer's preface,
"first, a brief sketch of the processes of digestion; then a
consideration of the causes of indigestion, and their bearing
upon dietetic and other habits, to which is added a descrip-
tion of the various symptoms present in functional diseases
of the stomach, together with the means by which they may
be relieved, followed by a consideration of each of the sev-
eral classes of digestive disorders, and the proper dietetic and
other measures necessary- for their cure. " While the book
contains three hundred and fifty-seven printed pages, onlv
one page is given to the subject of •' Ulcer of the Stomach"
(p. 276) and one to that of "Cancer" (p. 277)! Dr. Kel-
logg dedicated his book to his patients; he probably foresaw
that but few physicians would be inclined to read it.
The Histopathologv of the Diseases of the .Skin.
By Dr. p. G. Unxa. Translated from the German with
the Assistance of the Author by Norman Walker,
M.D., F.R.C.P. Ed., Assistant Physician in Derma-
tology to the Royal Infirmary, Edinburgh. With Double
Colored Plate Containing Nineteen Illustrations and Forty-
two Additional Illustrations in the Te.xt. Edinburgh :
William F. Clay. New York: Macr^Iillan & Co. 1896.
Dr. Unna's work was too vast and. too important not to
be placed at the disposal of all dermatologists and those in-
terested in pathology who could not read it readily in the
original. It must be confessed that the ditficulties of master-
ing many of the details are by no means small, even when
the language in which they are described is that most famil-
iar to the reader. To thoroughly appreciate and understand
this treatise one must be or must become familiar with the
author's technical methods, and must use his stains and
study, with the aid of the book, as he has studied and worked
in order to write it.
The translator has undoubtedly been aided by the author's
knowledge of English, which all who have heard him speak in
international meetings and elsewhere know is quite extensi\-e.
The difficulties of expressing with absolute accuracy the
author's views in all instances would have been insurmount-
able, it would seem to us, without such aid. As it is, the work
is in many respects an improvement on the original text.
Some alterations have been made and illustrations have been
added. The translator, having worked for a considerable time
in Dr. Unna's laboratory-, seems to have been peculiarly fitted
for the task which he has undertaken and carried to so suc-
cessful an issue.
This histopathology will undoubtedly become an era
marker in the study of cutaneous pathology, and while all in-
vestigators may not accept the author's views and support
his claims upon ever\- question, they must admire his ener-
getic work and be stimulated by it to renewed efforts to
make the study of the skin what it should be. The volume
contains over twelve hundred pages. Each subject is intro-
duced by a short clinical description, but, while treatment
finds no place in all these pages, that which perhaps is more
important, the indications for proper management, are abun-
dant and evident to the careful reader. No organ or set of
organs offers such facilities as the skin for this branch of
study and those interested in the advance of science, no less
than dermatologists, may congratulate themselves upon so
deep a work as that of Dr. Unna and upon so attractive a
translation as that which Dr. Walker offers us.
Lehrbuch der Kinderkrankheiten fur Aerzte
UND Studirende. By Prof. Dr. Adolf Bagin-
SKV, Director of the Kaiser und Kaiserin Friedrich
Children's Hospital, Extraordinary' Professor of Diseases of
Children at the University of Berlin. Berlin : Friedrich
Wreden. 1S96.
This ver\- well-known text-book makes its welcome appear-
ance as a fifth edition and considerably enlarged.
The general division of the work consists of chapters de-
scribing in turn the physiological functions of the organs of
circulation, respiration, digestion, and dentition, also of the
umbilicus, skin, nerves, uropoietic system, and of the special
senses. Then follows the description of the phenomena of
growth and its relation to weight. The chapters on feeding
and general nursing are very instructive, giving all necessary-
details ; next follows a very important chapter on how to ex-
amine a patient.
In a chapter on general therapeutics the author gives indi-
cations and contraindications for treatment by drugs, anti-
pyretic measures, and emetics. The diseases of the newly
born are quite exhaustively considered. The septic disor-
ders of the newly born are also given in interesting detail.
The chapters on general diseases include acute infectious dis-
orders, scarlet fever, measles, rotheln, varioloid, varicella,
vaccine, and articles on the combined appearance of various
e.xanlhematous eruptions. In the discussion of these sub-
jects the author has called to his aid an ariiount of personal
experience exceptionally great, gained from the vast ma-
terial at his disposition in the numerous isolated infectious
buildings.
The subject of orrhotherapy is thoroughly detailed, and
Baginsky lays down the fundamental principles of this new
form of treatment so clearly and so positively, basing his
statements on the vast amount of material under his personal
supervision, that no doubt would seem to exist in his mind as
to the value of his deductions.
The most modern methods of arriving at a diagnosis in all
the exanthemata, together with bacteriological and histologi-
cal aids, are given in detail.
The nervous disorders of children, especially those per-
taining to the brain and lesions of the spinal cord, are han-
dled in a masterly manner. The digestive disorders, the
diseases of the genito-urinary tract, the diseases of the skin
and those of the spinal column (orthopadic) are given in a
clear and complete manner. The more recent drugs, their
doses, and a large number of prescriptions fittingly conclude
this valuable book.
The Students' Medical Dictionary. Including all
the Words and Phrases Generally Used in Medicine, with
their Proper Pronunciation and Definitions, Based on
Recent Medical Literature. By George M. Gould.
A.M., M.D., Author of "An Illustrated Dictionary of
Medicine, Biology, and Allied Sciences," " 12,000 Aledi-
cal Words Pronounced and Defined, " ' ' The Meaning and
the Method of Life," "Borderland Studies;" formerly
Editor of "The Medical News;" President, 1893-1894.
.'Vmerican Academy of Medicine. With Elaborate Tables
of the Bacilli, Micrococci, Leucomains, Ptomains, etc. ; of
the Arteries, Ganglia, Muscles, and Ner\-es; of Weights
and Measures. Analyses of the Waters of the Mineral
Springs of the United States, etc., etc. Tenth Edition,
Rewritten and Enlarged. Philadelphia: P. Blakiston,
Son & Co. 1896.
When a work has reached its tenth edition the reviewer's
task is light, for he has usually but to acquiesce in the popu-
lar verdict. It is, however, sometimes interesting to see
upon what the approval of the public rests and what there is
in the work that has won for it a popularity so far above that
of its predecessors or contemporaries. Here also, in the
present instance at least, the solution of the problem is easy.
The work is popular because it deser\es to be ; it is compact
in form and not so large as to be unwieldy; the type is clear;'
the definitions are concise but lucid; the method of indicating
the pronunciation is simple and free from the diacritical
marks which call for a constant reference to a key in another
part of the work ; the derivations are briefly and accurately
stated ; and there are very few omissions of words which a
student would meet in his reading. The only word, of
many of recent coinage, which we have looked for but failed
to find is "orrhotherapy," a term which is much to be pre-
ferred to its barbarous synonym, "serotherapy." "Opo-
therapy," of contemporaneous coinage, is given as a synonym
of "organotherapy." But we are sorr)- to note that the
author retains the indefensible form, " symphysiotomy," in
place of the correct "symphyseotomy," He is, morever, in-
consistent in this (a reproach from which he is usually remark-
ably free, even in his cacography), for in " epiphy.seitis. "
to which he gives the preference over "epiphysitis," he dis-
tinctly recognizes the cpsilon in the Greek root. " Sym-
physeotomy " is supported by the authority of the "Inter-
national" and the " Centui->-," as well as of the Greeks
themselves, who may be presumed to know their own lan-
guage, and it grieves us to see a learned medical lexicogra-
202
MEDICAL RECORD.
[August 8, 1S96
pher so obstinately sinning against light. An error such as
this, however ' fatal it may be to any claims of last appeal,
nevertheless detracts but little from the value of the dictionary
as a work of reference for students, and as such we can most
conscientiously recommend it. To the practitioner also, while
it cannot replace the author's "Illustrated Diclionar)- " or
Foster's " Encyclopedic Dictionary-," it will be indispensable
in the absence of those larger works. We may add that the
editor announces that this is really a new book entirely re-
written, the plates of the older editions having been de-
stroyed.
Proceedings of the AiMERiCAN Medico-Psvcholoci-
CAL A.s.sociATioN, at the Fifty-First .Annual .Meeting,
Held in Denver, June 11-13, 1895.
The papers in this volume, while necessarily of interest
chierty to alienists, contain much that is instructive to the
general practitioner as well as to the student of medical juris-
prudence.
The Three Ethical Codes. Detroit: The Illustrated
Medical Journal Company.
This is an interesting comparison of the three ethical codes
of the American Medical Association, the American Institute
of Homoeopathy, and the National Eclectic Medical Society
respectively. In addition this book contains the constitu-
tion and by-laws of the American Medical Association. It
will be found interesting to those who are concerned in .safe-
guarding the morals of their neighbors.
I'Hvsics FOR Students he Medicine. By Alfred
Daniell, M.A., LL.B.. D.Sc. F.R.S.E., Advocate
and Barrister-at-Law ; E.xaminer in Physics to the Royal
College of Physicians of Edinburgh ; formerly Lecturer on
Physics in the .School of Medicine, Edinburgh; .Author of
'•A Text-Book of the Principles of Physics." London
and New York : Macmillan & Co. 1 896.
This is a well-arranged little work containing all the essen-
tials of physics for the student of medicine or the practitioner.
Indeed it contains much more than medical students, in this
country at least, are ordinarily expected to know, e.xcept as re-
gards optics and perhaps electricity. The subjects are pre-
sented in a manner that renders them intelligible. The book
would be specially useful to one who wished to refresh his
knowledge of physics, and to learn what advances or changes
in theories had been inade since his college days.
Statistica Sanitaria dell' Armata per gli .Vnxi
1893 e 1894. Roma: G. Bertero. 1896.
This is a collection of sanitary statistics of the Italian na\'y
for the two years mentioned.
Antropometria Militare. Incaricato della Direzione
de Lavori, Dr. Ridolfo Livi, Capitano Medico.
Parte I. Roma: II Giornale Medico del Regie Esercito.
1896.
This is Part I. of a series of statistics concerning anthro-
pometry based upon the sanitary' reports of an Italian .Army
for the year 1859-63. The two volumes in -this part deal
with anthropological and ethnological data, one being made
x\p of a number of atlases of the anthropological geography
of Italy.
Burdett's Hospitals and Charities. 1896, Being the
Year-Book of Philanthropy. By Hexrv C. Bcrdeit.
London : The Scientific Press ; New York : Charles C.
Scribner's Sons; Boston and Chicago: D. C. Heath & Co.
This book of eight hundred and fifty-six closely printed
pages contains an enormous amount of information concern-
ing the hospitals and charitable institutions of the English-
speaking world, of this country as well as of Great Britain
and the colonies. The information regarding institutions in
the L'nited States is not so complete as we could wish, but
the fault lies with the officers of these institutions, and not
with Mr. Burdett, whose requests for information in many
cases did not even meet with the courtesy of a reply. We re-
gret this, for if we must suffer from a glut of charitable in-
stitutions we ought at least to be able to brag of their number.
In addition to the statistical information a considerable por-
tion of the book is devoted to a discussion of topics bearing
upon hospital management and the use and abuse of chari-
ties. No one interested in charitable institutions and their
management can dispense with this invaluable annual.
The An.\tomv of the Human Head and Neck.
Graphically Illustrated by Means of Superimposed Plates.
With Descriptive Text by Dr. SCH.MIDT. English Edi-
tion by Willia.m S. Furneaux. Author of ".Animal
Physiology," "The Outdoor World," etc. New York:
Thomas Whittaker.
Whitiaker's .Anatomical Model". A Pictorial Repre-
sentation of the Human Frame and Its Organs. With
Descriptive Text by Dr. Sch.midt. English Edition by
Willia.m S. Furneaux, Author of "Animal Physi-
ology," "The Outdoor World," etc. Illustrated. New
"S'ork : Thomas Whittaker.
These are two sets of superimposed plates representing
sagittal sections at various levels of the head and body, which
show very clearly and accurately the relative position of the
internal organs and structures. While intended primarily for
lay instruction, they ought to prove of service to the student
in giving him his first notions of topographical anatomy, and
might also be useful to the physician who wished to make
clear some point to an intelligent patient.
Philadelphia Hospital REpr)RTS. \'olume III. Edited
by George E. DeSchweinitz. A.M., .M.D., .Member
of the Ophthalmic Staff. Philadelphia: Printed by Mau-
rice H. Power. 1896.
Medical and Surgical Reports of the Boston City
H0SP1T.\L. Seventh Series. Edited by Georcje B.
Shattuck, M.D., W. T. CouNCi L.MAN, M.D., and
Herbert L. Burrei.l, .M.D. Boston: Published by the
Trustees. 1 896.
These two reports of two of the leading hospitals in the
country contain a number of essays and clinical reports of
more than usual interest.
A Treatise on Appendicitis. By Joh.v B. Deaver,
M.D.. Surgeon to the German Hospital. Philadelphia.
Containing 32 Full-Page Plates and Other Illustrations.
Philadelphia: P. Blakiston, Son & Co. 1896.
Dr. De.wer's work is a timely and valuable contribution
to the literature of appendicitis and will be hailed by those
who would consign the entire management of the disease to
the surgeon as a powerful argument for their side. The
author is uncompromisingly in favor of the knife and holds,
in common with many of his surgical brethren whose lot it
seldom is to see the mild and self-healing cases of this dis-
ease, that appendicitis should invariably be treated by early
operation. It is perhaps for the same reason that the autlioi
makes no mention of rheumatism as an etiological factor.
The disease is for him one which laughs at treatment, and
the only way of removing it is to remove the affected organ.
If for any rea.son resort must be had to non-o])erative meas-
ures, Dr. Deaver gives the preference to laxatives over opium.
The work is profusely illustrated with plates, mostly colored.
As a rule, the pictures are faithful as regards outlines, but
they are too brilliantly colored. The book is one which
ought to. and doubtless will, take rank as one of the best
treatises in English on appendicitis from a surgical stand-
point.
Quain's Elements of Anatomy. Edited by Edward
Albert Sch.Kfer, F.R.S., Professor of Physiology and
Histolog)- in University College, London, and Geokge
I.)ancer Thane. Professor of Anatomy in L'niversity
College, London. Appendix. Tenth Edition. London,
New York, and Bombay : Longmans, Green & Co. 1896.
The appendix to this new edition of " Quain's Anatomy " is
devoted to superficial and regional anatomy, and is written
by Profs. G. I). Thane and R. J. (^odlee. The illustra-
tions, many of which are colored, are twenty-nine in num-
ber. As an evidence of the vast amount of information
condensed in these sixty-six pages of text, we find an index
nearly ten pages in length.
Transactions of the Southern Surgical and (iVNE-
cological Association. Volume \'III. Published
by the Association. 1896.
This is the report of the eighth session of the association,
held at Washington. November 12, 13. and 14, 1895. Each
succeeding volume of these transactions adds to the high re-
pute enjoyed by this society.
August 8, 1896]
MflDICAL RECORD.
201
Transactions of the American Association of Ob-
stetricians AND Gynecologists. Volume VIII.
Philadelphia: William J. Dornan. 1896.
This is the report of the eighth annual meeting, held in Chi-
cago, September 24, 25, and 26, 1895, under the presi-
dency of Dr. J. H. Carstens. The book contains the usual
number of papers on various subjects belonging to the
branches noted in the title of the association.
The National Formulary of Unofficial Prepara-
tions. Revised Edition. Published by the American
Pharmaceutical Association. 1896.
In this new edition of the " Formularv' " the metric system
has been adopted in order to make it conform to the last
edition of the United .States Pharmacopoeia. The commit-
tee of revision of this edition was composed of Messrs. C.
Lewis Uiehl, A. B. Stevens. C. T. P. Fennel, and Charles
Caspari, Jr. They have done their work well.
Hemorrhoids and Other Xon-Malignant Rectal
Diseases: Diagnosis and Treatment. By W. P.
Agnew, M.D. Third Edition. San Francisco: Pacific
Press Publishing Company. 1896.
The author justifies the title of his book by entering at once
upon the subject of hemorrhoids, which occupies about sev-
enty-five of the two hundred pages. He is an earnest be-
liever in the treatment of this painful affection by carbolic-
acid injections, which he looks upon as all-sufficient for its
cure. Following the chapter on hemorrhoids is one upon rec-
tal examination, and after this come the various non-cancer-
ous affections of the rectum. The book is written in a con-
versational style which makes it easy of comprehension and
holds the reader's attention. The illustrations are rather
crude.
Sterility. By Robert Bell, M.D., F. F. P. S.G., Sen-
ior Physician to the Glasgow Hospital for Diseases Pecu-
liar to Women.
The author of this little book holds that the most potent if
not the sole cause of sterility is endometritis, and conse-
quently the treatment of sterility is that of the uterine dis-
ease. The writer states his case clearly, and his book
possesses the interest which always attaches to the straight-
forward expression of an honest opinion, even when this
opinion cannot be acquiesced in by the reader.
Handatlas der Anatomie des Menschen in 750 theils
farbigen Abbildungen mit Text. Mit Unterstiitzung von
WiLHELM His, Professor der Anatomie an der Universitat
Leipzig, bearbeitet von Werner Spalteholz, ao. Pro-
fessor an der Universitat Leipzig und Custos der anato-
mischen Sammlungen. Leipzig: .S. Hirzel. 1896.
This is the second part of the first volume of a very hand-
some anatomical atlas. It contains forty-four plates of the
joints and a few representing sections of bones made to show
their structure, accompanied by descriptive text. The book
is a valuable addition to anatomical literature.
Transactions of i he Medical Society of the State
OF New Vokk, for the year 1896. Published by the So-
ciety. 1 896.
This volume contains forty-two papers and three addresses
presented at the ninetieth annual meeting of the New York
State Medical .Society, held at Albany, January 28, 29, and
30, 1896, under the presidencv of Dr. Roswell Park, of Buf-
falo.
In Sickness and in Health. A Manual of Domestic
-Medicine and Surgery, Hygiene, Dietetics, and Nursing.
Dealing in a Practical Way with the Problems Relating to
the Maintenance of Health, the I-'revention and Treatment
of Disease, and the Most Effective .Aid in Emergencies.
Edited by J. West Rooseveli, .M.D. New York: D.
Appleton & Co. 1896.
In considering this, in many respects, praiseworthy work,
one question recurs most insistently to the mind of the re-
viewer— a question that asks itself in reference to .so
many of this species — to what class of the community is it
addressed ? Turning to the publishers' note we find that it
claims to be "a book for household use," addressed to " the
unprofessional man and woman." This is a modest claim,
which by no means does justice to the composite nature of a
work the first part of which is occupied by a great mass of
purely technical matter on anatomy, physiology, psychology,
etc. Such information as that • ■ regurgitation into the auricle
is prevented by the mitral valve " or that " the organ of Corti
is a complex mechanism resting upon one wall of the cochlear
canal, the basilar membrane, and extending from the base to
the apex of the cochlea, " may be the matter-of-course property
of every medical student in the land, but surely it is a stum-
bling-block even to the trained nurse, and to the laity it is fool-
ishness. Then again, while the colored frontispiece of a
trained nurse of somewhat appetizing aspect may be in order
as an object lesson, there can hardly exist any ordinar)- citizen
so greedy of useless knowledge as to waste time over diagrams
of retinal sections and magnified blood corpuscles, or colored
plates of anthrax bacillus and the spirillum of Asiatic
cholera. As a matter of fact, people in general are coldly in-
different to the shape and size of microbes, or to the theory
of germ plasm, while, on the other hand, they love to be re-
minded that crumbs should not be allowed to accumulate
under a helpless invalid and to be admonished to ventilate
sick-rooms at night.
Passing on, therefore, to that portion of the book devoted
to practical matters, much may be said for its utilitarian value.
The chapter on " Hygiene " may be especially noted for its
satisfactory covering of much ground in small space, while
those on " Physical Training " and the " Care of the Sick "
may almost be called conclusive from the non-professional
point of view. They possess the unusual virtue of telling
those things which should be told, erring, if at all, in the di-
rection of too minute particularization which would seem oc-
casionally to underrate the possible intelligence of the ama-
teur. We note, for instance, in the excellent paragraph on
lifting and handling, an admonition not to stick the nails into
the patient, followed by the somewhat superfluous comment
that "this causes pain and irritation." But small errors of
commission may be lightly held in a work where sins of
omission are conspicuous by their absence, and were this the
only fault we could conscientiously advise the physician to
recommend the book to the families under his care. As a
rule, the work is fairly free from injudicious prescriptions,
yet we cannot approve of suggestions, like that on page 836,
that " morphine may also be used in similar doses for sleep-
lessness," even though it is tempered by the caution that
other and less harmful remedies should invariably be tried
first. However, if there must be works on domestic medi-
cine, this is perhaps as good as any — it is certainly the latest.
The book is well printed and well bound, the illustrations
are interpretative of the text, and the whole is completed by
an excellent index.
Changes in the Spinal Cord after Amputation of
Extremities. — Dr. Grigoriew investigated two cases
of amputation of the arm, two of amputation of the
thigh, and one of amputation of the leg. The period
elapsing between operation and death varied from
twenty years to one year. The results of his investi-
gations agree with those of the greater number of au-
thorities, and are collected by the author in the follow-
ing summary {7'//e British Medical Journal ). In all
cases excepting that in which one year elapsed before
death, deviations from the normal appearance of tlie
cord were noticed; in all cases they were analogous,
affected the corresponding portions of the cord, and
consisted in a simple atrophy of certain portions of
the gray and white substance, differing in the cases
only by the degree of development. The simple atro-
phy of the n.ervous elements of the cord was greater
as the period elapsing between amputation and death
was greater, less as it was less; while in the case in
which the period was only one year atrophy was com-
pletely wanting. With reference to the relative time
before the separate paths and portions of the cord
became degenerated, the author found his cases in
agreement with those of other authors, and with those
obtained by experiment on animals, namely, that the
atrophic phenomena appear earlier and are more
marked in the sensorv than the motor areas of the cord.
204
MEDICAL RECORD.
[August 8, 1896
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, April 8, lSg6.
John Slade Ely, M.D., President.
Malposition of the Kidney. — Dr. G. A. Tuttle
presented a kidney whicli had been situated in the
hollow of the sacrum. The renal artery was given
off close to the origin of the sacral media artery. This
condition, the speaker said, was not e.xtremely uncom-
mon. In rare instances it had been known to inter-
fere with labor. An abscess of the kidney occurring
in this abnormal situation would render the diagnosis
obscure.
Cystic Kidney. — Dr. Tuttle exhibited a kidney
which had been removed from a man forty years of
age, who had been brought to the hospital in uremic
coma. At autopsy, the kidney had been found in a
state of advanced cystic degeneration. There was
practically no kidney tissue remaining. Such kidneys
are always bilateral. The principal symptoms in
these cases are those of Bright's disease — recurrent
attacks of ha.-maturia and albuminuria — and the pa-
tients always die in ura;mic coma. These cystic kid-
neys are found sometimes enormously developed in
the foetus. Virchow had advanced the theory that this
cystic condition in the foetus was due to imperforate
uriniferous tubules.
Tumors of the Kidney Dr. Tuttle presented sev-
eral microscopical specimens of tumors of the kidney.
He said that during the last five years, in the patho-
logical laboratory of the Presbyterian Hospital which
received pathological material from that hospital and
also from St. Luke's Hospital, there had been only ten
specimens of primary new growths of the kidney. Six
of these had been obtained by autopsy, and five out of
the six had been discovered accidentally, having ex-
isted without symptoms during life. There was one
tumor, a very large metastatic growth, which ould not
be treated by operation, which caused the death of the
patient. Of the remaining four sjDecimens removed
by operation, three were from the surgical service of
the hospital and one from an oustide surgeon. The
growths were from one-fourth to one inch in diameter
in most instances and situated in the cortex of the
kidney. Dr. Tuttle said that the exact origin and
classification of primary tumors of the kidney had
been a matter of much uncertainty. It was conceiv-
able that tumors might originate in the epithelium of
the pelvis, or in the tubules, or the connective tissue
between the tubules, or in the blood-vessels. The
structure of five of the tumors was as follows: (i) A
pure lipoma, one inch in diameter, projecting above
the surface of the kidney beneath the capsule. (2) A
minute myoma composed of smooth muscle and some
small-round cells. (3) .A small papillary adenoma
consisting of a small cavity lined with cuboidal epi-
thelium. (4 and 5 ) Two alveolar adenomata consist-
ing of rounded and oval spaces filled with cells re-
sembling gland epithelium, and some of these spaces
presenting a distinct lumen. In places these tumors
bore a slight resemblance to the tissue of the supra-
renal capsule.
In Virchow's Archiv was an article on the so-
called lipomata of the kidney, in which it was stated
tliat they were not rarely found accidentally at au-
topsy. The description corresponded with that of
adenomata just given. The author considered them
to be portions of suprarenal capsule which had be-
come enclosed in the kidney during foetal life. The
kidney at this period was more or less lobulated. and
it was possible that portions could be caught in these
clefts. In about one thousand autopsies at the Pres-
byterian Hospital, one case was recorded in which a
small fragment of suprarenal tissue was easily recog-
nized under the capsule of the kidney. Under the
microscope, in one portion, it was separated from the
tubules by a delicate connective-tissue capsule, and
in another portion the two tissues had no dividing
line. These fragments had been found in many other
situations, e.g., in the broad ligament, and in and
about the testicles. The speaker said that it was very
probable that these nodules did occasionally originate
in this way from closed portions of the' suprarenal
tissue.
Sarcoma of the Kidney. — Dr. Tuule then presented
specimens remu\ cd from a man forty-two years of age,
who had had for the first time a slight hamaturia
shortly before entering the hospital. The next day
there had been difficulty in passing urine, and then
pain in the left lumbar region, radiating down to the
left testicle and glans penis. After about five days
the urine had again become clear and the pain had
ceased. About two weeks later there had been a sec-
ond attack of ha-maturia. A third attack with pain
occurred just before his admission. About six weeks
before this a tumor had begun to grow from the right
shoulder. Examination showed a large hard mass in
the left kidney, and the diagnosis was made of renal
tumor with metastasis. At the autopsy there was
found a dense mass, weighing two pounds eleven
ounces, and extending from the spleen to the brim of
the pelvis, and from the floating ribs to the right bor-
der of the vertebral column on the left side. It was
a new growth involving the left kidney. There were
numerous metastatic deposits in the liver and lung,
var}'ing from one-fourtii of an inch to two inches in
diameter. Microscopical examination of these tumors
showed a stroma of dense connective tissue, forming
spaces subdivided into small rounded alveoli. Some
of these alveoli were completely filled with cells re-
sembling epithelium, but the larger number showed
the opening between the cells filled with blood. It
was possible that a hemorrhage into a carcinoma
might produce some of these appearances, but, consid-
ering that all the metastases showed the same struc-
ture, one would be justified in calling this a sarcoma
developed from the blood-vessels of the kidney. The
tumor and metastatic growths were exhibited under
the microscope.
Papilloma of the Kidney The next tumor pre-
sented was from a male, thirty-six years of age. who
had always enjoyed good health with the exception of
rather frequent and severe headaches. One week be-
fore coming under observation, the urine had been
noticed to be of a bright red color from the admixture
of blood. There was no pain or ill health. Cysto-
scopic examination was made with almost negative
results on account of the hemorrhage. The blood
seemed to come from a point close to the neck of the
bladder. Suprapubic cystotomy was then performed.
The bladder wall appeared normal except for a small
ulcer at the fundus. Blood was seen to issue from the
left ureter. No enlargement or tenderness of the left
kidney could be detected. The left kidney was re-
moved, but the patient succumbed to the operation.
The organ was moderately enlarged, and contained a
number of large cystic cavities into which projected
an abundance of papillary growths. The trabecular
tissue was in part like den.se renal tissue, and in part
soft and gray. Under the microscope there were long
delicate filaments of connective tissue covered \\\\\\
epithelium which closely resembled epithelium of the
pelvis of the kidney. The appearance of the tumor
seemed to indicate that it started in the pelvis of the
kidnev.
August 8, 1896]
MEDICAL RECORD.
205
Endotheliomata (?) of the Kidney. — Dr. Tuttle
said that the most interesting specimens were two
tumors, one of them brought to the hospital by Dr.
Krown from a case reported in the Boston Medical and
Surgical Journal, of .^pril 18, 1895, by Dr. W. M.
Swift, of New Bedford. The patient, a man, forty-
seven years of age, after suffering for a short time
with night sweats, noticed a tumor in the right side
of the abdomen. When examined a few months later
he complained of pain in the right groin, a dragging
sensation in the testicles, frequent and scanty micturi-
tion. .\. tumor, the size of a small cocoanut, was
found in the region of the right kidney. It was
slightly movable and somewhat tender to pressure.
The urine was normal in quantity. The tumor was
removed by operation and recovery was perfect. It
was situated at the lower end of the kidney and was
completely encapsulated. It had apparently devel-
oped from the lower and outer part. The minute
structure was the same as in the ne.xt tumor to be de-
scribed, which had been removed at St. Luke's Hos-
pital by Dr. Bangs in March, 1895. The tumor con-
sisted of a number of nodules scattered through the
kidney. The capsule was extremely vascular. \Iicro-
scopical examination showed a mass of rather large
cells, supported by slight, irregularly branching tra-
beculae, forming in places fairly complete elongated
alveolar spaces, while in other places there was no
alveolar arrangement. The trabeculas consisted of
minute blood-vessels. In some places small areas of
blood were seen surrounded by a very delicate but dis-
tinct limiting membrane. The tumor cells were rounded
or polygonal with a sharply defined outline. lor the
most part the cell protoplasm was homogeneous and
did not stain well with eosin. The nuclei were of
medium size and stained well with htemato-xylin. The
character of these tumors was still doubtful. Similar
tumors had been described as carcinomata, or ade-
nomata from the proper cells of the kidney tubules,
and as endotheliomata developing from the endothe-
lium of the perivascular lymph spaces. From the
great vascularity of these tumors and the relation of
the cells to the blood-vessels and the connective-tissue
trabecule, the speaker said it seemed to him that thev
were more probably developed from the endothelium
of the lymph tissue, as recently described by Hilde-
brandt. The cells of the suprarenal capsule were
very liable to undergo fatty degeneration and then
would closely resemble the structure found in these
tumors, with the exception of the great vascularitv.
Microscopical sections of these tumors were then ex-
hibited.
The President said that he could not bring him-
self to believe that the last specimens were endothe-
liomata. He was about to present a specimen in
which the adenomatous type was very clearly shown.
Dr. George P. Bigus said that in a specimen re-
cently brought to him by Dr. .\lexander for e.xamina-
tion there was an encapsulated tumor, about as large
as a medium-sized orange, projecting out a consider-
able distance from the kidney. The microscopical
structure of this tumor was quite similar to that shown
in the sections of the last tumors exhibited. In some
places there was a jserfectly regular adenomatous ar-
rangement, and he looked upon his specimert as one
of alveolar adenoma.
A Typical Adenoma of the Kidney. — Dr. F. Til-
DEX Brown presented microscopical specimens of
what appeared to be a typical adenoma of the kidney.
The growth had been removed from a woman, sixty-
two years of age, under the care of Dr. Kammerer.
It had existed for eight years. On examination it was
found to be about the size of a child's head, very mov-
able, so that there was some doubt as to its being a
neoplasm of the kidney. It was not particularly vas-
cular, and was made up wholly of new growth with the
exception of a little kidney tissue. The patient recov-
ered well from the operation, but died after an attack
of hemiplegia some two or three weeks later. Xo au-
topsy was obtained.
Adenoma (?) of the Kidney.— Dr. J. S. Ely pre-
sented a small portion of a tumor of the kidney, to-
gether with microscopical sections of the same. In
structure it seemed to him very much like the last two
cases presented by Dr. Tuttle. The tumor occupied the
upper portion of the kidney, pushing the remainder of
this organ downward and inward. It was ver} dis-
tinctly encapsulated and lobulated. The centre of the
tumor showed an extensive area of degeneration, but
the nature of this degeneration could not be deter-
mined. The whole tumor was soft and contained
much blood. There was no clinical history.
The speaker said that the most recent and complete
article on this subject was by Lubarsch in Virchow's
Arcliiv ior 1894. He endeavored to prove that thev
were of suprarenal origin, and he had collected
twenty-nine similar cases, in all of which careful mi-
croscopical examination had been made. In his opin-
ion they had all developed from inclusions of the
suprarenal capsule. The structure was as follows:
.\ fine connective-tissue reticulum, consisting almost
entirely of a slight adventitia of blood-vessels: on one
side slight endothelial lining and on the other side
large cells, for the most part columnar in shape, with
roundedends; very clear protoplasm; rather large, dis-
tinctly staining, oval nuclei, and a rather loose intra-
nuclear network. The whole arrangement was dis-
tinctly alveolar, and the disposition of the clear, large-
bodied cells was in most cases around a distinct
lumen. The presence of the blood in these himina
had evidently suggested to Lubarsch that these were
angio-sarcomata, but it seemed to the speaker that this
could be just as well explained by supposing that it
was the result of hemorrhage. Regarding the question
whether those growths originated from suprarenal
inclusions or were adenomata of the kidney, this ob-
server stated that the points in favor of suprarenal
origin were; (i) The clear protoplasm of the cells,
which distinctly resembled the protoplasm of the
suprarenal body and which was like the granulations
found in the cells of the tubular epithelium; and (2)
the presence of glycogen in the cell bodies and in the
lumina. This, the speaker said, he had found in his
specimen. Lubarsch had examined twelve tumors of
the kidney and in none of these had he been able to
find glycogen. Yet he cited another observer as au-
thority for the statement that the suprarenal bodv fre-
quently showed the existence of glycogen. The dis-
tinct acinus arrangement and the nature of the nuclei
of the cells, resembling as they did epithelial cells,
would lead him to class this tumor as an adenoma or
adeno-carcinoma rather than an endothelioma, r.l-
though he would admit the possibility of its being an
endothelioma originating from the lymphatics. So far
as he knew, glycogen was found in secreting cells —
epithelial cells— and this offered an obstacle to the
theory mentioned. He had on a number of occasicns
distinctly seen glycogen in the fubular epithelium in
cases of Bright's disease— at least the reactions which
are supposed to be characteristic of glycogen were
readily obtained. It should be stated, however, that
this glycogen is not ver}- soluble in water. With
iodine it readily stains a deep mahogany-brown, and
is digested and made to disappear under the inlluence
of the ferment of saliva. Singularly enough, after
treatment with iodine, the glycogen becomes soluble
in water, so that the subsequent manipulations of a
specimen so treated must be carried on without con-
tact with water.
Dr. E;iy said that the difficulty was to define just
206
MEDICAL RECORD.
[August S, 1896
what is an endothelial cell. Anatomists were inclined
now to make no distinction between epithelial and en-
dothelial cells. Personally, he had seen only what
appeared to be undoubted endotheliomata in connec-
tion with the pleura and dura mater of the brain. In
these cases there appeared to be a definite endothelial
structure, and the cells, when teased out, were flat or
irregularly shaped, with large nuclei with a loose open
reticulum — a distinct endothelial arrangement. He
did not think too much stress should be laid upon die
shape and size of cells: one should depend rather
upon the relation of the cells to the stroma than upon
the cells themselves, for pressure alters greatly the
shape of cells. It was well known th4t the cell body
might differ very materially in different conditions of
degeneration.
The society then went into e.xecutive session.
(I'Uniail gcpavtmcut.
REPORT OF .\ CASE OF APE.X LWTARRH
SIMULATIXG XASAL TROUBLE.^
By H0\V.\RD .S. .STR.\If.HT, M.D.,
CLEVELAND, O.
June 1 1, 1894, a young woman, aged twenty-two years,
consulted me as to a nasal difficulty. Until within a
short time she had never had any trouble with her
nose or throat. For a few weeks she had been troubled
with stuffiness in the nose and an inability to breathe
through her nose continuously. From a careful in-
quiry as to her history, little of importance could be
obtained. Her pulse and temperature were normal.
She insisted that she felt as well as usual, that she
had not noticed any diminution of strength or loss of
appetite, and scouted the idea that there was anything
in her case except the nasal difficulty. She admitted
finally that maybe she was a little tired out, but said
that she had been working unusually hard in s:hool
for the last eight months. While I was suspicious
that possibly some constitutional condition might be
present, I could not find any symptom that justified
my suspicions.
Her complexion seemed to me to be a little sallow,
and whether she was slightly ana;mic was a question
I could not decide. The patient's own belief that it
was useless to consider anything except the nasal con-
dition also assisted in quieting my suspicions that
there was a possible catarrhal condition of the apex of
one or both lungs. I felt certain that an examination
of the chest would be looked upon as unnecessary, that
it might needlessly alarm the patient, nor could I
detect anything in the case to justify a suspicion I al-
ways entertain in throat, nose, and ear cases, in pa-
tients over ten and under forty years of age. If I had
not waited until a later date for an examination of the
chest, my error in treating tlie case might have been
avoided. An examination of the upper air passages
revealed in the nose a longitudinal deviation of the
septum on the right ^de and a hypertrophy of the left
lower turbinated. Having concluded I had a local
condition only to deal with, the hypertrophy was cau-
terized, the patient was given an alkaline wash, and
directed to return in three days. Upon her return she
seemed to have been more affected than ordinarily as
a result of the cauterization. Her pulse was about 90.
and her temperature 100" F. While it is not at all
unusual to observe such symptoms after any intranasal
operation, in my experience a patient with an apex
' Read before the .\merican l.arjngological. Rhinological, and
Otological .Society at its second annual meeting in New York
City, April iS, 1896.
catarrh is much more apt to present such symptoms
than a patient in whom no such condition exists. Still
being somew hat suspicious as to the constitutional con-
dition, I gave the patient a prescription of benzosol.
Four days later she returned. Her temperature and
pulse were normal, and she seemed as well as at her
first visit. These observations deceived me more
completely than before. The constitutional treatment
was discontinued and the case thereafter treated from
the local standpoint only.
The return of the temperature to the normal within
four days can be explained only by rem'embering that
the patient had a normal temperature before any local
interference. She had a catarrhal process at the left
apex at the time of coming under observation, as later
developments proved, but, contrary to rule, she had no
fever. As a rule, in spite of any treatment, the slight
elevation of the evening temperature will persist for
weeks in such cases. The deviation was removed
from the right side of the septum, and after keeping
her under observation for about five weeks — until July
13, 1894 — she was discharged as cured.
September 18, 1894, two months after being dis-
charged and three months from the time she first came
under observation, she returned. She had been in the
country on a vacation. She had not felt well for a
number of %veeks. She had had a poor appetite, had
been nervous, had slept badly, had lost ten pounds of
flesh, was sallow and an.tmic, had a coated tongue, a
temperature of 101'^ F., and a pulse of 108 in the
morning. An examination of her chest revealed at the
left apex slight flattening in the left subcla\ icular re-
gion. There was tenderness on percussion in the sec-
ond interspace next to the sternum, no change in pitch
on percussion. Transference of heart sounds, cog-
wheeled breathing, and slightly shortened inspiration
were apparent on auscultation. The following diag-
nosis was made :
A well-marked simple catarrhal process at the left
apex, or a condition of disturbance of function of the
mucous membranes of the body, the gastro-intestinal
being in the majority of such cases the one of which
greatest complaint is made — a condition, however, in
which some one or all of the physical signs found in
tiie case reported may be detected at the apices of the
lungs, and one which is of much greater importance
than a simple unassociated disturbance of the gastro-
intestinal mucous membrane, for which the disease
called apex catarrh is often mistaken.
My belief is that at her first visit to me in June the
patient had a slight developing catarrh at the left
apex. This belief is not founded upon .this one case.
Over and over again have I had a similar experience,
although in no case has my experience been as humil-
iating as in this one. I have recently discharged a
patient after four months' constitutional treatment
w hom I treated altogether locally for tlie first four weeks
she was under my care, and I realized the need of
constitutional treatment in the case only after finding,
marked transference of the heart sounds at the left
apex. These experiences have not occurred to me be-
cause of carelessness. The possibility of such a con-
dition is considered in the case of every- patient under
forty years of age and over ten.
I ain'Tiot qualified to speak as to the occurrence of
the condition mentioned in other localities, but in
Cleveland apex catarrh — a disturbance of the functions
of all the mucous membranes of the body, the disor-
dered functions of the gastro-intestinal mucous mem-
brane often being the one of which the patient makes-
most complaint, but a condition in which certain defi-
nite physical signs at one or both apices of the lungs
can be detected — is of very frequent occurrence; and
after years of observation and large opportunity in
the study of the diseases of the ear and upper air pas-
August 8, 1896]
MEDICAL RECORD.
20:
sages, I believe that this condition — call it what you
will — is in Cleveland more important to the throat
specialist than all other constitutional conditions com-
bined. The question arises as to whether the subse-
quent ill health and loss of flesh were not due to the
local treatment. It is most natural for the patient to
hold this opinion. It is not at all uncommon for pa-
tients in perfect constitutional condition to feel de-
pressed for a short time after intranasal treatment and
even to lose flesh, but they quickly recuperate and
take no such course as the one reported.
If this patient had presented herself to a general
practitioner instead of a throat specialist, and he,
knowing nothing of the nasal condition, had detected
the condition of her left ape.x and treated her consti-
tutionally with as much success as attended my elTorts,
when she returned to the city in September what would
have been the result as to the local lesion ? She prob-
ably would have been relieved so much that the local
lesion -would have caused no more trouble than had
been e.xperienced when she was perfectly well. You
remember she had had no trouble with her nose until
within a few months. The local treatment certainlv
did no harm, for constitutional treatment would not
have remedied or relieved the hypertrophy of the mu-
cous membrane of the left lower turbinated or a devi-
ation of the septum ; but the overlooking of the con-
stitutional condition was an error indeed — such an er-
ror as brings specialism into merited disrepute. The
oversight was made by one fully alive to the impor-
tance of looking beyond the local lesion, and one who
was a general practitioner for years.
This e.xperience has simply added weight to an
opinion long since formed, that the specialist should
alwavs seek an explanation of local symptoms in a pa-
tient's constitutional condition. It may not always be
easy or possible to decide which factor is the more
important in a given case. The necessity of studying
the patients as a whole is understood by every one.
The general practitioner errs ordinarily in paying too
little attention to local conditions. The specialist, on
the other hand, errs too often in paying too great at-
tention to local conditions. The golden mean is the
position all are striving to attain. When the general
practitioner more carefully studies the importance and
possible influence of local conditions, the specialist
will no longer complain of lack of support in his
work; and when the specialist more carefully consid-
ers the possibilities and bearings of constitutional
conditions, he will command more respect and support
from the conservative, sensible general practitioner.
Little may have been proven in this report. It is
necessarily fragmentary because of the length of
time already occupied in the discussion of the case.
I know no way of absolutely proving one's opinion
in a medical case. The experience added weight
to a lesson learned often before and often since.
While the opinion e.xpressed in the report may be
such as is not generally held by the profession, it is
certainly worthy of consideration, for I am positive
that my success in the treatment of the ear and upper
air passages has been much greater and much more
satisfactory since I properly appreciated that which
was the key to the situation in the case reported, and
which I have called apex catarrh.
Al'BIL 13, 1896.
THE STRENGTHENING AND STERILIZATION
OF CATGUT.
Bv DONALD li. PRITCIIAKD, M.D.,
WINONA, MFN.V.
Having seen in some sample journal a two or three
line item recommending the preparation of aseptic
catgut by first treating it with formalin and then boil-
ing, I thought it worth while to try it. Being much
pleased with the result, it would seem but proper that
I should bring it more generally to the notice of the
profession. After trying various strengths of the for-
malin, I find the twenty per cent, to be the most satis-
factory, leaving the gut immersed in it for three and
one-half hours. It should then be at once transferred
to boiling water for fifteen minutes or longer, if one so
desires, when it will be found in excellent condition.
Raw gut that bears a weight of thirty pounds will af-
ter the formalin treatment lift twenty-six pounds, and
boiling it for fifteen minutes does not weaken it. If
is curious that the gut which has been prepared for
several weeks seems to become nearly as strong as the
original raw article.
If one wishes to boil it on spools, care should be
taken to wind it very loosely, as it swells and con-
tracts during boiling and might easily be broken. The
better plan is to prepare it before winding on spools;
then with aseptic hands it can be made read\ for stor-
ing away in alcohol for future use.
One day I left some gut in the formalin for eight
hours and found it rotten. It would lift but six
pounds. After boiling for fifteen minutes I was sur-
prised to find that it would bear a weight of sixteen
pounds before breaking. So far as I can ascertain,
twelve minutes is the longest time that bacteriolo-
gists consider that anthrax spores can resist boiling
water. Surely, then, fifteen minutes' boiling ought in
everv instance to render catgut sterile.
Intestinal Perforation in Typhoid — There is no
complication of enteric fever more dreaded by the
physician than perforation. It occurs in about two per
cent, of all cases. Its most frequent causes are improp-
er diet, distention of the bowel from any cau.se. or too
early and sudden movements of the patient. — Wicfa.v.
DISINFECTION OF THE HANDS DURINa
LABOR.
Bv HARVEV B. BASHORE, M.D.,
WEST FAIR\'IEW, PA.
There is always a danger that valuable methods ia
science and art may be neglected on account of their
complexity; and this seems to me to be just about the
position of hand disinfection during labor. The elab-
orate methods which are advised in certain quarters
will perhaps do well enough in a maternity hospital,,
but most women are confined at their homes, and what
we want is a method for the practitioner which is both
effective and at the same time as simple as possible.
It is generally conceded, I believe, that the strep-
tococci, staphylococci, and Escherich's colon bacilli
are about the only germs we have to fear during labor.
Staphylococci and streptococci are non-spore-bear-
ing, and consequently are easily destroyed. Robert
Koch is the authority for the statement that a solution
of bichloride, i to 1,000, destroys these organisms in a
few moments. Escherich's bacillus likewise does not
form spores, and is killed by the same solution in a
short time, unless the germs are in fa-ces or an albu-
minoid mixture (Sternberg).
In the light of these bacteriological facts, we can
build a method for protection against these germs.
This method, which has been widely used, is practi-
cally Fiirbringer's method of hand disinfection for
surgical operations;
(i) We wash our hands for several minutes in soap
and water — bichloride, if you wish.
(2) They are then thoroughly rubbed for one minute
w ith several ounces of ether.
208
MEDICAL RECORD.
[August S, 1896
(3) They are then scrubbed with a nailbrush for
three or four minutes in a solution of bichloride, i to
1,000.
(4) Finally, and this is very important, the hand is
introduced moist with the solution, without using any
lubricant and without coming in contact with the bed-
clothes or anything else more than is absolutely nec-
essary.
After disinfecting the hands in this manner, they
are practically sterile, so far as the germs mentioned
are concerned, and any extraneous bacteria which
should happen to drop on them would very likely be
incapacitated for anv further harm by the action of the
bichloride.
Escherich's bacillus, although a near neighbor in
all labor cases, cannot grow nor migrate in the acid
secretion of the normal vagina; but if the hand of the
attending physician was saturated with faeces and then
introduced to the os, the bacillus would probably find
very good pasturage in the alkaline lake at the upper
part of the vagina.
Disinfection of the hands in this manner will not
take more than six or seven minutes, and with care
during the vaginal examination is ample protection
against infection. Of course, the hands must be
treated in the same manner for each e.xamination, but
then we are told to avoid making more examinations
than are absolutely necessary. The last case I at-
tended, I think I washed my hands by the method
indicated above some six or eight times in the three
hours I was present. Perhaps this was rather exces-
sive. Kelly's method of disinfecting the hands with
permanganate and oxalic acid has no advantages over
Furbringer's method, while it has several disadvan-
tages.
NEUR.\L(;iA OF THE PFXIS.
Hv ROBERT BOVD, M.IJ.,
GRAND CAVMAN, BRITISH WEST INDIES,
After careful perusal of authorities upon venereal
diseases, such as Keyes, Otis, and others, and not
having met before with a similar case in my private
practice, I am of the belief that the subject of this ar-
ticle is a new malady and not heretofore mentioned
by any writer.
The following is the history of a patient who re-
cently consulted me in regard to his complaint:
C. B , male, aged twenty-six years, unmarried;
occupation, bookkeeper. For the past two days he
has been sutTering from severe paroxysmal pain of a
lancinating nature, occurring about e\'er)' half-hour,
day and night, and which begins at the root of the pe-
nis and extends along the shaft on the right side to
the glans penis, when it ceases. As the patient ex-
presses it, the pain seems to run along to the head,
and, having no farther to go, it escapes. The duration
of the pain is about one minute, and has been so se-
vere as to awake him from sound sleep several times
during the nigiit. The patient states that he suffered
from the same pains about a year ago, but that they
were less severe than at present, and that they gradu-
ally disappeared without any treatment. The patient
is of sedentary habits, neurotic constitution, and
suffers occasionally from severe general headache.
There is no history of venereal disease, nor is there
any history of traumatism of the penis or perineum.
The urethra is in a healthy condition; there is no dis-
charge or tendency to stricture (No. 10 .American
sound passing easily); micturition is free and non-
painful. There is a constant desire to micturate,
which desire is exaggerated during the paroxysms of
pain. Examination of urine gives negative results.
Bowels are regular. Examination of the prostate gland,
per rectum, shows it to be normal.
The patient was directed to sleep on a hard bed, to
avoid too much bed-clothing, a erections increased
the neuralgia, and the following medication pre-
scribed: Monobromate of camphor, ten grains, and
bromide of sodium, twenty grains, every three hours
during the day, and one-si.\th grain of morphine at
bedtime.
The pain gradually subsided, and in four days he
was free of it.
I have seen the patient lately, two months since the
attack, and so far there has been no return of the trou-
ble.
A CASE OF SEPTIC PERITONITIS— OPERA-
TION' (PRIMARY AND SECONDARY)— RE-
COVERY.
Bv H. E. KENDELL, M.D.,
sr. JOHNS, N. F.
E. V , aged fourteen years, suffering from appen-
dicitis, was seen in consultation on the fourth day of
the disease. The symptoms then were those of grave
peritonitis. An operation was advised and accepted.
The abdomen was opened over the appendix: incision
at the right border of the rectus. Sero-pus welled up
as soon as the peritoneum was incised. The right
flank and pelvis were full of fluid. It extended well
up under the liver and among the coils of intestine to
the left of the spinal column. There were no adhe-
sions. The cavity was mopped out by the dry method
and the appendix was removed. It contained an en-
terolith, was gangrenous and perforated. The intes-
tines were then well sandwiched between strips of
gauze put in every direction, according to the Mc-
Burney method, and the incision, about five inches
long, was left open. The patient did well and on the
sixth day the gauze strips were removed, the sinuses
being mopped out and gently repacked. On the
eighth day, while gently flushing the sinuses, I ob-
served that the fluid did not return well from that
which led to the left side of the pelvis. It had a
pretty sharp angle where it passed the pelvic brim,
which caused some pressure with rupture of adhesions.
That night my patient became very ill, and in the
morning when I saw him he had again developed all
the signs of septic peritonitis. The percussion note
in the left flank, which the day before had been tym-
panitic, was now flat. I accordingly decided to open
on the other side, and did so about eighteen hours
after the accident had occurred. The cavity on this
side was full of serum. It presented about one-fourth
the surface of the general peritoneal cavity, and was
limited by the adhesions set up by the former opera-
tion. The treatment was the same as in the first case,
with the exception that the latter side was flushed
with nonnal salt solution. It is, perhaps, worthy of
note that this side so treated discharged serum much
more ]jrofusely and for a longer time than the first side,
treated by the dry method. It would seem, likewise,
as though irrigation in the first instance would have
caused infection of a portion of the cavity which es-
caped by the method adopted. The patient had a slow
convalescence, about ten weeks. A secondary abscess
formed, which after a tedious watching opened through
the old wound. Recovery has, however, been perfect.
This case seems to me to be of interest on account of
the secondary infection and the happy result of the
secondary operation. Apart from this, I wish to report
it in order to get some light on one or two questions
arising therefrom.
(1)1 simply ligated and excised the appendix. A
small faecal fistula followed, which lasted for four
August 8. 1S96]
MEDICAL RECORD.
209
weeks and closed spontaneously. Should I have
adopted the invagination method under the existing
conditions of sepsis and gangrene?
(2) I left the gauze drains in until they fairly floated
out on pus. I thought it a safe method, and had not
the confidence to remove them at an earlier date. Is
it necessary for the sinuses to suppurate in these
cases? Is there any clear criterion which would per-
mit of the gauze being removed at an earlier stage?
Are secondary abscesses more likely to occur if the
drains are removed earlier?
MALARIAL H.i;MATURIA, OR HEMOR-
RHAGIC FEVER.
Bv W". D. BUSH, M.I).,
LEESBfRGH, FLA.
This disease is getting to be a very common occur-
rence in Florida, Georgia, and the Mississippi bot-
toms, and as I find verj- little literature on this subject
I think every physician in these regions should make
himself thoroughly acquainted with the symptoms and
treatment of the affection. Hemorrhagic fever attacks
those who have previously had some form of malarial
fever, as a general rule those who have their systems
full of the malarial poison.
Now, as to the pathology, the chief manifestation is
the alteration of the blood and the organs that are
disposed to congestion and inflammation, such as
lungs, bowels, and kidneys, due to a defibrinated con-
dition of the blood.
The symptoms and treatment I will give by refer-
ring to some cases that have come under my observa-
tion :
Case I. — Mr. F , a man of about forty years,
who has been in Florida some eight or ten years: very
dark comple.xion and of a bilious temperament. He
had hemorrhagic fever in Georgia and came very near
dying. I saw him at i p.m. He had a temperature
of 104° F., and was perspiring very^ freely. He was
deeply jaundiced over the whole surface; the conjunc-
tiva were of the same color as the skin. He had passed
bloody urine three times and a large quantity at each
time. He was somewhat nauseated and the tongue
had a yellow coat on it. I gave him at once calomel,
gr. vi. ; aloin, gr. ss. ; podophyllin, gr. ',3; sodium bi-
carbonate, gr. vi. I also left another capsule contain-
ing the same, to be taken next morning in case this
did not operate well. I also left turpentine, to be
given in ten-drop doses every three or four hours till
the urine cleared up. I told my patient I would
call again before night. So about four or five o'clock
I saw my partner. Dr. Green, and told him I had a
case of hemorrhagic fe\er and asked him if he would
not like to see it. We drove out and on our wav he
asked me what I was giving my patient. I told him
and also remarked that I intended giving quinine
next morning. He said that if I did I would be apt
to send my patient to the other world, for he had lost
enough to convince him of its uselessness before he
stopped the use of quinine and had not lost a patient
since. So I decided to prof.t by some older experience
in this disease and not give the quinine. Instead I
gave the patient Warburg pills, one every three hours,
till five were given in one day, using the two-drachm
pills with aloes. I saw him next day. The urine was
clear. The mercurial had operated well. There was
no fever. The skin was clear and the patient was in
a good condition.
Case II. — Mr. K had the same symptoms, the
same treatment was used, and the patient made a good
recovery.
Case III. — Mrs. B sent for me on Wednesday.
I was out of town, so she waited, as she thought she
had a case of intermittent fever. She grew worse and
sent again next day. I found her perspiring and show-
ing all the characteristic symptoms of hemorrhagic
fever. She had been passing blood for two days and I
found she had been taking quinine all the day before.
She was very ner\-ous, nauseated, and vomited black
bile. I at once put her on a mercurial, and gave tur-
pentine and Warburg pills. She was verj- bilious, but
by repeated doses of calomel she soon recovered.
Cases IV. and V. — Father and son. Two of the
worst cases I ever saw. These, like the rest, had pre-
viously had intermittent fever. Their systems were
full of malarial poison. These I saw with Dr. Green
at 3 P.M. The father had taken the day before thirty to
forty grains of quinine. When we saw him the father
was perspiring freely; the skin and eyes were most
deeply jaundiced. Both patients were vomiting ever)-
few minutes black bile and decomposed food. They
were so nauseated that it was a hard matter to get
anything to stay on the stomach. We at once put
them on the mercurial and Warburg-pill treatment.
We finally got the medicine to operate. The son was
soon convalescent, but to our great surprise as soon as
the urine of the father cleared up there was a total
suppression. Vomiting was troublesome for some
time and there was hiccough. There were then in-
voluntarj' discharges from the bowels, which were only
checked by strong astringents. We tried everj-thing
that was ever recommended for suppression of urine,
but to no use. We kept off ursemic convulsions by
giving pilocarpine, but the patient died from suppres-
sion and exhaustion.
INTESTINAL OBSTRUCTION ; L.\TERAL
ANASTOMOSIS WITH THE MURPHY BUT-
TON, INTRODUCED THROUGH THE VA-
GINA.
Bv JOHN A. PRINXE, M.D.,
SPRINGFIELD, ILL,
Mrs. L , aged thirty-three years, two children.
Vaginal hysterectomy was performed October 2, 1895,
for chronic ovarian and tubal disease. Hai'P^ostasis
was obtained by clamps, which were rem.oved on the
second day. On the fourth day several free move-
ments of the bowels were obtained. Flatus passed
freely from the first day. The patient passed flatus
on the seventh day, but all efforts to obtain a move-
ment of the bowels after that date failed. Tympanites
was present on the eighth day and rapidly increased.
On the ninth day, thinking some obstruction might
exist within reach of the hand introduced in the rec-
tum, I gave an anaesthetic, and after dilating the
sphincter, passed my hand as high as possible, but
could detect no trouble. Her condition, bad before
the operation, did not encourage the idea of a coeliot-
omy. On the tenth day I was out of the city and was
surprised on returning to find my patient still alive.
I suggested to the mother and husband of the patient,
who were present, the bare possibility of being able to
reach the point of obstruction by breaking up the ad-
hesions at the vaginal vault and exploring the pelvic
and abdominal cavities with the hand. After consid-
erable delay, consent was obtained, and after anas-
thetizing and cleaning the vagina the fresh adhesions
were broken up. The vault was completely closed by
omentum, being firmly united to the edges of the va-
gina. Whether this is always nature's method of clos-
ing the vault or not, I am in ignorance. There was
no suppuration present, the wound being as fresh and
clean as the day it was made.
2IO
MEDICAL RECORD.
[August 8, 1896
I could find no obstruction in the pelvis nor as high
;as I could reach in the abdominal cavity.
While passing my hand back and forth among the
•distended intestines a loop of collapsed gut got be-
tween my fingers, and I brought it down into the
vagina. I made efforts to trace it to the point of ob-
struction, but they were futile.
The thought entered my mind that a Murphy but-
ton might be inserted between this loop of collapsed
gut and one of the many distended loops, and an an-
astomosis made which might save this patient's life.
The idea was carried into execution at once, though, ow-
ing to the limited area in which I had to work, it was
only accomplished with much difficulty. A small rent
was made above the button, which was closed as well
as possible with sutures. Reaction was slow at first,
but when it did set in the woman rallied rapidly.
Gas and faeces passed freely through the natural orifice
until the second day, when some faical discharge ap-
peared in the vagina. This rapidly increased in
.amount, and soon, nearly the entire contents of the
bowel was discharged through the fistulous opening.
As this opening contracted, more and more of the dis-
charge passed through the natural opening, until at
this writing, December 2d, there is only an occasional
discharge from the vagina. The button passed by the
anus November 29th. At the present time the pa-
tient is entirely well and able to go about as usual.
This procedure would not be the operation of elec-
tion in cases of obstruction of the bowels, but in the
•case reported it was the only thing possible to do,
aside from making an artificial anus.
PRIMARY CARCINOMA OF INFERIOR TUR-
BINATED BODY.
Bv BEAMAN DOUGLASS, M.D.,
ASSIST.\NT SURGEON, MANHATTAN EVE, EAR, ANU THROAT HOSPITAL; IN-
STRUCTOR, POST-GRADUATE MEDICAL SCHOOL A.ND HOSi'ITAL.
The literature of medicine contains reports of several
cases of malignant disease, carcinoma or sarcoma of
the nasal passages, but nearly all the reported cases
seem deficient either as to the intranasal origin of the
growth, or in the diagnosis having been made without
the microscope. Data as to the early symptoms of the
disease are often wanting also. In looking over the
literature ot carcinoma of the nose, I find two cases
only in which a careful microscopic diagnosis of carci-
noma was made and in which the neoplasm clearly
began intranasally. In both these cases the disease
originated upon the septum. There are no recorded
cases in which the lesion began in the turbinated
tissues.
The case which is the subject of the following re-
port has a carcinoma beginning with symptoms so few
and so slight as hardly to attract serious attention, and
\et the history clearly points to the inferior turbinated
tissue as the point of origin, and it is only upon this
tissue that the disease can be found inside the nose.
Tne consideration of this patient and her hi.story would
lead us to believe :
(i) That carcinoma, primary and intranasal, may
occur in -a form so closely resembling an ordinary
rhinitis as to be overlooked, the distinguishing svmp-
toms being pain and the recurrence of nasal hemor-
rhage.
(2) In all nasal ulcerations of any extent, a careful
microscopic examination of a portion of the ulcerated
surface is the only accurate means of early diagnosis.
(3) That an early diagnosis affords the only chance
of operative interference.
(4) That primary carcinoma of the turbinated is
possible and should enter into the differential diag-
nosis of all nasal ulcerations.
(5) That carcinoma of the inferior turbinated may
occur without antrum involvement.
The history obtained as fully as possible from the
patient is as follows :
Family History. — The mother is living at the age
of seventy-seven years, is in fair health, except for in-
digestion. The father at twenty-nine years of age was
the collector and partner in a grocery business. He
developed after a prolonged exposure to cold and wet
a discharge from the nose, accompanied by a disa-
greeable odor. Right-antrum disease developed and
the antrum was drained by drilling through a tooth
cavity. This antrum disease lasted twenty years, dur-
ing which time he continued at his business. At the
age of forty-nine the right eye became inflamed and an
abscess developed over the frontal sinus on that side.
This was lanced and a large quantity of pus was re-
moved. The affection of the antrum during this time
remained stationary. He then lost llesh and strength
rapidly, became bedridden, and after seven months the
physician in charge called in consultation Dr. Hod-
gens, of St. Louis. The frontal sinus was opened,
some necrosed bone from the centre of the forehead
was removed, and the patient died ten days afterward.
There is no history of syphilis, and, except that the
patient's two sisters had some slight eye trouble, there
is no record of further hereditary taint in the family.
My patient, Mrs. H , aged thirty-one and a half
years, presented herself for examination at the office
of Prof. O. B. Douglas, and it is through his kindness
that I am able to report the present case. The pa-
tient has always been delicate and nervous, and yet
well if we except the usual category of children's ail-
ments, all of which she proudly asserts she has had.
The nose first troubled her about five years ago, when
she complained of a mucous discharge from the left
side. The discharge has been at times rather scanty,
forming scabs, which when removed were always fol-
lowed by slight bleeding. One year ago the patient
suffered from a severe nasal hemorrhage and this
has since been repeated at irregular intervals. There
has been pain in the nose only during the last three
months. The pain has been neuralgic in character
and confined to the left side of the face. She has
never suffered headache. One year ago patient no-
ticed the first external deformity. The left side of the
nose became slightly swollen and the left nasal orifice
was slightly lifted upward. There was no discolora-
tion of the skin. The nose remained in this condition
until three months ago, when upon the left nasal bone
and the left nasal process of the superior maxillary
two small bony lumps appeared, which have gradually
merged into one. About this time the skin became
discolored and the superficial blood-vessels of the skin
became dilated. The left lachrymal duct has been
obstructed somewhat for about a year, but the obstruc-
tion seemed to vary ; at one time the tears would flow
freely over the cheek, at other times for several weeks
hardly at all. The patient has not failed in flesh
much, but is very weak and easily prostrated. She
has had one child.
Present Condition — Examination. — The right
naris is normal; the pharynx and post-pharynx appear
normal; the right side of face presents no deformity.
The left ostium narium is slightly retracted upward
about one-eight^ inch and the ala with it. The intra-
nasal mucous membrane, except for that covering the
inferior turbinated bone, presents no change macro-
scopically. The inferior turbinate is quite innocent
in appearance and would perhaps be easily overlooked
except for the history of bleeding without any other
catarrhal symptoms and the extreme prostration of the
patient, together with the external deformity. This
left inferior turbinate seems atrophied or at least oc-
cupies less space than its opposite. It extends below
August S,
1896]
MEDICAL RECORD.
211
nearly to the floor of the nose, but does not lie in con-
tact with it. The surface is superficially ulcerated, is
not covered with pus or blood. It bleeds easily when
touched. The ulcerated edges are without thickening
or induration. The surface of the ulcer is not exca-
vated, but is fiush with the surface of the surrounding
mucous membrane. This surface has a roughened ap-
pearance and looks not unlike an atrophic ulceration
from which the scab has been newly removed.
The ulceration begins in front, about one-fourth
inch from the anterior end of the inferior turbinate,
•covers the whole of the turbinate on top, inside, and
below, and extends back about one inch; the posterior
■end is not ulcerated or enlarged. Two pieces of tis-
sue were removed from this ulcer, one corresponding
to the lower border of the inferior turbinate and the
•other from the inner surface. The pathological re-
port, signed by Henry T. Brooks, M.D., pathologist,
Post-Graduate Medical School and Hospital, is as
follows: "The piece of tissue from mucous membrane
■of the nose sent me for examination shows all the
■characteristics of a carcinoma."
The external deformity consists of a hard nodule on
the nasal process of the left superior maxillary, about
three-fourths of an inch in diameter, not adherent to
the skin, but the cutaneous blood-vessels are dilated.
There is obstruction of lachrymal duct and tears flow-
over the cheek. The whole of the left nasal region
seems somewhat deformed and the left ala is retracted
upward and outward. The conjunctiva is congested
at times. There is no exophthalmos and no displace-
ment of orbit.
A few days after the case came under my observation
the cellular tissue of the eyelid suddenly swelled till the
cedema closed the eye ; in the inner corner of the upper
eyelid a small nodule appeared and has persisted, ten-
der and swollen, since the subsidence of the cedema.
The case was transilluminated with negative results.
Both antra transmitted tiie light equally. Over the
■external bony deformity the light was somewhat ob-
.structed, less clear but remaining translucent.
(From case book. May 3, 1896.) " Patient to-dav has
left nasal cavity filled with a white crust; this is
cleaned away with peroxide of hydrogen and an oily
spray, showing the meatus clear. The light shines
through to the posterior pharynx. There is no dis-
charge, no tumor. The appearance of ulcer on the
inferior turbinate same as before. The posterior end
of turbinates normal in appearance. The external
bony nodule is quite prominent, about three-fourths
of an inch in diameter. The swelling at inner can-
thus on upper lid has nearly subsided. The treatment
is cleansing, tonic, and expectant."
Hydrogen Dioxide and Saline Solution. — Dr. Rob-
ert T. Morris (American Medical and Surgical Bulk-
tin, May 9, 1896) says: '"If we fail to destroy pus and
septic fluids when opening an appendix abscess, the
general peritoneal cavity is likely to become infected.
Hydrogen dioxide and physiological saline solution
I are the sheet anchors of clean appendicitis work, and
I would lose a few cases from post-operative septic
peritonitis if either one of these resources was omitted.
I do not know what surgeons mean when they speak
of leaving the free peritoneal cavity unopened, as a
rule, in appendicitis abscess work. There are few
cases in my practice in which it is not necessary to
expose uninfected peritoneum at one or more points.
But what is the harm if abscess cavities are properly
cleansed with hydrogen dioxide and saline solution?
1 have so much confidence in our resources to-day, and
in the ability of the peritoneum to manage infective
processes, that fear of infecting the peritoneum does
not enter into my calculations."
(Covrcspouclcuce.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE DROt'GHT — DANGER OF WATER FAMINE NEW
" NOMENCLATURE OF DISEASES" BATTLE OF THE
CLUBS — MEDICAL-AID CO.MPANIES QUACKERY AT
GLOUCESTER GENERAL MEDICAL COUNCIL — COLLEGE
OF SURGEONS P. AND V.P's. MEDICAL DEFENCE AND
PROTECTION — OPIUM EATING AND SMOKING AN
INDIAN "critique ON THE ROYAL COMMISSION"
— A KE.'iTS BED AT A HOSPITAL BURNS CELE-
BRATION EDINBURGH DEATH RATE — ROYAL INFIR-
MARY HOSPITAL SUNDAY FUND — REPORTS OF DR.
THORNE AND THE ADULTERATION COMMITTEE — DR.
BEALE, F.R.S.
London, July 17, i8c6.
A LUNG course of fine hot weather has brought about
some alarm as to the water supply. The drought has
been so pronounced that the grass in the parks has
been lighted by the careless throwing of matches
among it, thus producing a miniature prairie fire. A
number of deaths attributed to the heat have also been
recorded in various parts of the country. Mr. Symons,
F.R.S. , director of the Rainfall Association, feels no
alarm at the dryness of the last four or five months,
and expresses a belief that there is plenty of time for
1896 to take a place among wet years. Few people
are equally sanguine, and in some parts a water famine
seems approaching. The East London Water Com-
pany has already found it necessary, as a precaution-
ary measure, to cut olT the supply from nine o'clock at
night till six in the morning, and it is stated that in
one part of its district there has been no water dis-
tributed for the major part of a week. One of the
western companies is also considering the necessity of
curtailing their supply, the other companies apparently
being satisfied that they will be able to meet the de-
mands upon them. Perhaps these fears of water fam-
ine are premature, for in various parts of the country
heavy thunder-storms with enormous downfall have
already succeeded the great heat, caused by the high
barometrical pressure which has now passed by. In
London the fall of temperature was equally sudden
and welcome.
A third edition of the " Nomenclature of Diseases"
has been published, but only a few have received their
copies. The treasury has sanctioned a gratuitous issue
to every member of the profession, so that in a short
time this edition wall supplant its predecessor. It has
been very carefully revised by the committee of the
Royal College of Physicians, appointed four years
ago, twenty-four separate sub-committees having oc-
cupied themselves with the several sections. The
names of diseases are given in English, Latin, P'rench,
and German. The column of Italian names has this
time been omitted, as they do not materially difter
from Latin or French. The list of nan\es follows as
closely as possible the terms employed in the office of
the registrar-general, so as to avoid the confusion
which would necessarily occur if the past statistics of
that office were rendered difficult or impossible of com-
parison with future figures. Accuracy of nomencla-
ture, facility of comparison, and continuity of records
are more important in a work of this kind than patho-
logical classification. The English index has been
separated from the Latin, the latter being intended
rather as a guide to those who do not know English
than for other purposes. Nevertheless, it is very full
and accurate. It was commenced by the late Dr.
Greenhill and has been completed by Dr. Perry. The
work, altogether, is certainly equal to its predecessor.
212
MEDICAL RECORD.
[August 8, 1896
For several months past '" the Battle of the Clubs"
has been a stereotyped heading in our journals. Un-
der it a series of fights have been recorded, so that
'■ the campaign" or " the war'" would be more e.xpressive
of the contest which has been going on in many parts of
the countr)' between the managers of friendly societies
and medical men. The war, which broke out in Cork,
and of which I gave you an account at the time, has
extended to many towns in England, and unless the
clubs listen to reason may become universal: for it is
undoubted that the system is everywhere abused.
Originally intended to meet the necessities of the
poorer members of the working classes, the doctors'
fees of these clubs were fixed on a charitable basis.
Nevertheless, not only skilled workmen and foremen
availed themselves of these terms, but tradesmen, pub-
licans, town councillors, and other well-to-do people
joined the clubs as honorary members. Many were
too proud to draw the usual sick allowance and so pro-
claim their meanness to every member of their club,
and at once raise the question as to whether it would
be right to do so. But the doctor's fee of ^^2 6^. or
£.2, i>s. per annum having been subscribed, these same
persons made their demands on the doctor's time with-
out scruple. This is the fact put forward as the chief
reason of the medical revolt: at the same time it must
be rembered that in all cases the fees are too jmall to
be remunerative, and, free as all doctors have always
been with their charitable help, they cannot but feel
aggrieved with those who have larger incomes than
their own, but seek to impose on them for assistance.
Other grievances are the increase of cheap dispen-
saries, the abuse of the out-patient departments at hos-
pitals, and the recent developments of the joint-stock
principle in the shape of medical-aid associations.
These last engage a medical man to attend all their
members in a district, paying him a small salary, and
by dint of touting get large numbers to enter as mem-
bers, thus loading the unfortunate doctor with continual
work for the barest pittance and making a profit out
of his labors, in which he does not participate. This
practice is condemned in all professional circles, and
the " sweating" of doctors for the benefit of others
must, it is held, be put an end to. The matter has
even been brought before the Medical Council, but
nothing has been done, though it is expected that out-
side pressure may eventually lead to some effectual
resolution. Many years ago I was paying a long visit
in a manufacturing town, where a very large proportion
of the population belonged to clubs, and a difficulty
had arisen which was met in the following manner:
Each of the doctors — there were five in the town —
opened a club of his own: that is to say, he entered in
a book the names of all patients who had been in any
of the clubs of which he had been doctor and who
were willing to pay a weekly or monthly sum. In re-
turn for this the doctor engaged to attend them as he
had previously done under the club system. A col-
lector was engaged to call for subscriptions, and as
long as they were paid regularly medical attendance
was insured. There were no other rules, and the mem-
bers were to all intents and purposes on the same foot-
ing as private patients, and could, of course, change
their doctor whenever they pleased. .\s each of the
doctors attended on the same conditions there was no
competition as to prices, and every man could choose
his own doctor. This plan gave satisfaction and might
now be tried, perhaps, in other places. Something of
the kind has, I hear, been done in Coventry, where a
kind of medical service has been established in self-
defence. .As soon as the work of a medical aid asso-
ciation was thrown up, a qualified man was sent into
the town to carry it on: and this illustrates the chief
difficulty of fighting these trading societies. In some
towns the fear of a new man beino introduced has
sufficed to prevent union : but even at Coventry I am
told the plan has been fairly successful and promises
still better results. This shows that it is only neces-
sar)' for the medical men to act together to defeat the
scheme of limited companies absorbing the profits of
their labors.
An almost incredible instance of gross quackery is
reported from Gloucester, where it appears that during
the epidemic an unqualified man. calling himself a
hydropathist, started in the town with large professions
of curing small-pox and preventing its spread. Pa-
tients, as usual, did not fail him, and I hear that not
less than twenty-three of his cases were fatal. Where
is the coroner.' No inquests seem to have been held,
and on what authorit)- the deaths have been registered
might well be inquired into. The inaction of the cor-
oner lays upon him a grave responsibility.
-As I anticipated, the coming election to the (General
Medical Council has been seized upon by the ISritish
Medical Association or some of its leaders in the hope
of once more putting in their nominees. Drs. Wood-
cock and Drage are excellent candidates and could
well have afforded to stand alone, but have naturally
accepted the advances of the association, which I am
sorry to see has again " nobbled " Dr. Glover, whose
position, after ten years' work on the council, ought tc^
be so secure as to prevent his accepting extrinsic aid
and so far tending to restrict the choice of the elec-
tors. Yesterday there was a meeting at the rooms of
the Royal Medical and Chirurgical Society, to hear
addresses from these three gentlemen. As I have re-
ported, other candidates have declared themselves,
but with the wire pulling of the association against
them they have scarcely a fair chance. I should like
to vote for Dr. Glover, but this union with a great as-
sociation is so interfering with tlie freedom of electors
that I hesitate, and I know that many others feel the
same, and some are really indignant.
\X the meeting of the new council of the Royal Col-
lege of Surgeons, Sir William MacCormack was elected
president, and Messrs. Macnamara and Langton vice-
presidents, for the ensuing collegiate year.
LoND(»N, July 24. iSy'^
The proposed amalgamation of the Medical Defence
Union with the London and Counties Medical Protec-
tion Society seems finally to have failed, as the two
cannot agree on the name to be registered, each pre-
tending that its own name is valuable as "good will."
Some of us would say: ''What's in a name?" To
register the combination as the '" Medical Defence
Union, with which is amalgamated the London and
Counties Medical Protection Society," and so render
that long description the only legal name, certainly
seems preposterous and would lead to curious re-
marks in court. If both names must be expressed,
why not reduce it to London and Counties Medical
Union? But the question of defence will be further
discussed, as the British Medical Association proposes
to take it up. For this purpose its memorandum must
be altered, and that is rather a serious step, for the nec-
essary legal proceedings are very complex. .\ special
meeting has been held at which it was resolved to initi-
ate the change. Only a handful of members was pres-
ent, but great .ditTerences of opinion were expressed.
.\nother special meeting has been convened, to be
held at the C.irlisle assembly, when the matter may
be fully discussed. There are four or five .schemes for
carrj-ing out the intention, and a certain degree of in-
terest is exhibited in them. If the association, with
its large numbers and great income, can agree upon
a practicable scheme and get legal authority and com-
mit the management to an able board, much may be
done, and the members would be insured against vex-
August 8, 1896]
MEDICAL RECORD.
21
atious actions. The two protection societies might,
perhaps, be absorbed, and the men who have worked
them so well should find places in the executive and
be trusted to carry out on a larger scale work for
which they have evinced so much talent.
Vou will remember that the opium commission re-
ported somewhat unexpectedly in favor of rather than
against maintaining the present regulations respecting
the traffic in India. It was inevitable that this report
should excite keen criticism, and the Indian Medical
Hc'iord devoted a series of articles to combating the
memorandum of Sir William Roberts, the medical
member of the royal commission. These articles
have been revised and are now being circulated in
pamphlet form. Sir William Roberts' views are sub-
jected by the Record to severe criticism, founded on
careful examination of tlie facts. At the outset it is
remarked that the qualifications necessary for a medi-
cal exfiert are wanting in Sir William Roberts, that he
has fixed opinions on one side, and that the India
office was wise in selecting one who was almost cer-
tain to express official views. Sir William Roberts
attributes a dual character to the opium habit — the
medicinal and what he calls the "euphoric." This
last term, he says, "'means feeling perfectly well and
able to bear pain and anxiety easily; but only a select
portion of the population are susceptible to the eu-
phoric effects." He takes it for granted that the
habit prevails in excess in malarious districts, but this
notion is completely exploded by the critique before
me, which shows that in Bengal the minimum of con-
sumption is in the most malarious districts, while ex-
cess prevails where there is little or no malaria. The
real origin of excess seems to correspond with the
cultivation of the drug, for wherever it is grown it is
eaten, and the more grown the more is eaten. In some
districts where it is not grown, but where the habit pre-
vails, the explanation is found in the fact of past cultiva-
tion. Further, the distribution and prevalence of the
habit has no relation to the medicinal qualities of the
drug; but as to its so-called "euphoric" effects it ap-
pears that Indian physicians would laugh the idea to
scorn. There are many startling statements in the
report of the commission, but none, perhaps, more
surprising than that the r)-ots of eastern Bengal use
opium as a household remedy, although this statement
has been supported by Dr. Crombie. It is, however,
shown in the pamphlet mentioned that this is not and
cannot be true.
As to the question of a prophylactic influence, .Sir
William Roberts has revived the exploded notion
which attributes antiperiodic properties to anarcotine;
but I do not suppose any thera]3eutist will be ready to
support him, for an efficient dose of this constituent
would be accompanied in opium with a dangerous
amount of morphine. Our critic apologizes to Ben-
gal physicians "for being obliged to drive the phan-
tom of opium as a prophylactic into the congenial
atmosphere of fiction, whence it first emerged." It is
startling to find that Sir Williajn Roberts would not
interfere with the practice of giving opium to children
— a custom for which great responsibility rests on the
government of India and which has been so often de-
nounced as cruel and criminal. Another point in
reference to this question is the relation of suicide
to the opium habit; and here, again, the memorandum
of the official expert is shown by his critic to be alto-
gether erroneous. Again, the relation of the habit to
food is treated in the report in a very one-sided man-
ner, which the writer of the critique effectually ex-
poses. The views of Drs. Crombie and Cobb, as they
appear in the evidence, contradict and so destroy each
other, and afford the critic no little merriment.
Smoking opium is a modern habit compared with
eating it, and no one has ventured to come forward
in defence of the snioking-dens. The anti-opium agi-
tation really derives its force from the evils of the
smoking-habit, which is so rapidly spreading, owing to
the regulations of the government on account of its
contribution to the Indian exchequer. It is a " social
and public vice," says our critic; "hence, more cal-
culated to propagate than the unostentatious and less
pernicious habit of opium-eating." \\'hen the roval
commission was appointed, the smoking-habit in China
and the far East was supposed to be the chief sub-
ject of inquiry; but it seems that official influence has
managed to make this quite secondary and to give the
opium-eating habit the most attention. There is a
general consensus of opinion that opium-smoking
should be abolished, and it is admitted that smokers
themselves think so. Even the commissioners admit
that " native public opinion condemns the habit as
disreputable, and this opinion is shared by the great
majority of European witnesses — official and private
— including medical practitioners." Nevertheless, Sir
William Roberts seems to constitute himself an apol-
ogist for this habit.
A blue book on the consumption of opium in India
in 1892 reported that the government decided that the
total prohibition of smoking-shops was the right pol-
icy to follow. The local governments of Bombay and
Bengal have, however, managed to prevent this being
carried out. New regulations, indeed, were issued,
but have failed, and the pamphlet shows that the
habit has continued to spread and is likely to do so
until the imperial government alters its methods. As
an appendix to the pamphlet, the evidence of Dr.
Mookerjee, the first native practitioner ever elected to
the presidency of the Calcutta Medical Society, is
given, and he is supported by the vast majority of In-
dian physicians. He urges that the vice of opium-
smoking should be restricted by legislation, that the
preparations used for smoking should not be allowed
to be manufactured, and he hopes that the commission
on the subject will be followed by one on alcohol, and
that England will be induced to deliver India from
drunkenness and opium-smoking.
It is proposed to endow a Keats bed at Guy's Hos-
pital, in memory of the great poet who left medicine
for the muses. One thousand pounds is wanted for
the purpose.
We have just had a Burns celebration, and though
we cannot claim him as belonging to the profession,
his hatred of shams was expresed in his '"Death and
Doctor Hornbook," which is one of the most scathing
satires on quackery ever penned.
Edinburgh has been rejoicing in a low death rate
for several months. For many weeks rates of thirteen
and fourteen per thousand have been recorded. For
the last three weeks, thirteen, fourteen, and fourteen
were the numbers registered.
The Edinbiu'gh Infirmary is to have a new medical
pavilion. The architect's plans have been accepted.
The estimated cost is ^730,300. Plans have also been
approved for a new laundry for the infirmary, al-
though Sir Henry Littlejohn pointed out that it was
very undesirable to have this laundry in so close
proximity to the hospital as on the site selected.
The Hospital Sunday Fund has now reached the
sum of ^?43,2oo, and some additional donations are
expected. Sir S. Crossley has promised a further
^,1,000.
Dr. Thome Thome's third annual report as medi-
cal officer to the local government board has just
been issued. It is exceptionally instructive and
valuable.
The report of the select committee on the sale of
foods and drugs has also been issued. It proposes
some drastic legislation against adulteration, which
if enacted would be a great protection to the public.
214
MEDICAL RECORD.
[August 8, 1896
Dr. Lionel S. Beale has resigned his professorship
at King's College and his physiciancy to the hospital.
He held the physiciancy forty years and was a pro-
fessor rather longer.
"HERMAPHRODISM (?)."
To THE EuiTOK OF THE MeDICAL ReCORO.
Sir: Seeing in the Medical Record of July 25th,
just received, a report of " A Case of Hermaphro-
dism (?)"by Dr. Carl Beck, -with four illustrations,
the first two of which represent the usual form of
spurious hermaphrodism, viz., imperfect development
of the male genital organs, I proceeded to read the
article with curiosity to discover wherein this case
differed from the numerous instances of this malfor-
mation which have come under my observation. I
read on without perceiving anything peculiar until I
came to the description of the " infundiisulum '" be-
neath the arch of the pubes and the discovery of
" a canal four inches in length (undoubtedly the
vagina) at the end of which a well-developed uterus
could be felt."
On reading the above statement, which I quote in
the words of the author, I thought that at last a living
subject had been found with unquestionably male ex-
ternal sexual organs and with a vagina and uterus
(and probably ovaries) representing the internal female
sexual organs.
What was my surprise, however, to find absolutely
no mention made of the condition of the internal sex-
ual organs when the abdomen was opened for the re-
moval of the mysterious abdominal tumor, which, as
might have been expected, proved to be the right tes-
ticle and (although the author does not distinctly say
so) probably the left testicle also. I naturally ex-
pected to see the upper portion of the " well-developed
uterus " which had been felt through the canal, four
inches in length, " undoubtedly the vagina," mentioned,
and perhaps {mirahile diet 11!) the uterine appendages.
But the author appears to have entirely overlooked the
glorious opportunity offered him (which I regret to
say has never been tendered me) of verifying through
an abdominal incision the presumptive diagnosis of
true hermaphrodism. The case as he reports it is
simply one of the very common congenital malforma-
tions of the external male generative organs (of which
I have seen several dozen at least), with small but
erectile hypospadiac penis, blind perineal pouch
(sometimes three to four inches in depth), thick bi-
lateral scrotal folds, simulating labia majora, and tes-
ticles either in the scrotal folds or in the inguinal
canal, besides fairly distinctive general male habit.
The only interesting feature in the case seems to
me to be the sarcomatous degeneration of the in-
tra-abdominal testicles. The title of " Hermaphro-
dism (.')" therefore is not justified even with the
interrogation mark, for the case was simply one of hy-
pospadiac male with undescended sarcomatous testicles.
I think the author owes us an explanation of his
diagnosis of the '"well-developed uterus'' which he
felt through the "canal" (" undoubtedly the vagina"),
and I shall look with interest for the reasons which
induced so careful an observer and expert an operator
to omit the demonstration of the very point which would
have made his case remarkable, if not unique.
Paul F. Munde.
Xfw York, July 27, 1896.
Judging from the report, the patient seems to have-
been a female with an enlarged clitoris. His (?)
voice, face, form, mamma;, and, if I ma)' judge from
the photograph, arrangement of the pubic hair were
feminine. \\'as the pubic hair continued up to the
umbilicus, as in the male, or did it stop short at the
mons veneris, as in the female.' The groove on the-
ventral surface of the penis (?) may have been simply
a continuation of the female vestibule, and the-cutane-
ous prominences remains of a female frjenum. The-
urethra and introitus vagina', hymen, vagina, and uter-
us were female in character, the two lateral openings
probably openings of Bartholin's glands (could their
secretion be examined ?). These glands empty them-
selves during sexual excitement in women, and an en-
larged clitoris might admit of coitus after the fashion
of the male.
Was it the tumor -which Dr. Beck removed which he-
describes as having been recognized as the right testi-
cle, and why was it so recognized? Fig. 3 looks like
an ovary, not a testicle, and no report is given of its
structure; and if Fig. 4 be the so-called testicle, was
testicular tissue recognized microscopically?
Altogether, as a reader, I would point out that Dr.
Beck's case as reported is utterly valueless to the col-
lector of statistics, when surely careful microscopic
search for ovarian or testicular rudiments might have
made it of the utmost consequence to teratologists.
Fuller examination of the specimens might make the
case one of great value.
William Keiller, F.R.C.S. Ed.,.
Professor of Anatomy, University of Texas.
To THE Editor of the Medical Recokd.
Sir: Referring to Dr. Beck's article in the Medical
Record of July 25th, it seems to me a pity that the
report should be so vague, especially on a subject
concerning which sufficiently attested cases are much
needed.
THK APPENDICITIS CONTROVERSY.
To THE Editor of the Medical Record.
Sir: Years ago I was called in consultation to see a
bright young physician %vho had appendicitis. He
had a high fever, up to 103° F., and severe pains for
forty-eight hours, but the symptoms were sub.siding
when I saw him; the next day his temperature was
only 99° F., and nearly all the symptoms had disap-
peared. I told him there was no question about his.
getting over this attack; that an operation could be
talked about later. I was obliged to leave the city,
and twenty-four hours after he had a sudden change
for the worse, with high fever, chill, and severe pain,
and when I returned twelve hours later he was ///
articulo mortis and an operation was of no benefit.
With every case of appendicitis, there arises before
my mind the picture of that bright young doctor and
his poor, six-months-pregnant wife.
Ever)' case of appendicitis must be operated upon
immediately; to-morrow it may be too late. I seldom,
if ever, meet with a refusal ; the patients always say
yes. After years of experience, I never varied from
this rule until two months ago, when I had a case
in which the symptoms had all subsided, and I thought
the patient would recover without operation. I waited
until the next morning. I found that the pulse had
increased in frequency, although the temperature was-
only 99" F. I operated and found a gangrenous ap-
jjendix surrounded by pus. Fortunately the patient
recovered, but by deviating from my rule and hesitat-
ing a life was nearly lost.
I have had general practitioners tell me that they
.see a good many cases of appendicitis and the patients
all get well without an operation; but those very same
physicians have ca.ses within the next six months in
which the patients die. I know a number of such
cases in which two or three patients have died in the
hands of these men. That has cured them; they now
advocate early operation. Having seen a few cases
which recovered, they thought they all recover. We,
Aug-ust 8, 1896]
MEDICAL RECORD.
215
who operate a great deal and see the terrible results of
waiting, naturally become radical. We insist that the
only safe way is to operate in every case promptly.
We admit that in ten or fifteen per cent, of our cases
the patient would recover without an operation and
without recurrence, but in the present state of our
knowledge we cannot pick out the one from the other.
We must, as the boys say, go it blind. But we do
know that in a hundred consecutive cases operated on
promptly our mortality would be very low, while out
of a hundred consecutive cases treated without opera-
tion the mortality would be large; and those who
would recover would be subject to two, three, and many
more attacks, and with every recurrent attack ten or
fifteen per cent, would die. They would not only be
in constant danger, but would have the constant worry
and the dread of recurring attacks; no peace day or
night, summer or winter; at home or travelling about,
the sword of Damocles will always
hang over them ; while, if we operate
on them and cure them, the mind will
be at peace and they can enjoy life.
Dr. MacArtney, who started this
controversy, takes a somewhat different
stand. He simply claims that cases
occurring in the country, away from skilled operators,
should rather be trusted to the vis medkatrix natiinc.
To this we all agree. Such cases need but seldom
occur. It is wonderful how easily the patient can be
removed one hundred or two hundred miles on a
stretcher, taken from the train to an ambulance, trans-
ferred to a well-equipped hospital, and operated on by
an experienced man. And if the patient cannot be
moved on short notice, an experienced man can be got
in almost any part of the country within a very few
hours.
I admit the force of the argument of the fee, which
seems to be the brte noir of some general practitioners,
yet I have known experienced men to travel fifty or
one hundred miles and operate, in order to help some
fellow practitioner, for a merely nominal sum, when
the patient could not be brought to a hospital. Many
hundred such cases are operated upon gratuitously.
Surgeons sometimes get large fees, but these are few
and far between. Some general practitioners claim
that if they give up the patient the specialist gets the
fees. Those simply betray selfishness.
I would conclude, then, by saying that since appen-
dicitis is a treacherous disease, changing from an ap-
parently mild case to a most virulent one within a few
hours, the only safe treatment is prompt operation.
It does absolutely no harm, nor does it increase the
danger when performed by an experienced surgeon
with aseptic surroundings. Secondly, when such cases
cannot be moved to a hospital, an experienced surgeon
can be obtained, within a very short time, in any part
of the country. The question of fee does not enter
into the controversy at all and is unworthy of being
mentioned by an honorable practitioner.
J. H. Carstens, M.D.
Detroit, Mich.
Incontinence of Urine. —
'S, Neutral sulphate of atropine in two-per-cent.
solution ' iss.
Muriate of strj-chnine in one-per-cent. solu-
' tion gtt. iv.
Syr. aurantii amari 3 viss.
M. S. From five to sixty drops every evening on going
to bed.
Commence with five drops (one thirty-second grain),
and increase by five drops every fourth evening until
thirty drops per diem are administered. — Macalister,
La Seniaiiie Med.
[exiT ^nstntnicnts.
SOME NEW INSTRUMENTS FOR THE TREAT-
MENT OF RECTAL DISEASES.
Bv SAMUEL T. EARLE, M.D.,
l*Ki)FESSOR OF DISEASES OF THE RECTUM AT THE BALTIMORE MEDICAL
COLLEGE,
In the treatment of internal incomplete fistulte witK
their openings just between or over the sphincter mus-
cles, also abscess pockets formed between the columns
of Morgagni, I have heretofore found great difficulty
in getting the ordinary curved bistouiy into these open-
ings, and it suggested itself to me that a bistoury with
the complete curve, or, what might be better under-
stood, a hawk-bill bistoury, would meet the difficulty
successfully. I accordingly had one made, the cut of
which is here submitted (Fig. i ). I have found it to
answer the purpose admirably, and would recommend
it to those working in this line.
Since the time that I began to devote special atten-
tion to rectal work, more than eleven years ago, I
have found the rectal specula that I have tried (and
they have been many and of various patterns) most un-
satisfactory, either in not fulfilling the object for which
they were designed or in being painful to introduce.
Some four years ago, when in search of a satisfactory
rectal retractor, which I have yet been unable to find,
a gynecological friend suggested and gave to me for
trial a Neugebauer's vaginal speculum; while I found
it entirely unsuitable for the purpose of a retractor, it
proved itself by far the most efficient and satisfactory
rectal speculum that I have ever seen. It is here nec-
essary to explain that only one blade of this instru-
ment is used for this purpose, its use in vaginal work
requiring the double blade. I found the cur\e and
the point exactly adapted to the conformation of the
parts, so that it can be introduced with less pain to the
patient than any rectal speculum I have ever seen.
The principle on which it acts is exactly similar to
Sims' vaginal speculum.
With the hips slightly elevated in Sims' position,
the instrument merely dilates the sphincter with the
greatest possible ease; the air, rushing in, distends
the rectal wall, giving an unobstructed view. The
original instrument did not have a satisfactory handle
for rectal work; so, after proving its practicability for
four years, I then de-
signed my present
speculum, retaining
entirely the original
model of N e u g e -
bauer's speculum, as
herein given (see
Fig. 2), which repre-
sents the instrument
closed, one-third size,
merely adding a convenient handle, which is attached
to the blade by a hinge, permitting it to be folded into a
small space. There are two sizes, one for children
and one for adults.
I would heartily recommend the trial of this instru-
ment to physicians, feeling confident that it will prove
entirely satisfactory.
2l6
MEDICAL RECORD.
[August 8, 1896
A NEAT SPHERICAL GAUZE SPONGE.
By G. W. PERKINS, M.D.,
<JGDEN, UTAH.
Since the general use of heat for sterilization, gauze
has largely replaced marine sponges in surgical work.
Flat pads made up of several layers of gauze, and
spherical sponges made by enclosing masses of loose
gauze or absorbent cotton in an envelope of gauze, are
the forms in which it is usually employed.
The flat pads are easily folded in such a way as to
place all raw edges of the fabric in the inside of the
pad, and a few long stitches serve to keep them there.
The spherical sponges which I have seen described
and figured have been made by simply tying the envel-
oping layer of gauze and cutting off the e.xcess a short
distance beyond the ligature, thus leaving this cut
surface w-ith threads of the gauze projecting. This
seems to me undesirable, because some portions of
these threads might become detached and be left in
the wound or cavity in which the sponge had been
used.
In casting about for a way to obviate this disadvan-
tage, I first made the sponge as above described, but
went one step farther by carrying around the project-
ing stump a circular purse-string suture, and in tying
this pushed the stump into the centre of the sponge,
thus burying it out of sight. This answered very well,
but left a hard lump at one side of the sponge, which
sometimes interfered with grasping it in a sponge-
holder. I next tried the following manceuvre, by which
I succeeded in making as neat and satisfactory a sponge
as one could wish for. Instead of ligating the pedicle
of the envelope of gauze, I twisted it once or twice and
grasped it with a small haemostatic clamp; then cut
away the e.xcess close to the outer side of the clamp
and placed my purse-string circular suture about half an
inch distant from the stump, and as I tied it pushed
the clamp holding the stump of the pedicle into the
sponge, disengaging and withdrawing the clamp just
before the suture was drawn tight.
The result is a symmetrical, sub-spherical mass of
loose gauze, without raw edges on its surface and
without hard lumps in its substance, which has in my
hands admirably answered its purpose.
This is merely an adaptation of the Dawbarn meth-
od of inverting the unligated stump of the appendix
into the csecum, and I dare say has been used before
by other surgeons; but as I have never seen it in print,
I offer the suggestion for what it is worth.
The Spermatic Fluid in Secondary Syphilis
-According to Dr. Rochon there may exist in the sec-
ondar}' period of syphilis, either in the seminiferous
tubes or in the spermatic cord, manifestations capable
of contaminating the semen and making it infective.
These manifestations are aided by inflammations of
any kind, and in particular by gonorrhcea, the pus of
which thus becomes doubly dangerous. All acute or
chronic non-syphilitic affections of the prostate and
ureter may, in the secondary stage, mingle virulent
blood with the semen, and thus render it inoculable.
This added virulence of the semen may manifest itself
by chancres of the integuments accessible to exami-
nation, and also by intra-cervical or intra-uterine
chancres, especially if the intercourse at which infec-
tion takes place is followed by conception. There is
thus no longer a relation of cause and effect between
conception and syphilis; but there remains, neverthe-
less, a close link of necessary coincidence, owing to
the modifications of the uterine mucosa at the time
favorable to fecundation. This link is close enough
to justify the retention of the term syphilis by concep-
tion.—Zi? Medecine Aloderne.
3;]rtcdical Items.
Contagious Diseases — Weekly Statement — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending August i, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinai meningitis
M easles
Diphtheria
Small-pox
Cases.
Deaths.
216
99
15
7
45
3
4
6
gS
7
159
24
0
0
Pathological Society of Philadelphia — At the
stated meeting of the Pathological Society of Phila-
delphia, held on May 28th, in conjunction with the
Philadelphia Neurological Society, an exceedingly
interesting and instructive programme was carried
out. An initial report of the work of the neurological
laboratory of the Philadelphia Polyclinic was pre-
sented. In a communication entitled '" Lesions of the
Nervous System in Acute Yellow Atrophy of the Liv-
er," by Drs. C. W. Burr and A. O. J. Kelly, degener-
ative changes were described in the cells of the cere-
bral cortex comparable with those observed in other
intoxication processes, experimental and pathological.
Dr. A. O. J. Kelly presented sections of the cord from
a case of paraplegia in an old man, showing thicken-
ing of the blood-vessels and increase of the neuroglia
of the cord; and also sections of a cord presenting the
classic changes .secondary to fracture of the vertebra.
Dr. J. H. \V. Rhein related a case of ataxic paraplegia
and presented sections of the cord, showing the usual
sclerosis of the posterior and lateral columns of the
cord. Dr. H. D. Boyer reported a case of Pott's dis-
ease and demonstrated sections showing myelitis with
ascending and descending degeneration. Dr. Mary
A. Schively described with much detail the histologi-
cal changes found in a case of syphilis of the brain
and presented many illustrative photographs and
sketches. Drs. F. White and \\'. G. Spiller showed
brains from two cases of infantile cerebral paralysis.
One was from a hemiplegic child, the other from a
diplegic. The former presented the lesions of vascu-
lar occlusion, the latter the condition of defective de-
velopment (microcephalus), with secondary changes in
the cord. Dr. Spiller also exhibited a specimen
treated with ^\'eigert's new neuroglia .stain, showing
only the cells and the fibres of the supporting struc-
ture of the cord. Dr. H. M. Fisher reported a case of
caries of the lumbar vertebrae with myelitis and
ascending degeneration, and presented histologic sec-
tions. Hy invitation Dr. Woods Hutchinson, profes-
sor of comparative pathology in the University of Buf-
falo, made some remarks on that subject. Dr. B. F.
Stahl reported a fatal case of diphtheria of the uterus.
Dr. D. Riesman presented specimens of Charcot-Ley-
den crystals from a case of bronchitis, and spoke of
the theories offered in explanation of their origin and
discussed their relationship to other similar crystals
found in the body. A resolution was unanimously
adopted protesting against the passage by Congress of
a bill restricting vivisection in the District of Colum-
bia.
Wanted, Another Doctor " If I was pa an' ma,'
said Willie, "I'd hire another doctor. The baby we
got last time wasn't finished. It hadn't a tooth or a
hair."
Medical Record
A IVeekly younial of Medicine and Surgery
Vol. 50, No. 7.
Whole No. 1345.
New York, August 15, 1896.
$5.00 Per Annum.
Single Copies, loc.
(Drigimtl Jirticlcs.
THE DISORDERS OF THE MUSCULAR
SYSTEM IN INSANITY.'
Ky THEODORE H. KELLOGG, M.D.,
NEW YORK CITY,
LATE MEDICAL SITERINTENDENT OF WILLARD STATE HOSPITAL, NEW ^■ORk•.
Insanity, viewed in its broadest clinical relations,
may be defined as a reflex psycho-somatic manifesta-
tion of a diseased nervous system.
In the vast majority of cases it will be found that
the presidial functions of the entire nervous system,
as regards internal organs, the muscular system, cir-
culation, respiration, digestion, and secondary meta-
bolism, are all involved in the symptom comple.K of
insanity.
One of the practical means of advance in psychiatry
therefore lies in the faithful study of the bodily phe-
nomena of insanity. In pursuance of this idea, and
as the continuation of a series of articles already
published on the somatic symptoms of mental disease,
viz., on " Disorders of Speech," '" Modifications of
Respiration," " Pneumogastric Disorders," and on
"The Pulse in Insanity," this present paper on "The
Disorders of the Muscular System in Insanity" is
now presented for the consideration of my hearers.
Attention will be directed first to the striped
muscles, constituting the voluntary muscular system,
which serves all purposes of adaptation to e.xtemal
relations, and then to the unstriated muscles, those of
organic life, as found in the viscera and vascular sup-
plies of the organism.
In the first place, then, it is well to recall for one
moment the main anatomical and physiological points
in the nervous mechanism which presides over the
innervation of the voluntary muscular system. The
prime source of motor innervation for the voluntary
muscles is the corte.K of the brain. The motor im-
pulses originating in cortical areas are conveyed
downward by the nervous fibres which converge to
form the pyramidal tracts and by the latter to the
motor cells of the anterior cornua of the spinal cord,
and from thence by the anterior roots to the motor
nerves and to their peripheral distribution in the vol-
untary muscles. Thus, the local pathology of the dis-
orders of the voluntary muscular system may be, as
will appear more fully later on, disease of the brain
corte.x, as in the degeneration of cortical areas in
general paresis; solution of continuity of the fibres
which go to form the pyramidal tracts, as in internal
capsular lesions in organic dementia; morbid
changes in motor cells of the anterior cornua of tlie
spinal cord, as in the sclerotic processes of alcoholic
dementia: or disease of the peripheral nen-es, as in
the multiple neuritis of to.xic insanity.
The above are the main points of localization in
the morbid anatomy of the muscular disorders to be
mentioned. Some of these disorders, however, are of
unknown pathology throughout their entire course,
' Read before the .Vmerican Medico-Psychological .Association,
at Boston, .May 28, 1S96.
and still others, like the paralysis of hysterical in-
sanity, though functional at first, through prolonged
vasomotor and trophic changes finally pass into the
category of affections having distinct organic lesions.
The description of these muscular disorders will
now proceed somewhat in the order of the frequency
with which they are encountered in actual clinical
practice, and the first one to receive attention is
atrophy.
.\trophy of voluntary muscles is much more fre-
quent in insanity than is supposed, and careful meas-
urements and tests as to muscular dimensions should
form a part of the daily clinical study of insane
patients. The general loss of bodily weight, which is
almost universal in all acute stages of insanitv. is
largely due to general atrophic changes in the volun-
tary muscular system. Even in the chronic stages of
mental disease the malnutrition of striated muscles
may proceed so far as to amount to a tropho-neurosis,
which is only a part of the more general neurosis of
which the insanity is the expression.
The most rapid atrophy of muscles takes place in
delirium acutum, whole groups of muscles wasting in
an incredibly short time. There are recalled in this
connection cases of typhomania (which, by the way,
seems to be less common than formerly) — instances of
large and powerful men in whom at the end of some
days, and in spite of every effort to sustain nutrition,
the atrophy was so great that, as an attendant once
well expressed it, " the muscles seemed to have all
melted away."
In various acute toxic insanities muscular atrophy
may result from lesions of trophic centres, and in al-
coholic dementia especially it is common from scle-
rotic degeneration of the motor cells of the anterior
cornua of the spinal cord. In the diathetic insanities
muscular atrophy is a not infrequent symptom. Thus,
there is arthritic atrophy in cases with gout and
rheumatism; atrophy from focal or disseminated
lesions of nervous centres in syphilitic insanitv;
atrophy in cancerous or tuberculous cases from dis-
ease of joints or bones or deep-seated burrowing
abscesses which evacuate pus, which passes into the
sheaths of muscles and by long-continued contact ex-
cites fibrillary atrophy. In the scorbutic diathesis
from changes in the blood and extensive intramuscu-
lar hemorrhages atrophy may result, just as it mav be
a sequel in post-febrile insanity from rupture, hemor-
rhage, and abscess in degenerated muscles. And in
this connection it is apropos to call attention to the
great frequency of deep and diffused abscesses among
the insane from diathetic, toxic, traumatic, and other
causes, and to suggest the early and thorough evacua-
tion and antiseptic washing out of the same in order
to avoid the possibility of muscular atrophy as well as
other disagreeable sequels.
Incidentally it is hereto be noted that inflammation
of muscles, though a rare affection, is relatively fre-
quent in rheumatic and syphilitic and in other forms
of insanity. It may be due to accidental traumatic
injuries or to toxic influences. It may have a chronic
and subacute fonn, manifested by repeated lumbago,
torticollis, and pain and soreness of the muscles of the
e.xtremities on slight exposure to cold or dampness or
2l8
MEDICAL RECORD.
[August 15, 1896
on unusual fatigue. This myositis may also have an
acute and .severe course, followed by deep-seated
abscesses, and then it may be mistaken for phlegmo-
nous erysipelas or cellulitis. The skin over the in-
flamed muscle will be cedematous and red, and blood
and serum will be effused on section: but pus will not
be evacuated, but will gravitate dififusedly in muscular
sheaths, according to the position of the limb, and may
finally become a cause of atrophy.
.\gain, muscular atrophy in general paresis and al-
coholic dementia follows polyneuritis, just as it is the
result of the multiple neuritis of the various to.xic in-
sanities. Space will permit only the passing mention
of the common existence of muscular atrophies in
idiocy, imbecility, and cretinous insanity. In senile
dementia there is sometimes premature muscular
atrophy with actual neuritic degenerations, and a
point of practical clinical importance in these cases
is that there is a corresponding cutaneous atrophy.
Through muscular wasting the skin is in close apposi-
tion with bony prominences, and such is its tenuity
that on slight manual pressure there is danger that
extensive abrasions may arise.
Muscular atrophy may also be of traumatic origin.
Through accidental falls or blows, such as seem more
or less ine\itable among the insane, there arise severe
contusions, which may be attended with so much swell-
ing and loss of motion as to suggest fracture at first.
The patients from advice or choice remain in bed
and inhibit all motion of the injured part, to avoid
pain at first, but finally out of mere habit or delusion,
and the result is atrophy.
.\mong demented, stuporous, and bedridden cases of
insanity atrophy often comes from simple disuse.
These supine and helpless patients when left to the
natural course of muscular events sink into fixed at-
titudes of flexion and adduction, and in course of time
loss of motor function and atrophy of muscles result.
The prophylaxis of this form of atrophy is friction
and passive movements of limbs and the avoidance of
permanent postures in this class of patients.
Another disorder of the muscular system in insanity
which is very common, and has a varied pathology,
is tremor. These tremors may be coarse or fine, they
may be partial or general, they may be constant or
interrupted, they may be present only on intentional
effort; and whatever maybe their clinical character,
they almost invariably cease during hours of repose.
In general paresis there are three kinds of tremor
which are to be distinguished from ataxic disorder
and from fibrillary twitchings of muscles. In the first
place there is a fine and rapid tremor having a prob-
able average of ten oscillations per second, which is
present much of the time, though it* may escape super-
ficial inspection, and which exists independently of
purposive muscular movements. It is found chiefly
in advanced stages of general paresis, and is doubtless
due to widespread organic lesions of nenous centres.
The second kind of tremor is coarser and belongs
rather to the class of intention tremors, or at least is
most evident on intentional muscular efforts, and it
will be readily observed as the patient extends the
hands and se]3arates the fingers. The third kind of
tremor is still coarser than the one just mentioned.
It may be described as a grossly exaggerated tremor,
and, though it may not be positively and exclusively
of psychic origin, it is apt to be most manifest in the
hands of the patient during movements of great emo-
tional excitement.
Space will not permit a discussion of the various
tremors present in alcoholic insanity. They assume
a variety of interesting forms, and when permanently
present they are of unfavorable prognostic import, as
pointing to disseminated organic lesions of cerebro-
spinal ner\-ous centres. The various toxic insanities
have tremors differing somewhat in type, that of
hydrargyrism being especially pronounced in char-
acter, though that of nicotinism may be almost equally
well marked. One youth under my charge, who was.
insane from great excess in cigarette smoking, had a
fine tremor which was almost constant, while in an-
other case of like origin the tremor was notable only
during movements requiring special co-ordination.
The insanity of auto-intoxications also may be ac-
companied by tremor increased under strong emotior*
or on intentional efforts.
In the tremor of senile dementia the head as well
as the hands is often involved, and this is a symptom
which augurs ill for the recovery of the patient.
There is another class of tremors found in the func-
tional psychoses, and most frequently in debilitated,
ill-nourished, or neurasthenic cases, due solely to the
failure of cortical motor cells to furnish the physio-
logical quantum of continuous efferent motor im-
pulses, and a similar tremor from defect of cortical
inner\-ation may occasionally occur in ver)' youthful
subjects in the insanity of childhood and in states of
arrested mental development. It is of interest to
note that this tremor in some degree keeps pace with
the general rhythm of psychic processes, and it will
be found accordingly more rapid in mania than ir»
melancholia. Emotional tremors so frequent in in-
sanity are too well known to call for special descrip-
tion here.
Hastening on, with a mere allusion to the tremor of
tabetic types of insanity, to the tremor of cases with
paralysis agitans or with disseminated cerebro-spinal
sclerosis, to the tremor of organic dementia with de-
scending degeneration of the pyramidal tracts, and to
the tremors of sudden brain anwmia from vasomotor
spasm, there next comes under consideration a much
grosser disorder of the muscular sy.stem known as
contracture.
Contractures are so common among insane patients
that a lengthy description of their familiar features is
hardly necessary, and attention will be directed here
more especially to their etiology. One of the most
common cau.ses of contracture in dementia, stupor, or
melancholia is the fact that in these states the flexors
act in excess of the extensors, and through delusion
or entire lack of spontaneity on the part of patients
their limbs remain in permanently flexed positions.
Now, if no correction of this flexed posture habit is
made it will not be long before the physician will be
called upon to recognize the pathological fact that the
muscles of limbs continuously flexed and disused un-
dergo first shortening, then degenerative tissue changes,
and finally permanent contractures. If the patient has
been long bedridden the foot will be found flexed on
the leg, the leg fle.xed on the thigh, and the thigh flexed
on the abdomen, and sometimes nothing but a severe
operation —anaesthesia, the free use of the tenotomy
knife, and the overcoming of ankylosed joints — will re-
lieve the contractures; so that '' an ounce of prevention
is worth more than a pound of cure" with these sub-
jects whose physical condition often will not justify
the severity of the operation necessar}' for their relief.
Another familiar example in this same categor}' is ref-
erable to the forearm group of muscles, and in this in-
stance by pennanent contracture of the digital flexors
the finger ti])s are fairly buried in the palms of the
hands and there is almost invariably a simultaneous
forearm flexion. The po.sture habit of crossed knees
sometimes causes contracture in a way not wholly
parallel to the above, as there is superadded the in-
fluence of pressure partially interrupting circulation
and ner\ous innervation.
The etiology of another class of contractures is to
be sought in the central nervous system. In organic
dementia the early and late rigidity of paralyzed limbs
August 15, 1896]
MEDICAL RECORD.
219
is followed by structural contractures from descending
degenerations of the motor tracts, and they occur like-
wise in syphilitic, alcoholic, or epileptic and paretic
insanity, from disease of the pyramidal tracts, and it
is probable that the permanent contractures of hyster-
ical insanity are due to a like cause. In the above
forms of insanity there are also exceptionally observed
a variety of spastic conditions of the muscles due to
sclerotic changes in the lateral columns of the cord.
In alcoholic insanity also, as in other toxic forms, con-
tracture may be the sequel of multiple neuritis. In
idiocy contractures are very common as the result of
early encephalitic processes. In rheumatic insanity
contracture at times follows the arthritic affection, just
as in general paresis it may be secondary to arthritis
deformans.
Another muscular disorder which the alienist often
encounters among his patients is spasm, which may be
clonic or tonic, and which for want of a better term
will here be extended to embrace a variety of allied
affections common among the insane. One of the
most notable forms of spasm is that which causes the
familiar symptom of the grinding of the teeth, which
may be thus almost completely worn away, and the
tongue and buccal mucous membranes may be severely
bitten, more especially in the tinal stage of general
paresis. This is a bilateral masticatory spasm of
muscles supplied by the motor branch of the trigeminal
nerve. It is found also in phthisical insanity with
basilar meningitis, in delirium acutum, in idiocy, in
hemiplegic dementia, and in syphilitic insanity with
basal gummata. It is well to know that there may be
actual paralysis of this motor branch of the trigeminal
nerve in the terminal stage of general paresis, and
that the inability to masticate in these cases is due
to this fact and is not merely ataxic in nature.
There are frequently observed, among the neuras-
thenic insane more especially, fibrillary spasms, which
consist in the independent clonic action of the separate
fibres or strands of muscles. These fibrillary spasms
occur usually in the orbicular, facial, or forearm
muscles and often recur at more or less rhythmic in-
ter\-als of a few seconds or moments during all the
waking hours of the day for weeks or months together.
Their pathology is probably local irritation of cortical
cells in motor areas representing the muscles affected,
and it might be considered as so proven should they
be reported in a case of insanity from trauma capitis
with lesions of motor cortical regions and with spas-
modic muscles exactly corresponding to our knowledge
of the crossed innervation of the brain cortex, and of
localization of motor centres.
Another kind of spasm of some interest, though of su-
perficial importance, because usually artificially pro-
voked in origin, is met with in patients under the tension
of persistent delusions or emotions, as in melancholia
attonita and like states. When such a subject is urged
to speak or otherwise aroused, the only response may
be a series of spasms of one or several muscles of the
face, neck, or pharynx. The condition of these pa-
tients is one of extreme mental inhibition, and when
it is suddenly interrupted there is a spasmodic libera-
tion of motor impulses, chiefly in the regions of the
mimic facial muscles. Permanent forms of unilateral
convulsive tics of face and neck muscles are not in-
frequent and also bilateral spasms of clonic form, es-
pecially of the eyelids, as in facial habit chorea, only
greatly exaggerated in character. Nictitation is more
common than nystagmus. Typical blepharospasm
may exist for weeks or months together.
A man insane from alcoholic excess came under my
care with clonic unilateral spasm of the right sterno-
cleido-mastoid accompanied by a loud inarticulate
noise. The noisy part of this phenomenon was re-
garded as an instance of vocal-impulse tic engrafted
on a spasmodic muscular tic, as in my observation of
the insane the conjunction of psychic tics and of con-
vulsive tics occasionally occurs. Echolalia and copro-
lalia may coexist with this muscular disorder, the
patient repeating what is spoken in his presence or
uttering some profane or obscene word at the instant
of the spasmodic movement. There are also slow
rhj-thmic tics and a variety of alhetoid movements in
which the fingers move slowly or briskly even in the
same case, according to the amount of emotion pres-
ent. The sudden twitching of muscles or groups of
muscles known as subsultus tendinum, which in its
simple fomi is wont to occur on the verge of sleep,
often becomes a very troublesome symptom among the
insane, recurring throughout the day and preventing
sleep at night, the patient being awakened with a
spasmodic start almost like an electric shock.
Confirmed clonic spasm of the muscles supplied by
the external branch of the spinal accessory nerve is
sometimes found in hysterical and epileptic insanity,
and other muscles of the neck and arm may become
involved. Clonic spasm of the diaphragm is met with
in hysterical and hypochondriacal cases very often,
and in my observation it has occurred also as a per-
sistent antelethal symptom in both organic dementia
and general paresis. Clonic lingual spasm is not a
very rare symptom in general paresis, and it may
somewhat interfere with speech or mastication, the
tongue sometimes being severely bitten.
The clonic spasmodic disorders of choreic insanity
are to be named here also, though want of space will
not permit their special description, but it is impor-
tant to state the general principle that the younger the
patient the more apt is the insanity to reveal itself
through the medium of the muscular system, and it is
safe to estimate that in the insanity of childhood dis-
orders of the muscular system exist in seventy-five per
cent, of all cases.
There is a whole chapter of spasmodic clonic affec-
tions in general paresis. Some of them occur during
any of the stages w'ithout loss of consciousness, and
others during the paretic seizures with loss of con-
sciousness. In the latter case the clonic spasm be-
gins usually in the face and e.xtends to the arm and
then to the leg. This customary order of protospasms
is often interrupted in general paretic seizures, how-
ever, the spasms skipping from one side to another
and from one muscle to another, in ocular, facial,
brachial, and crural regions, in a most remarkable
manner. There is no certainly in these seizures that
the conjugate deviation of the eyes will be toward the
side of the lesion. Nystagmoid motions often precede
any other spasmodic ocular movements in these seiz-
ures.
The tonic spasms of insanity, in contradistinction
to the clonic ones above described, are very numerous.
One of the most common is spasm of the orbicularis
palpebrarum, which may persist for days or weeks to-
gether. Tonic spasm of the sterno-cleido-mastoid and
trapezius muscles is a common symptom, especially in
its milder forms, usually spoken of by patients as stiff
neck. Tonic oesophageal spasm and pharyngeal spasm
are not very rare, and the latter in hysterical insanity
may be so severe and continuous as to interfere seri-
ously with the alimentation of the patient, and in these
cases also ctsophagismus and gastric spasms may cause
obstinately repeated emesis. In ascending cases of
general paresis these pharyngeal spasms may be very
annoying. Laryngeal spasms also occur, and some
years ago, in my article on " Laryngeal Hyperkineses,"
read before the New York Neurological Society, a case
was recorded of larv'ngeal spasm continuous for two
years as a premonitory symptom of general paresis,
which finally terminated fatally in typical form.
There are also to be enumerated here diaphragmatic
-:220
MEDICAL RECORD.
[August 15, 1896
"and abdominal spasm, intestinal and gastric spasm,
phantom tumors from muscular spasm, prolonged
chasmus and aphthongia.
Strabismus in its various forms must also receive a
word of notice. It is common in all types of insanity
with severe organic brain lesions, and it is my im-
pression that permanent divergent squint especially
is of unfavorable prognostic import.
Cramps of all kinds are among the muscular anom-
.-alies to be noticed, the gastrocnemius being perhaps
the most frequent site of the disorder, which may be
very painful or a persistent cause of insomnia, espe-
cially in neurasthenic and alcoholic insanity. There
■ are, moreover, in alcoholic and in other toxic cases,
spastic states of the muscles of the legs, more particu-
larly due to the sclerotic degenerations of the spinal
-cord. There are also the various cataleptoid and tet-
anoid states of muscles, requiring more space for de-
scription than can be accorded in the brief limits of
this article. Suffice it to mention the tetanoid rigid-
ity of muscles in post-hemiplegic insanity, the tonic
and spasmodic pedal extensions in alcoholic dementia,
the catalepsia spuria of hysterical and pubescent in-
sanity, the " flexibilitas cerea" of stuporous and epi-
leptic cases, the tetanoid seizures of the final stage of
general paresis, and the saltatory cramps of acute de-
lirious mania.
To complete this patliological array of symptoms
of the voluntary muscular system in insanity, there re-
mains finally to be described the group of pareses and
paralyses. The dilierential diagnosis of these pareses
and paralyses is a complete test of the physician's
knowledge of neurological pathology, as the utmost
skill is required to determine whether the source of the
anuscular disorder is in lesions of cortical motor re-
.gions, efferent conducting fibres, internal capsule, py-
;ramidal decussation, spinal motor cells, anterior nerve
Toots, or in the spinal nerves or in their peripheral
•distributions. These muscular disorders may occur
.in syphilitic dementia at any of the points mentioned.
.In arrested mental de\elopment they arise from en-
•cephalitis; in general paresis they are chiefly cortical;
in all the toxic insanities they may proceed from spi-
nal cellular degenerations or from peripheral neuritis;
in organic dementia fiom thrombotic or embolic soft-
•ening and internal capsular lesions; in senile de-
mentia from vascular atheroma and atrophy of brain
cortex; and in alcoholic dementia from sclerotic inter-
ruptions of the fibres of tlie pyramidal tracts or from
the pressure caused by subarachnoid or intraventricu-
lar etlusions; and they will be found to be sometimes
functional, or at least of undeterminable morbid anat-
omy.
These pareses and paralyses may assume every va-
iriety of form, such as hemiplegia, paraplegia, crural
•or brachial monoplegia, or loss of motion in facial,
•ocular, orbicular, and sphincter muscles.
The paralysis of muscles supplied by cranial ner\-es
is especially common in syphilitic dementia, the mono-
plegias are frequent in organic dementia, the paraple-
gias are wont to occur in hysterical and alcoholic
insanity, while hemiplegia appears in epileptic de-
mentia; and a combination of these affections is to be
■witnessed in the various types of general paresis. It
will be found on closer study, however, that the paral-
yses of general paresis are more apparent than real —
that the muscles have not lost power to act .singly but
in co-ordination with one another, and that it is ataxia
■and not true paralysis which gives the impression of
loss of voluntary motion. The disorder of the muscu-
lar mechanism of speech in general paresis is also es-
sentially ataxic, proceeding first from disease of cor-
tical cells, and later from bulbar lesions of the facial
and hypoglossal nuclei and of nerves of innervation of
lips, tongue, and vocal organs. In typical paresis the
gait also is ataxic throughout, but in ascending cases
it is tabetic at an early stage, and in occasional in-
stances of sclerotic lesions of the lateral columns the
gait becomes markedly spastic, just as in alcoholic de-
mentia. It is possible in the same case of general par-
esis to have these three typical anomalies of locomo-
tion illustrated --first, the true paretic gait from disease
of cortical motor cells; second, the tabetic gait from
lesions of the posterior spinal columns; and third, the
spastic gait from sclerosis of lateral columns. The
clinical fact, however, is that in fully develojjed gen-
eral paresis the defects of gait vary considerably from
time to time, and bear an intimate relation to the na-
ture and number of the convulsive seizures. There
are to be mentoned here, also, certain remarkable cases
of insanity, in which there is static ataxia as well as
complete locomotor inco-ordination. These patients
cannot stand or walk alone, and on trying to do so they
have violent random movements of arms and legs and
of head, neck, and body, and if not firmly held by the
hands of nurses they are apt to suffer severe falls or
injuries.
The pareses of insanity have a diversified etiology.
They may spring from failure of exhausted cortical
centres to evolve sufficient motor impulses, or of effer-
ent nerve fibres to conduct them, or they may be the
sole result of mental inhibition in melancholic states
with great mental tension. They appear in various
forms of insanity, and may affect any or all of the
muscles. They are less apt to escape diagnosis in the
extremities than in some other muscles, and attention
is directed here to their frequency in the levator and
tensor palati muscles, in the pharyngeal constrictors,
in the oesophageal muscles, and in the tensors of the
vocal cords. Prolapsed or deviated palate, various
forms of dysphagia, and marked changes in vocal tone
are very common from this cause. In hypochondrical
and neurasthenic insanity these pareses are often the
outcome of delusion, and may be very persistent, affect-
ing, as a rule, only one extremity; but in hysterical
insanity they may be interchangeable, involving one
or both upper or lower limbs, and in almost any imag-
inable order. The paresis of the muscular organs of
speech is occasionally very pronounced in neurasthenic
cases and in states of brain exhaustion from overwork,
and the ignorance of this fact has led many a physi-
cian into gross error in mistaking these functional
speech defects for those which spring from organic
brain lesions. There may be paresis of speech mus-
cles in the hypochondriacal insane, not alone from
strong prepossession by an idea or an emotion, but
from force of imitation also, just as stuttering may be
likewise acquired by sane persons. Muscular disor-
ders from force of imitation are to be witnessed, espe-
cially in epileptic insanity, and St. Vitus' dance, taran-
tulism, and spasmodic muscular disturbances have
always been prominent phenomena of historic epi-
demics of insanity. Again, there are intention pareses
as well as intention tremors among the insane.
There remain to be brought to notice a few func-
tional abnormalities and some sensory disorders of the
muscular system. One of the decided anomalies in
muscular functions is the inco-ordination so common
in many forms of insanity. It is by no means confined
to tabetic, paretic, senile, or toxic cases of mental dis-
ease, in which well-known cerebro-spinal lesions may
act causatively. Inco-ordination in the functional
psychoses may be associated with cortical anamia
from vasomotor spasm, or with stomachal, aural, or
cardiac vertigo, or with powerful mental inhibition,
or with loss of the muscular sense. The symptom is
none the less real, however uncertain its etiopathology
may be. This inco-ordination may show itself in neu-
rasthenic insanity, for instance, in gait, speech, hand-
writing, or any of the highly specialized acts. It is
August I;
1896]
MEDICAL RECORD.
221
also to be seen even as static ataxia, as a modified
form of Romberg's symptom, or it may present itself
as pseudo-astasia abasia. Another functional change
in muscles is their abnormal reaction to external
stimuli. The mechanical muscular excitability may
be shown by slight blows over muscles to be some-
times increased and at other times diminished in epi-
leptic, hysterical, and paretic cases; and in phthisical
insanity a slight tap on the body of muscles may pro-
voke a tonic contraction for a very perceptible period.
In the acute stages of certain forms of mental disease
the reflex irritability may be increased to the degree
of general convulsibility. The electro-muscular reac-
tions are not infrequently abnormal in insanity, both
as regards the use of the faradic and of the galvanic
current, and the reaction of degeneration is occasion-
ally to be witnessed. The electro-muscular contrac-
tility is diminished in idiocy and in profound demen-
tia, and the electro-muscular sensibility may be lost in
hvsterical and in some other forms of insanity.
In health the muscles of the body in repose are not
completely relaxed, but they are in a permanent state
of tonicity, which is known as the ■" tonus muscularis."
In insanity this physiological muscular tone may
be increased, diminished, or lost.
As a general nde, the tonus muscularis is increased
in states of exaltation and diminished in states of de-
pression, and in deep melancholy and stupor and in
the final stage of general paresis it is lost. The lack
of all expression in the face of soine insane patients
is duo partlv to this absence of normal tone of facial
muscles.
A careful study of the muscular system among the
insane will often reveal to the expert eye certain per-
manent signs of neurotic degeneration. These muscu-
lar stigmata degenerationis consist in asymmetrical
lateral development of the muscles of the face, limbs,
or body. In addition to this inequality in the size of
muscles, there is often inequality in the innerv'ation
of the same on the two sides of the body, and this dis-
parity in facial muscles causes an asymmetry of ex-
pression characteristic of the insane physiognomy.
A final abnormality in the functional activity of the
whole voluntary muscular system may be termed the
automatism of insanity. The largely reflex and me-
chanical nature of the semeiology of mental disease
has never vet been sufficiently expounded, .\dditional
light would be thrown on that which is to be said did
space here i^ermit some explanation of the psychic au-
tomatism of insanitv, but this must be reserved for a
separate article, and muscular automatism alone will
be here briefly noticed.
The fi.xed attitudes of the demented in whom,
through predominant action of flexor and pronator
groups of muscles, the extremities are flexed, the body
inclined, and the head bent forward on the chest, and
other characteristic postures retained for weeks,
months, or years, at first possibly in obedience to de-
lusions but finally mechanically, constitute permanent
examples of passive automatism. This passivity may
be so great that positively no movement of hand, foot,
or head is spontaneously initiated, and the passive
automatism becomes absolute. On the other hand,
the repetition of the selfsame aimless movements for
months and years together is characteristic of active
automatism. The head, bodv, or limbs may be con-
stantly moved to and fro, or from side to side, or ro-
tated, during all the waking hours, the monotonous
motions ceasing only during sleep, and reappearing
at the earliest moment of awakening, just as in the au-
tomatism of idiocy. These automatic acts may be
simple, complicated, or rhythmical, and they exist in
great variety. In the first instance they may origi-
nate in some motive or delusion, but eventually they
become insignificant of any idea, and simply represent
the automatic escape through motor channels of such
nervous energy as is daily evolved in cerebro-spinal
centres. The constant swinging of the foot with
crossed knees, the incessant friction of some part of
the clothing, the stationary rocking from one foot to
another, the shuffling in one position, walking in a,
circle, stereotyped movements of the head with hum-
ming or strange noises, rhythmical stroking of the
head or face, rubbing of the hands together, measured
time-beating with hand or foot — all these are instances
of active automatism. In a somewhat unique case
under mv observation, the automatic rotary friction of
one thumb nail on the other had resulted in epithelial
hypertrophy, so that the nail had attained several times^
its natural size both in length and thickness. The
most complicated automatic acts form a part of the
symptomatology of epileptic insanity. In fact, post-
epileptic automatism reveals an astonishing variety of
highly co-ordinated and even most skilful acts uncon-
sciously performed. In mania, also, with acute ex-
acerbations and entire loss of mental inhibition, both
acts and ideation become largely automatic, and the
efferent peripheral and sensorial stimuli play upon the
central psychomotor mechanism of the patient as upon
an instrument. All ideas and feelings tend to issue
at once through muscular channels, and by intense
cortical irritation tumultuous emotions are spasmodi-
cally liberated and are expressed in incoherent and
disorderly movements or in automatic laughing and
crying. In some dements and with insane children
the inco-ordinate and aimless muscular movements
are more nearly to be compared with those which arise
automatically during the early months of infancy-
The ceaseless and purposeless muscular activity of cer-
tain idiots and imbeciles is also nearly allied to the
spontaneous hyperkinesis of infancy.
The sensory disorders of the muscular system in in-
sanity must be briefly noticed.
There is physiological proof that man has six senses.
The muscular or kintesthetic sense, like the others,
has cortical representation, possibly in Rolandic areas,
as it conveys to consciousness impressions of the re-
sistance of external objects, and of the muscular effort
essential to overcome the resistance, and also of the
relative position of the limbs in space. The loss of
the kinesthetic sense in general paresis accounts in
some cases for the pseudo-astasia abasia, and also for
the fact that paretics often fail to know the position
of their arms or legs in bed, and that they cannot esti-
mate the force required to lift things. In hysterical
insanity with paralysis the muscular sense is lost, and.
it is generally impaired in epileptic insanity.
Muscular anaesthesia is not infrequent in epileptic
and paretic cases, and muscular analgesia is so
marked among some insane patients that the infliction
of injuries and even the most extensive self-mutila-
tions may be painless.
Muscular hyperaesthesia is also to be found in neu-
rasthenic insanity, causing exaggerated muscular re-
flexes and giving rise to delusions as to the size of
the body and limbs. It also accounts in some acutely
hypochondriacal and melancholic cases for the sense
of weight and soreness of the muscles. The extreme
restlessness and the " anxietas tibiarum" of melancho-
lia agitata is in part due to muscular hyjjeraesthesia.
Myalgia in its various forms is very^ common among:
the insane, who complain of stiffness, soreness, and
pains in the muscles of the arms, legs, neck, and back.
Lumbago and pleurodynia are not so common as
temporal, frontal, and occipital muscular pain, and the
nuchal mus les of all others seem to be the most fre--
quent seat of this sensory disorder. In occasional!
cases of hypochondriacal insanity myodinia is the most;
constant symptom.
In conclusion, there remain to be mentioned the
222
MEDICAL RECORD.
[August 15, 1896
disorders of the involuntary muscular system of organic
life.
The pathological variations of vasomotor innerva-
tion of the muscular coat of arteries in insanity
account for many important symptoms. Thus there
may be increased or diminished intravascular blood-
pressure and many rhythmic variations in pulse char-
acter, best determined by sphygmographic tracings, as
described in my paper on " The Pulse in Insanity,'* read
before the American Neurological Society last year.
The tonic spasm of the arterial muscular coat is
most marked in melancholia and in certain phases of
epileptic and paretic insanity. The increased '" tur-
gor vitalis" of mania and the angioparetic symptoms
of various forms of insanity are to be mentioned in
this connection.
According to recent reports of careful post-mortem
examinations in one hundred and twenty-three cases
of dementia by Wulff — a German investigator — the
heart, as the most important muscle in the body, is di-
minished in total weight in chronic insanity.
It is well known that the muscular structures of the
intestinal tract, of the bladder, of the rectum, and of
the reproductive organs are inner\-ated in a reflex way
by spinal centres, and that they are all under a certain
voluntary control through ner\-ous fibres, which place
the spinal reflex centres in connection with cortical in-
hibitory centres.
Irritative or destructive lesions of these centres or
nerve fibres in insanity may occasion a great variety
of muscular disorders in the parts above named.
Thus, through paresis of the intestinal muscular coat
arises obstinate constipation and troublesome and
even dangerous impaction of fascal masses in the large
intestine. Or there may be spastic muscular condi-
tions and greatly increased peristalsis, with pseudo-
diarrhcea and pseudo-dysentery and borborygmi and
false tympanites, through spasm of abdominal muscles.
In some cases of insanity there is spasmodic retention
or evacuation of the bladder or rectum, and in other
cases paralysis of the same and involuntary and even
unconscious escape of their contents, as in general par-
esis and other forms. The delusions of the insane,
so often referable, especially in women, to the repro-
ductive organs, may in some instances be connected
with real disorders of the muscular structures of these
parts.
To make an exhaustive study of all the symptoms
which occur in insanity from disorders of the unstri-
ated muscular system of internal organs would far
exceed the intended limits of this article.
The whole question of muscular reflexes and pupil-
lary reactions in insanity, though naturally a part of
our subject, has been purposely omitted, because it
has already been adequately treated by otlier writers.
The final summation of conclusions deemed to be
legitimately drawn from this paper is as follows:
The organic lesions of the cortical, bulbar, or spi-
nal centres and of the peripheral nerves in insanity
cause frequent disorders of the muscular system.
Functional diseases of cerebro-spinal nerve centres
in insanity are likewise attended by functional mus-
cular disorders.
The incoherence, excitement, and general psychic
disorder of insanity are reflected directly through the
voluntary muscular system.
The deep derangement of vital functions and of in-
ternal organs in insanity is accompanied by disorders
of the muscular system of organic life.
All these muscular disorders constitute a most es-
sential part of the somatic symptomatology of insanity,
and as they are of the greatest value both in the diag-
nosis and prognosis of mental disease they deserve a
more complete clinical study than they have hitherto
received.
THE DAWN OF REASON.
By IAMES weir,
OWENSBORO, KV.
M.D.,
Some animals, exceedingly low in the scale of life,
give evidences of the possession of a ratiocinative
faculty, ay, of a reasoning faculty, the same in kind
though not in degree as that possessed by man.
The following experiment, one that I have per-
formed time and again, will demonstrate this. The
natural habitat or dwelling-place of athalium, a mi-
nute, microscopic animalcule of very low organiza-
tion, is sawdust. If these creatures be taken from
sawdust and placed in a watch crj-stal in which there
is water, they will confine themselves to it; but if the
glass be placed on sawdust they will leave it, crawl-
ing over its sides in order to get into more congenial
surroundings — the sawdust. This shows conclusively
that they recognize the dust througli the transparent
glass, and that they also remember and regard it as
a more desirable home. Memory, conscious deter-
mination, and the fundamental principles of reason
are, in this instance, clearly demonstrated. On one
occasion, while examining a water louse through a
large low-power lens, I saw it approach a polyp,
gnaw off one of its buds, and then retreat to some
distance, where it hid itself behind a particle of mud
and proceeded to devour its victim. After a while
it left its sheltering lump of mud and again swam
to the polyp, which it immediately deprived of an-
other of its young. It then swam back to the same
little mud heap and there resumed its meal. This
louse showed, in this instance, that it knew that the
polyp was good for food: that it remembered the
road to and from its source of food supply; and that
to avoid interruption it hid itself while eating.
A wasp, of the variety commonly called " mud-daub-
er,'' last summer built her nest on the ceiling of my
room in one corner. The windows of this room re-
mained open night and day during the hot summer
months, -so her nest was easy of access. One day, while
the wasp w-as busy about her home, I closed all of the
w indows and awaited developments. At length she flew
toward a window, against which she landed with a
thump which for a moment or two completely dazed
her. The wasp soon discovered that she was barred
from the outer world by some transparent, translucent
substance ; she then proceeded on a voyage of discovery,
flying around the room and searching here and there
and everywhere for an exit. She finally found a small
hole in the window casing which communicated with
the outside: through this she made her escape from
the room. Upon opening the w indow I saw her ex-
amining the passage through which she had come,
going through it repeatedly. She finally flew away,
but shortly returned with a pellet of mud. Notwith-
standing the fact that all of the windows were then
open, the wasp went at once to the hole in the casing
through which she made her way into the room and
thence to her nest on the ceiling. She never again, so
far as I was able to ascertain, made an exit or an en-
trance through the w-indows, but always made use of
the hole in the casing. This little creature undoubt-
edly gave unmistakable evidences of ratiocination;
she found that a transparent barrier had been placed
in her way — a barrier so translucent and transparent
that she could not see it until she actually felt it. She
therefore concluded that she would never again risk
injur)' by flying through the windows. What is most
remarkable about this instance is that this insect de-
rived her knowledge from a single experience and at
once profited thereby. All wasps, however, are not
so intelligent as was the one just mentioned, for it
required several lessons to teach a ground wasp some-
August 15, 1896]
MEDICAL RECORD.
22'
thing similar. A ground wasp once built her nest be-
neath the brick pavement in front of my door. The
entrance of the nest was situated in the little sulcus
or ditch between two bricks. While the wasp was ab-
sent I stopped the entrance with a pellet of paper, and
when the little housekeeper returned she was non-
plussed for a moment or two, when she discovered that
her doorway had been closed. The wasp, after exam-
ining the pellet of paper, seized it with her jaws and
tried to pull it away; but, since she stood on a brick
and pulled backward (toward herself), the edge of the
brick interposed and she could not dislodge the ob-
stacle. Finally, the wasp got down into the little
gully between the two bricl^s and pulled the pellet
away from the opening of the nest without any fur-
ther trouble. Three times I performed the experi-
ment, the wasp going through like performances each
time. At the fourth time, however, she went at once
into the little space between the bricks and then re-
moved the wad of paper without difficulty. I stopped
the hole five or six times after this, but she had
learned her lesson ; she always got into the sulcus be-
tween the bricks before attempting to remove the
paper. She had discovered the fact that she could not
remove it when she stood upon the surfaces of the
bricks, owing to the interposition of their sides, and
that she could drag it away if she got down into the
little ditch and pulled the paper in a direction where
nothing opposed.
Fleas have, comparatively speaking, highly devel-
oped minds. There are many people alive to-day
probably who saw the trained fleas which were on
exhibition in the large cities of the United States
some thirty or forty years ago. These insects had
been taught to go through certain evolutions at the
command or signal of their owner and trainer. The
mere fact that they possessed memory enough to learn,
retain, and remember their lessons is not proof posi-
tive of reason; but the fact of their having restrained
their natural tendency and desire to escape when
they could so easily gratify such a desire or tendency
is a potent factor in an argument for their possession
of the ratiocinative faculty. Their teacher explained
that he '" brought them to reason'' by keeping them at
first in a glass vessel, where they jumped and bumped
their heads to no purpose against the transparent
walls of their prison. Thus their vaulting ambition
was held in check and they learned to reason from
cause and eiifect.
On one occasion I saw a flea show an evident grati-
fication in a bit of malicious sport. I w^as observing
a sleeping flea among the short hairs on a dog's leg,
when another flea made her appearance beneath the
lens. This flea soon discovered her sleeping sister,
stopped short, and seemed to be in deep thought for
a second or so. She then crept slowly up to within
an inch of the recumbent flea, gave a little bound, and
landed squarely upon her back. She clasped the as-
tonished slumberer in her hindlegs and proceeded to
vigorously " touzle her hair" with her forelegs; then,
springing to one side, she hurried away, closely pur-
sued by the thoroughly aroused and evidently angry
victim of her sport, and was soon lost to sight among
the long hairs of the dog's back. I have seen like
scenes time and again, in which human beings instead
of fleas were the actors.
When we come to study the higher animals, evi-
dences of their possession of reason crowd thick and
fast upon us, and, were I so minded, I could fill ream
upon ream of paper with authentic anecdotes of their
ratiocinative powers. I purpose, however, to give in-
stances of ratiocination in animals that have occurred
under my own observation or that have been witnessed
by people whom I know and for whose probity and
truthfulness I can vouch.
The ant is generally classed among the lower ani-
mals by observers, but a careful study of its cerebral
anatomy and of its psychology leads me to place it
among the higher animals, especially in point of men-
tality. U'hen we take into consideration the fact
that an ant's brain has gray matter analogous to the
gray matter found in the cortex of the human brain,
we should not feel surprised when we find striking
evidences of ratiocination in these little creatures.
The better creatures are able to communicate ideation
or thought, the stronger and more frequent are the evi-
dences of their possession of reason. Ants can un-
doubtedly communicate: how and in what manner, it
is not generally agreed. Some time ago I crushed an
ant in the path usually taken by the inhabitants of a
nest (which was situated in a hollow tree) in their
journeys to and fro. A soldier ant came along pres-
ently, and, smelling the blood of her murdered com-
panion, was seized with a sudden terror and fled away
into the nest. She soon returned, however, with thir-
teen other soldier ants, and made a careful examina-
tion of the body and its surroundings. Her compan-
ions also examined the corpse, and, having satisfied
themselves that their comrade was dead and that her
murderer was not to be found, returned to the nest.
Soon afterward a large worker ant, guarded by two
soldier ants, came out, and, proceeding to the body,
picked it up, carried it down the tree and away be-
neath the grass, where I lost sight of them. In this
instance there is every evidence of complex reasoning;
the discoverer of the murder hurried away into the
nest, where she gave the alarm: the police of the
community, the soldier ants, went immediately to the
scene of the tragedy, made an examination, and then
returned and gave in their report; the undertaker, in
the shape of the large worker ant, then went out. got
the body, carried it away and buried it; the two sol-
dier ants followed the body to the grave, in order to
protect it from cannibal ants.
It has been my good fortune to have witnessed sev-
eral pitched battles between large bodies of ants.
In a battle between some black ants and some yellow
antagonists of another species, I saw many evidences
of intelligent communication. The yellow ants had a
commissariat and an ambulance corps, and I fre-
quently saw them drop to the rear during the battle
and partake of refreshments or have their wounds at-
tended to. The blacks, which composed the attack-
ing army, were in light marching order and had neither
of these conveniences and necessary adjuncts. The
yellow ants frequently sent back to their village for
reinforcements; those of them that had been out on
hunting expeditions when the battle was joined were
notified as soon as they arrived at the nest, and
immediately hurried out to join in the fray. The
blacks had discovered a herd of aphides belonging to
the yellows, and had sought to surprise the guards and
steal the herd: hence the battle. I am glad to report
that the black horde was defeated by the brave yel-
low warriors and had to decamp, leaving many of its
number dead upon the field of battle. On another
occasion I saw an army of red ants besieging a colony
of small black ants. 'I'he object of the red ants was
the theft of the pupa; or voung of the black ants.
These pupa; they take to their own nests and rear as
slaves, the enslaved ants to all appearances becoming
entirely satisfied with their condition and working for
their masters willingly and without demur. The be-
sieged ants evinced a high degree of reason and
forethought, for, as -soon as the presence of the be-
siegers was noticed, strong guards were posted in all
of the approaches to the nest, both front and rear.
The red ants sent a detachment to surprise the colony
from the rear, but they found that surprise was im-
possible, for they were met by a strong party of their
224
MEDICAL RECORD.
[August 15, 1896
gallant foes, which vigorously opposed them. The
red ants were, however, eventually victorious and
sacked the town, carrying away with them a large
number of pupa: or )'oung. I cheerfully bear witness
to the fact that the great naturalist, Huber, was cor-
rect in his description of his experiment with these
black slaves and their masters. Like Huber, I put
some red ants into a glass jar in which I placed an
abundance of food. Notwithstanding the fact that
this food was of easy access, being, in fact, immedi-
ately beneath their jaws, they would not touch it. I
then placed a black slave in the jar; she at once went
to her masters, and, after thoroughly cleansing them
with her tongue, gave them food, of which they rav-
enously partook. These red ants would have starved
to death in the midst of plenty if they had been left
to themselves. So utterly subser\'ient had they be-
come to the ministrations of their slaves that they had
even lost the faculty of feeding themselves! Here we
have an example of degeneration in the mentality of
animals, incident to the enervating influence of slav-
ery. Sir John Lubbock's remarks anent the four gen-
era of slave-making ants are so interesting that I may
be pardoned for introducing them.
Says he: "These four genera" {^formidr sartgiiinea^
polyergus, stroiigylogiiathiis, and anergates^ " offer us
every gradation from lawless \iolence to contemptible
parasitism. Formica sanguiiicn, which may be assumed
to have comparativel)' recently taken to slave-making,
has not as yet been materially affected.
"Polyergus, on the contrary, already illustrates the
lowering tendency of slavery. They have lost their
kiKjwledge of art, their natural affection for their
young, and even the instinct of feeding! They are,
however, bold and powerful marauders.
■■ In stroiigylognathiis the ener\'ating influence of
slavery has gone further, and told even on the bodily
strength. They are no longer able to capture their
slaves in fair and open warfare. Still, they retain a
semblance of authority, and when aroused will fight
bravely, though in vain.
"In aiicrgati's, finally, we come to the last scene
of this sad history. We may safely conclude that in
distant times their ancestors lived, as so many ants do
now, partly by hunting, partly on honey ; that by de-
grees they became bold marauders, and gradually
took to keeping slaves: that for a time they main-
tained their strength and agility, though losing by de-
grees their real independence, their arts, and many of
their instincts; that gradually ei-en their bodily force
dwindled away under the enervating influence to which
they had subjected themselves, until they sank to their
present degraded condition — weak in body and mind,
few in numbers, and apparently nearly extinct, the
miserable representatives of far superior ancestors,
maintaining a precarious existence as contemptible
parasites of their former slaves.'"
During the summer of 1887 I spent several weeks in
New Mexico, and while tliere had the great good for-
tune to discover a colony of honey-making ants. I
found this colony in a little valley debouching out of
Nuerfuanos Park, a government reservation, if I re-
member correctly, at that time. I made a very careful
study of the habits of these interesting little creatures,
and witnessed many evidences of true ratiocination in
their mental operations. In order to make clear one
or two instances in which they evinced true rea.son, a
short description of this colony and its inhabitants
will be necessary. The nest was situated on the sandy
shore of a little creek, and was a perfect square of
three or four feet, from which all grass, weeds, etc.,
had been carefully removed. Around three sides of
this square, viz., north, east, and west, a column of
black soldier ants continually patrolled night and day.
Near the southeast corner of this open space the en-
trance to the nest was situated. The south side of the
square was not guarded, but was left open for the en-
trance and exit of the hundreds of dark yellow work-
ers, which were always engaged in bringing food to
the village. This food they carried to the centre of
the square and then deposited. No sooner was it put
down than it was seized by black workers, which then
carried it into the nest. At no time did I ever see a
black worker bringing in food to the centre of the
square, nor did I ever see a yellow worker carrj'ing
food into the nest; the blacks and the yellows never
interfered with one another's particular duties. To
test the reasoning powers of these ants, I partially dis-
abled a centipede and threw it into the square a short
distance from the patrol line. For a moment or so
the line was broken by the warriors hurrying out to do
battle with the squirming intruder. But only for a
moment, for orders were issued by some one in author-
ity; the line was re-established, though somewhat
thinned by absent soldiers; a messenger was dis-
patched to headquarters and reinforcements were
sent out, and soon the line was as strong as ever,
though hundreds of soldiers were battling with the
centipede. This latter animal was soon killed and
its body removed piecemeal by yellow workers, which
carried it far outside the boundaries of the square.
Again, with my hunting knife I dug a deep trench
across the border of one side of the square. The ants
seemed dazed at first, but rapidly adapted themselves
to their new surroundings. They extended their pa-
trol line until it embraced the entire trench; then a
countless liorde of yellow workers went to work, and
in a day's time filled up the trench level with the sur-
rounding surface. The patrol was then established
along the old line as though nothing had occurred to
interrujjt the ordinary routine of the colony. Before
leaving the valley I dug up the, nest and examined the
peculiar individuals whose enforced habits give these
interesting ants the name of " honey-makers." Each
one of these curious creatures was confined in a sepa-
rate cell, the entrance to which was very small. Here
they lived in total seclusion, being fed by the black
workers with pollen, the nectar of flowers, tender
herbs, etc. They had no anal orifices, these passages
having been artificially obliterated, I am convinced,
by the other ants, which probably bit them, thus pro-
ducing an inflammation which resulted in the growing
together of the parts. These imprisoned honey-mak-
ers were merely animated bags of honey and were kept
solely for the purpose of furnishing a never-failing
supply of sweet and wholesome food. I tasted the
honey and found it delicious; its flavor was distinctly
winy and aromatic.
When we come to examine the mentality of the
higher animals, such as the dog, the cat, the horse, the
monkey, etc., we find that the evidences of ratiocina-
tion increase and become stronger as we approach the
highest of the higher animal.s — man. Vet in the very
lowest of the lower animals, the germs, the fundamen-
tal principles of true reason are in evidence; and the
more we study the habits of these creatures and place
ourselves as far as is possible on their levels, the more
must we become convinced that instinct, while it does
undoubtedly account for the greater portion of the
psychical manife.stations to be observed in the lower
animals, does not, by any manner of means, account
for all. Reason puts in an appearance very low, in-
deed, in the scale of animal life.
Retro-Pharyngeal Abscess. — Dr. Ambler {Ckve-
land M(il. Giizctli', March, 1896) says this aflfection is
more commonly met with in children than in adult life,
and when occurring in the former is generally asso-
ciated with the strumous diathesis.
August
15, 1S96]
MEDICAL RECORD
22s
ON THE VALUE OF THE OPHTHALMO-
SCOPE AS AN AID TO THE DL\GNOSIS
OF CEREBRAL DISEASE IN PURULENT
AFFECTIONS OF THE MIDDLE EAR.'
By THOMAS K. POOLEV, M.D.,
NEW \OKK.
The purpose of this paper is briefly to consider the
value of the ophthahiioscope as an aid in the diagno-
sis of those cerebral complications which occur in
purulent affections of the middle ear. It has been
thought by the writer that to discuss this subject in
such a society as this, largely made up of those who
have not made use of the ophthalmoscope in their
researches, might be of some service in calling their
attention to an additional factor in determining
whether cerebral implications maybe present, and in-
duce those who do not use this instrument to add a
knowledge of its use to their accomplisiiments or refer
their patients to an oculist for examination.
It is only within recent years that the importance
of examining the fundus oculi in cerebral affections
has attracted attention. Dr. Kipp, of Newark, was
the first to call attention to the value and importance
of such e.xamination in the class of cases we are con-
sidering, and probably deserves, as Dr. Knapp says,
the priority, although it would appear that several
publications appeared about the same time; that of
Albutt" was the first, in which he. reported two cases
of otitis media purulenta with optic neuritis, in
which recovery took place. Dr. Kipp's ' paper was
published some time after, in which he reported two
cases of optic neuritis, in otitis media purulenta, in
which recovery took place. Following these papers,
Zaufall ' also recorded the case of a student, aged si.\-
teen, with purulent otitis media and optic neuritis,
which latter condition was observed to recede rapidly
after the mastoid was opened, and the patient made a
good recovery. Since these cases, which are cited only
to bring out the names of those to whom belongs the
credit of first calling the attention of the profession to
them, many others have been published and the
value of their observations thus confirmed. It is not
my intention, however, even to attempt an enumera-
tion of the papers which have been published on this
subject, or of the cases of otitis media purulenta and
its complications in which optic neuritis has been
observed. It will suffice for my purpose to enu-
merate some of them and to report a single case of
my own.
In 1883, Dr. J. A. x\ndrews read a most interesting
paper on this subject before the American Otological
Society, which, like all other communications from his
pen, deals with the subject in the most comprehensive
and masterly manner. He reports four cases, and, as
they embrace all that is essential in the observations
of those who wrote before, I will briefly refer to three
of them.
(Ja^e I. — Otitis media purulenta chronica, abscess
of middle lobe of cerebrum. Death. This patient,
aged twenty-four, had had otorrhcea on both sides since
an attack of scarlet fever when twelve years old. Ten
years thereafter pain developed suddenly in the right
ear and corresponding side of head. During the
night he vomited. Ne.vt day vomiting continued and
he was dizzy. His physician's attention was attracted
to the right eye, because of pain referred to it. Tem-
perature, 103 F. ; pulse, 130; respiration, 30. When
' Read before the .American l.aryngological, Khinological, and
Otological Society, .^pril 17, iSyO.
■■' .\lbutt : "On the Use of the Ophthahiioscope," 1S71. pp.
322-324. .\ppendix.
' .Archives of Ophth. and Otolog., vol. vii., p. 14S.
■* Wiener .Medical Press, 1S81, No. 46. p. 1.452.
seen by .\ndrews three days later, he was conscious
and talked intelligently. Right ear, hearing for watch
and voice very much impaired, slight purulent dis-
charge, small perforation in antero-inferior part of
membrana tympani, swelling of wall of auditory canal ;
left ear, no active disease. Double optic neuritis.
Right eye, counts fingers at 6'; left eye, vision, ^.
The patient died four days later in coma. No paraly-
sis, no convulsions. .-Vt the autopsy an encapsulated
abscess of the middle lobe of the cerebruin was found,
extending from the tympanic portion of the Glaserian
fissure outward into the external auditory canal for four
millimetres, but not involving the ossicles. The bone
was ulcerated. The communication with the brain
was made at this point through a small fissure in the
centre of the ulcerated bone. The dura over the dis-
eased bone was also ulcerated and separated from the
same by foul pus. The pia was congested. The
middle and anterior fossa; contained pus. The brain
was normal in consistence. 'Jlie sinuses and inner ear
were normal. These conditions refer to the right side
of the brain; the left was normal.
Case II. — Chronic purulent otitis media, optic neu-
ritis, phlebitis of the right lateral sinus, meningitis of
the convexity. Death. The patient, aged forty-two,
had had otorrhcea for eight years, which had not been
treated. Three years ago there seems to have been an
acute exacerbation and he was treated for inflamma-
tion of the brain, but his ears received no attention.
He said he had enjoyed good health since, but he had
had, since the attack referred to, slight headaclies.
When seen by Andrews he had been confined to the
house for two weeks, was very irritable and had severe
pains in the head, sometimes diffused, at times referred
to the right side. There had been no paralysis nor
convulsions, but he had vomited during the first week
of his present attack. For the first two days of attack
he had illusions and delirium. Temperature had not
been above 100.5° ^- O" '•^^ occasion of Andrew's
first visit there was severe diff'use pain in the head,
purulent discharge from the right ear, removal of
which showed the bottom of the canal filled with gran-
ulation tissue. Right optic neuritis; left disc hazy;
veins large and dark colored but not tortuous. Right
vision, |J|; left vision, fsj. There was intensely sen-
sitive induration extending in the course of the right
jugular. He was under .Andrews' care five days. The
third day the right mastoid was opened with temporary
relief, but he died on tiie fifth day in coma under the
usual symptoms of sinus thrombosis. At the autopsy
phlebitis of the right superior petrosal and lateral
sinus was found. The right internal jugular con-
tained a disintegrated thrombus. The dura covering
the tegmen tympani and adjacent bone W'as congested
and showed points of hemorrhage. There was puru-
lent meningitis of the convexity of the cerebral hemi-
sphere and the upper surface of the cerebellum, most
abundant on the right side.
C.\SE III. — Otitis media purulenta chronica, menin-
gitis, optic neuritis. Recovery. Patient, aged nine-
teen, had otorrhcea of left side for eighteen months.
The discharge was profuse until about one week before
he was seen by .\ndrews, when it became scanty.
He came under his care six days after threatening
symptoms began. The left ear contained a large
polypus springing from the superior surface of audi-
tory canal at the junction of its bony and cartilag-
inous part. Removal of tlie polypus showed the bone
beneath exposed and rough. There were also tw'O
polypi springing from the tympanic cavity, which re-
\ ealed pulsation at the bottom of the canal, .\fter re-
peated efforts air was blown in the membrane corre-
sponding to the point where pulsation was noted, but
there was a perforation which could not be seen ow-
ing to swelling in the canal. The left membrana
226
MEDICAL RECORD.
[August 15, 1896
tympani was incised, the mastoid red and painful.
Severe headache was general, but at times more se-
vere on the left side and in the forehead. Tempera-
ture, 101° F. ; pulse, 85. The patient was restless
and vomited. Left eye, marked optic neuritis; right
eye, retinal veins enlarged, disc very red but not cede-
matous. There was no other change in the fundus.
Incision over the mastoid showed the bone inflamed
but firm.
Thirty-six hours later the mastoid was opened by
trephine. A small amount of blood and a trace of
pus escaped. The cortical plate was thick; free com-
munication between the opening in the mastoid and
auditory was established and there was immediate im-
provement. There was from this time on a continuous
improvement, loss of pain, lowering of temperature,
and free discharge from the mastoid. The eyes were
not examined the day following the ojoeration, but on
the morning of the fourth day thereafter. The left
disc was less cedematous, the veins were not so full or
dark looking, but the improvement was not striking.
The patient was under Dr. Andrews' care for about
two and one-half months. At the expiration of this
time the left optic disc was hyperaemic, and the veins
were much smaller than when last examined, about
two weeks previous. The opening in the mastoid
was closed, but there was still discharge from the ear;
the right nerve was somewhat obscured.
Three months later the patient returned. The dis-
charge had ceased. The left disc appeared to be nor-
mal and the right slightly hyperaemic. Right vison,
|-[}; left vision, |{| ; right vision field normal, left
vision field contracted.
The patient was seen again one year after the attack.
There was no abnormal change in either fundus, but
the visual field of the left eye, therefore on the same
side as the afTected ear, was slightly contracted.
In this case the diagnosis of cerebral complication
was believed to have been confirmed by the ophthal-
moscopic examination.
Before reporting my own case I wish briefly to re-
port one published by Dr. C. J. Kipp,' of Newark,
because of its great interest as demonstrating the value
of repeated examinations of the eye with the ophthal-
moscope in cases of otitis media purulenta, and also
because it is one of the earliest development of optic
neuritis from the ear trouble.
A case of acute purulent inflammation of the mid-
dle eai ; a double optic neuritis, but without tender-
ness or swelling of or spontaneous pain in the mas-
toid process, in which the opening in the mastoid cells
was followed by a rapid subsidence of the optic neu-
ritis and cure of the ear disease.
The pati-ent, a woman, aged thirty-five, consulted
Kipp July 7, 189 1. She complained of pain and
throbbing in the right ear, from which she had been
suffering for about six weeks. .\ month before the ear
became aff^ected she had influenza, which left her de-
bilitated. The physician who attended her when she
was first attacked by the ear disease punctured the
membrana tympani, which gave some relief. Since
then she had been syringing the ear, etc. She was not
suffering much from earache then, but had a constant
throisbing in the head and ears. Hearing was im-
paired for watch and voice. The tuning fork was
better heard through bone than air, and when placed
on the vertex best in the diseased ear. There was but
little pus in the external canal. The walls were
somewhat red and swollen. The membrana tympani
was of a deep-red color, swollen, and much thickened.
In its upper anterior quadrant there was a small perfo-
ration, through which air but no secretion passed dur-
ing the Valsalvian experiment. The parts behind and
' Transactions of .\merican Otological Society, vol. v., p.
216.
in front of the auricle were neither red, swollen, nor
tender on pressure. Examination of the eyes with the
ophthalmoscope showed them to be entirely normal.
The opening in the membrana tympani was enlarged,
and this was followed by syringing with warm salt so-
lution and politzerization once a day. She improved
for two weeks; then the opening in the drumhead had
nearly closed, the walls of the canal were but little
swollen, and throbbing in the ear was not so bad.
July 22d he enlarged the opening in drumhead, and
again washed out the tympanic cavity with warm salt
solution by means of a middle-ear syringe. The soft
parts over the mastoid were perfectly normal, and
there was no pain on pressure.
Patient was not seen again for a month. Her
physician had continued the treatment advised by
Kipp. On August 29th he made another examination
of the ear and found it in about the same condition as at
her first visit. The mastoid process was neither cede-
matous nor red. The ophthalmoscope revealed, how-
ever, a remarkable change in the eyes — a well-marked
optic neuritis in both. Vision was not at all impaired
in either eye. Her general condition had grown worse.
The throbbing in head and ear was more pronounced.
She felt very weak in her lower limbs, her gait was
somewhat staggering, and she had occasional attacks
of dizziness. She was listless and drowsy, her appe-
tite poor; she had had neither nausea nor vomiting.
Temperature, 99" F. ; pulse, 72. She had had no
chills nor fever.
On September 2d the mastoid was opened by
Schwartze's method. After the removal of the cortex,
which was about the average thickness, a cavity of
about the size of a hazelnut was reached. It was
filled with foul pus and granulating tissue. The cav-
ity was thoroughly cleaned out with a sharp spoon
and the mastoid antrum reached without difficulty.
Free communication through the external auditory
canal and mastoid wound was established. The wound
was dressed in usual way. No reaction followed, and
the patient then gradually improved.
A month or so after the operation there was more
or less discharge through the wound, but it was never
profuse. After that time it ceased entirely. A silver
drainage tube was kept in the wound for three weeks,
and then it was allowed to close. The otorrhoea
ceased four days after the operation, and soon after
the operation the perforation was found closed. The
optic neuritis remained stationary for about a week
after the operation, then began to subside gradually,
and at the date of her discharge from the hospital,
September 26th, the optic discs were almost normal
in appearance.
For six months following she was seen occasionally,
and when last examined she was in perfect health,
having a normal drum membrane of grayish color, and
in its upper anterior quadrant a scar. The opening in
the mastoid was firmly closed. The ophthalmoscope
showed the optic disc to be pale: otherwise it was
normal. The fundus oculi was f>erfectly healthy in
both eyes. The vision was normal.
My own case is as follows:
Patient, aged twelve, male, admitted to the New
Amsterdam F,ye and Ear Hospital, July 20, 1892.
Otitis media purulenta, mastoid periostitis, mastoidi-
tis interna, abscess of cerebrum, thrombosis of lateral
sinus, meningitis, optic neuritis. Death.
History: The patient complained of discharge from
the ear for many years. Wilde's incision was made six
years previous to the patient being seen by us, by a
surgeon connected with a hospital at Buda-Pest. Fol-
lowing the operation he had severe pain, etc., in head
and ear, which in a great measure subsided but con-
tinued as a subacute condition until the time of his
appearance at our clinic. His condition at that time
August 15, 1896]
MEDICAL RECORD.
227
was as follows: There was a large, firm swelling over
left mastoid region, which was reddened and very ten-
der, and a slight discharge of pus from the external
auditory canal. Temperature, 102.5° ^■- pulse, 128.
Wilde's incision was made, and three hours after oper-
ation pain was absent and temperature had dropped
to 100° F.
On the evening of the day following- the operation
his temperature went up to 103^ F., accompanied by
severe pain in the ear.
On the following afternoon a mastoid operation was
resorted to by method of Schwartze, accompanied by
an escape of a considerable quantity of pus. By
means of Volkmann's spoon about a drachm of foul-
smelling caseous material was removed from the an-
trum, and irrigation by means of a one-half-per-cent.
solution of carbolic acid was employed. During the
operation a considerable surface of the dura over the lat-
eral sinus was exposed and could be seen in the poste-
rior part of the wound. The wound was lightly packed
with gauze and absorbent dressings were applied.
As the discharge from the external auditory canal
was slight, on the following day a paracentesis of the
membrana tympani was resorted to. Two hours fol-
lowing this patient was taken with severe chills.
Temperature rose to 104.5° ^- The day after the tem-
perature declined to 102.5" ^■< ^""^ '^e patient was
more comfortable. The ne.xt day he had severe pain
in head and eyes. Pupils contracted. Ophthalmosco-
pic examination revealed choked disc, left side.
For twenty days the patient continued in a preca-
rious condition, temperature oscillating between 101.5 "
and 105.5° F. and pulse behaving badly. At inter-
vals he complained of severe pain in ear and head,
the latter toward the last being severe and constant in
character. He was much perturbed in mind and at
times maniacal.
On the thirty-first day of his entrance into the hos-
pital patient was found to be blind in the right eye,
apparently over the entire field. Ophthalmoscopic
examination was ;///.
On the following day the ophthalmoscope revealed
slight venous hyperasmia on the right side and violent
choked disc on the left side.
Two days later patient was afflicted with more par-
alysis on the right side, lapsed into a typhoid condi-
tion, became comatose, continued so for twenty-four
hours, and on the forty-first day of his entrance into
the hospital he died.
-An autopsy was made and brought to view the fol-
lowing conditions: The vessels of the dura were found
to be intensely engorged and lifted up. On opening
the dura a layer of foul-smelling thick pus, about one-
fourth inch thick, bathed the entire left hemisphere,
dipping down into the longitudinal fissure and up as
far as the convexity on the right hemisphere, and ex-
tending some distance over the upper parietal lobe.
On lifting the frontal lobes the pia was seen to be
intensely engorged. The entire base was found to be
bathed in pus. The optic nerves were swollen and
the sheaths distended. The cerebellum was normal;
its upper portion, however, was surrounded by pus. A
large encapsulated abscess was found in the anterior
portion of the occipital lobe on the left side, around
which the brain was softened, with considerable puru-
lent collection, especially external to it. A cut sec-
tion of brain showed the abscess cavity to be about
one and one-half inches antero-posteriorly and one
inch laterally. The ventricles and other portions of
brain were normal. The right hemisphere was found
to be normal, except for pus collections dipping down
into the sulci from the longitudinal fissure.
Ear: There was extensive thrombosis of the lateral
sinus, extending to the torcular Herophili. The dura
was not perforated during the operation for opening
the mastoid, but at time of autopsy an opening through
the temporal bone from the mastoid cells along the
lateral sinus was found. The opening extended along
the lateral sinus for about eight millimetres, and was
about four and one-half millimetres wide. Around
this the dura was adherent, and the bone at its posterior
and inner border was found to be carious.
No evidence could be found of purulent infection
through any of the nerve or venous canals of the pe-
trous portion of the temporal bone. The tegmen tym-
pani was chiselled away and the ossicles and membrani
tympani were found to be absent. Communication be-
tween mastoid cells, antrum, and middle ear was found
to be free.
Deductions. — From a consideration of these ca^es
and many others in literature the following conclu-
sions are drawn :
1. That the ophthalmoscope is of value in arriving
at a diagnosis of the presence of cerebral disease — in
some instances by confirming the evidence which is
given by other svmptoms, in others by being the prin-
cipal if not the only reliable evidence of the existence
of brain disease.
2. The subsidence of the optic neuritis after opera-
tion, which gives a favorable turn to the ear disease,
is shown by the recovery of the eyes and their restora-
tion to normal vision. In this connection the case of
Kipp's is particularly interesting and instructive, be-
cause there were wanting positive evidences of either
mastoid disease or cerebral extension until the oph-
thalmoscopic examination detected double optic neu-
ritis, upon which indication alone the operation was
determined upon.
3. The percentage of cases in which the lesion under
consideration is found is small, as, indeed, are brain
complications. Kipp thinks that in most cases where
meningitis is present there is some degree of optic
neuritis. This seemed to have been the consensus,
of opinion in the discussion which followed the read-
ing of the paper in the American Otological Society
and was participated in by a large number of members
present. This may be accounted for in a large meas-
ure, I think, by the neglect to look at the eyes — an
omission which I for one confess to in many of my
cases. Again, the attention is frequently not directed
to the eyes, because, as is well known to ophthalmolo-
gists, vision is often unimpaired even in the most
pronounced inflammation of the optic nerve.
4. The intra-ocular end of the nerve is never in-
flamed when the disease remains limited to the mid-
dle ear and mastoid, but is a certain evidence of brain
disease. If, therefore, optic neuritis is found, the di-
agnosis of extension to the brain is certain, no matter
whether other evidence exists or not.
5. The form of optic neuritis which exists is always
of the kind seen in aflfections of the brain, viz., choked
disc: but this may vary in degree from simple venous
stasis, hypera;mia of the disc, cedema of the disc and
surrounding retina, to, as in my case, the most pro-
nounced choked disc. In my opinion the various
forms described are only difi^erent grades of this form
of neuritis. The eye trouble and impaired vision are
most marked on the side where the ear disease is.
6. The presence of optic neuritis is unfortunately
no aid in a solution of the difficult dilemma of locat-
ing the situation or even the nature of the disease, al-
though, as we shall see under another head, the latter
may be inferred from its more frequent occurrence in.
some of these affections than in others.
7. Optic neuritis occurs more frequently in cases of
otitis media purulenta chronica than in acute cases,
in which, indeed, its occurrence is very rare, the
case of Kipp's in this respect being the earliest exam-
ple of its occurrence after the onset of the ear atTec-
tion. I have found that most of those I have looked!
228
MEDICAL RECORD.
[August 15, 1896
■up were observed in cases of otorrhcea of long stand-
ing, in many instances a number of years.
8. Tiie list of brain lesions from otitis media puru-
lenta in which optic neuritis has been observed, veri-
fied by autopsies, embraces nearly if not all those
observed, i.e., abscesses of brain and cerebellum, men-
ingitis, and sinus thrombosis.
9. The occurrence of optic neuritis in a case of otitis
media chronica with implication of the mastoid, with a
history of long-standing otorrhcea, is by inference very
apt to be due to a cerebral abscess, although it must
not be lost sight of that all of the lesions enumerated
may be found in the one case — as in mine, where there
was an abscess, meningitis, and sinus thrombosis.
'lo. The e.xtent to which the presence of slight cede-
ma of the optic disc should influence us in determin-
ing upon an operation on the mastoid is, in the ab-
sence of other sufficient evidences, necessarily an open
question. But I think we may safely accept the con-
clusion arrived at by Dr. Andrews, a sound one,
that ■■ as the operation when intelligently performed
is not a dangerous one, without waiting for pro-
nounced neuritis we may accept the condition of oede-
ma of the optic disc in the case under consideration as
an indication for the opening of the mastoid: and if
not with the expectation of liberating pus, at least to
establish free drainage from the middle ear. The
procedure is certainly consistent with a good surgical
principle, and is not likely to add to the pre-e-xisting
mischief." In regard to the presence of a marked
neuritis alone or in connection with other symptoms
being an indication to open the mastoid, no doubt can
exist. Another indication of great value is pointed
out by Knapp, who has been guided by the recession
of the ocular symptoms in arriving at a decision when
to let the opening in the mastoid (after operating)
close. It is not necessary, he says, to keep up the
syringing and drainage from the mastoid cavity until
the suppuration has completely ceased, and it is just
in these cases that the use of the ophthalmoscope has
been of advantage.
1 1. The existence of optic neuritis as an indication
for a more serious operative procedure than opening
the mastoid, of the nature of an exploration of the
brain for intracranial disease, can be considered only
in connection with other symptoms which would go
to render so grave a procedure justifiable. So far as
it goes, however, it ser\-es to make the presence of in-
tracranial disease more certain.
BACTERIURIA."
By HERMANN GOLDENBURG, M.D.
NEW %'ORK.
A Barbarous Exhibition — A correspondent of the
Britisli Mtulical Journal describes an exhibition of
hanging which is attracting large crowds of morbid
spectators in Paris: "A man is attached by a cord to
the ceiling. He is dressed in a blouse, with a red
muffler round his neck. His head is bent toward his
chest. His face is thin and bony and appears con-
vulsed, his eyes are almost shut, his veins are swollen,
and the complexion is ashen. The arms drop down at
a little distance from the body; his hands are con-
tracted, the fingers bent. The veins are .so swollen
that they seem on the point of bursting. The legs
hang straight and stiff. This barbarous spectacle is
served up with an accompaniment of music. It is ob-
served that when the music strikes up the hanging
man is seized with painful convulsions. In this posi-
tion he will remain thirteen days; after that trial he
will remain buried three hundred and sixty-five, and
will then take his place among the living. The rest
the man takes in this hanging position consists of
leaning against a ladder, which is placed in a position
to permit him to doze without in the least changing
his attitude. During this time he is rubbed with a
sedative lotion and inhales ether. No £ od of any
kind is taken.''
The subject of bacteriuria, judging from the lim-
ited number of cases reported, is one quite novel in
medical literature. It was first described by Roberts
in 1881 and has seldom been referred to by American
writers. Much of what we now know on the subject
was brought out by Ultzmann in his lectures, which
I had the opportunity of listening lo and which were
published after his death by his former assistant. Dr.
Brik. In recent French literature a paper, " Sur la
Bacte'riurie," has been published by Krogius, wherein
he reports eight cases in which a thorough bacterio-
logical examination had been made.
I am of the opinion, however, that the disease is
more frequent than would be inferred from the scant
literature on the subject and that many cases recog-
nized as cystitis are really types of bacteriuria.
Bacteriuria is characterized, as the name implies,
by bacteria in the urine. But not every case with
bacteria in the urine can be classified under this
term. Seiisii stricto, the latter applies only to those
cases in which the freshly voided urine contains a
large number of bacteria. The urine is always cloudy,
opalescent, and has a peculiarly disagreeable odor.
The reaction is acid or neutral, and, if it is alkaline,
there is some other cause at work. The cloudiness
does not disapix-ar on boiling nor after the addition
of a mineral acid. The urine does not become clear
on filtering with the ordinary filtering paper, but it
does so after passing it through a Pasteur filter or by
shaking it with calcined magnesia (Salkowskij or car-
bonate of barium (Ultzmann). When the urine is
properly filtered, it does not become opalescent either
on boiling or on addition of an acid, if the case is not
complicated by bladder or kidney trouble. For mi-
croscopical examination a drop of aniline violet is to
be added to a drop of urine on a slide, heated for a
short time, allowed to cool, and afterward examined
with oil immersion. Examination will then reveal an
abundance of micro-organisms of different shapes and
sizes, such as the ordinary bacterium termo, the bacteria
of intestinal fermentation, cocci, and bacilli. In eight
cases Krogius found the bacterium coli commune in
pure cultures, and it .seems that this bacillus is the
most common cause of tlie disease. Formed elements
are absent if the bacteriuria is not complicated by an
affection of the urethra, bladder, or kidneys.
As to the symptomatology of the disease verj- little
is to be said, as the subjective symptoms are generally
absent. The peculiar odor is often the only thing
that draws the attention of the patient to his ailment.
The latter is in most cases exceedingly obstinate: it
shows a tendency to chronicity and relapses, and some-
times no i^ermanent cure can be obtained.
Etiology. — 'l"he bacteria being those of fermenta-
tion and identical with those found in the intestinal
tract of the healthy individual, in the contaminated
air, in the normal urethra, under the prepuce, on the
vulva, and in the vagina, it is surprising indeed that
cases of bacteriuria are not more frequently found,
especially in women, in whom there is a good chance
for the bacteria to enter the bladder from the vulva
and vagina through the short urethra.
A question which is of the utmost importance in
the etiology of the disease is: '" How do the bacteria
enter the urine?" The answer is, either through in-
fection or through auto-infection.
Infection. — Ultzmann states — and his statement is
copied by later authors — that bacteriuria is found in
patients with malaria and in physicians who work in
' Read before the genito-urinary section of the New York
Academy of -Medicine, May 12, 1896.
August 15,
1896]
MEDICAL RECORD.
229
dissecting-rooms, where the infection takes place
through the respiratory organs. Some years ago I
treated a patient with bacteriuria complicated by he-
maturia of renal origin, general malaise, and emacia-
tion, due to malarial infection. The patient rapidly
improved under quinine and salol.
More frequent are the cases in which the bacteria
enter the bladder per urethram through the introduc-
tion of instruments, especially of unclean catheters.
Auto-Infection takes place from the intestines either
directly through contiguity, or indirectly through ab-
sorption.
As to the direct auto-infection, perforation of a
prostatic abscess either into the rectum and urethra
or into the rectum alone may be the cause of bacteri-
uria. In the former case the bacteria are directly
transported from the rectum into the posterior urethra
and the bladder; if the abscess open only into the
rectum, the bacteria of the intestines enter the urethra
through the prostatic duct.
There is, however, another way for the intestinal
bacteria, viz., through the lymphatics.
Wreden demonstrated in the laboratory of Professor
Nencki that after a slight artificial traumatism in the
rectum of male rabbits the bacteria coli could be
found in the urine of the animals. By producing an
artificial loss of epithelium in the region of the pro-
static gland, or higher up, a cystitis was caused and
the intestinal bacteria, as well as those which, expcri-
menta causa, were introduced into the rectum, could be
found in the urine. Wreden claimed that the bacteria
enter the bladder directly, per cfliitiguitatan, through
the lymphatics which connect bladder and rectum, and
was able to demonstrate that in rabbits after a super-
ficial erosion of the rectal epithelium fatty substances,
such as oil or vaseline, which were introduced into
the rectum, were found in the urine.
Looking over the text-books of human anatomy I
do not find a statement that in man the lymphatics of
the bladder communicate with those of the rectum.
Quain says: "The lymphatics of the bladder are few
and small and their course and termination are not
sufficiently known;" and of the lymphatics of the rec-
tum : " Some of them pass through small glands which
lie contiguous to it [/.<■., rectum] and finally they enter
the lymphatics situated in the hollow of the sacrum."
Sappey states that the lymphatics of the bladder,
although conceded by most authors, have never been
demonstrated: "One sees, it is true, lymphatics on
the outer surface of the bladder, but all those come
from the seminal vesicles or from the prostatic gland,
both of which have an abundance of lymphatics."
From these anatomical facts it seems that the in-
fection takes place through the lymphatics of the pro-
static gland or of the seminal vesicles to the perito-
neal covering of the bladder and through the walls of
that organ to the bladder itself.
The last mode of entrance of the bacteria into the
urinary tract from the intestines is by e.xcretion of the
absorbed bacteria through the kidneys. It has been
known for a long time that the kidneys are not a per-
fect filter, but that particles which are not dissolved
in the blood, such as cinnabar, fat, etc., can pass
through them.
Grawitz, Schweizer, Baumgarten, and others demon-
strated that even living elements can be eliminated
through the kidneys. Recently Biedl and Kraus have
shown that micro-organisms which circulate in the
blood can be excreted through the absolutely intact
kidneys. They chloroformed dogs, fixed a sterilized
cannula into the vena jugularis or femoral is, per-
formed laparotomy on the animals, inserted cannulas
into the ureters, and examined the urine thus obtained
under all the necessary precautions, after having in-
jected the staphylococcus pyogenes aureus, the bacte-
rium coli commune, and anthrax bacillus into the veins.
Cultures made from the urine showed the micro-organ-
isms which had been injected, examination of the
urine was negative as to blood or albumin. They
concluded that the normal kidney through its physio-
logical function is able to excrete the micro-organisms.
Posner demonstrated the bacterium coli commune
in the blood of the heart, in the kidneys, and in the
urine of rabbits in which he had ligated the ureters
and had caused a prolapse of the rectum and had oc-
cluded the prolapsed part with a ligature.
Treatment depends entirely on the cause of the
bacteriuria. It is obvious that the therapeusis is dif-
ferent in cases due to an infection from without from
that in cases due to an infection from within. The
sceptical views of some authors as to the curability of
the trouble are partly due to a too schematic thera-
peutic procedure. If the bacteria are introduced intc»
the bladder through instrumentation, irrigations of the
bladder and of the entire urethra with a solution of
nitrate of silver, i to 2,000 or i to 1,000, are probably
the most efficacious. Of internal remedies salol \\\
doses of fifteen grains or oil of gaultheria are to be
recommended. When there is a distended bladder
and a disturbed contractility of this organ, the patient
is to void his urine at shorter and regular intervals,
as the distention of the bladder facilitates the decom-
posing action of the bacteria. If the bacteriuria is
due to a perforated abscess of the prostatic gland and
if there is no more direct communication betw-een rec-
tum and bladder, it is advisable to use massage to
empty the prostatic gland of the bacteria which are
deposited in that organ. After the massage the patient
should pass his urine, and then the empty bladder and
the entire urethra are to be irrigated with antiseptic
solutions.
Much more difficult will be the treatment when we
have to deal with bacteriuria due to an auto-infection
from the intestines. Theoretically the indication is
to prevent increased decomposition and fermentation
in loco nasccndi by means of intestinal antisepsis, or, if
the fermentation is not abnormal, to prevent the ab-
sorption of the bacteria which under normal condi-
tions inhabit the intestines.
The number of internal remedies recommended for
intestinal antisepsis is legion and their value is in-
versely proportional to their number.
According to Albu intestinal antisepsis is illusory:
" A great number of experimental observations have
demonstrated that it is impossible to suppress the pu-
trefactive processes in the intestines by means of in-
ternal antiseptic remedies. Nature, however, accom-
plishes this task by producing a diarrhoea."
Following this suggestion in the case I am about to
report, I produced an artificial diarrhoea by administer-
ing laxatives, but did not find any marked effect on the
bacteriuria. As this case offers some especially interest-
ing features I may be permitted to report it at length.
The patient, thirty-three years of age, was seen by
me in consultation with Dr. Manges on November 15,
1894, on account of a chronic urethritis of twelve
years' standing with occasional acute exacerbations.
When I saw him the profuse discharge with which he
came under the doctor's care had disappeared under
the usual treatment. Examination of the urine
voided after irrigating the anterior urethra showed
clear urine with a moderate amount of small shreds
from the posterior urethra. Urine passed after mas-
sage of the seminal vesicles, which were found en-
larged, of a doughy consistence, and tender to the
touch, contained an abundance of pus cells, spermato-
zoa, detritus, and epithelia. Endoscopy showed a
normal anterior urethra, a few granulations here and
there in the posterior part of the canal, and hyper-
trophy of the coUiculus seniinalis.
230
MEDICAL RECORD.
[August 15, 1896
Diagnosis: Chronic vesiculitis seminalis, mild ure-
thritis posterior.
The treatment suggested by me and carried out by
Dr. Manges, viz. : massage of the seminal vesicles,
rectal cooling sound, irrigation of the urethra with ni-
trate-of-silver solution, caused a marked improvement,
so that Dr. Manges notes on December 24th : '" Urine
very good, only a few shreds in first portion. The
patient has had connection without any injurious
effect." Treatment was discontinued, as the patient
considered himself cured. He enjoyed perfect health
until June, 1895, when he came again to Dr. Manges
with a relapse of the same nature as before. Although
while under the old treatment a marked improvement
took place, a perfect cure could not be obtained. The
discharge, to be sure, was very slight, but the urine,
which before had been perfectly clear, became cloudy
and offensive about the middle of September and re-
mained so in spite of all treatment.
The patient, therefore, was sent to me for the second
time for consultation on October 7, 1895. The diag-
nosis of bacteriuria which Dr. Manges had made, both
clinically and microscopically, was confirmed. In order
to clear up the question how and where the bacteria
entered the urinary organs, a catheter was introduced
into the empty bladder and the latter was irrigated with
a mild boric-acid solution. On this occasion it was
found that the bladder was considerably distended;
the patient was able to hold an unusually large quan-
tity of liquid without feeling a desire to urinate. The
irrigation of the bladder was continued until the
liquid came out perfectly clear; the catheter was then
left in the bladder a sufficiently long time to receive
the urine as it entered the bladder from the kidneys.
This was found perfectly clear and normal, so that the
renal origin of the bacteriuria could be excluded.
The bladder then was filled again with boric-acid solu-
tion and in withdrawing the catheter the entire urethra
was irrigated with the same liquid. The patient then
passed part of the contents of the bladder and this
was found clear. The seminal vesicles were then
thoroughly stripped. He then passed the balance of
the urine, or rather of the boric-acid solution previ-
ously injected into the bladder. This liquid was tur-
bid and offensive, the color and odor being of the
same character as the urine filled with bacteria. Mi-
croscopically, bacteria, spermatozoa, pus cells, and
epithelia were found.
It thus was clearly demonstrated that the foiis tt
origo ;«(«■/'/ was situated in the seminal vesicles, where-
from the bacteria, probably the bacterium coli com-
mune— I regret to say that a bacteriological exami-
nation was omitted — entered the posterior urethra.
It was deemed advisable to strip the seminal ves-
icles in order to rid them of the bacteria, which by the
massage were emptied into the urethra and bladder,
where they could be attacked with suitable remedies,
in the form of irrigations and instillations.
For the next four weeks these suggestions were
faithfully carried out by Dr. Manges, but without suc-
cess. Besides massage and local treatment, applied
every other day, salol, methylene blue, turpentine, oil
of gaultheria, and benzoic acid were given internally.
Per rectum, ichthyol suppositories were added; per
urethram, AgNO,, potassium permanganate, and ich-
thyol were applied, but the treatment had no effect.
In the beginning of January, 1896, Dr. Manges, to
whom I am indebted for his notes of the case, kindly
transferred the patient to me, but I was unable to see
in what way I could be more successful in the treat-
ment, as everything was done that I had suggested.
The failure of all therapeutic procedures proved to
me that the continuation of the symptomatic treatment
— for such it was — was useless.
Clearly the bacteria originated in the intestines and
the indication was either to prevent their excessive
formation — the patient stated that he was occasionally
troubled with Hatulence and constipation — or to pre-
vent their absorption.
Close inquiry into the previous history did not re-
veal anything pointing to the patient having had an
abscess of the seminal vesicles or of the prostatic gland.
A direct communication could be excluded, from
the fact that a solution of methylene blue injected
into the rectum did not appear in the urine until
twelve hours afterward, when it had been absorbed
and excreted through the kidneys. The patient, who
had watched the condition of his urine very closely,
was instructed to note particularly if the bacteriuria
was the same at all times of the day. His attention
having been drawn to this, he noticed that when he
had had an evacuation of the bowels in the early morn-
ing upon rising the urine passed between nine and
twelve o'clock was fairly clear, but that it was cloudy
again at subsequent urinations in the afternoon. All
local and internal treatment was then discontinued,
natural Carlsbad salt was ordered to be taken every
morning, and the patient instructed to abstain from
e\erything in his diet that was apt to increase the in-
testinal fermentation. The Carlsbad salt moved the
bowels freely, but the bacteriuria remained unchanged.
The patient was then advised to take enemala of soap-
suds with borax, one tablespoonful of the latter to two
quarts of the soap emulsion. This was carried out for
one week, once daily, and at the same time the patient
took enteric pills of corrosive sublimate, yJjj grain,
t. i. d., purposely prepared so that they should not
dissolve imtil reaching the intestines. M'hile the
enemata produced a free evacuation of the bowels in
the morning and the urine cleared up for the first few
hours after the evacuation, it was full of bacteria in
the afternoon and evening. Once only, on a Sunday,
when the patient could arrange to irrigate twice with
soapsuds, viz., at 9 .-v.m. and 3 P..M., the urine was clear
during the entire day, but the first urine passed the
next morning was as cloudy as before.
He then consented to take two enemata regularly
every day, one upon rising, the other before retiring.
Under this treatment within one week the condition
improved to such an extent that when he presented
himself again after the lapse of the week the urine
was found clear in all its portions at all times of the
day. For the sake of completeness, however, I must
state that for the first four days of that week the patient
had taken creosote, three minims, t. i. d., in the form
of enteric pills, of which twelve had been prescribed.
From my experience with the multitude of other in-
ternal medicines which the patient had been taking, I
can hardly think that the cure can in any way be at-
tributed to the twelve capsules of creosote. The ene-
mata were continued twice daily until the beginning
of March, when the patient used them only once daily
until March loth. He then discarded them entirely.
The condition has not changed, the urine has re-
mained absolutely clear and normal, and as a suffi-
ciently long time has elapsed since all treatment was
discontinued the patient can safely be considered
cured.
Without any hesitation I attribute the cure to the
rectal irrigations with soap and water, the excellent
disinfecting properties of which have long been known
and have lately been again experimentally demon-
strated by Max JoUes, particularly in their relation to
the bacterium coli commun.
As to the etiology of this case of bacteriuria, the
clinical observation and the therapeutic result clearly
point to an intestinal origin. I am inclined to be-
lieve that through the different rectal manipulations
(cooling sound and massage) a superficial loss of epi-
thelium was produced, thereby facilitating the absorp-
August 15, 1896]
MEDICAL RECORD.
231
tion of the millions of bacteria which were in the faces,
in the glands, and in the follicles of a subject in
-whom the possibility was an unusually good one on
.account of the constipation and the increased intesti-
nal fermentation. The infection which took place
was most likely analogous to the one experimentally
produced by VVreden, viz., through the lymphatics.
As stated before, there is an abundance of lym-
phatics going to the prostatic gland and seminal vesi-
cles, and it is easy to understand this mode of infec-
tion.
The development of the bacteriuria was furthermore
facilitated through the distention of the bladder,
caused by the habit of sometimes not urinating more
than twice or three times within twenty-four hours.
If we consider that the normal urethra is the habitat
of a great many microbes and that a thorough disin-
fection of the urethra is well-nigh impossible {(f.
Petit and Wassernian), we must assume that the vis
meiikatrix natiira' plays an important part, inasmuch
as the bladder through regular urination rids itself of
the microbes introduced by instrumentation before any
•decomposition of the urine has taken place.
Krogius reports among his eight cases one in which
a patient who had had a number of gonorrhoeas de-
veloped bacteriuria, due to the bacterium coli comniu-
■ne. He states that in spite of all irrigations of the
'bladder and instillations into the posterior urethra
and bladder of two-per-cent. solutions of nitrate of
■silver, no cure could ht obtained. I believe that this
■case resembles rather closely in its obstinacy in the
■concomitant symptoms, such as increased intestinal
fermentation, the one which I have just reported.
22 East Sixtv-Third Street.
A STUDY OF HYDRAMNIOS AND SOME OF
ITS COMPLICATIONS, WITH REPORT OF
A CASE.
By a. p. STONER, M.D.,
CAINSVILLE, MO.
Hydramnios, or dropsy of the amnion, is an excessive
accumulation of liquor amnii. It is only when the
amount of liquid exceeds four pints that the term hy-
■dramnios in eligible. Its occurrence is not rare;
Iiowever, the literature is not so prolific on the subject
as one might be led to suppose, and I dare say that
•many physicians have passed their first decade in prac-
tice and not had the opportunity of studying a case
at the bedside. A great deal of discussion has taken
place in regard to the etiology of this anomaly, and I
■doubt if the cause is to be found in any one morbid
■condition.
On the one hand, the theory of fcetal origin h.i>
found favor with many observers, notably witlr Sallin-
:ger, who injected liquid into the umbilical vein and
found that it transuded readily into the amniotic sac,
governed as to rapidity by the amount of pressure
>e.xerted and the size of the cord. Jungbluth and Levi-
«on have found that a capillary network is connected
-with the vessels of the umbilical cord and closely in-
rterwoven beneath the amnion in that part of the chorion
■covering the placenta during the early part of preg-
tnancy, but does not persist to the end in a normal
case.
Between these vessels and the internal surface of the
amnion there exist canalicular spaces, furnishing a
number of communicating passages. Now, in cases of
hepatic obstruction or of cardiac or pulmonary disease,
which might clog the umbilical vessels, a transudation
from this network would take place, provided it exist
■ed at the time.
On the other hand, cases have been reported in
which overproduction of the fluid was due to inflam-
mation of the amnion itself, .\ccording to Landois,
the amniotic fluid is due to foetal origin, and is. per-
haps, a transudation through the fcetal membranes;
and, inasmuch as it occurs in birds, this fact throws a
great weight to the fcetal origin of hydramnios.
Symptoms. — 'J'he uterine distention usually begins
slowly; iiowever, a rapid increase may take place, oc-
cupying only a few days, and .Sentex has reported a
case occurring in a single night. The expansion soon
produces discomfort in breathing, owing to the en-
croachment on the diaphragm. This lengthens into
actual pain, by the stretching of the abdominal walls
and viscera. Actual dyspnoea and palpitation of the
heart occur in consequence, and the urine may become
scanty and loaded with albumin. CEdema and ascites
follow, a result of obstruction to the portal circulation
and pelvic and abdominal vessels. Vomiting from
reflex irritation takes place, and may become inces-
sant. The patient may find locomotion difficult or
even impossible.
Pregnancy rarely reaches its normal termination in
cases of hydramnios. \\'hen it exists to a marked de-
gree it produces death of the fcetus, even though preg-
nancy should advance to full term.
Complications. — As before mentioned, cardiac em-
barrassment through the pressure of the diaphragm,
and nephritic obstruction from the direct pressure
upon the kidneys, are produced. Should there be a
tendency to organic disease in either of these organs,
it is liable to become permanent; the heart is over-
worked, compressed, the blood vitiated from the im-
proper oxygenation, the kidneys cease to respond to
their natural duties, blood becomes dammed up, al-
bumin passes through the filters with the other waste
products, and the result is a permanent impairment.
Portal circulation may suft'cr to a less degree. At the
precipitation of labor the child may occupy any posi-
tion: the occiput, breech, shoulder, or face may pre-
sent: and, last but not least of the complications, may
be mentioned post-partum hemorrhage.
A few cases have been reported in which congenital
hydrocephalus was present, as was found in my own
case. \. N. Whitam reports a case accompanied by
spina bifida and enlargement of the head.
Diagnosis is usually easily made out. It may be
mistaken for twin pregnancy, which is generally eas-
ily excluded by palpation, digital examination, and
absence of the foetal heart sound. Hydramnios may
resemble ovarian tumor, which may be differentiated
by the history of the case and the duration of the trou-
ble, but it must not be forgotten that both disorders
may be present in the same case. 0\arian tumor and
pregnancy may exist at the same time, and be mistaken
for hydramnios.
The Prognosis for the child is nearly always fatal;
not more than twenty per cent, survive, the high mor-
tality of the fcetus being in a great measure due to
malformations and faulty presentations.
Treatment. — An abdominal binder may be worn
and the patient be made to refrain from active exer-
cise. Should grave cardiac or renal disease appear,
abortion should be produced. Porak concludes that
it is not desirable to rupture the membrane too early
in cases of hydramnios, lest the placenta be detached
and the child lost. It may also lead to post-partum
hemorrhage. Lusk advises not to puncture the mem-
brane during uterine contraction, as it would be lia-
ble to change the position of the child. Post-partum
hemorrhage must be treated according to the methods
laid down for the management of those accidents.
Tiie following case, which occurred in my own prac-
tice in 1894, may be of interest: November 7th of that
year I was summoned to see Mrs. A , who was
threatened with a miscarriage. She was the wife of a
MEDICAL RECORD.
[August 15, 1896
farmer, fleshy and robust, thirty-five years old; had
given birth to three children at full term, all of whom
were now living. The youngest, two years of age,
has congenital rachitis. The patient stated that she
had been unable to do her housework for several weeks
past, and more recently had found locomotion ne.xt to
impossible; hence she had spent most of her time in
bed or in an easy rocker.
E.xamination showed the abdomen to be enormously
distended, and it was impossible to map out any part
of the child by external palpation or detect the foetal
heart beat by ascultation. The integument over the
abdomen was sallow, glistening, and tense. Pulse
irregular, respiration shallow and somewhat aug-
mented, extremities swollen and cold. On examining
the uterus per vaginam the cervix was found soft and
dilatable. Passing my finger cautiously up to the sac,
it was ascertained that there was a limb presenting:
by gently tapping the same with the finger-tip, the
child was made to bound entirely out of reach and
produce a perceptible oscillation of the liquid within.
I judged from the evidence before me that I had to
deal with a case of hydramnios with foot presenta-
tion. Uterine contractions were now regular and
strong. The patient was bathed with soap and water,
and afterward sponged with a solution of bichloride
of mercury, i to 800, as is my custom in preparing
patients for confinement. The patient was placed on
a couch with clean sheets, etc. At the end of six
hours, the uterus having dilated suflficiently, chloro-
form was cautiously administered by an assistant.
The membranes were ruptured, at which time the fluid
gushed out with powerful force, passing over the foot
of the couch and striking the wall beyond. The flow
was suddenly checked by the descent of the child.
Both feet being brought down, the uterus continued to
dilate regularly and rapidly, and the progress was un-
interrupted until the head became engaged in the lower
segment of the uterus, when it ceased to advance.
Suspecting that the arms had been misplaced upward
by the side of the head during the sudden descent of
the child, I examined, but found them snugly folded
on its breast. After cautious performance of the or-
dinary manipulations by traction on the body of the
child, the pains being frequent and exceptionally
strong, it occurred to me that there was a complica-
tion of hydrocephalus, there being no progress what-
ever to expulsion. Accordingly, a puncture was made
in the dorsal vertebra, and an elastic catheter passed
into the cranial cavity, from which about one quart of
fluid was withdrawn, after which the head was readily
delivered, at which time another gush of amniotic fluid
poured out, thoroughly saturating the bedding and
trickling through on to the floor. It was estimated
that about thirty pounds of fluid were evacuated in all.
Turning my attention now to what I feared most,
post-partum hemorrhage, I at once injected hypoder-
mically one-half drachm of ergotol ; but before it could
have time to act, the blood began to pour forth. I
quickly thrust my hands into a hot five-per-cent. creo-
lin solution, and passed my right hand into the uter-
ine cavity, which stimulated it to contraction: that
portion of the placenta not already detached was read-
ily loosened by a sweeping movement of my hand and
forced out before it, when the hemorrhage ceased.
The head measured, when fully distended, twenty-
two inches in circumference ; the sutures were widely
separated; the fontanelles were of large diameter; the
eyes bulged and presented a hideous sight: otherwise
the child was well formed and presented the appear-
ance of a foetus at the seventh or eighth month.
The mother made a protracted but perfect recovery.
In conclusion, I would make the following sugges-
tions:
(i) That cases of hydramnios are frequently compli-
cated with cardiac or renal disease, in which case the
life of the fcetus must take .secondar}- consideration.
(2) That faulty presentations frequently accompany
this anomaly and should be sought out early.
(3) That malformations of the fcetus may exist and
obstruct the progress to delivery.
(4) That the danger to post-partum hemorrhage is
great and should be carefully guarded against.
(5) That an antiseptic management is a prerequisite
to the successful treatment of these cases.
^trogrcss 0f ^Xcdiail Science.
Venesection in a Case of Hemorrhage into the
Pons. — At a recent meeting of the Clinical Society of
London, a report of which appears in The Liiiiccf, Dr.
F. L. Benham read the details of a case of hemorrhage
into the pons Varolii in which venesection was fol-
lowed by recovery. The case was that of a widow,
aged fifty-three, whose mother had died from apoplexy
followed by hemiplegia, at the age of fifty-five. She
was a healthy woman, rather stout in build. She bore
the marks of old scrofulous absces.ses in the neck, but
was otherwise free from organic disease. She had had
two attacks of influenza in the last three years. The
present illness began without any premonitory symp-
toms. She was suddenly seized while dressing one
morning with apoplexy attended by epileptiform con-
vulsions, chiefly on the left side, and complete uncon-
sciousness. The eyes were shut; the head, eyeballs,
and mouth were all drawn to the right side; and the
pupils were much contracted, the left being rather the
smaller. Respiration was much embarrassed. There
was foaming at the mouth, but the tongue was not bit-
ten. The surface of the body was pale and dusky,
with a clammy sweat. Within three-quarters of an
hour from the onset of the attack she was bled from
the right median cephalic vein. Forty-eight ounces
of blood were withdrawn. When this was done the
convulsions ceased and breathing became easy; the
pupils were larger and the conjugate deviation of the
eyes and head was less marked. The skin was pale
but less dusky. Consciousness had not returned.
Five grains of calomel were administered, in addition
to croton oil. There was no return of the convulsions
at all; the eyes, head, and limbs moved more freely
and spontaneously, but there was found to be some
weakness of the right side, and later distinct ansesthe-
sia was detected in the right ann and leg. Sensibil-
ity and consciousness gradually returned, but complete
consciousness and memory did not return for twelve
days, the patient describing this interval afterward as
an absolute blank. There was slight aphasia during
recovery. The paralysis of the left side of the face
and right limbs lasted only a short time, but traces
of ana:thesia in certain fingers and toes persisted for
some weeks. Retention of urine occurred immediately
after the apoplexy, which caused cystitis. 'I'here was
obstinate constipation all along. The patient steadily
recovered. In a month's time she was able to walk
about the room, and in six weeks from the onset she
went out of doors for a walk. She had remained in
excellent health up to the time of the report, eleven
months after.
Sterilization of Catgut Boil in a mixture of
eighty-fi\e parts of ethyl alcohol, five parts of phenic
acid, and ten parts of water. Five minutes' boding
suffices for the sterilization with a temperature reach-
ing 78' C. Without the water the process is not so
complete nor so rapid. — S.\UL.
August 15, 1896]
MEDICAL RECORD.
233
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, August 15, 1896.
ACUTE DISSEMINATED SCLEROSIS WITH
NEURITIS IN THE SEQUENCE OF DIPH-
THERIA.
The modem toxic theories of disease processes, aris-
ing out of a knowledge of the biologic activity- of
micro-organisms, maybe viewed as a kind of reversion
to the ancient humoral pathology, with the distinction,
however, that the latter-day views are based more
securely upon data furnished by scientific observation,
rather than upon mere inductive reasoning, however
rigid. As a rule, infectious processes give rise
primarily to local lesions only, the constitutional
manifestations resulting from the circulation in the
blood of the soluble poisons generated at the primary
focus, and the secondary lesions and complications
occurring through metastasis or through independent
or associated secondar\' infections.
Diphtheria is perhaps the most demonstrative and
the most convincing illustration of the foregoing re-
marks. Primarily a purely local process, it becomes
general through the absorption of the toxic products
of the reaction between the invading bacteria and the
tissues, and through the activity of complicating in-
fections, especially those due to the presence of the
streptococcus pyogenes. The resulting intoxication
makes itself especially manifest by the most varied
symptoms, referred to the nervous system as one part
or another is brought under the influence of the nox-
ious agent. In the preponderance of cases these symp-
toms are referable to neuro-muscular apparatus.
The motor disabilities arising in the sequence of
diphtheria vary in clinical character in accordance
with the structures affected and the pathological altera-
tions that take place. Most commonly the peripheral
nerves undergo inflammation or degeneration, espe-
cially the motor nerves, although the sensory nerves
do not always escape. In some instances the muscles
themselves are involved in the degenerative process.
In a third group of cases destructive changes take
place in the ganglion cells of the anterior horns of the
spinal cord. Finally cerebral hemorrhage or embo-
lism may occur and give rise to hemiplegia of apoplec-
tic onset.
An observation recently recorded by Henschen
(Fortschritte der Aledtcin, November 14, 1896) illus-
trates an unusual nervous sequel of diphtheria and
throws some light upon the etiology of disseminated
cerebro-spinal sclerosis. A girl, fourteen years old,
previously healthy, was seized, together with a number
of other persons, with an acute affection of the throat
of mild type, on the second day of which she was
compelled to go to bed. On the fifth day a sense of
pricking and formication was referred to the lower ex-
tremities, which were tremulous and weak. On the
sixth day the patient was unable to walk, and retention
of urine occurred. A day later she was scarcely able
to support herself on her feet. The palsy of the legs
grew gradually complete, and sensibility was lost as
high as the costal arch. Later the right arm became
paretic and the anaesthesia extended still farther up-
ward. The knee jerks were now increased, although
subsequently abolished. The mental state remained
unaltered. The cranial nerves were uninvolved, ex-
cept that visual acuit)' was impaired on the left and
the eyelids could not be readily elevated. The pupils
were large and of sluggish reaction.
In the further progress of the case the left arm also
became paretic; the ptosis increased; hyperaesthesia
appeared in the lower portion of the face and in the
right arm ; the voice became nasal, the right vocal
band being less active than the left; and the muscles
of the throat failed in their functions. The electric
irritabilit)' of the paralyzed muscles was diminished
and the contractions were sluggish. The sphincter
ani also became ansesthetic and a thrombus formed in
the right leg. After the illness had thus continued
for more than a month, improvement in the motor and
sensory symptoms began to set in, but a bed sore
formed, the patient wasted greatly, and broncho-pneu-
monia brought death. Upon post-mortem examination
numerous disseminated sclerotic areas were found
throughout the length of the spinal cord. These were
few and small in the cervical region, where the postero-
median columns had undergone degeneration. The
areas of sclerosis were greater in number and extent
in the dorsal region, in the lower portion of which the
postero-median columns were especially affected; but
elsewhere the distribution of the sclerosis was general,
though smallest in the pyramidal tracts. In places
the gray matter of the cord was invaded. In the
affected areas the ner\'e fibres were more or less com-
pletely degenerated ; the axis cylinders were best pre-
served. The separation of healthy from diseased
structure was rarely defined sharply. The neuroglia
of the white matter appeared increased and contained
many nuclei. In the areas in the gray matter the
large ganglion cells presented varying degrees of de-
generation and the tissues contained numerous small
glia cells, as well as fibrils. Diphtheria bacilli were
looked for but not found. Degenerative changes were
also present in the nerve roots. The vessels were
surrounded by an abundant round-cell infiltration;
the walls of the vessels, had, as a rule, undergone but
little change. The nerves of the lower extremities
were degenerated and those of the upper also, though
in slighter degree. The brain was not examined.
While the case as reported pursued the clinical
course of diphtheria, it is to be regretted that the
diagnosis was not confirmed by the discovery of the
bacillus of Loeffler. Accepting the diagnosis as cor-
234
MEDICAL RECORD.
[August 15, 1896
rect, however, the observation is exceedingly interest-
ing, as illustrating a hitherto unnoted sequel of diph-
theria and as showing further that disseminated
sclerosis is histologically an inflammatory process.
NIGHT TERRORS.
Dr. J. A. CouTTS some time ago gave an interest-
ing review of our present knowledge regarding the
above subject, and contributes some of the results of
his own experience and reflection. He says that
systematic writers have not paid as much attention to
this topic as its frequency and importance demand.
He thinks that the descriptions given by English
writers are incomplete and unsatisfactory. The
.-Vmerican additions to the literature of the complaint,
though not numerous, are of extreme value, and he
refers particularly to the writings of Lyman, Wood,
and Putnam. The disorder known as " night terrors"
is attributable to a very wide range of causes. The
list includes digestive irritation, — always the most
popular one, — adenoids of the pharj'n.x, enlarged ton-
sils, rheumatism, epileptic tendencies, and hysteria.
Dr. Coutts thinks that there are two classes of cases,
of which the common symptom is " terror" arising
during sleep, and it is because of these different
classes that the etiology is so variously given. In the
first class there come cases of a reflex character, due
to abdominal or nasal trouble. In the second class
there come cases of comparative infrequency, in
which the malady arises from central cerebral disturb-
ances. For the first class of cases Dr. Coutts pre-
fers the name of " nightmare," and would reserve that
of "night terrors" for the second class only, in which
the malady is of central origin. This separation has
been made before, as Dr. Coutts admits, in corre-
spondence with a classification of night terrors into
symptomatic and idiopathic. The main question is.
How can the physician tell when the patient is suffer-
ing from the symptomatic or idiopathic form? Dr.
Coutts is of the opinion that the diagnostic points are
these in true night terrors: it is essential that the pa-
tient should see visions, or, in other words, have hal-
lucinations. In nightmare, it is sufficient that he
merely dream dreams. Night terrors, he adds, seldom
occur in children under the age of two or above that of
eight years. In nightmare, there are no such limits
of age. In night terrors there is a history of neuroses,
such as epilepsy or hysteria in other members of the
family, and sometimes infantile convulsions have pre-
ceded the night terrors in the history of the patient.
In night terrors the attack comes on when the child is
in the best of health, and is quite sudden in its onset,
while children who suffer from nightmare are usually
subjects of indigestion or nasal trouble, and in rather
poor general health. In the course of the night there
is usually but a single attack of night terrors, but there
may be several of nightmare. Nightmare occurs in a
child often at the end of a number of hours of restless
sleep, while night terrors frequently show themselves in
the form of a sudden violent explosion, so to speak. If
the physician has been able to distinguish the case.
as between a serious neurosis and a dyspeptic or other
reflex disturbance, the treatment is simple enough.
For pavor nocturnus bromide of potassium or some
similar drug is absolutely necessary, while in the
nightmare of children it is necessary to regulate the
diet, look after the throat and nose, and improve the
general health of the patient.
THE BRITISH MEDICAL ASSOCIATION.
The meeting of the British Medical Association in
Carlisle the last week in July, a special report of
which will be found elsewhere in this issue, seems to
have been up to the usual average of such gatherings.
The attendance was expected to be between seven
hundred and eight hundred, which is the figure usu-
ally reached at the provincial meetings, but on the
afternoon of the third day only six hundred and
fifty members had registered. The addresses at the
general sessions were not of a very high order, and will
hardly rank among the best efforts of their authors.
The most suggestive was perhaps that of Sir Dyce Duck-
worth, on " Prognosis in Disease." The non-scientific
proceedings of the last session were very stormy and
the record of them was ordered to be suppressed for
various reasons. The nature of the discussion can be
imagined from the subject, which was " Ethics in Ad-
vertising." During the past year several men high
in the councils of the association have been thought to
favor, for their own use, rather unethical methods of
keeping themselves before the public, while they were
at the same time more or less scandalized by the em-
ployment of apparently no more reprehensible methods
of obtaining the same results by their less eminent
brethren. Some of these latter had an opportunity to
express themselves at this meeting.
The acceptance by the association of the invitation
from the Montreal branch to meet in that city next
year is interesting. We believe the Canadian branch
of the British Medical Association has been in exist-
ence only since 1893, and that it now feels competent
to entertain the parent body next August is an evi-
dence of healthy growth. The selection of Dr. Rod-
dick, of Montreal, to preside at the meeting will be
gratifying not only to his compatriots but to all his
friends in this country as well. Doubtless many
Americans will assist as spectators at the meeting in
Montreal, and New Yorkers at all events will have the
pleasure of meeting old acquaintances and of forming
new ones among those coming to the meeting from
Great Britain and Ireland. While, therefore, our Can-
adian brethren only have an official concern in this
action of the British Medical Association, all of us, as
Americans, are pleased to know that its members are
coming to our side of the Atlantic.
But there is another matter of interest in connection
with this move, and that is the effect it will have upon
the attendance of English-speaking physicians at the
Moscow congress. No one would think of attending
two meetings within one month in places so remote
from each other as Moscow and Montreal, if indeed
the inter^al of time between the two conventions
August 15, 1896]
MEDICAL RECORD.
235
would suffice for the journey. It is safe to assume,
therefore, that no Canadians and but few British will
go to Moscow, while the attendance of Americans
would be small in any case. So doubtless the English
language will be heard but rarely, notwithstanding its
tardy recognition as an official tongue by the organiz-
ing committee. Whether or not the leaders of the
British Medical Association intended any slight by
turning their backs upon the International Congress
we are unable to guess, but their action might easily
bear that construction.
^a.V3 0f tTxe ^^cefe.
The Heat Mortality The e.xcessive heat from
which we have been suffering since the 4th of this
month, and from which we have only just now ob-
tained a slight measure of relief, is almost unprece-
dented in the records of the weather bureau. No
such iong period of unbroken high temperature has
been experienced, in this city at least, since 1S72,
even the centennial year, the miseries of which are
not yet effaced from memory, having had no single
term of such length of unremitting high temperature.
Fortunately, the heat was tempered part of the time
by a rather low humidity. The number of deaths re-
ported as from sunstroke in New York City alone in
eight days was two hundred and eighty-eight, and
doubtless these figures would be doubled were all the
deaths included which could justly be attributed to
the effects of the heat. The number of cases of pros-
tration of which the police and health authorities had
cognizance was over sixteen hundred and fifty in the
metropolitan district. The greatest number of deaths
from insolation on any one day was one hundred and
twelve, the next greatest being sixt\'-five. The high-
est temperature recorded at the signal station in the
city was 94' F., but this station is located some three
hundred feet above the level of the streets, where the
mercury ranged several degrees higher. During one
of the least torrid days of the period, a thermometer
placed in the sun registered 113° F.
Cholera in Egypt. — The official cholera returns
from Cairo show that on August 9th and 10th there
were throughout Egypt 322 deaths from cholera.
Since the outbreak of the disease this year there have
been 13,986 deaths.
Pennsylvania State Medical Examinations. — It
is announced that of the 381 applicants recently ex-
amined for license to practise medicine in the State of
Pennsylvania 340, 89.24 per cent., were successful.
Delaware County (Pa.) Medical Society. — At the
regular monthly meeting of the Delaware County
Medical Society, held at Elwyn on July 24th, Dr. A.
A. Eshner, of Philadelphia, read a paper entitled
" Some Considerations on the Treatment of Typhoid
Fever;" Dr. H. W. Cattell, of the University of Penn-
sylvania, demonstrated Roentgen photography and
e.xhibited a number of interesting lantern slides.
Kentucky School of Medicine. — At a recent meet-
ing of the faculty of this school, the following lectur-
ers were appointed: Drs. Louis Frank, clinical and
operative gynecology; Henry E. Tuley, obstetrics;
Carl Weidner, physiology; W. E. Grant, anatomy;
Ewing Marshall, physical diagnosis; T. C. Evans,
ophthalmology, otology, and laryngology.
Lehigh Valley (Pa.) Medical Association. — The
sixteenth annual meeting of the Lehigh Valley Medi-
cal Association was held at Wilkesbarre on August
6th, with a large attendance. Twenty-four new mem-
bers were elected, including Dr. George M. Gould, of
Philadelphia, and Dr. Roswell Park, of Buffalo. Dr.
Gould read by invitation a paper entitled '" Some Cu-
riosities of Medical and Surgical Practice.'" The fol-
lowing officers were elected for the ensuing year:
President, Dr. J. R. Bucher, of Lebanon; Vice-Presi-
dents, Drs. Mary Greenwalt, of Stroudsburg, G. T.
Fox, of Allentown, O. F. Harvey, of Wilkesbarre, C.
J. Deaver, of Reading; Secretary, Dr. Charles Mcln-
tire, of Easton ; Assistant Secretary, Dr. W. S. Stewart,
of Wilkesbarre ; Treasurer, Dr. A. Stout, of Bethle-
hem. The executive board was constituted as follows :
Drs. J. Reisser, of Berks County ; A. M. Cooper, of
Bucks; W. E. Seipel, of Carbon; O. H. Sproul, of
Hunterdon, N. J. ; J. W. Keath, of Lebanon ; M. E.
Hornbeck, of Lehigh; C. P. Knapp, of Luzerne; W.
E. Gregory, of Monroe; J. W. Groff, of Montgomery;
N. Ziegenfuss, of Northampton ; Montetius, of North-
umberland; and P. Hermany, of Schuylkill.
Bucks County (Pa.) Medical Society At the reg-
ular quarterly meeting of the Bucks County Medical
Society, held at Bristol on August 5th, Dr. Edwin
Rosenthal, of Philadelphia, read a paper on '"Intuba-
tion for Diphtheria," e.xhibiting the instruments em-
ployed and demonstrating their mode of application.
Guarding against Yellow Fever and Small Pox.
— Dr. Doty, health officer of the port of New York,
has gone to Havana, to institute measures there for
the prevention, as far as may be, of the exportation
of small-pox and yellow fever on steamers coming to
this city.
Dr. Bismarck. — The German universities have ex-
hausted their supply of honorary degrees in their de-
sire to express their appreciation of Prince Bismarck.
He was already a doctor of laws, of theolog\% of phi-
losophy, and of political science, and now Jena has
made him a doctor of medicine. We welcome our
distinguished colleague.
Physician to the Shah of Persia. — It is reported
that the Shah of Persia has selected as his family
physician Dr. William S. Vanneman, a graduate of
the University of Pennsylvania in 1888 and formerly
a resident physician in the Philadelphia Hospital.
Fees for Insurance Examinations. — One of the
life-insurance companies in this city has returned to
its former uniform rate of S5 for the medical examina-
tion of an applicant, no matter what the amount of the
insurance which is to be taken.
236
MEDICAL RECORD.
[August 15, 1896
Obituary Notes. — Dr. Robert M. Boyd died on
August 6th, in Springfield, Mo., of typhoid fever. He
was twenty-seven years old, and the son of the late S.
H. Boyd, minister to Siam under the Harrison admin-
istration.— Dr. Charles H. Weinholtz died at his
home in this city on August 7th, from the effects of
some narcotic poison taken accidentally in overdose
for the purpose of inducing sleep. He had been un-
usually busy and was suffering from insomnia. He
was born in Richmond, Va., of German parents, and
came to this city at an early age. He was a graduate
of the University Medical College in 1883. — Dr. J. A.
S. Grant Bey, of Cairo, Egypt, died suddenly on July
28th, while en route to attend the meeting of the Brit-
ish Medical Association in Carlisle.
Viewing the Internal Organs. — At the Interna-
tional Psychological Congress, held early this month
at Munich, there was an exhibition of the " X" rays
which fairly eclipsed all previous ones. The body of
a man was submitted to the action of the rays through
an apparatus of special design, which enabled the
spectators to clearly observe the action of the dia-
phragm, heart, and stomach. The experiment was en-
tirely successful.
Professor Mendel, the alienist of Berlin, was re-
cently called to St. Petersburg to see a patient in con-
sultation with the local physicians. Some excitement
was occasioned by a rumor that it was the Tsar whom
he was to e.xamine, but this has been contradicted, al-
though the sufferer is still supposed to be a member of
the imperial family.
Suicide appears to be epidemic in Austria at pres-
ent. Vienna had two hundred and seven suicides
during the first six months of the year, which is dou-
ble the average for the last ten years. .\t Lemberg,
in the same period, seven .soldiers in the thirtieth in-
fantry regiment killed themselves. Quite recently a
shoemaker in Vienna adopted a spectacular mode of
exit. He joined a party of English tourists visiting
the steeple of St. Stephen's Cathedral. When they
had reached the jslatform from which Count Star-
kemberg watched the 'I'urks during the siege of 1683,
he jumped off, landing on his neck on the roof below.
Unwarranted Liberties with Medical Thought
Cases. ^In a certain shop in Carlisle, during the re-
cent meeting of the British Medical Association, there
was shown in the window a contrivance for taking the
shajse of the head when one desired a new hat. It
was labelled: "Shapes of heads taken with the 'Con-
formateur.' Local doctors." Here followed, spread
out in the window, some twelve or fifteen pieces of
cord, each labelled with the name and address of the
medical man whose head the cord was shaped to repre-
sent. Among those whose names and addresses were
given was Dr. Barnes, Portland Square, the president
of the association. The Lancet published quite a list
of these names, innocently remarking that " of course,
these gentlemen are quite ignorant of the use that is
being made of their names and will take care that it is
not continued."
The Health Board Sustained. — The board of
health of this city has been looking into the condition
of rear tenement houses and condemning all such as
it deemed insanitarj-. An owner of one of these
houses recently made application to enjoin the board
from evicting his tenants, which it was doing prelimi-
nary to tearing the house down as detrimental to the
public health. The petitioner did not attack the con-
stitutionality of the law under which these rear tene-
ments are being condemned and removed, but he de-
nied the right of the board to order the tenants to get
out before a judicial decision had been given con-
demning the rear tenement. Justice Stover, of the
Supreme Court, denied the application, saying that
under the statute the board of health is constituted the
authority to pass upon the condition of the property
and to determine its sanitary condition. In doing
this it is performing a judicial act, and that act ought
not to be interfered with by the injunction of the court,
unless it should clearly appear that the board was
without jurisdiction. He thought the board was act-
ing within its rights, and although some of the features
of the law appeared to be arbitrary and the proceeding
summary, yet with the provision for compensation and
with the rights of the property owners so well guarded,
no lasting or irreparable detriment could come to the
property owner. The public health demands that the
provisions of the law should, in all cases in which it is
once determined that they apply, be summarily and
rigidly enforced. If, however, an appeal to the court
is to be taken in each instance, the court becomes the
arbiter of the question and the object of the statute
is defeated. It was the intention of the statute to
place all responsibility of the inspection and adjudi-
cation as to the condition of the premises with the
board of health ; and, so long as the board had facts
sufficient to give jurisdiction, the court would not in-
terfere.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
August 8, 1896: August 4th. — Passed .\ssistant Sur-
geon G. H. Barber, detached from the A'ew York, or-
dered home, and granted two months' leave; Passed
Assistant Surgeon V. C. B. Means, detached from the
Maine and ordered to the New York.
Dr. James G. Kiernan has resigned the editorship
of the Mcclictj! Standard of Chicago.
Chicago's Medical Schools.— A St. Louis contem-
porary says that Chicago has seventeen medical
schools — nine regular, six homceopathic, one eclectic,
and one " physio-medical." It must be quite a dis-
tinction there not to be a " professor."
The American Medical Association will establish
its quarters permanently in Chicago, according to the
count of the recent ballot of its members. Three thou-
sand and sixty-one votes were cast out of 5,265 bal-
lots distributed, and of this number 2,128 were for
Chicago, 810 for Washington, and the rest were scat-
tering.
August 15, 1896]
MEDICAL RECORD.
237
Communicable Diseases in the State of Penn-
sylvania.— According to the annual report of the
secretary of the Pennsylvania State board of health
for the year 1895 recently issued, it appears that as a
result of prophylactic vaccination small-pox pre-
vailed at only nine points in the State during the
year. In Philadelphia there were three hundred and
ninety-six cases, with fifty-five deaths. In the town
of Aslibourne the first case was mistaken for one
of chicken-pox, and in the failure to adopt suit-
able precautions the infection spread quickly. As
a result of this and a similar previous experience, a
resolution was adopted by the board expressing the
desirability in all cities having hospitals for contagi-
ous diseases to arrange for the practical instruction of
medical students. Typhoid fever prevailed with its
usual frequency. An outbreak at Oil City illustrates
the resistance of the typhoid bacillus to cold and its
portability in large streams for considerable distances.
The disease appeared in those parts of the city that
received tlieir supply of water from the Allegheny
River as soon as the ice began to melt and the ma-
terial that had collected at various points along the
river was washed into the stream by the melting snow
— typhoid fever having prevailed during the winter in
a number of towns situated higher up. There was an
increased prevalence of scarlet fever, which in some
places was of virulent type. Diphtheria also prevailed
largely and was attended with a high mortality.
A Chance for a First-Class Thaumaturge — It is
reported in the newspapers that a wealthy and eccen-
tric New Yorker who is blind from atrophy of the
optic ner\e and one of whose employees is in the
same condition, has oftered a fee of one million dol-
lars to the person who will restore him his sight, the
attempt to be first tried on this employee.
A Case of Double Consciousness.— There was
brought into the Philadelphia Hospital on March 3d,
of the present }'ear, a man who was found on the
streets and maintained that he did not know his name
or the circumstances that led up to his admission or
in fact have any memory of events prior to that date.
In his possession was found a pawn ticket bearing the
name of Brandt and by this name he was registered.
After some days of observation it was found that the
man presented no evidences whatever of organic dis-
ease and he was put at clerical work, which he per-
formed with readiness and ability. He was exhibited
at the meeting of the American Neurological Associa-
tion in Philadelphia in June last. When a new set of
resident physicians went on duty at the hospital early
in July, one of their number recognized the new clerk
as a former schoolmate, but the recognition' was not
mutual. The identity of the man was verified by a
photograph in the possession of the resident physician
and was subsequently confirmed by other acquaint-
ances, as well as relatives of the patient. The man
maintains that he has no definite recollection of any-
thing that transpired prior to March 3d, although he
admits that he has a vague notion of having travelled
abroad. His familv, who live in Kansas, knew of his
presence last in New Orleans, where he occupied a
responsible position with a sugar concern. The man
presents no evidence of traumatism, or of epilepsy, or
of other well-defined neurosis. It has been suggested
that the case may be one of malingering or of hypno-
tism, but it looks like an instance of double conscious-
ness or dual personality.
The Composition of Human Fat. — Mr. C. A.
Mitchell reports in the Analyst the results of an an-
alysis of human fat, according to which it consists of
about seventy per cent, of liquid acids, principally
oleic acid, thirty per cent, of solid acids, probably pal-
mitic, with small amounts of stearic and myristic acids,
and traces of lower volatile acids.
Diphtheria of malignant type is prevalent at Man-
heim. Pa. At St. Clair, near Pottsville, the disease
is reported to be attaining epidemic proportions.
Ungallant Irish Students. — .At the recent election
of e.xaminers at the Royal College of Surgeons in Ire-
land, Dr. Winifred Dickson, a fellow of the college,
was selected a member of the midwifery board. There
was no question as to her fitness for the place, but the
students were offended and have held a meeting, and
have requested Dr. Dickson to resign. The reasons
are not stated, but it is understood that they object to
being examined by a woman, on the plea that it is not
quite proper. So great, indeed, is their modesty that
they threaten, if their demand is not complied with, to
transfer themselves to some other school and to an-
other licensing body. .
A Russian Dermatological Journal. — At the Con-
gress of Russian physicians, held at Kieff during the
first days of May, the members of the dermatological
section voted to establish a journal devoted to dis-
eases of the skin. The editors of the new journal are
to be M. T. Stukovenkoft' and O. B. Petersen.
Handsome Legacy for the University of Penn-
sylvania.— By the death of Dr. William D. McGow-
an, of Latrobe, Pa., the University of Pennsylvania
becomes heir to a considerable estate, of which $20,-
000 is represented by personal property, the remainder
consisting of unappraised real estate.
The Effects of Alcohol. — The Women's Christian
Temperance Union of Philadelphia has decided to
communicate with the provost and the trustees of the
University of Pennsylvania, requesting them to con-
sider the advisability of establishing a school to be
devoted, partially at least, to the study of alcoholic
drinks, in connection with those of physiology and hy-
giene. It is suggested that a portion of the $500,000
appropriated to the university by the legislature shall
be used in establishing a school, to be known as the
Rush School of Toxicology or Scientific Temperance.
The Policlinico at Rome, in which the section
meetings of the International Congress were held,
which was then in an unfinished state, has not even
yet been completed. Professor Durante has been
placed in charge of the matter, and it is now hoped
that the hospital will be ready for the reception of
patients in November next.
2.^,8
MEDICAL RECORD.
[August 15, 1896
Society Reports.
BRITISH MEDICAL ASSOCIATION.
Sixty-Fourth Annual Meeting, Held at Carlisle, July
28, 2g, JO, and 31, i8g6.
(Special Report for the Medical Record).
First Day — Tuesday, July 28 th.
The proceedings commenced at 9:30 a.m., by a pri-
vate meeting of tiie council.
At 10 A.M. an extraordinary general meeting, to
consider and if thought advisable to confirm a special
resolution relating to medical defence, was held. This
meeting was, of course, restricted to members, as it
was proposed to alter the constitution of the association
in order to take up the work of medical defence. The
matter was fully discussed, and eventually the resolu-
tion confirming that of a recent special meeting was
adopted. The association is therefore committed to
an attempt to modify the " .Articles." This will in-
volve delay and an application to the High Court.
Pledges were given that the matter should not be un-
duly hurried forward, so that the opinions of the
branches could be considered. It was stated that
twenty-eight branches had already approved of the
proposal, and only one had expres.sed a contrary view.
At 11:15 A.M. there was a special service in the ca-
thedral, with a sermon by the bishop of Carlisle, who
took for his text, " Give praise to the physician, for
verily the Lord created him." In the course of his
remarks the bishop said: " Sickness is the dark shad-
ow cast by sin, and it is the business and duty of the
medical man to bring light to bear upon it. Medi-
cine and religion work hand in hand, and were for-
merly combined in the same person, as when Christ sent
his apostles to preach the gospel and heal the sick."
At present, three distinguished missionary bishops of
the .Anglican Church began by being medical practi-
tioners, and this was very appropriate, for the com-
mand to heal the sick involved the investigation of
disease.
Chairman's Address. — At 2 p.m. the first general
meeting of the association was held. Dr. Ward
COUSIN.S, president of the council, in moving the adop-
tion of the report, mentioned the great loss that the
association had sustained by the death of the presi-
dent. Sir Russell Reynolds, and a telegram from Lady
Reynolds was read, acknowledging the receipt of the
message of condolence sent to the family by the coun-
cil in the name of the association. Dr. Ward Cousins
then alluded to the prosperity and increase in num-
bers of the association, which now consists of 16,332
members, 145 having died and 442 resigned during
the year, out of a total of names on the books amount-
ing to 15,669; during the year 1,240 new members
were received, leaving a total as above. During the
year \.\\^ Journal o{ the association had treated a num-
ber of questions of great public importance, such as
the health and physical condition of the pauper chil-
dren cared for by the State, the commemoration of the
Jenner centenary, and other matters. He also an-
nounced that the library and reading-room had been
used by an increasing number of members, and that
the former now contained eight thousand books, while
thirty-five hundred duplicate copies had been presented
to local medical libraries on requisition.
The subject of the registration of midwives and mat-
ters connected with the army medical .service, the
poor-law medical ser\'ice, etc., had occupied the atten-
tion of the council; with respect to the first. Dr.
Ward Cousins expressed his opinion that the delays
that had taken place in bringing it forward were valu-
able, as affording the profession more time to consider
the matter. He also mentioned that the number of
cases of parturition necessary for a student to attend
before presenting himself for examination had been
increased from twelve to twenty, five of which must
have been attended in conjunction with a fully quali-
fied medical man.
The question of medical protection had given the
council "'days of waiting and nights of watching,'' for
they were determined not to " rush" anything.
'Fhe president of the council congratulated himself
and the association on the formation of ethical com-
mittees by almost every branch, and said that the as-
sociation appeared to be waking up to a consciousuess
of its power and importance, and that soon the voice of
the association would be that of a united profession.
After referring to the changes that had taken place
in the branches during the year, Dr. Ward Cousins
moved the adoption of the report, together with the
financial statement appended to it.
It was moved by Dr. KiNcsiiURV that it be referred
back for consideration and further elaboration of the
financial statement, which '" humped things too much."
He also said that Dr. Ward Cousin's speech reminded
him of a missionary meeting, it was so full of encour-
agement and hope, for which he confessed he saw lit-
tle ground. Referring to the statement that only a
small number of the communications forwarded by
members would be utilized, he said that anonymous
articles should not be paid for; which provoked the
retort that these were the only ones that were paid for
in cash, for the signed articles carried their own rec-
ompense with them by giving a sort of advertisement
to the writers, of which, no doubt, many made the most
use they could. He did not wish to put himself in
antagonism with the council, but spoke as a business
man to business men.
Dr. Inch seconded the amendment and wanted to
know what became of the money; for no limited lia-
bility company would consent to receive a balance
sheet like the one presented to them. Many fingers
were dipped into the bag, and some of these fingers
had long nails. He did not mean to impute impropri-
ety to any one, but there were careful and careless
cooks. The former took as much flour as she wanted
out of the barrel, but the latter took so much that she
let half of it fall on the floor. That was all he
meant. Dr. Ince then referred to typographical errors
in \.\\tt Journal, which he did not think deserved any-
thing like the encomiums bestowed upon it by the
president. He found four typographical errors in the
last number in the little word "to," and was of the
opinion that two to's were too many.
Dr. Lawson Tait supported the amendment, but
only in the spirit of one who asked for information;
he wanted to know why, when the council would not
use more than a small percentage of the communica-
tions received, it allowed the editor to occupy two
hundred and thirty colunms with signed matter of his
own, in addition to his imsigned editorials.
Dr. Lakfan also supported the amendment, and
complained that the association had not taken any
steps in the matter of pupilage. None but a few priv-
ileged teachers were permitted to take pupils. He
also complained that the Dublin hospitals admitted
as patients men who were well able but too mean to
pay for treatment, and no notice was taken of a signed
communication to that eflfect which he had sent to the
Journal.
Dr. G. Brown also supported the amendment,
though he approved of much that the council had done,
and was of opinion that the general practitioner
chiefly required to be protected against himself.
Dr. Rentoxe also spoke in favor of the amend-
ment.
August 15, 1896]
MEDICAL RECORD.
'■39
The amendment was then put to the meeting by llie
president-elect, Dr. Henry Barnes, but only thirty-
three hands were held up for it. The report and finan-
cial statement were then adopted by a very large ma-
jority.
The President then moved '' that the best thanks
■of the association be given to Mr. Henry Butlin for
his able services as treasurer for the past six years
and for the interest he has shown in the welfare of
the association." Carried unanimously.
It was then proposed that Dr. Parsons, of Dover, be
appointed treasurer for three years, in succession to
Mr. Butlin, and this, too, was carried unanimously in
the absence of the doctor.
The meeting then proceeded to the consideration of
the reports by the various committees to the council,
which were duly carried without material alteration.
An elaborate report of the scientific grants commit-
tee gave rise to more discussion than the others, but
presented no special features, though, a propos of the
e.xperiments detailed, it may be of interest to quote a
passage from a sermon preached on Sunday evening,
July 25th, by the Rev. James Christie, in the Presby-
terian Church, Fisher Street, Carlisle, with special
reference to the visit of the British Medical Associa-
tion to that city. " I should never dream," said the
reverend gentleman, "of lending my name as a minis-
ter of the gospel to any association mainly composed
of faddists and cranks, who would seek to traverse the
dogma of pure medical science or attempt to thwart
any of its investigations into the causes and cure of
maladies; even vivisection can be pursued with a
minimum of pain and with the greatest humanity.
The lower creation has been given for the use of man,
and when investigation is carried out upon its living
body, not needlessly or lightly, but with an earnest
and reverend desire to secure the amelioration of the
sad lot of so many among us, I say to the deft-handed
anatomist: 'Well done, brother; God give thee good
speed in thy senice to the human race.' "
Another Code of Ethics. — A resolution was car-
ried inviting the council to draw up a new code of pro-
fessional ethics, to be submitted to the association.
Address of Welcome. — ^The evening meeting
opened with an address of welcome to the association
by the mayor of Carlisle. He said it was his pleas-
ing duty to tender a hearty welcome to the British
Medical Association, which was the representative of
the great healing profession, whose highest powers
were devoted to promoting the welfare of the human
rare. Many societies made Carlisle their meeting-
place, but this was the first time the medical associa-
tion had honored the city with its presence, but he
trusted it would not be the last; and in the name of
the citizens he once more tendered them the most cor-
dial welcome.
President's Address.— Dr. Henry Barnes, the
president of the association, after a few preliminary
remarks, observed that the question whether the Ro-
man armies during the occupation of the district were
or were not provided with medical officers was one that
had not deeply engaged the attention of archaologists;
but recently during some excavations on the Roman
wall a tablet had been discovered, dedicated by the
first cohort to their medicus ordinarius, and the na-
ture of the carving furnished strong evidence of the
esteem and respect in w hich the soldiers held their phy-
sician, whose name was Anicius Ingenuus. Another
point in connection with the ancient and ro\ul city of
Carlisle was that outside its walls was built the Hospi-
tal of St. Nicholas, one of the first institutions set apart
in England for the reception of cases of leprosy, a dis-
ease which at that time appeared to have been a some-
what common one, and evidence had recently been dis-
covered that King Robert Bruce was afflicted with it. It
was also interesting to note that when Edward I. was
seized at Burgh-by-Sands with the attack of dysentery
to which he succimibed, his physician sent for medi-
cine to London from Carlisle, and that the apoth-
ecary's bill amounted to ^,134 i6.f. 4;/., and the cost of
conveying the same from London to Carlisle came to
^"159 ii.f. \od. more. The list of drugs included dis-
tilled oil of turpentine, aromatic flowers for baths,
carminative electuaries, plasters and ointments of va-
rious kinds, the oils of wheat, ash, and bay, water of
the roses of Damascus, wine of pomegranates, reme-
dies prepared from pearls, jacinths, and coral, and
many more which he (the president) was unable to
identify. At that time and for long afterward medi-
cine was under a cloud, and there was but little
progress to report; there was great faith in charms,
witchcraft, and miraculous gifts of healing, but the
services of medical men were not very highly apprised
For instance, in 1689 the bishop of Carlisle had con-
tracted with a physician for professional attendance
on himself and family for two guineas a year (much
laughter, in which the bishop, then on the platform,
joined, protesting apparently to Sir T. Grainger Stew-
art, next to whom he was sitting, that it cost him, the
bishop, a good deal more than that). The plague had
visited Carlisle with very disastrous results, sweeping
away such multitudes that the living were scarcely able
to dispose of the dead. The country at that time was
in a very impoverished state, and thirty thousand fam-
ilies were stated to be in want of bread. Two bishops
of the diocese died from the plague within a few
months of each other, as did also the first wife of Sir
Francis Howard, who was thought to have taken the
disease from a new gown for which she had sent to
London. The fact that this lady and the two bishops
were each buried a few hours after their death showed
the importance attached by the authorities to the
speedy disposal of the victims as a means of arresting
tlie spread of the disease. The mortality from small-
pox toward the end of the last century was remarkable,
w^hen one in every seven deaths in Carlisle was due to
that disease; but during the last twenty years, out of
fifteen thousand six hundred and sixty-four deaths
registered in the city, only four were attributed to
small-pox. Carlisle has a well-vaccinated community.
The president then described the services rendered to
medical science by several distinguished Cambrians,
making special reference to Dr. Heysham, whose ta-
bles of mortality were the foundation for the calcula-
tions of many life-assurance companies, and were
known as the Carlisle tablco. In conclusion, he re-
ferred to the necessity for further medical reforms
which demanded their earnest consideration, and he
hoped that the deliberations during the week would
help forward their settlement.
A vote of thanks to Dr. Barnes for his able and in-
teresting address was moved by Sir Thomas Grain-
ger Stewart, in a humorous and most felicitous
speech, during which he touched upon the salient
points of the address, particularly referring to the del-
icacy with which Dr. Barnes had referred to what had
befallen Edward I. when that monarch was doing what
no doubt he thought was his duty, but which was al-
ways a sore point with Scotchmen; while, on the other
hand, Englishmen who might feel aggrieved by the
reference to the Bruce could derive a crumb of com-
fort from the reflection that the valiant Scot was a
leper.
Sir Wii.loughp.y Wade seconded, and exhorted he
ladies present to profit by the sad experience of Lady
Howard, and not send to London for their g; aus but
to buy them ai Carlisle.
The moti;ii was then put and carried by acclama-
tion.
The Indian Medical Service. — A motion was then
240
MEDICAL RECORD.
[August 15, 1896
brought forward by Dr. Bahadurji, to the et^ect that
the Indian civil medical department should be thrown
open to the whole profession. Dr. Bahadurji freely
admitted that at one time it was right to reserve ap-
pointments in the scientific and sanitar}- departments
in India to the military medical officers, but he held
that the time had come when a change should be made.
He attended the meeting as a representative of Indian
practitioners, and received a good deal of support.
It was eventually agreed to refer this question to the
Indian branches of the association.
The President announced that twenty-two colonial
delegates were expected to be present during the meet-
ing. A branch at Pietermaritzburg was recognized.
It was resolved to admit to the sectional meetings
medical students resident in the district.
What is Ethics? — The ethical committee was in-
structed to prepare a code of ethics, to be submitted
to the association. Some of the members of the coun-
cil having remarked that they had never heard a defi-
nition of the term "medical ethics," Dr. d'Ansox, of
Whitehaven, said he fancied they all had a notion that
their ethics were comprised in their duty to their
brother practitioners and their patients and the world
at large, and the necessity of upholding the honor and
dignity of their profession.
Second Day — Wednesday, July 2gt>i.
The Presiden't announced that Dr. Saundby had
been elected president of the council for the ensuing
three years in succession to Dr. Ward Cousins, to
whom a vote of thanks was awarded by acclamation.
The Next Meeting in America.— It was resolved
that the invitation to hold next year's meeting at
Montreal be accepted, but that the business part of the
meeting should be held in London and the scientific
only in Canada — this because there was some doubt
as to whether it would be legal to transact some of
the financial and business matters outside the United
Kingdom.
The Address in Medicine.— Sir Dvce Duckworth
then delivered the address in medicine, taking for his
subject "The Prognosis of Disease." After a few
modest words of self-depreciation, in which he said
that the Scotch had big heads and that he was himself
half a Scotsman, the speaker entered upon the discus-
sion of his subject, one to which in spite of niucii prog-
ress in other directions the attention of the profession
has of late years been inadequately directed. We
have been too exclusively occupied in acquiring
knowledge of facts and our views are thus apt to be
narrowed and distorted. We are prone to argue too
much from the particular and fail to see thhigs in due
proportion. The education of to-day is overladen
witli details and somewhat barren of the inculcation
of general principles. If we are to be great in medi-
cine we must sometimes lift our eyes from the micro-
scope and away from the researches of the laboratories,
and, rising to a higher level, survey the wider fields
which lie before and beyond us. If we do so we shall
come to know more of the due proportions of things
relating to man as he passes through his present life.
But for this we need both the talent of the ancient
philosophers, who had an eye for general truth, and
the qualities of the modern philosopher, whose eyes
are set on particular facts. The problem now before
us is to combine these in due harmony, and as he had
expressed the opinion that we have somewhat failed
in modem times to gather knowledge as did the an-
cients, he proposed to address himself to a neglected
subject, that of prognosis in medicine, considered by
the light of our most recent attainments. We can
make advances in prognostic skill only by careful and
patient study of the whole subject of semeiology, and
on few parts of our art has greater light been shed
during the last half-century than on this. We culti-
vate tlie study of semeiology- for three reasons: First,
to enable us to make a diagnosis: secondly, to direct
the treatment of the case: and, thirdly, to help us to
frame a prognosis. Ever\'thing, therefore, depends on
an accurate appreciation of the symptoms and the
physical signs presented to us in any case. If we err
at the outset, our treatment and our prognosis will also
err.
There is no lack of teaching in these days directed
to the subject of semeiology in its several parts: but
we are apt to depend too much on our instrumental aids,
and too little on a careful study of the patient, his
personal peculiarities, and the intimate nature of his
ailments. We thus miss the due recognition of note-
worthy features proper to the whole case, features often
suggesting further inquir)- when appreciated by the
trained eye and the open mind accustomed to consider
every point in due proportion and in proper relation to
the rest. The speaker was constantly training stu-
dents in this direction, and imposing upon them the
fact that as physicians they would exist to small pur-
pose in the body jjoliiic and their art would be of
small avail if it was not in the highest and best sense
practical. The specialism so ripe among us is in
danger of narrowing our conceptions of diseases.
Sir Dyce Duckworth then discussed at some length
the subject of prognosis in relation to diseases generally
of the several systems of the body. After that he al-
luded briefly to the assistance in prognosis which we
may obtain from tile condition of the pulse and tongue.
Physicians have long been wont to gauge the degree
of vital and residual power in the sick by reference to
the pulse, and accurate physiological research has now
made plain and placed on a scientific basis the several
conditions so long known to observant physicians,
thus aiding materially no less in treatment than in
prognosis.
The conditions of the tongue have more recently
attracted scientific attention in this direction, for a
careful study of which we are indebted to Dr. Dickin-
son. To use his words, we may aflirm that '"the
tongue, indeed, has a whole book of prognostics writ-
ten upon its surface." The older physicians paid
great attention to the condition of the tongue in dis-
eases, and probably noted all that was observable to
the eye. Modern studv, however, places a different
interpretation upon the nature and significance of
many of the piienomena. Of the conditions which
enable us to form a fa\orable or unfavorable prog-
nosis, we have to take note more particularly of the
dry tongue. This has always been regarded as grave.
Dickinson found that patients, examined without
.selection, who had dry tongues of whatever origin, ex-
hibited a mortality of fifty per cent. This indication
mainly relates to prostration. '"The kinds of diseases
which it accompanies are chronic more than acute; if
febrile, usually continued." Pyrexia and deficient
secretion from the salivary and the buccal glands are
the chief factors. " The tongue is found dry, glazed,
and smooth in tlie later stages of tuberculosis, and in
exhaustion from continued suppuration ; dr)' and rough
at the end of cases of cerebral disease, hepatic cir-
rhosis, cancer, pya^nia, and severe pneumonia."
Among the conditions of the tongue which favor a
satisfactory prognosis in any case are to be noted re-
covery of moisture, and a cleaning of fur from the tip
and edges toward the dorsum.
It it is not always an easy matter to certify how
long a patient has to live, even in the presence of
well -recognized symptoms of impending death. The
end comes sometimes more rapidly and suddenly than
had been anticipated. Again, life is sometimes pro-
tracted in a remarkable manner, and our forecasts are
August 15, 1896]
MEDICAL RECORD.
241
proved to liavebeen fallacious. Relatives and friends
of the sick sometimes demand a prognosis and look
to the physician to give dependable information in the
most decided and dogmatic form. \o part of the phy-
sician's duty demands more skill and tact than to afford
a proper reply to such questions. While we must al-
ways be as hopeful and encouraging as is permissible,
yet we niu.st not shirk the unpleasant truth which has
so often to be declared. The physician who brings
most healing power with him to the bedside is gener-
ally one who is bright and encouraging and inspired
always with good hope. The most accurate prognosis
comes from him who has with care and a large chas-
tened e.Kperience first established a correct diagnosis,
and who has also learned to employ remedial measures
with judgment and good sense. The younger men
may often afford light in the matter of modern diag-
nostic methods to their seniors, but the knowledge and
experience of the latter are needed, not seldom, in
forecasting the issue of a case. Of this issue, the
most shrewd may be perhaps the least confident, for
he always remembers that no praesagia mortis are in-
variably to be relied on.
In closing he quoted the words of Hippocrates which
commend to us all the study of prognosis: '" It ap-
pears to me a most excellent thing for the physician
to cultivate prognosis, for by foreseeing and foretell-
ing in the presence of the sick the present, the past,
and the future, and explaining the omissions which
patients may have been guilty of, he will be the more
readily believed to be acquainted with the circum-
stances of the sick, so that men will have confidence
to entrust themselves to such a physician; and he will
manage the case best who has foreseen what is to hap-
pen from the present state of matters."
Dr. Philipson, of Newcastle, proposed a vote of
thanks to the orator and Dr. Affleck, of Edinburgh,
seconded the proposition, which was carried unani-
mouslv.
Thini Day — Thursday. July joth.
The Address in Surgery Dr. Roderick. Mac-
i,.\REX, of Carlisle, delivered the address in surgery,
taking for his title " Preventive Surgery," by which he
meant '" a surgery in which treatment or operation is
■entered upon or undertaken for some risk or sequence
which we expect to result from an existing condition,
and not on account of what is actually present at the
time." This he held to be a product of modern times,
the outcome of recent advances in our knowledge of
the intimate causes of disease, of the discoverv of
anasthesia, and of tiie adoption of aseptic and anti-
septic methods of wound treatment. Circumcision
had been instanced as an example of a preventive
■operation, but Herbert Spencer had shown that there
never was any prophylactic significance attached to
the rite, but that it was originally a work of subjuga-
tion and was later exalted to a religious and tribal
custom. Another old operation was the medical treat-
ment of hernia, but it was only in recent years that it
had been regarded as justifiable. The speaker then
dwelt upon the conditions which render preventive
operations justifiable, and said that such an operation
should be devoid of risk to life both at the time and
during the healing stage, and that it should not in-
volve much suffering. Passing then to a considera-
tion of special operations. Dr. Maclaren took up the
\arious systems and regions of the body in succession.
The Naso-Pharynx. — This is a very important
region, and one which offers a wide field for preven-
tive surgery. Enlarged tonsils and adenoid growths
produce some local discomfort, but their chief e\ il is
that they check growth and nutrition. Children who
are affected with them are generally small for their
age, anaemic, and ill-develojjed ; but it is often striking
to see the growth and development which follow the
removal of large tonsils and the scraping away of ade-
noids. The speaker did not favor the guillotine
operation, but thought it is much more satisfactory to
give the patient a deep anaesthetic and cut out — or,
with a blunt director, tease out — the whole structure.
Adenoid growths in the naso-pharynx produce similar
remote effects to those of enlarged tonsils, and the
removal of tonsils is not a complete operation without
a scraping away of all growths. There are few opera-
tions which accomplish so much with so little risk to
the patient or trouble to the operator.
Purulent otitis is another condition calling for pre-
ventive surgery. Not every case of suppurating ears
should be operated upon, for many are amenable to
medical treatment, but every one, the speaker said,
who has a chronic suppurative otitis media which re-
sists treatment is in deadly peril an<*ti5.hould be sub-
jected to a mastoid operation — not necessarily with a
view to restore hearing or even for the sole purpose
of curing the local inHammation, but for the sake of
averting the danger threatening the individual's life.
Cervical adenitis is often an indication of disease
in the neighborhood, such as an ulcerated throat or
mouth, a suppurating ear, a diseased tooth, or an
eczema of the scalp, and these should be looked for
and treated. If diseased glands be left alone they
commonly cause years of ill-health, with the ever-
present risk of the development of disease elsewhere.
The operation for the removal of these glands, whether
simple suppurating or tuberculous, is often difficult,
owing to the deep location of the diseased bodies and
their proximity to most important parts. The results
following the removal of simple suppurating glands
are much better than when tuberculosis is present.
The radical operation for hernia is a most import-
ant preventive surgical measure, yet it must not be too
readily or rashly undertaken. So long as a hernia
can be steadily kept up by a truss which does not
much incommode the patient or prevent him follow-
ing his occupation there is no necessity for operative
interference. But if trusses fail for any reason to
keep up the intestine; if the truss is painful'to \\ear
and excites repeated inflammations of the sac; or if
the patient's occupation requires exceptional activity,
then an operation is indicated. The operation, as
now performed, the speaker believed to be almost
absolutely safe, and he thought good results could be
obtained from almost all the operations now in favor.
Whatever secures closure of the abdominal openings
brings about a cure. He described the operation for
oblique inguinal hernia as the type of all. "The
plan of dissecting out the sac, cutting it across at the
neck, separating the peritoneum for an inch or so
round the internal ring, twisting the neck into a cord,
bringing it through one or other pillar of the ring by
an artificial opening just large enough to let it pass,
suturing it there, then stitching together the pillars
of the ring behind the cord with two or three silk
sutures, and closing it as thoroughly as possible, gives
a result which leaves nothing to be desired. The
same may be said of other hernia-, local peculiarities,
however, necessitating slight modifications."
Enlarged prostate is present in one of every three
men over sixty years of age, but it causes trouble in
only about one in every ten of those, and even then
the daily use of a catheter is often the worst that be-
falls the patient. Hut we must not wait for sepsis of
the bladder before operating, and we should not defer
the operation if the patient is uncleanly in his habits
or if there is difficulty in passing the catheter so that
bleeding is common. Suprapubic cystotomy with re-
moval of the enlarged prostate is the operation of
choice in most cases. Castration is still on trial, but
242
MEDICAL RECORD.
[August 15, 1896
the speaker thought that the results of the operation
thus far warranted a further eniploymenl.
Appendicitis next received attention. Three views
of surgical duty in this disease prevail, Dr. Maclaren
said. Some hold that the appendix should never be
removed, that the probability of infection of the
peritoneum during the operation renders the latter
unjustifiable. Another opinion, held both in Great
Britain and in America by men of the first authority,
is that every appendix which has given rise to morbid
symptoms should be removed when in a quiescent
state. The third view is that only after a repeated at-
tack of appendicitis are we justified in resorting to a
preventive operation. The speaker favored the last
view and brought forward the following arguments in
support of it. The great majority of attacks are not
repeated. Most instances of perforation are first at-
tacks— an evidence that one seizure does not increase
the probability te perforation in the case of recurrence.
A milk and farinaceous diet and mild aperients are
often successful in preventing return. The time for
preventive operation comes after a relapse, not after a
first attack. " When the operation is done during the
quiescent stage, and with every possible care and pre-
caution which human ingenuity can devise and human
knowledge direct, it is devoid of risk and absolutely
effective, for the source of trouble is entirely taken
away."
Cancer is another disease in which there promises
to l)e a profitable field for preventive surgery. It is
probable that there is a prolonged latent period before
the development of the disease at the point of incep-
tion or elsewhere. We must study carefully the earli-
est changes in carcinoma in order to discover the pro-
dromic or even the first symptoms, for then we may be
able to prevent it. At present the tendency is for
operations for cancer to become more and more exten-
sive, stretching out farther and farther into the appar-
ently sound tissues, but the speaker hoped that, with
greater knowledge and earlier interference, preventive
surgery may come in and bring with it a small opera-
tion.
.\fter touching briefly upon the surgery of accidents,
Dr. Mdtlaren concluded with a few words on the pre-
vention of surgical diseases, referring especially to
the necessity of looking after the plumbing of our
modern houses, but above all to the care of the teeth.
He had known death from septicaemia or putrid throm-
bosis originating in a dead tooth root, and he sus-
pected, as the result of many examinations of the teeth
in cases of gastric ulcer, that the latter might occur by
direct infection by food or saliva containing septic
micro-organisms derived from carious teeth.
A vote of thanks was passed to Dr. Maclaren for his
excellent address.
The Gold Medal of the Association was presented
at the close of the address on surgery to Surgeon
Captain Harry Frederick Whitchurch, V.("., I. M.S.
The president of the association. Dr. Harnks, having
briefly related the circumstances which took place
during the Chitral expedition that led the association
to select Surgeon Captain Whitchurch to be the re-
cipient of what he (the president) described as the
"blue riband" of the profession, then hung it round
the gallant officer's neck, amid loud applause from the
large number of people assembled, one lady in the
gallery getting so excited that lier hat fell off into the
arena below
The subsequent proceedings of the general meeting
related to business and other matters regarding the
a.ssociation and the action of some of its officials.
Some of these proceedings were of such a decidedly
stormy character that it was voted that thev must be
regarded as private.
The President of the Association Dk. I. G.
Roddick, of Montreal, was duly appointed president-
elect for the meeting in that city in 1897. Great
satisfaction was felt at the decision to visit the Do-
minion and it was decided to hold the meeting at the
end of August, immediately following that of the .As-
sociation for the Advancement of Science, to be held
also in Canada, thus afi^ording British practitioners
the opportunity of attending both within the holiday-
period.
SIXTIOX ON MEDICINE.
JH'irst Day — Wednesday, July 2gth.
Address of the Chairman. — Dr. George F. Duffey,
of Dublin, delivered the opening address, taking for
his title ''Some Historical Notes." He said that he
had the honor to be the first Irishman to preside over
a meeting of this section, except on three of the four
times that the association had met in the sister island.
The first meeting held in Ireland was the thirty-fifth,
in 1867, under the presidency of the distinguished
physician and teacher, William Stokes. It was the
same year that Mr. Ernest Hart assumed editorial
charge of the Journal oi the association, an office w'hich
he has held ever since, except for a brief interval in
1869-70. At the time of this meeting there were
three thousand and eighty-two members on the books
of the association. The date of the second meeting
in IXiblin was 1887.
Set discussions were first held at the thirty-fourth
annual meeting, in Leamington in 1865. They were
then held in the general meetings, the first subject,
the discussion of which was opened by Dr. (now Sir)
B. W. Richard.son, being on the question, " Is there
any Foundation for the Hypothesis of the Origination
of Disease by Zymosis or Ferment?" At the forty-
sixth meeting, in Manchester in 1877, the discussior*
of special subjects was transferred to the section meet-
ings. He hoped that in the important discussions
which were appointed for the present meeting of the
section of medicine the members might realize with
Trophilus (as recorded in the Greek inscription on a
wall in the medical department of the Oxford Mu-
seum) that the perfect physician is he "who is able to
distinguish between what can and what cannot be
done."
Treatment of Heart Failure Sir Thomas
Gkain'(;kr SiKWART then opened the discussion on.
this subject. If there was to be no other result, he
said, the comparing of notes would be valuable; but
there would be more, as no doubt would appear in the
course of the discussion. The muscular fibres of the
heart unable to discharge their functions are greatly
benefited by rest, which alone often brings about a
cure. As a rule, howe\er, private patients do not de-
rive so much benefit from this mode of treatment as do
hospital patients, who are generally working men and
women who.se condition is mainly due to overwork,
and they unquestionably are greatly improved by com-
plete rest, which hey cannot get in their own homes.
At one time the mere suggestion that the patient had
disea.se of the heart was tantamount to signing his
death warrant; hut all that is altered now, and many
forms of heart disease can be not onlv alleviated but
cured by treatment.
Private patients, as a rule, derive more benefit from
diet. Highly nitrogenized food must be either de-
nied or supplied in greatly reduced quantity, and the
amount of liquid taken into the system is to be mate-
rially reduced : the drier the diet, the better. Many
cases of fatal cardiac failure are undoubtedly due to
the ingestion of large quantities of fluid at a meal.
Alcohol taken in moderation — that is to say, not
more than four ounces during the twenty-four hours —
August 15, 1896]
MEDICAL RECORD.
24J
has a beneficial effect in the class of cases under con-
sideration.
Exercise, either passive, as massage, or according to
the Schott method of treatment, is frequently of the
greatest benefit.
It is possible to determine accurately the area of
cardiac dulness by percussion, but the new photogra-
phy will shortly render such manipulations unneces-
sary (the speaker presented two photographs of large
size taken recently, that showed the heart quite dis-
tinctly, as well as the buttons of the man's clothes) ;
the heart area is reduced by passive exercise, when
an improvement is also manifested in the cardiac
sounds and the rhythm of the pulse. Cases in which
the Schott e.xercise certainly did harm improved when
massage was substituted for it. Other cases were
improved not by massage but by active exercise;
a happy medium must be obser\-ed, and the nervous
influence must not be overlooked nor the element
of hope, both of which are factors in the success-
ful issue of whatever mode of treatment is adopted.
Another method is that by baths containing salines
and carbonic-acid gas, but this gives the best results
when combined with exercise, active or passive, as the
case may indicate.
The old remedial medicines are by no means to be
laid aside, and in digitalis we have the most powerful
cardiac tonic known, though strophanthus runs it close
and occasionally can be given when digitalis is not
tolerated. The latter acts by inducing contraction of
the muscular fibres and diminishing the flow of blood;
good results have followed the use of caffeine and
theobromine. The speaker advised caution in the use
of diuretics, but thought that iodide of potassium was
of use only in cases in which inflammation or some
syphilitic complication coexisted with the cardiac dis-
ease; when such existed its effect was often remark-
able, while in others it seemed to exert no influence
whatever.
Tapping the pleura when there was even but a very
little effusion was productive of benefit, but tapping
the abdomen was to be deprecated, and the speaker
had recourse to that expedient only after everything
else had been tried. Opium when judiciously ad-
ministered was invaluable, and sulphonal, chlorodyne,
and Hoffman's anodyne were extremely useful, too.
To sum up, the speaker proceeded to say that the
remedial agents in cases of cardiac weakness were
rest, diet, medicinal agents, and Schott's treatment;
but he doubted the necessity and often the desirability
of sending patients a long and tedious journey to Nor-
way, when the same treatment could be obtained nearer
home.
Dr. Herrin'gham stated that his experience led him
to give the preference to digital over auscultatory per-
cussion for determining the area of cardiac dulness;
the latter was available over soft parts, but over bone
it was absolutely of no use whatever.
Dr. Calder Leith doubted whether percussion
could be relied upon in the living subject, and believed
that it was the carbonic acid contained in the bath and
not the salines that acted upon the heart of the pa-
tient subjected to that mode of treatment. He also
thought that the patient breathed an air charged with
the gas, which acted directly on the blood-vessels.
Not only must the element of hope be taken into ac-
count in such cases, but the patient's mental and in-
dividual peculiarities were factors that should not be
overlooked.
Dr Edgemont found that the effects of the Harro-
gate baths largely charged with saline matters and
taken at a temperature of from 92 to 96 F. were but
transient, but the position of the patient during the
bath was important. On the whole, he preferred the
bath to exercise, whether passive or active, and had
found the pulse to drop from 150 to 65 in the bath in
a case that was aggravated by movement, but which
recovered when recourse to the bath was again had.
Children are often terrified by the bath, and in this
case he, as a rule, prefers movement. He has it in
contemplation to give the needle bath a trial, and
thinks the good effect produced may be the result of
reflex action.
Dr. Liddell concurred with Sir Thomas G. Stew-
art in a general way. In one case that came under
his notice the pulse dropped suddenly from 125 to 74,
when the patient said he felt better than he had
for months. He, the speaker, agreed that the element
of hope played a most important part in these cases,
and asked how long the treatment was to continue.
One of his patients was able after three months to re-
sume work, and experienced no return of his ailment.
More experience was wanted.
Dr. Saundby considered that the essential points
of the treatment were the temperature of the bath and
the amount of saline matters contained in it. Digi-
talis caused recession of the apex of the heart ^before
ever the Schott treatment was heard or thought of.
He deprecated using the different modes of treatment
concurrently, arid thought with other speakers that
hope was a potent factor in all these cases.
Dr. Byro.m Bramwell preferred the old to the new
plan of treatment, but admitted that the latter may come
in usefully at times and in certain cases. The sheet
anchors, however, are rest and cardiac tonics, and he
could endorse every word said by the opener of the dis-
cussion in this connection. To his medical brethren
he would say: "What would you like to be done if
you were the patient.'" No doubt there were many
supposed cases of cardiac failure that had benefited
immensely by a visit to Norway, and the virtues of the
treatment pursued there were loudly proclaimed, espe-
cially by neurotic women, who had enjoyed their holi-
day and labored under no cardiac complication what-
ever. Muscular movements assist the circulation, and
photography was about introducing to us absolute cer-
tainty in the diagnosis. No drugs are more useful
than digitalis and strychnine, especially when com-
bined with perfect rest and rectal feeding. Great
benefit had resulted in his experience from the mode
of treatment he laid down, for much cardiac disorder
was the result of a distended stomach and congested
liver.
Dr. a. Morison thought there were cases of cardiac
shrinkage that were not open to doubt, but he held
them to be of rare occurrence. He thought they re-
sulted from stimulation of the peripheral nerv'es, and
was of opinion that the Schott treatment was more use-
ful in cases of mitral than of aortic disease.
Dr. Bezley Thorne thought rest was a fundamen-
tal part of the treatment when exercise was not appli-
cable, but in other cases it did harm. Massage was
valuable and so were drugs, neither of which W'ere ex-
cluded by the Schott method. He did not agree with
the undue limitation of fluid, but, on the contrary,
gave water freely; not much with the meals, but when
the process of digestion was about complete he allowed
a large quantity of water to be taken, and found it ad-
vantageous. A limited amount of water conduced to
the storage of toxin in the blood, and free diuresis
cleared it all away.
Dr. Jamieson believed in the Schott treatment. He
had just returned from Norway, and was of opinion
that the method there pursued was an admirable ad-
junct to other methods, but in cases of aneurism and
dilatation of the blood-vessels it was not so useful as
some of the older plans of treatment. He instanced a
number of cases in support of his contention.
Dr. Barr remarked that the uniform peripheral pres-
sure in an ordinary bath amounted to one-fourth pound
244
MEDICAL RECORD.
[August 15, i8g6
to the square inch of the surface of the body, and that
would have a tendency to raise the arterial tension.
Tlie bath was therefore inadvisable in cases of mitral
stenosis, to which the tension was prejudicial. He
thought good was accomplished by the limitation of
ingested fluid, but suggested that the diet should be
so regulated as not to produce toxin in the system,
and then there would be no necessity for washing it
away. He utterly disagreed with the idea of rectal
feeding; it was never intended that man should take
his food that way. Formerly we gave enemata of egg
and brandy — the latter was absorbed, the former was
left: now we give peptonized matters, and free to.xin
is actually formed in tjie rectum, taken up by the rec-
tal veins, and carried into the circulation.
Dr. Russell thought there was a tendency on the
part of the public to want to be sent to Norway,
but the treatment practised there could be carried on
nearer home. He thought it possible accurately to
determine the outline of the heart during life.
Dr. Kingscote thought it was possible correctly to
determine the outline of the heart during life, but not
by the ordinary methods. He, however, had devised
an instrument for the purpose, which he showed, and
for which he also claimed the advantage of being able
to outline the kidneys from behind. It was most im-
portant that the part percussed should not be made to
vibrate, and his instrument obviated this. A sheep's
heart slung in a square cardboard bo.x could be accu-
rately outlined by means of his instrument, which
could be obtained from Down Brothers, Borough, S. E.
He had treated about three hundred cases by the Schott
method, including some of fatty and gouty heart, as
well as some due to various internal congestions, but
the method was of less use in instances in which there
was valvular disease, and in which a relapse might be
looked for in about six months.
Dr. Harry Ca.mpkell thought that a widespread
muscular contraction stimulated the heart, and baths
were useful by causing involuntary contractions, but he
attached no importance to the constituents of the bath.
Dr. Earle had found that a bath the temperature of
which was 75 ' F. caused the pulse to fall rapidly, and
he accounted for the phenomenon on the theory of the
rapid abstraction of heat from the body. Carbonic
acid in the water prevented the sensation of cold,
which at once became noticeable if the little sheet of
bubbles was brushed off from any part of the body.
Dr. Fisher had found that cases of hypertrophy
benefit more than those of valvular disease of the
heart, especially those of hypertrophy due to a toxic
agent, such as alcohol.
Sir Thojlvs Graixcer Stewart, in closing the
discussion, said that he was not going- to make a
speech, for they were all beginning to be more or less
conscious of cardiac failure and anxious for an ad-
journment to give them an opportunity for treatment
by the stomach. He would merely remark tliat car-
bonic-acid gas combined with salines had, in his ex-
perience, afforded tlie liest results.
Chorea and Rheumatism. — Dr. 'i". Chlrton, of
Leeds, then read a paper on the " Rheumatic Causa-
tion of Chorea," and remarked that it might follow
arthritis but not a chill, unless there was cerebral ex-
citement coexisting; while sudden emotion might be
followed by instantaneous collapse and death — in-
stancing a case of a young woman who was suffering
from chorea, and who, on being found to be pregnant,
though every care was taken not to let her know that
her condition had been discovered, instantly fell down
and died in a few minutes.
Dr. Samuel Hyde presented a paper advocating
■' The Treatment of Sciatica by Means of Baths ami
Climate:" Dr. A. G. Barrs, of Leeds, one on "Alco-
holic Cardiac Failure;" Dr. William Russell, of
Edinburgh, one on " Abdominal Cases Illustrating
Diagnosis:" Dr. Harry Campbell, of London, on
"Respiratory E.xercises in the Treatment of Disease;"
Dr. James Cagxey, on " Early Energetic Treatment
of Infantile Paralysis;" Dr. G. V. Perez, of Teneriffe,
on "New Auscultatory .Sign in Mediastinal Affec-
tions:" and Dr. Herbert Snow, of London, on
"Opium-Cocaine Treatment of Carcinoma (with
Cases)."
AMERICAN NfEDICO-PSYCHOLOGICAL AS.SO-
CI.VITON.
Fifty- SciOinl Annual Meeting, Hchi in Boston, May
26, 2j, 28, 2g, i8g6.
The President announced the presence of Acting-
Governor \A'alcott, of Massachusetts, who addressed
the meeting briefly.
President's Address. — Dr. Richard Dewey then
delivered his address, entitled "' Our Association and
Our Associates," in which he represented psychiatry
not as one science, but as the outcome of many sci-
ences which were as its handmaids. He treated of
the relations of alienists to the general medical pro-
fession, to the trustees of hospitals, to a properly con-
stituted controlling State board having visitory and
advisory powers, but no right to paralyze the inde-
pendent energies of superintendents or trustees.
The Neuron Theory. — Dr. Theo. W. Fischer, in
a paper on " The Neuron Theorv and Cerebral Lo-
calization," held that tlie brain cortex should be di-
vided into e-xcitable and non-e.xcitable areas — the
former to be subdivided into sensory motor centres
for all the different muscular movements. The non-
excitable cortex posterior to the excitable area may be
subdivided into centres of special sensation. The re-
mainder will constitute the area of general tactile and
muscular sensibilitv. The neuron excitable cortex in
front of the ascending frontal convolution relates to
mental operations and conscious voluntary move-
ments.
Word Deafness. — Dr. W. L. Worllmek then gave
the hi.story of fourteen cases of " Paraphasia and
Word Deafness," which had been under his care, and
in several of which autopsical examination showed
embolism and softening of brain tissues about the
island of Reil, and involving also the first temporal
convolution on the left side. These cases, he said,
often got into hospitals for the insane, and as the
dementia was sometimes more apparent than real it
became a nice question in these instances as to whether
they were proper subjects.
Gynecology in the Asylum Dk. R. M. Bucke
read a ])aper with this title, in which he held that
as a part of the physical examination women on ad-
mission should receive gynecological attention, and, if
found locally diseased, should be treated as they would
be in general practice if sane and likewise affected
with uterine troubles. Out of thirty-four women who
underwent gvnecological operations in his aslyum
fourteen recovered their reason promptly and .some of
them most unexpectedly, seven were improved by the
operations, eight derived no benefit, and five died sub-
sequently.
Thyroid Treatment of Catalepsy.— Dr. J. G.
Rogers reported the results in "Some Cases of
Catalepsy under Thyroid Treatment." He mentioned
the cardiac and other disagreeable features attending
the administration of the remedy, which he deemed
powerful for good or evil, and to be accepted in
psychiatry as a most valuable addition to our materia
medica, judging from the decided improvement in the
August
IS96]
MEDICAL RECORD.
245
mental condition of some of his patients, but to be
employed with cautious discrimination.
Psychic Influence of the Night. — Dr. A. B. Rich-
ardson read a paper on the "" Psychic Influence of the
Night Season," showing the general loosening of men-
tal inhibition and the predominance of fear and other
depressing emotions at night, both in sane and insane
persons.
Dr. John B. Chapix, of Philadelphia, then brought
out some important forensic points in a paper on
" Several Writs of Habeas Corpus and What Became
of Them.'" He mentioned among other things of in-
terest that the judges of courts in Pennsylvania, since
1896, in dealing with insane persons seeking relea.se
through habeas corpus proceedings, based their de-
cisions not so much on technicalities of law as on the
higher ground of the medical welfare of the patients,
remanding them to the hospital for further treatment,
if it appeared for their best interest, without regard
to the question whether they were dangerous to others
in the legal sense of the term.
Neuritis in the Insane — Dr. E. N. Brush read
an excellent clinical analysis of the symptoms of
'■ Four Cases of Insanity Associated with Peripheral
Neuritis,'" which had been under his personal care.
State Care of the Insane. — Dr. Carlos F. Mac-
DoN'Ai.n then made a lengthy special plea for State
maintenance of the dependent insane in New York, as
finally established with such great success by tlie com-
mission in lunacy guided solely by humanitarian views,
rising above political influence and personal motives,
promoting harmony among officials of hospitals and
largely extending their powers, and seeking with pa-
ternal solicitude naught but the welfare of the unfor-
tunate patients.
There being neither assent nor dissent to the paper,
a New York superintendent arose to apologize for
such ideas of their own as he and his associates had
held, as everything was now merged in harmony under
the controlling commission.
Disorders of the Muscular System in Insanity.
— Dr. Theo. H. Keli.ogi;, of New York City, then
read a paper with this title (see p. 217').
Deformities of the Hard Palate. — Dr. Walter
Channi-Vi;, in a paper on "The Hard Palate in
Idiots,'' based on a comparative study of several hun-
dred casts made by himself and selected from large
numbers of school children and idiots, concluded that
definite generalizations could not yet be made on this
subject, and that too much importance had been at-
tached to palatal de\iations as .stigmata.
General Paralysis in Sisters. — Dr. Augu.st Hoch,
of McLean Hospital, presented a report of " General
Paralysis in Two Sisters,'" aged eleven and sixteen
years, with report of an autopsy on one, and gave a
detailed account of the microscopic lesions of the cere-
bral cortex, basal ganglia, and spinal cord, he having
found e.xtensive lesions of fibres and cells in all these
regions.
The association then adjourned, to meet in Balti-
more next vear.
Practical Use of the Microscope. — Dr. Ohlmachee
{JW'W York Medical Journal ) comments on the fact
that a large majority of physicians in the United
States possess microscopes and are unable to employ
them satisfactorily even in their routine daily work.
This fact is due to a lack of familiarity with methods
of microscopic laboratory work. This is a reflection
on the educational methods practised in medical col-
lege laboratories, especially since many young and
enthusiastic men are markedly deficient in this re-
spect.
(L'liuiciil gqjavtmeut
A CASE OF POSl-MORTEIVI C-*:SAREAN SEC-
TION, WITH DELIVERY OF A LIVING
CHILD.
r,v HKNRV S. STE.ARX.S, M.I).,
NEW VORK,
VISITING GVNFCOUOCIST TO THE CITY HOSTITAL.
Perhaps the conditions most commonly calling for
a post-mortem Cesarean section are the sudden death
of the mother from traumatism, hemorrhage, or eclamp-
sia. And in such cases the delivery of a living child
is certainly the exception. This is my reason for re-
porting the following case:
Mrs. S , aged twenty-eight years, a primipara,
menstruated last on July 4, 1895. LTp to the begin-
ning of January pregnancy advanced in quite a nor-
mal manner, save for a very intractable morning nau-
sea and vomiting. In November a troublesome cough
appeared, but there were no physical signs of any con-
solidation nor were any tubercle bacilli found in the
sputum.
Early in January the cough became more persistent,
with considerable pain in the laryn.x when swallowing.
Physical examination revealed many coarse and fine
mucous rales scattered over the chest, with a small
area of consolidation at the right apex. Tubercle ba-
cilli were now very numerous in the sputum. About
the last of January small round gray nodules, proba-
bly tuberculous, could be distinctly seen on the epi-
glottis, with considerable cedematous swelling of the
tissues around the vocal cords. Dysphagia became
extreme, no local treatment having anything more than
a very temporary beneficial effect. This, combined
with the persistent vomiting and hectic, caused rapid
emaciation. In February it was determined that the
most advisable course was to induce labor at once,
but the procedure was not consented to by the family
of the patient. From this time she gradually sank,
her temperature ranging between 99.5° and 102.5" ^■
Urine became more and more scanty, the daily aver-
age during the last two weeks of her life being eleven
ounces, but containing no albumin.
Labor began on the morning of March 27th, and in
the evening, when I saw her for the first time that day,
the pains were very weak and absolutely ineffectual.
Pulse, 160; temperature, 101° F., and unconscious
about half of the time. By midnight, absolutely no
advance having been made, and as any effectual inter-
ference would have certainly resulted in her immediate
death, it was determined to wait for the patient's de-
cease naturally, and then, if possible, save the child
through an abdominal incision.
At 3:15 A.M. she was sinking rapidly, and all pre-
parations were made for the section. Death occurred
fifteen minutes later, and as soon as the family could
be persuaded to leave the room, the incision was made
and a living female infant delivered. The time elaps-
ing between the death- of the mother and delivery of
the child can, of course, only be approximately stated,
but was certainly not more than five minutes.
When delivered the child was deeply cyanosed, but
began to breathe in a minute or two in response to the
usual stimuli.
An interesting point was the action of the foetal
heart, it remaining perfectly steady up to within two
or three minutes of tiie mother's death, but after that it
could not be detected even with the stethoscope.
At birth the infant weighed four and one-half
|X)unds, when one month old five pounds, and at the
time of writing — May 25th — she weighs a trifle over
six pounds. During the first three weeks she was fed
246
MEDICAL RECORD.
[August 15, 1896
on a diluted and peptonized milk; but, having consid-
erably more digestive disturbance than seemed neces-
sary for even such a puny specimen, a change was
made then to '"modified milk" from the "Walker-
Gordon Laboratory." This change resulted favorably
on its general condition, all gastric disturbance ceas-
ing very promptly and appetite increasing materially.
21 East FoRTY-FofRTH Street.
INDUCED ABORTION, PERFORATION OF
THE UTERUS, WITHOUT PERITONITIS.
l!v ORISS.\ W. GOULD, M.I).,
NEI.I.OKE, INDIA.
December 2d, 10 a.m, a Sudra woman, aged about
thirty-six, who had walked fifteen miles, came to the
■dispensary, exhibiting what at first sight appeared like
a superficial abdominal abscess.
History: Twenty days previous criminal abortion
was induced, and since that time the patient had suf-
fered severely with pain and had had attacks of fever,
and for several days a very foul discharge.
Examination: Fluctuation over a place the size of
a dollar, surrounded by deep induration, the whole be-
ing five inches in diameter. Two fingers' breadth be-
low the umbilicus a hard point was felt just beneath
the integument.
Bimanually: The body of the uterus reached nearly
to the umbilicus, but was not fully outlined, because
•of the abscess. The anterior lip of the cer\ix was en-
larged and resistant. Pressure made over the abdo-
men on the hard point felt beneath the integument was
conducted to the finger on the anterior lip. Nothing
was felt in the os. There was a foul purulent dis-
charge. The temperature was normal, the pulse
.strong and regular.
Not being prepared for operative interference then,
I gave an antiseptic douche, inserted an iodoform
tampon, and put the patient to bed.
3 :3o P.M. — Temperature, 101.4' F. The woman had
suffered much pain since entering; her bowels had
moved twice. The hard point on the abdomen had
disappeared, and projecting from the os was a stick the
size of a large knitting-needle. This was removed
without difficulty. It measured eight inches in length.
December 3d, a.m. — Temperature normal, pulse
good. There was a foul sanguino-purulent discharge
from the opening in the abdomen, like the discharge
from the cervix, whicli was increased by pressure on
the abdomen. Slow intra-uterine irrigation, i to 50
carbolic, with hips elevated, was ordered.
1 P.M. — ("hill, followed by temperature of 103 F.
The internal os was at once dilated, and I removed
a foul strip of cloth six inches long, irrigated again,
and ordered quinine and stimulants.
6 P.M. — Temperature, 100.2° F. ; pulse good. .\n-
■other irrigation.
December 4th, a.m. — Temperature normal. The
body of the uterus was much reduced in size, but there
was still some discharge from both cervix and abdom-
inal wall. I made a small incision in the latter and
put in a short drainage tube. Intra-uterine douches
were continued for two days, when all discharge had
■ceased.
December 8th. ■ — The patient was discharged. The
abscess was closed and the uterus was reduced to its
proper size.
This case was interesting in many points, viz., the
perforation of the uterus, the presence of the stick in it
for so manv davs, the abdominal abscess evidently in-
duced by irritation, the speedy and complete recovery
without peritonitis or septicjemia
REPORT OF A CASE OF SYMPHYSEOTOMY.
);v KOKBES R. McCREERV, M.D.,
.NEW YORK.
The recent revival of the operation of symphyseotomy '
has aroused such widespread interest that the follow-
ing case seems worthy of report :
Mrs. R , aged thirty, IVpara. In her first
labor the child was lost, after a ver\- difficult forceps
operation. In her second I attended her. There was
a marked projection of the promontory of the sacrum,
with a resulting internal conjugate of only three and
one-fourth inches. After a tedious labor, I applied
forceps above the brim and delivered with great diffi-
culty. The infant lived only three-quarters of an hour.
When she was pregnant for the third time, I decided to
bring on labor at the middled the ninth month. This
was, however, unnecessary, as the membranes ruptured
two weeks or more before term. Two days later I
again applied forceps above the brim, and delivered
with moderate difiiculty. The child was small, but
thrived and is still living.
Her fourth labor began with rupture of the mem-
branes on October 19, 1895. Pains began on the
2ist, and continued strong and frequent till the after-
noon of the 22d. The os was then one-half dilated.
The head was still above the brim. The patient was
becoming exhausted and begging for relief. She was
then seen in consultation by Dr. John A. McCreery,
who agreed with me in my proposition to divide the
symphysis. The patient was accordingly etherized
and the operation begun. I made the usual incision
above the pubes, passed my finger down behind the
symphysis until I felt the subpubic ligament, and
divided it and the other ligaments by cutting from be-
low and behind upward and forward with a blunt-
pointed bistoury. The urethra was held to one side by
a staff. Very free hemorrhage followed the incisions,
but was controlled by pressure. The bones separated
about two inches. The child was then delivered with-
out ditliculty by forceps. It was asphyxiated, but ulti-
mately revived and is still living.
The after-treatment was troublesome. I sutured
the upper part of the wound, introducing iodoform
gauze into the lower angle, applied wet bichloride
dressing, and strapped the hips. Two days later I
removed the drain. A considerable amount of fluid
blood followed. The drain was reinserted superfi-
cially. The following day it was again removed, and
as the wound was apparently healing, there being no
discharge, I sealed it with iodoform gauze and collo-
dion, and put on a dry dressing. On the fifth day the
temperature rose to 101° F., and the right labium was
tedematous. On removing the collodion a large
amount of bloody pus welled up from the wound. The
probe entered two and one-half inches. I then in-
serted a drainage tube, and irrigated twice daily with
bichloride solution. The wound soon began to gran-
ulate, and the temperature fell to normal. On the
ninth day I removed the strapping and found that it
had caused an ulcer to form over the right ilium. This
was covered with boric acid and sterilized gauze, and
the hips were restrapped. From that time on the case
progressed favorably. I kept her in bed four weeks.
The sinus closed in about five weeks. A fortnight
later it reopened to a depth of one inch, but soon
closed. Seven weeks after the operation there was a
separation of about one-half inch at the symphysis,
with sliglit motion. She walked well. I have not
examined her since, but have frequently seen her and
cannot observe the slightest abnormality in her gait.
She says that she has no difficulty whatever in walk-
in sr.
August 15, 1896]
MEDICAL RECORD.
247
CONSTIPATION AFTER CHILDBIRTH, PRO-
DUCING SYMPTOMS OF PUERPERAL IN-
FECTION.
By R. p. MYERS, M.D..
HONOLrLl', H. I.
I DELIVERED Mrs. , primipara, aged twenty-eight,
on January ist. It was a natural labor, save that it was
■tedious. On the third day the temperature rose to
102 '-2°, fourth day 104 ''2°. Upon inquiry I found
she had an operation from the bowels daily before
delivery, also daily after the birth of the infant. The
lochial discharge was very scanty — scarcely any, and
Tione after third day. There had not been the slightest
hemorrhage during delivery, only a few blood stains.
It was truly a dry labor. I used warm carbolized
■vaginal douches with no result. I then ordered copi-
•ous warm injections per rectum, followed by a large
'dose of salts. This resulted in an enormous discharge
■from the bowels. The temperature fell at once to
•normal and remained so until the woman got up well,
•on the twelfth day after delivery.
TWO CASES OF AN ENLARGED ASCEND-
ING PHARYNGEAL ARTERY, SITUATED
ON THE POSTERIOR WALL OF THE
PHARYNX.
Bv E. HARRISON GRIFFIN, M.D.,
NEW YORK,
tLECTt'RER ON DISEASES OF THE THROAT AND NOSE AT BELLEVUE HOSPITAL
MEDICAL COLLEGE ; ATTENDING SURGEON FOR THE THROAT AND NOSE,
OUTDOOR DEPARTMENT OF BELLEVUE HOSPITAL.
•Very few of these cases are on record. The two
ithat I report are the only cases that have come under
my observation during my throat experience of four-
teen years at the Bellevue Hospital throat clinic.
Dr. J. W. Farlow, of Boston, reported five cases in
the Boston Medical and Surgical Journal oi March 31,
3887. Mr. Sanderson reported a case in the Bntis/i
Medical Journal oi September i, 1887, and Mr. Criss-
•well Baber in the same journal of March i, 1887.
The fact that the pharyngeal artery may in some
■cases be as large as the radial artery in the wrist and
at the same time lie superficially on the pharynx, so
that its pulsations can be plainly seen and counted,
gives an importance to a rigid examination of the
pharynx before such an operation as excision of the
tonsils or even' an opening of an ordinary quinsy, as
.an injury to this vessel when so situated and enlarged
would mean a copious hemorrhage and anxiety to the
operator, which could have been avoided if the
pharynx had been thoroughly inspected and the point
borne in mind that in some cases the pharyngeal artery
receives the dignity of being one of the large medium
arteries of the body.
Case I. — .\ woman, aged forty-nine, came under my
•observation one year ago, complaining of difficulty in
swallowing. An examination of the throat showed the
hard and soft palate covered with about a dozen cica-
trices, stellate in form and having that peculiar ap-
pearance that diagnoses a past syphilitic infection.
A small cicatrix was also situated on the pharynx,
showing a past ulcer now healed.
The large number of these trademarks showed that
at some remote period her throat had been covered
very extensively with superficial and deep ulcers of a
.syphilitic nature.
The history of the case was as follows: The patient
had married at eighteen years of age, and had had a
•number of miscarriages and dead-born children. Pains
an the tibia bones and re]x:ated headaches were present.
From her history, I would place the primary inocu-
lation at about her first year of marriage. When she
applied for treatment at my hands, in conjunction
with the numerous cicatrices, a large pulsating tumor
was visible, situated on the riglit side of the pharynx,
extending from its extreme end to almost its median
line, in size about the volume of a lead pencil. It
extended downward on the pharynx to the distance of
an inch and one-half. It gave her no trouble whatso-
ever. The difficulty in swallowing was due to an
acute attack of follicular tonsillitis. The tenderness
in her throat subsided after the tonsillitis was cured.
Case II. — .\ woman, age forty-five, German, applied
for treatment for a nasal catarrh. An examination of
her pharynx showed a large pulsating vessel on the
left side of the pharynx about a quarter of an inch in-
side the posterior pillar of the fauces.
The artery was about the size of the one I have re-
ported above, namely, as large as a lead pencil. It
extended above the margin of the soft palate and as
far down as I could see by depressing the tongue with
the spatula. This abnormal condition of the artery
gave rise to no symptoms.
It is an interesting fact that all the cases of an en-
larged ascending pharyngeal artery reported, occurred
in females and not one, so far, has been reported in a
male subject. Out of the five cases Farlow reported,
the artery was on both sides in two cases.
112 West Fortv-Fifth Street.
AN EMERGENCY— OBSTETRICAL AND EPIS-
TOLARY (INVERSIO UTERI).
Bv II. S. KILBOURNE, M.D.,
tT. CLARK, TEX.
surgeon I". S. ARMY.
In the vicinity of this frontier station is a camp of
Seminole negroes, once residents of the opposite side
of the Rio Grande, whither they had fled soon after
the removal from Florida to the Indian Territory of
the Indians who held them in slavery. Of late years
they have been drifting back toward their native soil.
The public schools of this State are open to their
children. Their familiarity with the country along
the border has led to the employment of some of them
as scouts in the military service, in which some of
them have gained distinction. Their language is a
curious patois of Spanish, English, and the Seminole
dialect, in various degrees of admixture. Early one
morning recently the following note was handed me
by a breathless negro boy:
" Dr please come down here my wife had a birth to
a kidd this moing an hir woum all come out please
come an see if you come
" Chiarle dinnel
" Brother John dennil"
I lost no time in responding to so moving an ap-
peal. On reaching the cabin I found a young colored
woman, primipara, who just before daylight, without
assistance of any kind, after a quick labor of one and
one-half hours, had delivered herself of the " kidd"
lying beside her. "Hir woum all come out" I found
extended between the thighs. The inversion was not
quite complete and hemorrhage had ceased. The
prolapsed organ was replaced without an anesthetic
and without much difficulty. It went back to its place
w^ith something of a snap, like the return of a dislo-
cated humerus to its socket. The child and placenta
had been shot out, I was told, with similar suddenness.
'■ Chiarle" had been sent on a mission to a minister-
ing neighbor and I left the patient in her hands, with-
out pain or threatening symptom. In the evening
" Brother John dennil" rode in with the following note :
" Doctor yo told me if the thing was most all right
she had her causes right after i left. Do vo think
248
MEDICAL RECORD.
[August 15, 1896
that she will nead that sereange and she left with a
gripem like a.rinning off at the blatter"
I judged that " the thing was most all right" and sent
the necessary instructions in regard to the use of the
'• sereange." Her " causes" have continued to pro-
gress favorably and the "gripem" was no worse than
is common. The recovery promises to be complete.
REPORT OF THREE CASES OF PHTHISIS
PULMONALIS FOLLOWING SCALD OF
THE CHEST.
liv J. N. H.\LL, M.D.,
DESVER, COL.,
PROFESS<)R OF THERAPEt'TICi AND CLINICAL MEIUCINE, I'NIVERSITY OF
COLOKADO.
In the past three years I have treated three cases of
pulmonary consumption in which the trouble origi-
nated upon that side of the chest which had in in-
fancy been severely scalded, as evidenced in each case
by an extensive cicatrix. In each instance there was
contraction of the side of the chest upon which the
scar was found. It seems reasonable to suppose that
this contraction, by interfering with the normal lung
movements, may have at least detennined the develop-
ment of the disease upon this side of the chest, and
possibly when, without this element of danger, the pa-
tient might have successfully resisted the e.vposure to
tuberculosis.
C.-\SE I. — A. B , twenty-four years of age, prin-
ter, single, a dispensary patient. He had worked in a
Chicago printing-office, but in the spring of 1893, de-
veloping cough and loss of weight, he consulted a
physician, who told him that he had consumption and
advised a change of residence to ('olorado. I treated
him during the summer and fall of that year, and re-
ported his case in the December number of the Colo-
rado Clivtatohgist of 1894 as one of arrested phthisis,
not mentioning the fact that he had marked contrac-
tion of the right chest as a result of a scald in infancy.
I did not at that time fully realize the possible con-
nection with his chest disease. When I first saw him
he presented dulness, bronchial respiration, and abun-
dant fine rales over the right chest above the fourth
rib, front and back. Bv December he had regained
eighteen pounds of his lost weight, thus bringing it up
to the normal, while cough and all other svmptoms
had disappeared. The dulness and bronciiial respi-
ration, of course, remained in his right chest. He in-
sisted on returning to Chicago, but came back in tiiree
months, worse off than when first seen. He was grad-
ually regaining tiie lost ground when I lost sight of
him.
Cask II. — L. G , American, machinist, single,
from New York. His mother's brother died of phthisis
and a younger brother has now some serious chest
disea.se, apparently of the same nature. When two
years of age the patient was severely scalded over the
left chest, an extensive cicatri.x and .some contraction
of the side remaining. He states that he had a pleu-
ri.sy eighteen months ago, but apparently, from his
story, without effusion. During the past few months
he has fallen in weight from one hundred and fifty
pounds to one hundred and tliirty-two, and has devel-
oped cough, night sweats, expectoration, and dyspnoea
upon exertion. He has marked dulness and broncho-
phony in the upper half of the left chest, and abundant
moist rales in the region of the second rib. Similar
signs, but much less marked, are found over the re-
mainder of the left lung, and respiration is much di-
minished. The heart is displaced one inch and a half
to the left, and its area of dulness increased by the re-
traction of the left lung. The patient has resided
upon a ranch here for the past five months, and, al-
though he has gained sixteen pounds, still coughs con-
siderably and has nearly as much expectoration as
upon arrival. The only change in the chest signs con-
sists in a lessened abundance of the moist rales.
Case III. — S. T , forty -one years of age, dentist,
married, .American, recently from Connecticut. He
-States that his family was considered scrofulous, but
there have been no cases of consumption to his knowl-
edge. He nearly lost his life when two years of age
from a scald of the right chest, caused by his pulling
a vessel of hot water over on to himself. A large and
markedly roughened and contracted cicatrix remains
over the second, third, and fourth ribs, with moderate
contraction of the chest upon this side. He has been
failing for three or four years, and has complained for
some two years of cough, expectoration, dyspntta, loss
of weight, and debility, not materially benefited by his
residence for the past eleven months in Colorado.
There are dulness, bronchophony, and abimdant moist
rales above the fourth rib, front and back, upon the
right side, and very slight dulness with a few moist
rales over the left chest near the sternal end of the
clavicle. There seems to be no reason to doubt that
the trouble originated upon the side where it is now
so extensive. His urine has a specific gravity of
1.024, one-fifth by volume of albumin by the heat test,
and abundant granular and fatty casts and fatty epi-
thelial cells. He is gradually failing.
The report of these cases must enforce, I believe,
the fact, long recognized, that it is the lung which is
prevented from expanding to the fullest extent which
offers a harbor to the bacillus tuberculosis. It is im-
perative, in my opinion, in the treatment of scalds of
the chest involving contraction, if we would avoid the
grave danger of phthisis, to adopt the same precau-
tions as regards diet, exercise, residence, occupation,
and all other factors entering into the etiology of
phthisis, that we now do in the treatment of other con-
ditions involving limitation of expansion of the lung.
In view of the long interval in each case between the
receipt of the scald and the development of the dis-
ease, it seems scarcely possible that any other factor
than the contraction, so markedly developed after in-
juries of this nature, could have been operative.
CONGEXir.M, ABSENCE OF THE UTERUS,
FALLOPIAN TUBES, AND ()\ARIES.
liv \V. ll.ARPUR SLO.VN, M.l).,
I'HlLAItKLPHIA, l-A.
C. D , aged twenty-four, died after a protracted
illness, which was of such a complicated nature that
a diagnosis was not arrived at, although the most
prominent symptoms pointed very strongly to perito-
nitis with marked cerebral involvement.
The patient was small of stature, of the brunette
type, well nourished, and lleshy. Her ajjpetite was
always voracious. She was subject to periods of un-
consciousness, that would last from ten to twenty min-
utes at a time, and after being revived from one of
these attacks she appeared exceedingly bright, and was
invariably hungry and would eat a hearty meal with a
ravenous appetite.
Her family history was good, mother and father both
living and well. .She had one brother, who enjoyed
good health. The patient herself had none of the
usual diseases of childhood. She was blind from
birth, although her other faculties were good. She
had never menstruated in her life.
Post-mortem : Externally the body presented nothing
worthy of note, except a poorly developed condition of
the breasts, with an entire absence of the nipples: the
areola was well marked on each breast. The mons.
veneris was totally devoid of hair.
August 15, 1896]
MEDICAL RECORD.
-49
'I'he brain was congested, especially the right lobe,
with marked meningeal engorgement ; the dura mater
was also much congested.
The right lung was in a normal condition ; the left
one much congested.
The heart was normal, except that it was slightly
displaced to the right.
The stomach was dilated and contained food partly
digested.
The liver was markedly hyperamic, containing large
masses of a cheesy substance throughout, while the
capsule of Glisson was drawn extremely tight over the
whole organ.
The spleen was normal, as were also the kidneys
and bladder, the latter containing a large quantity of
acid urine.
The most interesting find was that there was an
entire absence of the uterus, Fallopian tubes, and
ovaries, there being no evidence of their existence
even in an immature state. The vagina had a nonnal
external opening: the clitoris and labia majora and
minora were normal, as were also the meatus urinarius,
vestibule, and hymen. The vagina ended in a cul-
de-sac with no farther extension or development.
CYCLOPIA.
By F. H. ALLEN, >I.D.,
STAPLES, MINN.
The mother of the monster here described is a Fin-
lander, who has always enjoyed good health and has
had three other healthy children. The "freak" was a
girl baby, born at seven months. She weighed at
birth five pounds eight ounces, and was well developed
with the exception of the face. Here the nasal bone
seemed to be wanting, while the orbits were fused to-
gether, making one large, four-cornered, staring eye
about the centre of the face, with a fleshy teat over it,
probably representing the soft parts which should have
gone to form the nose. The child lived for about half
an hour after birth.
To Preserve Rubber Instruments.— It has been
recommended (Zeitschrift f. Krankenpjl., April, 1896)
that rubber instruments be kept in a three-per-cent.
solution of carbolic acid. Should they not be used
frequently they should be removed and stretched oc-
casionally.
;5Ticvapcutic itiuts.
Pulmonary Tuberculosis. —
1? Potassii iudidi gr. xiv.
lodi pur gr. xv.
Sodii chloridi 3 iss.
.\qu.t dest O ij.
iL S. Take three or four tablespoonfuls in a glass of milk
tliree to sLx times daily.
— Ren'zi, y^^/cr. (k Med. de Bordeaux.
Tinea Favosa — Dr. Khrenitchek (Semaine Medi-
caU\ 1896. Xo. 8) recommends washing the scalp with
tincture of green soap and shaving the affected area.
Then the following mixture should be applied. If
the hair grows rapidly the shaving may be repeated
every two or three days.
I? .\cidi carbolic!,
Balsam! peruviani aa 3 iiss.
Petrolei,
Glvcerini aa r iij.
M.
Local Anaesthesia
R Chloroform 10 parts.
Ether 15 "
Menthol i part.
The anaesthesia resulting from this application lasts
about five minutes. — Le Ger.\nt and E. Pierre.
Acute Coryza. —
R Zinc! phosphidi gr. viiss.
Extract! belladonna gr. vi.
'\\. fiant pilulas No. xl. S. One twic edaily, after each meal.
In case of general impairment of nutrition one grain
of arsenious acid may be added to the foregoing pre-
scription.— Gaz. Hebdom. de Alcd. et de Chit:, No. 42.
Dry Eczema with Pruritus. —
^ Menthol gr. xxx.
Resorcin gr. xv.
Sulph. precip I iiss.
Zinc! oxidi Z iiiss.
\"aseline ; !.
Ft. unguent.
— Thibierge, Medical Times and Hospital Gazette.
Spasmodic Asthma. —
K Tine, lobelia.- a-therea; tn, -xv.
Spts. Ktheris fH xx.
Tine, chlorof . comp TU v.
-■Vquje camphor.ie ad | i.
M. S. To be taken when breathing is difficult.
— The Practitioner.
Sick Headache. —
li Sparteine sulphate 0.02 gm. ( ^ gr.)
Caffeine o.i gm. (ij^ gr.)
-Vntipyrin 0.5 gm. (7>j gr.)
Taken at intervals of two hours until four have been taken,
even though the pain has disappeared.
— Aritzman, Presse Aledieale.
Strangulated Hernia. — .\fter several days of futile
efforts at reductio.n the patient w-as placed upon the
back witli the hips raised and the legs flexed. At inter-
vals of ten' minutes tw^o teaspoonfuls of sulphuric ether
were poured over the tumor and strangulated parts.
The surrounding skin was protected by vaseline.
Slight efforts at reduction were made at first; the
tumor gradually diminished beneath the hand on mak-
ing gentle pressure and at the end of half an hour had
completely disappeared. — Fkiedlander, Wiener med.
Woc/i.
250 MEDICAL
Salol in Vaseline, its best solvent, is found by Dr.
Colombini {Ri/orma Medica) to possess a local action
in contact with alkaline fluids or living tissues which
is far superior to that of the salicylic acid and phenol
into which it is decomposed, the usual irritant prop-
erties of tliese substances being lost. The skin and
inflamed surfaces are found not to be irritated and
ulcerations heal without pain or local reaction.
Prostatics may be benefited, Dr. Bazy thinks {Presse
Mcilicalc, February 29, 1896), by thyroid medication.
He asks if there is not some relationship between the
thyroid body and the prostate. The effects observed
by him would lead him to believe that a study of the
question in old men might have good results.
Neuralgias. —
I^ Menthol,
Guaiacol 5a I gm.
Alcohol abs 18
M. ,S. Apply one drachm locally two or three times in
twenty-four hours and cover with cotton.
— Sabbatani.
Thyroidin is the name by which Wennerhen has
desi"-nated an amorphous substance which he believes
to be the active principle of the thyroid gland and
which he extracts from it in the following manner. The
thyroid pulp is left for twenty-four hours in contact
with twice its weight of glycerin. This is pressed
and filtered through absorbent cotton. Absolute al-
cohol is added to the filtered liquid, which precipitates
the thyroidin.
Thyroproteid is a substance e.xtracted from the
glands by Notkine, who believes it to be the determin-
ing cause of myxcedema by accumulating in the blood.
The true product of the gland he thinks is a soluble
ferment which neutralizes the thyroproteid, transform-
inc it into thyroidin. This neutralization takes place
in the circulation. — Yvo.\, Arch, de A'fiind., March,
1896.
Poisoning by trional in daily dose of one and a half
grains for a period of thirty-six days has been reported
by Hecker. The patient showed extreme intellectual
and physical signs of paralytic dementia. Suppres-
sion of the drug caused the alarming symptoms to
disappear. — Arch, de Neurol., November 3, 1896.
Syphilitic Neuritis of the secondary period, prob-
ahlv due to an embryonal infiltration of connective
tis.sue and leading to destruction of nerve fibres, is
benefited by the daily injection of a cubic centimetre
of the following solution :
I? Benzoate of mercury 0.25 cgm.
Pure chloride of sodium,
Chlorohydrate of cocaine .ia 6.06 cgm.
Distilled water 3" gm.
— Champenier.
Syphilis of the Cord. — In this infrequent affection
most active measures are requisite. Vesication the
whole length of the vertebral column, followed by a
dressing of mercurial ointment, has produced most
marked improvement. — Mauriac.
Iodides Other than That of Potassium, in the
Treatment of Syphilis — Dr. Brizuel draws the fol-
lowing conclusions; 1. All the iodides have anti-
syphilitic properties. 2. Iodide of potassium is usu-
ally the most active; iodide of rubidium, often better
tolerated, seems to be almost its equal. 3. When
iodide of potassium is not well borne there need be
no hesitation in having recourse to iodide of sodium,
which often acts well. 4. Iodide of strontium his no
advantage over others. 5. Iodide of ammonium
should be reserved for certain cases of grave syphilis
RECORD.
[August 15, 1896
if the potassium salt disagrees or is not active; it
seems especially useful in tertiary eruptions. 6.
Iodides of lithium and calcium act more slowly and;
less surely than those mentioned. 7. To secure aa
effect equal or at least comparable to that which iodide-
of potassium gives, all other iodides must be pre-
scribed in the same doses. — Journal des Mai. Cut. ef
Sypli., p. 87, Februar)', 1896.
Vomiting in Pregnancy —
13, Diluted nitrohydrochloric acid 3 iss.
Spirit of lemon 3 i.
.Simple syrup 5 'J •
M. Give one teaspoonful in a wineglass of ice water three-
limes a day.
— Buffalo Medical and Surgical Journal.
Round Worm (Ascaris Lumbricoides). —
IJ. Fl. e.\t. spigelian 3 x.
Fl. e.\t. sennse 3 vi.
Olei anisi "l v.
Olei cari "l v.
M. S. For a child of two years half a teaspoonful two or
three times daily ; for child from four to ten years a teaspoonful.
— C. W. TOWNSEND.
Laxative for Children. —
1{ Bicarbonate of sodium 3 iij.
Powdered rhubarb § ij.
Sulphate of sodium 5 i.
Oil of peppermint gtt. x.x.
Half to one teaspoonful before breakfast.
— Journal de Med. de Paris, March 8, 1896.
Corns — •
V, Acid, salicylici gr. xxx.
Ex. cannabis ind gr. x.
CoUodii 3 iv.
M. Paint on corns night and morning for several days.
— Stelwagon, Medical World, July, i8g6.
Ulcerations in Gonorrhoea! Ophthalmia.—
I^ Eserin.t sulph gr. i.
Cocain. murial gr. v.
Aq. dest |i.
M. S. Two drops as directed.
— De Schweinitz.
Acetanilid. — Dr. Wimble (Pittsluirg Medical Review,
May, 1S96) says he concurs with what Dr. Morton,
professor of surgery in the Philadelphia Polyclinic,
has said, namely: " I have employed acetanilid locally
in a large number of surgical affections, with results
so surprising in some resjDects as to make it difficult
to restrain enthusiasm in commenting upon the anti-
septic properties of the drug."
Konig-Maas Method of Resuscitation from Ap-
parent Death by Chloroform. — Dr. Ludham-Green
{Birmingham Medical Review) says the efficacy of this
method lies in its direct action on the heart. It re-
stores both respiration and circulation. If, on a fresh
cadaver, the precordium be quickly and forcibly com-
pressed, a distinct impulse wave in the carotid arteries
is easily detected, and the pupils will contract as the
blood tills the capillaries of the iris. The authors
direct that the operator should stand on the left side
of the patient and face him, placing the ball of the
thumb of the open right hand upon the patient's chest
at a point between the apex beat and the sternum.
The thoracic wall should then be repeatedly pressed
in with quick, strong movements, at the rate of from
thirty to one hundred and twenty times per minute.
August 15, 1896]
MEDICAL RECORD.
251
Olarrcspondcncc.
OUR LONDON LETTER.
(From our Special Correspondent.)
A WEEK OF CONGRESSES LIVERPOOL, GLASGOW,
CARLISLE PHARMACEUTICAL CONFERENCE PUBLIC
HEALTH AND SMOKE PREVENTION DEFECTIVE SIGHT
OF SCHOOL CHILDREN INQUIRY INTO OPHTHALMIA
WATER FAMINE.
London, July 31, 1896.
The season of congresses is upon us — some irrever-
ently call it the "silly season." Three meetings con-
currently should satisfy the appetite for this form of
entertainment. It is a rather '" far cry" to Glasgow,
and to include Liverpool and Carlisle en route is too
fatiguing a preparation for letter writing. You have
your own reporters at Carlisle, so I may give the go-
ijy to the proceedings of the British Medical Associa-
tion and refer your readers to the reports of the sever-
al sections which you print. The same day that this
began — Tuesday — the Pharmaceutical Conference
opened at Liverpool, when Mr. Martindale, the author
of the " Extra Pharmacopoeia," delivered the presiden-
tial address. He passed in review many of the
changes he has witnessed in his quarter of a century's
e.xperience. The new medicaments introduced in that
period are numerous and of the highest importance.
It was natural for so eminent a pharmaceutical chem-
ist to dwell upon them. Many of the older drugs are
now produced by much improved processes in a purer
condition and yet at a lower price. On all these
points and many others Mr. Martindale discoursed out
of the fulness of his knowledge in a pleasant enough
manner. When he came, however, to condemn in in-
dignant phrases the Royal College of Physicians for
leaving pharmacology out of the subjects for a sepa-
rate examination, I thought he was going beyond his
province and was only echoing the discontent of the
protesting professors of pharmacology. To pretend
that those who have not passed a separate examination
in pharmacology will be imable to prescribe any but
the simplest remedies is manifestly absurd, and I
wonder Mr. Martindale should venture on such a pre-
diction. Were men afraid to prescribe before the re-
cent effort to alter the meaning of the word pharmacol-
ogy ? Are they not now injecting organic fluids, about
which even Mr. Martindale himself knows but little?
He was more at home in advocating the metric weights
and measures, which are to be introduced into the new
pharmacopoeia as an alternative to the old system.
At Glasgow the Public Health Congress has had a
discussion on the smoke nuisance, and the following
resolution was passed: "That as the infonnation put
before this congress shows that the undue emission of
smoke from the chimneys of mills, factories, and ho-
tels can be prevented by careful firing or mechanical
stokers, and without causing extra expenditure to the
owners, it is desirable that the local authorities should
enforce the smoke-prevention clauses in their local
acts or in the general acts more stringently than they
have hitherto done." A gentleman from London gave
the metropolis an excellent character in this respect;
even went so far as to say that though there were five
millions of people in London, they would not have
smoke. From furnaces, perhaps, but however much
clearer the air in London may be than that in Glas-
gow, I could not admit it to be comparable with many
smaller cities. The gentleman from London felt, no
doubt, the depression of the still murkier Glasgow.
Mr. Brudenell Carter has made a report to the edu-
cation department on the eyesight of school children
in London. He finds only 39.15 per cent, possess
normal vision. .Slight hypermetropia is the most com-
mon defect, but is seldom sufficient to require glasses.
Myopia is not frequent and is less both in number and
degree among girls, who have sewing as well as les-
sons to do, than among boys. Hence, Mr. Carter con-
cludes it does not depend on defective lighting of the
rooms or other school cause. He was struck by the
large proportion of subnormal vision, and suggests as a
cause that town children have not the opportunity of
cultivating the sight by looking at distant prospects.
The eyes of eighty-one hundred and twenty-five chil-
dren were examined for the purpose of this report.
A more important question respecting the eyes of
school children is the prevalence of ophthalmia, and
the local government board has entrusted an inquiry
on this subject to Dr. Sydney Stephenson, who pos-
sesses special qualifications for this task. He will
have authority to inquire into the condition of every
child in London chargeable to the poor law. This
will be a laborious undertaking, involving inspection
of some twenty thousand children, but Dr. Stephenson
has already had great experience in ophthalmia and is
just the man for the work.
The water famine in parts of London is exciting
considerable fear as to its effects on the public health.
plecUcal ^tcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending August S, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-po.\
Cases.
Deaths.
144
79
27
9
41
4
I
I
92
8
149
21
0
0
Treatment of Styes — The following treatment is
suggested for this troublesome condition: Locally, as
soon as the evidence of a stye is appearing, an at-
tempt may be made to abort it by cauterizing the spot
with the fine point of a galvano- or thermo-cautery.
In other instances, if it cannot be aborted it is best to
aid the maturation of the boil by providing warmth
and moisture, and evacuating the pus as soon as this
is formed. In order to render the eyelid perfectly
aseptic, it is well to wash the margins of the lid with
one of the following solutions, hot:
1} Bichloride of mercury grs. iv.
Distilled water. -. O i.
Or in place of this, if it is thought the individual will
be susceptible to the action of the mercury:
If Bichloride of mercur)- grs. ij.
Distilled water C) i.
In other instances an ointment made as follows is of
value :
1} Powdered calomel grs. iv.
Vaseline " Ixxx.
As a general rule, styes tend to return, owing to auto-
inoculation. Care, therefore, should be taken that the
edges of the lids are kept well cleansed, and if neces-
sary a mild antiseptic wash should be used for some
time after one stye has healed, in order to prevent the
coming of others. Careful attention should also be
252
MEDICAL RECORD.
[August 15, 1896
paid to the condition of the alimentary canal, and it
is pointed out that Bouchard believes tliat auto-intoxi-
cation from the alimentary canal may result in the
formation of styes, through the entrance of staphylo-
cocci into the sebaceous glands of the lids. Ver)^
often in these cases the administration of naphthol is
of value for this reason. The following prescription
may be employed:
li lienzo-naphthol ; i-
Kt. in capsul. No. .\x.\. One to two capsules three times a
(lay.
Or if the patient is young, with scrofulous, arthritic,
or ana;mic tendencies, Fowler's solution in full doses
may be administered with great advantage. — Thera-
peutic Gazette, June 15, 1896.
Preparation of Gauze Dressing. — Dr. Martenson
gives the following directions: Rolls of cheesecloth
about thirty yards in length are folded and placed in
jars. On these the following solutions are poured,
depending upon what kind of gauze it is desired to
produce. Carbolized gauze, five-per-cent. :
V, Coloplienc 50 parts.
Castor oil 15
Carbolic acid 28
.■Vlcohol, 90 2'r
Three hundred parts by weight of this mi.xture are
taken to five hundred parts of gauze. Or the follow-
ing may be used :
1^ \aseline 30 parts.
Carbolic acid 2S "
Henzin 24:= "
Three Jiundred for five hundred of gauze. Thymolated
gauze :
R Thymol 10 parts.
Essence of turpentine 3
I'araffin oil 10 "
lieiizin 200
Three hundred and three of the solution to five hun-
dred of the gauze. Sublimated gauze:
I{ Bichloride of mercury i 'i parts.
Chloride of sodium . '2 part.
C.lycerin 15 parts.
Distilled water Joo
Equal parts of the solution and gauze are employed.
Iodoform gauze :
K Iodoform. . .
I'araffm oil.
lither
50 parts.
,10 "
400
The weight ratio between the amount of solution used
and the gauze is four hundred and si.xty to five hun-
dred. The gauze is allowed to sOak for twelve hours
in this solution, is then dried, and stored in an anti-
septic, air-tight jar. — La Medecine Aloderne.
Intra-Uterine Photography — Dr. Pinard has re-
ported an experiment performed by ^'arnier and ("hap-
puis on the uterus of a woman who died of pernicious
ana-mia in December, 1894, at which time she was
three and a half months pregnant. This is reported
as the first intra-uterine use of the Roentgen rays {The
Liiiversity Magazine). The specimen had been frozen
and divided by two sagittal cuts and preserved in
spirit. The surfaces were accurately adjusted and se-
cured by rubber bands. The cavity of the uterus ap-
peared clear in the centre of the photograph: the out-
line of the specimen was distinct, and the inequalities
in the thickness of the muscular wall could in part be
detected. The picture was crossed by two ligiu verti-
cal lines, the lines of the section and two dark hori-
zontal bars portraying the rubber rings. The fittus
could be seen lying at the upper and right side of the
cavity face downward, and extending from the fundus
to within about four cubic centimetres of the lowest
part of the inferior segment. The head was flexed on
the thorax and completely in profile, but the ribs and
spinal column, which finished \ery black, showed that
the trunk lay obliquely to the right and backward.
The outline of the neck, occiput, vertex, and forehead
was well marked; that of the nose, mouth, and chin
not so distinct. Near the elbow of one of the arms
fle.xed with the hand on the forehead, two dark parallel
bands indicated the radius and ulna, and the lower
part of one thigh with the knee and lower leg and the
dark shadow of the femur were quite evident. Both
walls of the gravid uterus, the bladder, placenta, rec-
tum, and fatty tissue had proved more permeable to
the ravs than the rubber bands a half millimetre in
thickness. In the photograph the foetus and its posi-
tion were more distinctly seen than through the un-
broken membranes of an aborted ovum. Pinard be-
lieves that it is probable that the uterine wall will
be as easily traversed by the rays when recent and
full of blood as when hardened in alcohol, and that
the position and attitude of the fatus can be thus as-
certained in post-mortem specimens without freezing,
and so interfering with their microscopical examina-
tion.
The Old World's Centenarians. — A German sta-
tistician has studied the census returns of Europe to
learn a few things about the centenarians of the Old
\\'orld. He has found, for instance, that high civili-
zation does not favor the greatest length of life. The
German empire, with 55,000.000 population, has but
78 subjects who are more than 100 years old. France,
with fewer than 40,000,000, has 213 persons \\ho have
passed their looth birthday. England has 146, Ire-
land, 578; Scotland, 46: Denmark, 2: Belgium. 5;
Sweden, 10; and Norway, with 2.000.000 inhabitants,
23. Switzerland does not boast a single centenarian,
but Spain, with about 18,000,000 population, has 410.
The most amazing figures found by the German statis-
tician came from that troublesome and turbulent re-
gion known as the Balkan Peninsula. Servia has 575
persons who are more than 100 years old: Roumania,
1,084; antl Bulgaria, 3,883. In other words, Bul-
garia has a centenarian to every thousand inhabitants,
and thus holds the international record for old inhabi-
tants. In 1892 alone there died in Bulgaria 350 per-
sons of more than 100. In the Balkan Peninsula,
moreover, a person is not regarded on the verge of the
grave the moment he becomes a centenarian. For in-
stance, in Serbia, there were in 1890 some 290 persons
between 106 and 115 years, 123 between 115 and 125,
and 18 between 125 and 135. Three were between
13s and 140. Who is the oldest person in the world?
The German statistician does not credit the recent
■story about a Russian 160 years old. Russia has no
census, he savs, and except in cases of special official
investigation the figures of ages in Russia must be
mistrusted. The oldest man in the world is then, in
his opinion, Bruno Cotrim, a negro born in .\frica and
now a resident in Rio Janeiro. Cotrim is 150 years
old. Next to him probablv comes a retired Moscow
cabman, named Kustrira. who is in his 140th year.
The statistician says the oldest woman in the world is
130 years old, but neglects to give her name or ad-
dress, possibly out of courtesy, or perhaps in view of
the extraordinary figures which came to his hand from
the Balkans he thought a subject only 130 years old
was hardly worthy of particular mention. — Medical
Revie-iii.
Medical Record
A Weekly youmal .of Medicine mid Surgery
Vol. 50, No. 8.
Whole No. 1346.
New York, August 22, 1896.
$5.00 Per Annum.
Single Copies, loc.
APPENDICITIS AS IT AFFECTS LIFE IN-
SURANCE RISKS.'
By albert woods, M.D.
WORCESTER, MASS.,
MEDICAL DIRECTOR OF THE STATE MUTUAL LIFE INSURANCE COMPANY.
No disease has assumed more importance in recent
years, or excited greater interest in the medical pro-
fession, both at home and abroad, than appendicitis.
It has been studied by the ablest physicians and sur-
geons in this country and in Europe, and their contri-
butions have followed each other in rapid succession,
so that now its literature has become voluminous.
From such abundant material, one would think that
the necessary data could be easily collected to show
the relation which this disease bears to life insurance;
but I have studied many of the scholarly articles upon
this subject, published within the last ten years, and
I have failed to find just the information needed to
enable me to form an intelligent conclusion.
Wells published in the Medical Examiner, in Novem-
ber, 1894, a valuable paper on "Appendicitis and In-
surance" that contained many important facts, a knowl-
edge of which is necessary to appreciate fully the
bearing of this disease upon insurance. Besides this,
I have found scattered through the medical journals
only one or two short items in which any allusion has
been made to this disorder, from an insurance stand-
point.
To obtain exact information, I addressed a letter of
inquiry to the various companies, to learn the practice
of each in dealing with an application of a person giv-
ing a history of appendicitis. The replies showed
such a remarkable difference in the methods of the
several companies in deciding upon this class of risks
that I was strongly impressed wi.th the importance of
bringing this subject before this association for dis-
cussion, and with the necessity of our trying to formu-
late some uniform rules for the guidance of all the
companies.
In this circular letter there were six questions.
The first was : How long after an applicant has re-
covered from a mild or catarrhal attack of appendici-
tis, before you consider him eligible for insurance.'
Three companies replied: "We decline all, unless
the appendix has been removed." Another answered :
"Ten years." Another said: "Six months." The
other companies variously fixed the limit between
these two extremes. No two companies, excepting
those which declined all, gave the same answers to the
six questions submitted. For this wide difference in
the rulings of the several companies I can offer no
satisfactory explanation.
Many persons who have had appendicitis are now
seeking life insurance, and no doubt the number will
be much larger in the near future.
The question of the eligibility of this class of risks
is one which is comparatively new to us, and its defi-
' Read before the Association of Life Insurance Medical Di-
rectors, May I, 1806.
nite solution may not be possible at the present time.
It may be necessary for us to wait until a larger clini-
cal experience furnishes us with more accurate knowl-
edge of the natural course and the ultimate outcome of
the disease, or until the differences of opinion among
the physicians and surgeons upon some of the points
in its pathology, prognosis, and treatment have become
settled. Even with the knowledge now at our com-
mand, we ought to agree upon some uniform mode of
action, which will do neither injustice to the appli-
cants nor to the companies which we represent.
I have not attempted to collect from the several
companies the number of policy holders whose deaths
were attributed to appendicitis and who had a his-
tory of having had the disease at the time of being
insured, for I thought that even the combined expe-
rience of all the companies would be so limited that
it would not be of much value for the purpose of this
study.
I have seen no statistics showing the frequency with
which inflammation of the appendix occurs. That it
is quite common we all know. The statement often
seen, that at least one-third of all post-mortems made
upon adults at random give evidence of old inflam-
matory lesions of the appendix, indicates as clearly as
anything the frequency of this ailment. Some of the
expressions used by those surgeons who have so
forcibly advocated early operations in all cases would
lead us to infer that they believed that this dis-
ease was unusually frequent at the present time. It
is generally thought, however, that more cases of ap-
pendicitis are seen nowadays than formerly, simply
because the profession has learned to recognize its
true nature.
It appears oftener in men than in women, four to one,
according to Fitz' first series of cases, but in his
second series the proportion is two to one. The
Munich statistics, however, show relatively more
women than men affected.
There are no observations which indicate the exact
mortality of this affection. Fitz says: "The rate of
mortality is by no means clearly established. The
physician who sees only mild cases says it is low:
while the surgeon who is called upon for aid in the
gravest cases considers the mortality very high."
Bridges writes: "The mortality from appendicitis,
considering the frequency of it, cannot be regarded
as great. The mortality of those cases eventuating in
perforation of the appendix is, however, great."
Richardson, of Boston, writes: " Excluding certain
zymotic diseases, it causes more deaths than any other
abdominal lesion. The number of deaths from ap-
pendicitis, in which the true cause is not even sus-
pected, is, I have no doubt, very large. If we take the
returns, however, and select those cases where death
has been caused in males under forty by ' inflamma-
tion of the bowels,' we should get an aproximate esti-
mate of the number of deaths from this disease. It is
only by collecting a large number of cases from many
observers that the true death rate can be determined.
This I have not attempted to do."
Let us look now at a few statistics. In his second
series of cases, Fitz gave the number of those who died
as 26 Der cent. Porter, of Fort Wayne, collected 448
254
MEDICAL RECORD.
[August 2 2, 1896
cases, in which the death rate was 17.23 per cent.
Sahli reports' 7,2 13 cases treated by 446 Swiss doc-
tors; only 476 were operated on; of those not dealt
with by operation only 8.8 per cent. died. Richard-
son gave me his personal experience in 401 cases,
with a death rate of 13.4 per cent. Hawkins states
the death rate of 264 cases admitted into the St.
Thomas Hospital, London, as 14 per cent.
Ferguson says : " I see on an average about twenty-
cases of well-defined appendicitis each year, and out
of this number about four would come to an operation.
All the patients would get well, and the vast majority
would remain well."
Brj'ant says : " Undoubtedly from sixty per cent, to
eighty per cent, of the cases would recover from pri-
mary attacks without operation."
White writes: "Perhaps eighty per cent, of the
cases of this type (catarrhal) recover under medical
treatment. Of the remaining twenty per cent., at least
one-half can be saved by operation during the condi-
tion of localized abscess, which occurs in probably
that proportion of cases; of the remaining ten per
cent., in which no protective adhesions would form, a
certain indeterminate proportion recovers after opera-
tion, before septic peritonitis and intestinal paresis
had occurred. This would leave a death rate of say
five per cent, to eight per cent.'' (Wells).
If we examine the recent reports of those surgeons
who believe that this disease should always be treated
as a surgical one, and who have so vigorously pleaded
for an operation in all cases as soon as a positive
diagnosis has been made, we shall find that the death
rate has been remarkably reduced. Deaver states that
he has made two hundred consecutive operations, with-
out any death; and Morris has recently published the
results of one hundred consecutive operations, with
only two deaths. These included all forms of the
complaint. The reports of other surgeons show-
equally good results. Wyeth writes to me: "I have
seen very few- cases of death from relapsing appendi-
citis. I think this is accounted for by reason of the
adhesions which form and include the first inflamma-
tory focus, mechanically retarding the rapid infection
of a recurring inflammation. I believe if every- case
of appendicitis were operated upon by a competent
surgeon within twelve hours of the first symptoms of
well-marked emigration of infectious organisms
through the diseased or [serforated wall, the death
rate would not be over one per cent."
Richardson, who does not advocate operations in
all cases, said to me that he had had seventy-five con-
secutive operations with no fatal results. Even gen-
eral peritonitis, which is so much apprehended and
dreaded as a result of an inflammation of the appen-
dix, and which has always been considered to be
almost surely fatal, until quite recently, has lost its
terror in a measure, so that now a large per cent, of
these cases recovers. McBurney has given us the rec-
ords of his operations for diffuse suppurative peri-
tonitis occurring as a result of appendicitis. Out of
twenty-four cases, fourteen recovered. Albee saved
three out of seven similar cases. Hawkins gives nine
recoveries in thirty-six cases, some without operation.
Richardson reports nine recoveries in thirty-two cases.
When we review the rapid progress made by the
American surgeons in the treatment of this malady in
the last few years, with its brilliant results in the sav-
ing of life, it is not unreasonable to anticipate that in
the near future, with this improvement in the treat-
ment still continuing, its death rate will become quite
low.
I have dwelt upon this question of mortality because
it is important that we should have a proper apprecia-
tion of the dangers to life resulting from appendicitis.
Especially is this true when we consider the remark-
able tendency of this disease to return, and the possi-
bility that the subsequent attacks may be followed by
the same fatality as the primarj' one.
In studying this disease as afTecting life-insurance
risks, we need to recognize only non-suppurative and
suppurative appendicitis.
Non-suppurative Appendicitis I will briefly re-
view some of the essential features of this type of the
disease. It has been stated by some observers that
about eighty per cent, of all cases seen are of this
form. The percentage of recoveries after the first at-
tacks is variously given. Death is rare, and occurs
only when general peritonitis or some other serious
complication supervenes. The pathological changes
in the appendix may be of the slightest, or they may
be such as to leave the organ permanently diseased,
or its lumen may become partially or completely ob-
literated, and the organ converted into a fibrous cord.
It may be the seat of tuberculosis or other morbid
conditions. Adhesions may be formed, of various ex-
tent and importance, which have been found to be
the cause of some of the remote after-effects of the dis-
ease. There may be only one attack, or one or more
subsequent attacks may occur at short or long inter\-als.
Complete and permanent recovery may follow the
primary or any of the succeeding atacks; or it may
not take place until the appendix has been removed.
Septic general peritonitis, or other serious complica-
tions, may appear. It is believed by many eminent
surgeons that the appendix once severely or mildly
inflamed is ever after a diseased structure, which is
apt to give rise to serious trouble at any time in the
future, and that it is a risk to the life of the patient to
leave sucli an infected organ within the abdominal
cavity. Many equally prominent in the profession
have not accepted these extreme views.
It is in this variety that most of the relapses and
recurrences are .seen. Fowler .states so clearly the dis-
tinction which should be made beUveen the chronic
relapsing and the recurring forms that I quote fully
his words. He writes of the former: "The pa-
tient may become seemingly convalescent, in that all
pain and febrile symptoms disappear. He may even
be permitted to resume his vocation. Within a few
weeks, or even earlier, a relapse takes place, with the
sj'mptoms perhaps more violent and threatening than
at first. There is one symptom, at least, which does
not entirely disappear, and its presence should always
place the attendant upon his guard against this form
of the affection. I allude to the symptom of persist-
ent tenderness. This is sometimes accompanied by
the presence of a tumor, although the latter is not an
essential symptom of this type of the disease."
He says of recurring appendicitis: "The special
feature of this form is the fact that the attacks occur
at long or short intervals, suggesting some predispos-
ing cause, which continues active after recovery- from
the first attack. It differs from the relapsing form of
the disease in that entire recovery takes pla'-e The
patient remains free from any trace of the affection for
varying periods, when suddenly and without any warn-
ing, he is subjected to another attack."
In some cases the inter\'al between each succeeding
attack becomes longer, its severity decreases, and
finally the disorder ceases altogether, so that the pa-
tient is restored to health and is ever after as free from
the risk of future trouble as if the appendix had been
extirpated. This occurs when the lumen of the ap-
pendix has become completely obliterated. In those
cases of appendicitis obliterans reported by Senn,
in which ablation of the appendix showed only partial
obliteration of its lumen, the relapses were frequent,
and there was local discomfort or tenderness remain-
ing during the intervals, as in the chronic relapsing
form described bv Fowler.
August 2 2, 1896]
MEDICAL RECORD.
255
The two features of this type of appendicitis which
make it of peculiar interest to life-insurance compa-
nies are its tendency to recur and its possibility of
passing suddenly into the severe forms of the disease,
either at the first or any subsequent attack.
The statistics showing the liability to second at-
tacks are far from being satisfactory. The following
figures will show the percentage of relapses and re-
currences, as given by a few observers. Fitz, in his
first series of cases, stated it as n percent.; in his
second series as 44 per cent., and in a recent conversa-
tion I had with him, he said: " A relapse is as likely
to occur as not.'" Irish gave 50 per cent. ; Richardson,
49.4 per cent.; Price, 50 per cent.; Ransohoff, 13 per
cent.; Kraussold, 23 per cent.; Krafft, 22 per cent.;
Porter, 9.^ per cent.; Bryant, 11 per cent, to 17 per
cent; Sahli, 20 per cent.; Gage, 33^ per cent.
Gage writes : " Almost ;^;^^ per cent, of my cases
had previous attacks. This is by no means equivar-
lent to saying that 33JJ- per cent, of all cases will have
relapses, and I do not think this last proposition a fair
one."
Mynter writes: '' I firmly believe that a patient who
has had one moderately severe attack is bound to get
another sooner or later."
Morton writes: "A careful inquiry will usually
demonstrate one or more relapses."
Meyer says: " It is the duty of the physician to fol-
low up these cases, to determine how many remain
actually well after one attack. I do not believe that
twenty per cent. — no, not more than ten per cent.,
would be found to remain healthy."
Wyeth writes: "From clinical experience, it is
known that a considerable number of cases of appen-
dicitis, with more or less peritonitis and exudation,
and at times with suppuration, undergo spontaneous
resolution, the patient being usually restored to health,
and living indefinitely without a recurrence of the dis-
ease. It may be safe to say that twenty per cent, of all
cases have such a fortunate end."
I thought that if I could collect a large number of
cases showing the exact time at which the second
attack occurred, I should then be able to determine
the time within which a majority of second attacks
appeared. The published reports of cases do not give
the exact time of the second attacks, except in a few in-
stances. Probably there is stored up in the note books
of the many observers just this information, and, if it
were only accessible, it could be utilized in clearing
up some of the doubtful points in this investigation.
Accordingly, I wrote to several physicians and sur-
geons asking for such data. From their replies, and
from those published cases which I have had time to
examine, I have been able to collect 326 cases in which
the exact time of the second attack was stated. In
210 cases, it appeared before six months; in 60
cases, between six months and one year; in 14
cases between one year and eighteen months; in 13
cases, between eighteen months and two years; in
II cases, between two and three years; in 3 cases, be-
tween three and four years; in 2 cases, between four
and five years; and in 13 cases, after five years.
From these figures, it is seen that 64.4 per cent, of
the second attacks occurred before six months; 82.8
per cent, before one year; 87.1 per cent, before eighteen
months; 91.1 per cent, before two years; 94.9 per
cent, before four years; 96.5 per cent, before five
years, and ^.;i per cent, after five years.
These statistics, so far as I know, are the only ones
of the kind collected up to date, and they must be ac-
cepted as establishing the time within which second
attacks have appeared. The study of a larger number
of cases, no doubt, would alter these percentages some-
what, but .still the fact would probably remain that in
a large majority of the cases the relapses take place,
if they are going to occur at all, within two years after
the primary lesion. The same opinion is expressed
by those surgeons who replied to my question, without
giving me exact data.
Cabot writes : " In regard to your second question,
I should say usually, if a patient relapsed, he did so
within a year, although I do not feel that I could lay
down a positive rule in regard to this. In cases which
have gone over two or three years, I should say 1 have
almost never seen a relapse. My experience covers
several hundred cases."
Morton writes: "From thirty days to a year or
more."
Mi.xter says: " Within two years."
Gage says: "In my experience, a large majority
has occurred within two years if at all, and mostly
within one year."
The other replies received gave the number of re-
lapses seen in each case, instead of the time of the
second attack; so they are of no value for my purpose.
Suppurative Appendicitis. — It is in this variety
that nearly all of the grave cases are seen, and they
are usually the result of perforation of the appendix.
Should this perforation take place before protective
adhesions are fonned, then general septic peritonitis
is rapidly excited, with fatal consequences as a rule,
or there may be diffuse peritonitis without perforation.
It is this large death rate from peritonitis which
makes this form of the disease so much dreaded, though
with prompt surgical interference more cases recover
now than in times past. When protective adhesions
are formed before perforation occurs, then there is the
form^ion of a localized abscess, the result of which,
if relieved by skilful surgical aid, is almost always
favorable. If the abscess is allowed to rupture it-
self, the course of the pus may be externally, or into
some internal viscus, or into the peritoneum, causing
diffuse peritonitis. In those cases in which the appen-
dical abscess forms behind the caecum (extra-perito-
neal) the pus may pass in various directions. The most
favorable place for the abscess to discharge is into the
bowel, and next into the bladder. When into the
former nearly all recover, and when into the latter,
fifty per cent. In a large percentage of the cases, the
appendix is so changed in character by the attack, or is
so embedded and bound down in the adhesions, that no
further harm can result to the patient. Again, the ap-
pendix may slough entirely away, and consequently the
patient will be as exempt from a subsequent attack as
if the organ had been excised.
In the circular letter sent to the physicians and sur-
geons, foui questions were asked under the following
head : In the suppurative cases, in which the abscess
was opened and drained without the removal of the
appendix,
((?) What has been the percentage of relapses in
your cases?
(fi) Within what time did the second attack appear?
(c) Have you seen more than one relapse in any
one case ?
(d) Is the subsequent attack as liable to be followed
by so serious results as is the primary one?
I have transcribed the answers received.
(a) " Some have chronic infection, not assuming
forms of attacks; others have acute exacerbations"
(Morris). " None" (Mynter). " One in about twenty-
seven cases" (McGuire). " None, so far as I know"
(Homans). " I can recall two in seventy-five cases"
(Gay). "In no case" (Morton). "Out of seventy-
nine cases, four had return of the disease" (Richard-
son). " I have operated on at least two cases in
which previous suppuration had occurred and had
had an operation" (Stimson). " None" (Irish).
" I cannot give the exact number, but I should say
several" (Mixter). " Have had one case" (Gage).
256
MEDICAL RECORD.
[August 2 2, 1896
"None'' (Porter). ''I have seen several relapses'"
(Cabot).
(/>) '• Two, two weeks after the operation ; one, six
weeks after, and one had four operations in nine years"
(Richardson). Time not stated by Stimson. " With-
in a short time" (Porter). " Within si.x months'" (Mc-
Guire). "Within a year" (Mixter). "Five years
after the first operation" (Gage). " I cannot say with-
in what time the second attacks appeared, but usually,
I should say within a few months" (Cabot). "Two
years, both cases'" (Gay).
(<-) "Yes, several" (Morris). "No" (McGuire,
Homans, Gay, Porter, Mi.xter, Gage). "Yes, one had
two relapses" (Stimson). "I have seen several re-
lapses; in one case, certainly three" (Cabot).
(d) " I think so. It was certainly so in the two cases
seen" (Stimson). " I should say that subsequent at-
tacks usually appear as abscesses at a point along the
old line of operation, and are, therefore, not so serious
as in the first attacks'" (Cabot). " I should think so'"
(McGuire). "No" (Porter). "No. General peri-
tonitis is not likely to occur, because pus will travel
along the old channels" (Gage). "Yes. No differ-
ence" (Morris). " No" (Mixter and Gay).
Richardson, in a recent conversation with me, said:
" No. The most dangerous form is when the appen-
dix hangs freely in the peritoneal cavity. In the ab-
scess cases, as a rule, the appendix is bound down by
adhesions, so that general peritonitis is not so likely
to occur, and death following second attacks is rare.'"
It will be seen from the abave answers that while
several relapses have been observed, they cannot be
said to be very frequent ; that while two were stated
to have appeared more than five years after the initial
attacks, all the others were within two years, and most
of them within a few months; and that, in the opinion
of some of the surgeons, the subsequent attacks are as
likely to be followed by the same serious consequences
as in the primary one; but that others have expressed
the belief that there is not this danger to be expected,
and have very clearly given their reasons for this
opinion.
In a recent discussion before the New York Surgi-
cal Society, Stimson said : " The generally accepted
idea was that after one attack of suppurative appendi-
citis, sufficient changes were set up in the neighbor-
hood to render the patient exempt from the risk of
further attacks. Two ca.ses had occurred to him re-
cently, however, that indicated that this was not neces-
sarily the case, since one patient, after what had been
undoubtedly two attacks of suppurative inflammation,
presented himself for the cure of a resulting hernia,
and on operation it was found that the appendix was
free within the peritoneal cavity, and practically de-
void of adhesions."
Bryant and Fowler fully corroborated Stimson's
statement, that frequently after an attack of suppu-
rative appendicitis, the appendix was as fully capable
of originating another attack as formerly. Rushmore
was of the opinion that such cases did occasionally
occur.
I have quoted this in full, because it gives quite
clearly the two opposite views held by the profession
upon this point, at the present time.
To myquestion: "Have you seen a recurrence in
any form after the appendix had been excised?" I
received one answer in the affirmative. Morris
writes: "Yes, where more than one inch of the appen-
dix was left in." A few cases have been reported of
second attacks after the appendix had been removed,
usually the result of improper treatment of the stump.
The Remote Complications and After-Effects. — A
patient may have entirely recovered, to all appear-
ances, from the immediate efliects and complications
of the disorder; still he is in danger of having certain
other sequela; develop at any time in the future. The
remote after-effects which are most frequently seen are
an obstruction of the bowels in its various forms from
adhesions, and peritoneal tuberculosis. Other sequelae
have been observed.
It is generally thought that adhesions once formed
are permanent; but several operators have shown that
when a second laparotomy has been required, as for
the cure of a ventral hernia, the adhesions have been
found in many instances to have disappeared.
If no symptoms of obstruction have appeared within
a certain period after recovery, can we assume with
any reasonable certainty that the probability of these
symptoms developing at all is quite small? If so, at
what time after recovery would you fix this limit?
To these questions, I received the following replies:
Cabot: " I do not think we can ever rule out, with any
certainty, the possibility of obstruction occurring a
Irfng time after an attack, as it is impossible to tell
what bands have formed. It has been my experience,
however, that adhesions usually disappear after the
cause of irritation has been removed, so that, if a pa-
tient made a complete recovery, I should not expect
any further trouble from adhesions after they had been
a year in reasonable comfort.'" Homans says: "Yes.
Perhaps one and a half years.'" Gage says: "Yes. I
should think one year a liberal limit.'" Irish writes:
■■ I have not seen a ca.se of obstruction after recovery
from operation."" Morton says: "Yes. Quite safe at
four or six months." Mynter says: "Yes. I believe
there is very little probabilit)' of its developing."
Morris writes: "Not without operation to determine
the form of the adhesions." Porter says: "Yes. I
think thirty days a safe limit.'" McGuire says:
"Quite small after six months.'' Stimson says: "In
cases operated on, with removal of the appendix, the
chances of future trouble are verj' slight." Mixter
says: "Yes. Two years." Gay says: "Yes. Six
months." Richardson writes: "Yes. Six months."
The question. Would obstruction of the bowels be
more likely to occur after a general than after a local
peritonitis? was answered by a large majority of the
surgeons in the negative.
It will be seen that, in the judgment of these obser-
vers, the probability of the obstruction of the bowels
occurring after two years is very slight.
The danger of hernia following an operation in ab-
scess cases is great, but in non-suppurative cases,
when drainage is not required, this danger is quite
small. A few cases of strangulation in this kind of
hernia have been reported; though the possibility of
such an occurrence is not large. The condition is one
more of discomfort than of danger to the patient. The
rupture can be entirely cured by a second operation as
a rule.
Time will not permit me to consider tuberculosis of
the appendix, or of the peritoneum, following this ail-
ment; nor will I mention the other remote complica-
tions which may develop.
Of the other forms of abdominal disease which have
been mistaken for appendicitis, it is not necessary for
me now to speak. It is enough to recall to your mind
that long list of morbid conditions given by Dennis,
in which a wrong diagnosis was made.
Application to Life Insurance. — .^n applicant who
has had appendicitis is an impaired risk, but with
such a history he is not absolutely ineligible for in-
surance. Under what conditions is he insurable?
He should have completely recovered from the dis-
ea.se; in all other respects he should be up to the
standard of physique and health usually required, and
a sufficient time should have elapsed after the attack
to show that the probabilit)' of the return of the trouble,
or the development of any of its remote after-effects,
is reasonably minimized.
Auijust
[896]
MEDICAL RECORD.
257
To determine whether he has fully recovered from
the ailment, we must rely wholly upon the opinion of
our local medical examiner, and much will depend
upon the care and thoroughness with which he makes
the examination.
He should obtain a full history of the case, the date
of the attack, the form of the disease, its severity and
its treatment, whether there were any previous attacks
or any symptoms which might be construed as such.
He should inquire as to any symptoms of indigestion,
pain, or constipation. He should scrutinize the ab-
domen with care for any evidence of tenderness re-
maining, of dilatation of the caecum, of a hernia, of a
fistula, or of tuberculosis. When practicable, he
should employ the method recommended by Edebohls
for the examination of the appendix. If the applicant
is a female, then, in addition to the above, the condi-
tion of the uterus and its appendages should be care-
fully noted.
When possible, so much of his statement as relates
to the history and treatment of the case should be cor-
roborated by the attending physician or surgeon.
Many of our medical examiners have a proper ap-
preciation of the importance of an attack of appendi-
citis from an insurance point of view, and obtain all
the above facts and report them to the home office ;
but I am sorry to say that there are some examiners
who merely make the statement that the applicant has
had the ailment, without giving any further informa-
tion.
It would seem advisable, therefore, in all cases of
this class of risks, that a special letter of inquiry
should be sent to the local examiner, requesting such
details as may be desired.
How long after a person has recovered from an at-
tack of appendicitis, before he should be considered
eligible for insurance?
A different answer can be given to this question at
the present time from what could have been made ten
or even five years ago, for we have a more accurate
knowledge of the natural history and prospective con-
sequences of the disorder, and its proper method of
treatment is better understood, and therefore more
successful ; so that the general results to the compa-
nies will undoubtedly be much more favorable now than
formerly.
The following classification will probably include
all of the different phases of the disease which we
shall be called upon to decide as affecting life-insur-
ance risks.
1. Cases of primary attacks of non-suppurative ap-
pendicitis, in which the appendix was not removed.
In this class of risks, the dangers to be guarded
against are the return of the disease with its possibili-
ties, and the development of some of its remote after-
effects. The statistics show that the second attack oc-
curred before one year in 82 per cent, of the cases,
before two years in 91.1 per cent., before three years
in 94.4 per cent., before four years in 94.9 per cent.,
before five years in 96.5 per cent., and after five years
in ^.;^ per cent.
Those surgeons who could not report their cases
showing the exact time at which the second attack took
place, but did give their impressions from the study
of several hundred cases, used expressions on this
point as follows: " V\'e should say usually, if the
patient relapsed, he did so within a year. In cases
which have gone over two or three years, we should
say we have almost never seen a relapse." They also
expressed the opinion that if a patient went one year
without any of the remote after-effects of the disease
developing, the probability is quite small that they
will appear later.
Now if the second attack takes place within two
years in 91.1 per cent, of all the cases, there is less
than one out of ten chances that the disease will re-
turn after two years.
I have not been able to collect any reliable data
showing the death rate in those cases which relapsed
after two years. It certainly must be quite low. This
statement is confirmed by several surgeons. It would
seem reasonably safe, therefore, to accept this class of
risks after two years.
2. Primary non-suppurative cases with the appendix
excised.
In this class the recurrence of the disease is not to
be expected, but the other remote after-effects are to
be apprehended. It has been shown that the adhe-
sions disappear in many instances after ablation of the
appendix, consequently obstruction would not be so
likely to occur as in the first class. Cases of this
kind should be insurable after one year.
3. Suppurative cases in which the appendix has
been extirpated, or in which it can be clearly proven
that it has sloughed entirely away.
It may be very difficult to decide the latter point
absolutely in some of the cases. The remote conse-
quences from adhesions to be anticipated in this
variety would be the same as those in class 2, and I
can see no reason why the same rule should not be
adopted for both classes.
4. Suppurative cases in which the abscess was opened
and drained, the appendix not being removed.
From the data obtained, it appears that in this type
of the disease a recurrence was observed in less than
one out of twenty cases; and with only two exceptions
the second attack occurred within two years, and most-
ly within a few months after the previous one.
While all of the authorities state that there is a pos-
sibility that any subsequent attack may be followed
by serious consequences, still several surgeons who
have had large experience with appendicitis inform
me that, as a matter of fact, death is very rare after
these relapses.
It would seem, therefore, that the risk of a fatal is-
.sue in any case after two years would be slight. Cases
of this kind might be accepted for insurance after two
years.
In those cases in which the abscess ruptures inter-
nally, each one must be judged upon its merits. Many
of these cases make a perfect and permanent recovery,
and are justly entitled to insurance.
5. Chronic relapsing and recurring cases.
An applicant with a history of chronic relapsing ap-
pendicitis would be debarred from insurance, because
he does not make a full recovery- between the attacks.
When it can be decided that in all probabilit)' the ap-
pendix has become obliterated, then he should be in-
surable. He should be required to wait three years
after the last attack before he should be considered
eligible.
I find it very difficult to arrive at any just conclu-
sion in regard to those cases in which the recurrence
has been at irregular intervals, the patient having been
in perfect health and free from any symptoms of the
disease between the attacks.
It has been stated that the patient appears to have
some predisposition to the disease, and that the at-
tacks are excited by errors in diet, overexertion, etc.,
or there is an underlying rheumatic or gouty tendency,
as when the ailment has occurred in more than one
member of the same family.
This type, as a rule, is not liable to pass suddenly
into the grave forms of the disorder. If a person
gives a history of two or more attacks, at periods of
less than five years apart, he should be declined ; but
when he has gone over five years without a recurrence,
it is a question in my mind whether we should be as-
suming any more risk in accepting such a case than
we take every day in .some other diseases. Each case,
258
MEDICAL RECORD.
[August 2 2, 1896
however, must be judged according to the facts sub-
mitted. The age of the applicant would be an impor-
tant factor in enabling us to form a decision.
6. Cases which have recovered from general peri-
tonitis, either with or without an operation, the ap-
pendix having been e.xcised or not.
It is generally thought that very few patients sur\'ive
such an attack, but recovery does occur; and under
modern treatment the number which gets well is in-
creasing. Are the remote consequences of adhesions
more likely to develop after a general than after a
local peritonitis? Upon the answer to this question
we should base our decision as to the eligibility of
this class of risks.
The replies received from the majority of those sur-
geons to whom this question was addressed, indicate
that there is no difference in the liability between the
two forms of peritonitis. Whether there is greater
danger of the development of some of the other remote
after-effects, as abdominal tuberculosis, after a general
than after a local peritonitis, I have no means of know-
ing. With the appendi-\ unremoved, second attacks
of peritonitis have been observed. Richardson reports
a fatal case which occurred three years after the first
peritonitis.
I can see no good reason why the same rules should
not govern this class as those given for classes i and
2, excepting that a patient who has had a severe attack
of general peritonitis has a protracted convalescence as
a mle, and therefore a longer time would be required
to establish perfect health than after a milder form of
the disease; and, besides, there may be a greater risk
in this class of cases.
Taking the above facts as a basis upon which to
form an opinion, I should say that cases of this class
were eligible for insurance after one year when the
appendi.x has been excised, and after three years when
it has not been removed.
7. Cases of hernia following an operation.
These should be classified with other kinds of her-
nia, though it has been said that strangulation is not
so liable to occur in this type as in the other varieties.
The applicant should be required to wear a suitable
support.
The above recommendations seem to be justified by
the facts obtained from studying the literature of ap-
pendicitis, and from the opinions expressed by those
physicians and surgeons who have so kindly given me
the benefit of their large experience with the disease.
The rule '"to decline all applicants with a histor)-
of appendicitis, unless the appendix has been removed,"
is, in my judgment too stringent ; aiul, on the other
hand, the rule to accept an applicant after six months
with such a history, the appendix not having been ex-
cised, is too liberal, as it is assuming too great a risk,
excepting perhaps in the very mildest cases of the
disease.
While the former rule may more safely guard the
company, so far as the death rate is concerned, it will
at the same time deprive many persons of the benefits
of insurance to which they are justly entitled; and,
besides, it will turn away an amount of business which
should be retained.
The company may often suffer as much injury when
an injustice is done to the applicant, as when by an
error of judgment a doubtful risk is approved.
I am not strenuous that these recommendations shall
be adopted by the as.sociation in just the form sub-
mitted; but it is my earnest hope that we may be able
to formulate some rules which will be uniformly used
by all the companies in dealing with this class of
risks.
Epistaxis may often be controlled by snuffing into
the nostrils a saturated solution of antipyrin.
MESCAL BUTTONS.'
Anhalonium Lewixii — Hennings (Lophophora
WiLLiAMSii Lewinii — Coulter).
Bv I). \V. PRENTISS, A.M., M.D.,
PROFESSOR OF MATEKIA MEDICA AND THERAPEUTICS, MEDICAL DEPARTMENT
OF COLUMBIAN UNIVERSITY*,
FRANCIS P. MORGAN, A.B., M.D.,
PROFESSOR OF PHARMACOLOGY, MEDICAL DEPARTME.NT OF COLUMBIAN UNI-
VEKSITV. WASHINGTON, D, C.
The study of Anhalonitim Lewinii is of comparatively
recent date, the subject having been brought to the
attention of the medical world in 1888 by Dr. Lewin,
of Berlin, who published at that time the results of his
observations upon the drug. In 1894 Drs. Lewin and
Heifter, of Germany, reported the results of further
study of the subject. In 189^ James Mooney, of the
United States bureau of ethnology, in a paper read
before the Anthropological Society of Washington, first
brought to public attention the remarkable religious
ceremonial use of the plant by the Kiowas and other
tribes of the Southern plains, among whom he had
been conducting researches for some time. In 1894
he brought back to Washington for examination a
large quantity of mescal, under the belief that investi-
gation would corroborate the claim of the Indians as
to its valuable medicinal properties. This was given
over to Mr. E. E. Ewell, of the department of agri-
culture for chemical analysis, and to the writers for
therapeutic test. Our study of the subject has shown
that the mescal buttons possess properties which are
remarkable, the exact likeness of which is not found
in any other known drug, and also that it possesses
virtues which, when applied in the treatment of certain
diseased conditions, may prove the drug a valuable
addition to our present list of therapeutic agents. It
is for these reasons that we have chosen to present
this subject in this paper for your consideration.
Anhaionium Lewinii is a plant belonging to the
natural order of Cactacea.- or cacti, as they are com-
monly called. One of the divisions of this great order
is the genus Anhaionium, of which there are several
species, and among them Anhaionium Williamsii, and
the one now under consideration, Anhaionium Lewinii.
As to the exact place in botanical classification
which the Anhaionium Lewinii should occupy, there is
some difference of opinion among botanists. Hen-
nings.' who first published an accurate description of
the plant, believed it to be a separate species of the
genus .\nhalonium. Dr. A. Heffter " holds the same
view, reasoning both from botanical characteristics
and the dissimilarity in physiological action bet\\een
the Anhaionium Williamsii and Anhaionium lewinii.
On the other hand, botanists who have investigated
the subject more recently hold that the Anhaionium
Lewinii is but a variety of the species Anhaionium Wil-
liamsii. Coulter, an authority upon the cacti, holds
this view and gives the plant the name Lopliophora
Williamsii Lewinii.' The botanist in charge of the
United States botanical gardens in Washington be-
lieves that the two plants belong to the same species.
The Anhaionium Lewinii inhabits portions of the
valleys of the Rio Grande and Pecos rivers in Texas
and New Mexico, growing in barren, rocky soil, and
often in places which can be reached only with diffi-
culty by tho.se who gather it. It reaches a height of
about one inch above the surface of the ground. The
' Read before the Association of American Physicians, Wash-
ington, U. C, May 2, jSc)b.
' Therapeutic Gazette, 1888.
' " Ueber Pellote." Arch. f. exper. Path. u. Phar., 1894,
xxxiv., 65.
■•J. M. Coulter: •'Preliminary Revision of Cacti." Hulletin
U. S. Depart. Agriculture, Washington, 1894.
Aueust
1896]
MEDICAL RECORD.
259
body (Fig. i) is comparatively thick, and is sur-
mounted by a top, which is composed mainly of the
blunt leaves of the plant. In the centre of this top is
a tuft about one-half to one inch in diameter, com-
posed of yellowish-white filaments or hairs. These
/>
^fm
^'^&-
Fig.
tops, when dried, constitute the mescal buttons, the
commercial form of Anhalonium Lewinii.
The mescal buttons (Fig. 2) are of a brown color,
circular, about one-half to one and a half inches in
diameter and one-fourth of an inch in thickness. The
edge curls upward, giving to the under surface a con-
v;^-"^'
4^'^i^^~::J ^\m
yy -'rX-^"^^' h
Fig.
vex appearance. In the centre of the upper surface is
a tuft composed of the yellowish-white hairs before
mentioned, and matted down so as just about to reach
the level of the upturned edge. The buttons vary in
weight from about one to eight grams, the average
being about four grams.
The button is somewhat brittle and hard and can
be pulvtrized in a mortar with difficulty. In the
mouth, however, under the action of the saliva, it swells
and rapidly becomes soft, the consistency which it ac-
quires giving somewhat the sensation imparted by
slippery elm. The taste is disagreeable and nauseous
and very bitter, with a persistent after-taste. A
marked sensation of stinging or tingling is produced
in the fauces, which remains for some time after the
drug has been swallowed. The powdered drug is
odorless when dry, but acquires a nauseous odor upon
being moistened.'
Physiological Action. — In connection with the
physiological action of the mescal, its use by the In-
dians is of great interest. The Kiowa Indians and
their associated tribes, formerly ranging from the Ar-
kansas River southward into Mexico, have, from the
earliest period, made its use a regular part of their re-
ligious ceremonies. When finally gathered upon the
Kiowa resen^ation in Oklahoma, which they now oc-
cupy, they continued the use of the buttons in their
ceremonies, the demand being supplied by traders who
obtain it from the valley of the Rio Grande. Its use
has spread to such an extent that the rite has become
the chief religion of all the tribes of the Southern
plains. Complaint being made to the government
authorities at Washington by missionaries and others,
the eating of the drug was rendered unlawful and was
forbidden under severe penalties. Nevertheless, the
use of the mescal has persisted to the present time.
The religious ceremony, as described by Mr.
Mooney, who has participated in it several times,
usually takes place on Saturday night. The men seat
themselves in a circle within the tent, around a large
fire which is kept burning brightly. After a prayer
the leader hands each man four buttons, and each,
having been freed from the tuft of hairs, is put into
the mouth and, after it is thoroughly softened, is
ejected into the palm of the hand, rolled into a bolus,
and swallowed. At midnight each man calls for as
many mescals as he wants, and in this way ten or
twelve of the buttons, as a rule, are taken at intervals
between sundown and daybreak. They sit quietly
throughout the ceremony, while the fire is kept burn-
ing brightly and a continual singing and beating upon
the drum is kept up. Most of the time they are in a
state of reverie, the intoxication of the drug showing
itself in the visions of color and other manifestations
which will be described later. The hours are inter-
spersed with songs, prayers for the sick, and baptis-
mal rites. They sit thus from sundown to nearly noon
of the next day. At the close of the ceremony they go
out, it is claimed, without the slightest depression or
unpleasant after-effect. Upon the day following the
ceremony they carefully abstain from the use of com-
mon salt with their food: this, it seems, for a relig-
ious reason, and not because of any incompatibility
of salt with the drug or its efi^ects."
To determine the piiysiological action of the crude
drug — the mescal buttons themselves — upon the
human system, they were administered in varying
quantity to different young men who kindly volun-
teered their services for the purpose. Eight of these
experiments were made, and in each enough of the
drug was given to produce decided characteristic
symptoms. Observations were taken at frequent and
regular intervals to ascertain the effects upon the dif-
erent portions of the body. Most of these experiments
have been reported in full,' but time does not permit
us to give a detailed account of them. The following
are briefly the results obtained:
' The writers, in Therapeutic Gazette, September, 1S95.
' See also ' Mescal Plant and Ceremony," James Mooney,
Therapeutic Gazette.
'Therapeutic Gazette, September, 1S95.
26o
MEDICAL RECORD.
[August 2 2, 1896
The most remarkable of the physiological effects of
the drug was the production of visions. These ap-
peared in most cases after three of the buttons had
been taken. The visions ranged from ill-defined
Hashes of color to most beautiful figures, forms, land-
scapes— in fact there seemed to be absolutely no limit
to the variety of visions which the drug could produce.
They could in but few cases be seen with the eyes
open, but upon closing them an ever-changing pano-
rama appeared. Drumming, or otherwise marking
regular time, had a marked effect upon the visions —
much enhancing the beauty and variety of the objects
seen. The fact is of interest in connection with Mr.
Mooney's statement that during the eating of the
mescal by the Indians there is kept up a continual
beating upon the drum. In three cases the visions
were under the control of the will, and in two they
were subject to the suggestion of others. The effect
of the drug in the production of visions is probably
due to stimulation of the centres of vision in the
brain. The persistent ache and feeling of e.\haustion
in the occipital region, which persisted for several
days after one of the experiments, is of interest in this
connection.
A clearer idea of the nature of these visions is given
by the following extract from one of the cases already
reported. In all other cases, similar effects were pro-
duced. "The first sensations that followed my taking
the drug came upon thoughtlessly closing my eyes.
Instantly there sprang into the field of view a host of
little tubes of shining light, down which green and red
balls the size of peas were constantly rolling. The
tubes of light bent themselves into the shape of letters,
but they would spell nothing, and, slowly curving
themselves into grotesque shapes, began to revolve
rapidly, the green and red balls going in the opposite
direction with even greater velocity. All the field of
view between these silent wheels was filled in with a
shifting mass of green. The colors were wonderful.
They were the colors of the spectrum intensified as
though bathed in the fiercest sunlight. No words can
give an idea of their intensity or of their ceaseless,
persistent motion. The figures constantly changed in
form and color, but always remained a series of fan-
tastic curves, revolving rapidly back and forth upon
their own axis. The forms clianged through rich ara-
besques, Syrian-carpet patterns, and plain geometric
figures, and with each new form came a new fiush of
color, every shade appearing, from pure white to deep-
est purple. When the eyes opened and the light was
turned up, the visions faded like stars going out in
daylight, and the room, tables, chairs, and all sur-
roundings came back into real existence and within
reach of the hands."
It will he .seen that the predominating hallucina-
tions are the wonderful color phenomena, although the
figures, forms, etc., are in themselves sources of pleas-
ure and admiration.
In some cases no effect whatever was produced upon
the reason or will of the individual. In others, there
was some slowness of thought and loss of power of
expression, and in one of the experiments a marked
delusion. Compared with other drugs of this class,
however, the effect upon the mind is extremely slight.
Dilatation of the pupil was well marked in every
case, and persisted for from tw-elve to twenty-four
hours after the drug was taken. The dilatation was
accompanied by a slight loss of the power of accom-
modation and consequent disturbance of vision.
More or less depression of the muscular system ex-
isted in every case, and this was the first effect noticed
after the drug was taken. It ranged from a feeling of
lazy contentment to marked muscular depression.
Susceptibility to this effect varied widely. Whether
the sedative effect is produced by action on the nerve
centres, peripheral nerves, or their ner\-e endings, or
on tiie muscular fibres themselves is not yet deter-
mined, but indications point to action through the
nerve centres.
Partial aneesthesia of the skin was present in three
of the cases, appearing when the effects of the drug
began to wear off.
The heart action is at first rendered slower and
.stronger. This is followed by a rise to the normal,
which continues during the period of greatest activity
of the drug. In the cases in which the muscular de-
pression was greatest, slight if any depression of the
heart was present.
The respiration was unaffected in all cases but one.
In this it seemed to partake slightly of the general
muscular depression.
Upon the stomach the drug produced an effect
which varied from a feeling of uneasiness and fulness
at intervals, to nausea and vomiting.
Inability to sleep for at least twelve hours after the
influence of the drug passed off was a uniform effect.
Appreciation of the duration of time was lost in all
cases — as in the effect of cannabis indica. In one
case a snowstorm appeared to last an hour, although
in fact the vision continued not more than one minute.
No constant effect upon the bowels, skin, tempera-
ture, or secretion of the various glands of the body
was found.'
The only record of the taking of Anhalonium Lewinii
for experimental purposes which we have been able to
find is that of Briggs." He took "a third of a speci-
men," and the symptoms jiroduced were the following:
In fifteen minutes the pulse rose from 60 to 70. In
thirty minutes there was fulness of the head, pulse 90,
respiration 26. The sense of fulness increased, and
was followed by a headache and swimming in the
head. Suddenly the pulse shot up to 160, and the
respiration increased so that he could with difficulty
get sufficient breath to keep himself alive. He
thought he was about to die, and became unconscious.
In six to eight hours his pulse and respiration went
down again to the normal. Great depression existed
for twelve hours.
The symptoms produced in this experiment are so
widely different from these which we have obtained
from administration of the drug that we cannot believe
that the drug taken by Briggs was the same one which
we have now under consideration.
Lewin,' in experiments upon animals, found that in
them the drug produced an acute muscular spasm of
varying intensity, with increased reflexes, its action in
this particular much resembling that of strychnine or
brucine. No such effect was present, however, in our
experiments upon man. Whether or not it would be
produced by much larger doses is, of course, a matter
of conjecture. In some animals, also, a quickened
respiration was noted, which effect was present in our
experiments only in one case, and in the presence of
great general muscular depression. In animals, also,
the heart remained unaffected, whereas in man we
found a primary slowing of the heart action. In both
animals and man more or less tendency to nausea and
vomiting existed in most cases.
The physiological action of Anhalonium Lewinii
upon man cannot be said to be identical with that of
any other known drug. Its effects resemble those of
certain drugs in some of the symptoms produced, but
differ widely from them in others. Cannabis indica
produces visions, with dilated pupils and with slight
effect upon the circulation. In these particulars its ac-
' Therapeutic Gazette, September, 1895.
' Lewin; Archiv flir experimentelle Palhologie und I'liarma-
kologie. Band xxxiv.. Heft 5 u. 6.
' Archiv fiir experimentelle Pathologie und I'harmakologie,
Band xxxiv , Heft 5 u. 6.
August 2 2, 1896]
MEDICAL RECORD.
261
tion is similar to that of Anhalonium Lewinii. But Can-
nabis indica is a hypnotic, and the delirium and hal-
lucinations are in most cases followed by sleep. An-
halonium Lewinii, on the other hand, tends to produce
wakefulness in every case. The Indians do not sleep
for twenty-four hours after the commencement of their
ceremony, and in our experiments sleep was found to
be impossible for about the same length of time.
In this tendency to produce wakefulness it resem-
bles cocaine. The visions produced by Cannabis in-
FlG. 3.
dica "are generally of a gay character, producing
much merriment, accompanied by a great inclination
to muscular movement." ' The visions of Anhalonium
Lewinii provoked wonder and admiration, but no mer-
riment, and there was present disinclination to make
any muscular effort. Other marked differences e.xist,
which will become evident to any one comparing the
action of the two drugs."
Alkaloids of Anhalonium Lewinii. — In 1888 Lewin
subjected the mescal buttons to analysis and suc-
ceeded, by chemical methods which need not be given
here, in obtaining an alkaloidal substance, to which
he gave the name anhalonine, and to which he as-
cribed the chemical fonnula C,.,H,.NO,. Mr. Ewell,"
who has succeeded in obtaining anhalonine in a pure
state, describes it as a white strongly alkaline sub-
stance. It crystallizes from aqueous solution in pris-
matic, sometimes tabular crystals of the rhombic sys-
tem. It is soluble in a large quantity of water, and
is unusually soluble in alcohol, ether, chloroform,
benzin, and petroleum ether. Its melting-point is
77.5 ' C, and it can be sublimed without decomposi-
tion. It forms salts with the ordinary acids.
Anhalonine hydrochlorate (Fig. 3), which was used
in our experiments with the first alkaloid, is a white,
odorless substance forming needle-like crystals. It
is soluble in water in the proportion of two parts per
one hundred. The solution is very bitter to the taste.
The hydrochlorate is also soluble in alcohol. It melts
at 254°-255° C. with decomposition. It rotates the
plane of polarized light to the left. Lewin describes
an amorphous as well as a crystalline hydrochlorate,
' Brunton: " Pharmacology, .Materia Medica, and Therapeu-
tics," p. 1,026.
■ The writers, in Therapeutic Gazette, September, 1S95.
^I am indebted to .Mr. E. E. Ewell, Bureau of Chemistry, U.
S. Department of Agriculture, for the chemical description of
the constituents of mescal buttons and the photographs repro-
duced in this article.
but Mr. Kwell believes that the former is but an im-
pure hydrochlorate.
Lewin' describes anhalonine sulphate as forming
needle-like crystals, colorless or of a slightly yellowish
tinge; easily soluble in cold water, but much more so
in hot water; almost insoluble in alcohol and ether.
The physiological action of anhalonine upon guinea-
pigs and other small animals has been investigated by
Lewin and Heffter. Lewin found that in these ani-
mals the alkaloid produced at first a primary collapsed
condition, which was followed by an increase in the
reflex excitability, and, if the dose administered was
large enough, convulsions which resembled to a cer-
tain extent those produced by strychnine. The action
of the drug, so far as these experiments would indi-
cate, is somewhat analogous to that of strychnine.
The lethal dose was found to be 0.16 to 0.20 gram
per kilogram of body weight.
These results we have verified by a series of experi-
ments upon guinea-pigs in the laboratory. The fol-
lowing experiment is fairly typical.
Guinea-pig; weight, four hundred and twenty-five
grams.
I :oi. Injected 0.05 gram anhalonine hydrochlorate
in solution.
I :o3. Tremor of body.
1 :o5. Tremor of body. ( )pisthotonos, followed by
convulsion.
I ;o8. Slight convulsion. Pulls itself around by
front legs; hind seem paralyzed. Opisthotonos.
I :io. Convulsion on touch.
1:12. Breathing rapid. Tremor of front extremi-
ties.
1:15. .Attempts to mo\e but cannot, except extrem-
ities.
I :25 to I 140. Constant convulsive movements of
whole body. Normal reflex to touch, breath-of-air
sound, etc., exaggerated,
I 130. Biting and chewing. Opisthotonos.
I :4o. On feet. Condition better. No tremor or
convulsions.
I :45. Convulsion, precipitated by rubbing back.
After it, legs extended for a short time.
I 147. Sits up. From this time gradually improved.
In order to ascertain the action of anhalonine upon
man, Dr. Morgan took the drug in progressively in-
creasing doses daily up to 0.20 gram without any ap-
preciable effect. As this amount is nearly four times
the quantity of anhalo-
nine contained in the
crude drug administered
in the experiment al-
ready reported, it is evi-
dent that anhalonine
cannot be the active
principle of mescal but-
tons, or even a potent
factor in the production
of their effects. A sec-
ond alkaloid has also
been obtained from An-
halonium Lewinii,' and
was called by Heffter
venience, we shall call mescaline,
talline form, solubility, etc., are
a subject of study by Mr. Ewell
ether, chloroform, and petroleum ether. In the last
it is much more sparingly soluble than is anhalonine.
It forms a hydrochlorate with hydrochloric acid.
Mescaline hydrochlorate is a white substance, form-
ing tabular crystals. It is much more soluble in water
and alcohol than is anhalonine hydrochlorate.
' Archiv f. exper. Path. u. Phar., 1888, xxiv.. 401.
'Dr. A. Heflter; Arch. f. e.\per. Path. u. Phar., 1894. xxxiv..
66.
Kic. 4.— Third .Alkaloid
alkaloid B
o diameters.
This, for con-
Its formula, crys-
now being made
It is soluble in
262
MEDICAL RECORD.
[August 22, 1896
We have conducted a series of experiments upon
guinea-pigs to determine as nearly as possible the
characteristic effects of mescaline, and in what particu-
lars its action differs from that of anhalonine.
I.. — Guinea-pig; weight, five hundred and sevent)--
six grams; o.oi gram mescaline hydrochlorate in so-
lution, hypodermically. No appreciable effect. Later,
0.02 gram injected in same animal. No decided
effect. Seemed more sluggish in movement and less
easily frightened than normally. Breathing more
rapid.
II. — Guinea-pig; weight, four hundred and twenty-
five grams.
12:15 P-^'- °-°3 g^'ini mescaline hydrochlorate, hy-
podermically into inner side of thigh.
12:19. In corner. Apparently drowsy. Will not
move when struck.
12 :23. Tremor of head and body.
12:28. Most rapid convulsive movements of ex-
tremities, as if running, but makes little progress, as
feet seem to take no hold upon floor.
12:30. Quiet, on belly, in natural position.
12:43. Same; seems drowsy. Recover)' from this
time.
III. — Guinea-pig; weight, four hundred and sixteen
grams.
12 : 53. 0.04 gram mescaline hydrochlorate in solu-
tion, hypodermically.
12:57. Runs around uneasily Rapid chewing-
movements of jaw.
12:58. Pupil slightly dilated. Chews rapidly.
Tremor of head.
12:59. Runs around in frightened manner, with
tremor of body. Chews. Breathing rapid.
I :oo. Runs around, jumps high, and falls on side
in convulsion. Extremities stiff. Opisthotonos.
1:01. On feet again. Tremor. Breathing rapid.
1:02. Pupil dilated. Breathing rapid and labored.
I :o5. Violent convulsion.
I :o6. More quiet. Tremor.
1:11. Looks around more normally. Breathing
1,0 per minute and difficult. Whole body shakes.
1:16. Moves backward. Breathing same.
1:20. Breathing 120 per minute. Walks back-
ward.
I ■.^^. Runs backward around cage.
I :4o. Breathing 1 04, but more irregular.
2:10. Walks backward. Breathing much slower,
but weak and irregular.
3 :oo. Animal bright and runs forward when touched
suddenly. Recovery.
IV. — Guinea-pig.
1:00. 0.047 gram mescaline hydrochlorate in solu-
tion, hypodermically.
I :o3. Frightened and restless. Breathing rapid.
1 :04. Rapid chewing-movement at intervals.
I :o5. Very restless. Tremor on moving. Respi-
ration irregular and labored.
I :o6. Cries out. Runs around at intervals.
I :o8. Jumps up and falls on side in convulsiori.
Extremities rigid.
I :o8 '2. Gasping on side.
1:10. Respiration ceased.
1:13. Thorax and abdomen oi^ened. .\uricles and
ventricles found beating, Init not synchronously. .A.u-
ricles beating rhythmically at 60 per minute. Ven-
tricles, 26 per minute.
1 :27. Ventricles 24 per minute and very weak.
Two drops ten-per-cent. solution mescaline hydrochlo-
rate dropped upon heart. ]5eats become more rapid
and stronger than before, and continue so for several
minutes.
I :38. Ventricles, 42 per minutes.
1 :47. Heart ceases to beat thirty-seven minutes
after breathing ceased. Cavities dilated and filled
with dark blood. Pupils dilated to maximum extent.
Lethal dose in this experiment, 0.12 per kilogram of
body weight of animal.
V. — Guinea-pig; weight, three hundred and eight
grams.
12:09. 0.054 gram mescaline hydrochlorate in so-
lution, hypodermically.
12:10. Tremor of body. Increased restlessness.
Runs around.
12:11. Restless. Convulsion, as in last experi-
ment.
12:13. Convulsive movements continue. Pupils
dilated.
12:14. Gasping on side.
12:16. Dead. At autopsy pupils found dilated to
maximum extent. Heart stopped in diastole: cavi-
ties filled with dark blood. Lethal dose in this ex-
periment, 0.17 per kilogram.
Experiments with mescaline hydrochlorate upon
kittens gave practically the same results. The pupil
was dilated even by small doses. The breathing soon
became very rapid and shallow. Convulsions similar
to the ones above reported were produced, and the
heart continued to beat after respiration had ceased.
The lethal dose was found to be practically the same.
The most important ditTerence in effect was that in
kittens the drug seemed to act from the very first to
depre.ss the muscular system, the animals resting
throughout the experiments upon the belly, the ex-
tremities extended fiat upon the table. They attempted
to move around, but could not.
It is evident from these experiments that the effects
of mescaline are widely different from those of anha-
lonine. The minimum lethal dose of inescalin in our
experiments as found to be 0.12 per kilogram, whereas
Lewin foinid the lethal dose of anhalonin to be 0.16
to 0.20 per kilogram.
While both alkaloids in large doses produce con-
vulsions, those of mescaline are different in character
from those produced by anhalonine. As already
stated, the convulsions of anhalonine somewhat re-
semble those occurring in strychnine poisoning.
They are accompanied by some increase in the reflex
excitability and more or less opisthotonos, and they
can be brought on by external stimulation. While
the animal under tlie influence of mescaline exhibits at
times great restlessness, nevertheless the effects are
not accompanied by increased reflex excitability and
the animal appears rather less responsive to external
stimulation than normally, and convulsions cannot be
precipitated by such stimulation. Opisthotonos also
is not a marked feature of the full effects of the alka-
loid, although it is present to a slight degree during
the convulsions.
It would appear that the convulsions produced by
mescaline more closely resemble those caused by non-
oxygenation of the blood. The effects of the alkaloid
are accompanied by rapid and difficult breathing and
symptoms of respiratory embarrassment. In experi-
ment III. this was true to such an extent that rll the
muscles of the body seemed to be brought into play to
aid the animal in obtaining sufficient air, and the
appearance presented was that of intense dyspnoea.
Death also is preceded by respiratory failure, the heart
continuing to beat for a variable length of time after
the breathing ceases. After death the ventricles are
found dilated and filled with dark blood. Further-
more, Heffter,' wiio made a limited number of experi-
ments with this alkaloid upon frogs, makes no men-
tion of convulsions as an effect of the drug in that
class of animals: whereas in our experiments upon
animals of higher development, convulsions were a
constant symptom when the drug was administered in
large dose. This alone would lead us to believe that
' -Vrchiv f. e.\per. Path. u. Phar., I8g4, 34, 65.
August 2 2, 1896]
MEDICAL RECORD.
26'
the convulsions produced by mescaline are asphyxial
in character and produced by contact of the non -oxy-
genated blood with -the motor-nerve centres, it being
a well-known fact that asphyxial convulsions do not
occur in frogs, whereas they do occur in animals of
higher development. Brunton' states that if any drug
produces convulsions in the higher animals and not in
frogs, the probability is that the convulsions it pro-
duces are asphyxial, and not due to direct irritant
effect of the drug upon the motor centres. This, taken
in connection with the facts already stated, leads us to
believe that the convulsions produced by'mescaline are
asphyxial in character.
From these experiments it i.' also evi lent that mes-
caline has HO influence upon the heart as a depr.-Shant,
even when administered in fat'l doses.
When given hypoderniically it acts to miate the
pupil. No effect upon the pupil was obtained by
dropping a five or ten per cent, solution of the hydro-
chlorate into the eye.
The alkaloid appears to depress the muscular sys-
tem and the respiration.
In its constitutional effects, mescaline much resem-
bles cocaine, and the similarity in action will at once
become apparent in comparison with the effects of the
latter drug upon the lower animals."
From the mother liquor left after the separation of
anhalonine and mescaline, Mr. Ewell has succeeded in
obtaining a third alkaloid, entirely different in its
chemical and physiological properties from the two al-
ready considered. The hydrochlorate of this third al-
kaloid, which was the salt used in our experiments, is
white or of a slightly yellowish color. It foniis nod-
ular groups of radiating needle-like crystals (Fig. 4)
which are readily soluble in water and alcohol. The
taste of the crystals is acrid and slightly bitter, with
a persistent after-taste. Its reaction is neutral.
We have performed a series of experiments upon
the lower animals to determine so far as possible the
physiological effects of this alkaloid.
I. — Rabbit; weight nine hundred and eighty-five
grams. •
11:55. 0.0133 gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
11:56. Restless. Great tremor. Animal rises upon
four extremities, which are perfectly rigid, and point-
ing outward from body like the legs of a "saw-
horse," and seems to be propelled slowly around table
by violence of tremor.
i'-S7- Quiet, on belly, hind legs flat on table.
On touch, extremities become rigid and violent tremor
appears.
11:58. On feet, with rigid extremities and tremor
as above.
1 1 :59. Breathing rapid. Quiet if not touched.
On touch, convulsive movements.
12 :o2. Breathing very rapid. Heart 156 per minute.
12:05. Breathing same. No convulsive movements
on touch. Hind legs flat on table.
12:07. Hops fairly normally, using back legs
awkwardly. Recovery from this time, breathing and
heart gradually becoming slower to normal. Amount
injected in this experiment, 0.0136 per kilogram of
body weight.
II. — Rabbit; weight, five hundred and twelve grams.
i2:o7J/2. o.oi gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
12 :o8. Tremor, especially of hind extremities.
1 2 :o9. Violent tremor. In hopping, hind legs some-
what stiff. Breathing rapid.
i2:io5<. "Sawhorse" phenomenon as in last ex-
' " Pharmacolog)', Materia Medica, and Therapeutics," pp. 1S9
and 237.
' See H. C. Wood: "Therapeutics, Its Principles and Prac-
tice."
periment lasting about ten seconds, after which, ani-
mal fell on side in tetanic convulsion. All muscles
rigidly contracted. Opisthotonos, and extension of
extremities. Followed by gradual relaxation of all
muscles.
12 :n. Muscles flaccid. Breathing ceased. Lethal
dose in this experiment, 0.02 per kilogram.
III. — Rabbit; weight, one thousand one hundred
and sbcty-five grams.
2 :i9^-2. 0.03 gram hydrochlorate of alkaloid 3 in so-
lution, hypodermically.
2 :2i. Tremor of body.
12 :2i J{>. Tremor so violent as almost to amount to
convulsive movement.
12:22. "Sawhorse" phenomenon, as in preceding
experiments, after which animal fell on side. Con-
vulsive movements. Rigid extremities. Opisthot-
onos.
12:22 '2. Gradual relaxation. Breathing found to
have ceased.
12:35. Thorax opened. Heart still beating. Heart
ceased in diastole, twenty-seven minutes after breath-
ing stopped. Lethal dose in this experiment, 0.025
per kilogram.
IV. — Rabbit; weight, four hundred and seventy-six
grams.
11:37. o-°25 gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
1 1 :38. Violent tremor. Jumped up and fell on side
in convulsions. Opisthotonos, extremities extended,
and all muscles rigid. No movement.
11:39. Convulsive twitchings. Gradual relaxation.
1 1 :4o. Breathing ceased.
11:45. Thorax opened. Heart beating rhythmi-
cally, 21 per minute.
11 :5o. Heart beating more slowly. Finally stopped
in diastole.
Lethal dose in this experiment, 0.053 per kilo-
gram.
In guinea-pigs the alkaloid produced effects very
similar to those produced in rabbits.
V. — Guinea-pig; weight, seven hundred and eight
grams.
12:29. 0.007 hydrochlorate of alkaloid 3 in solu-
tion, hypodermically.
12 :3i. -Slight tremor of ears.
12:34. Much startled by sudden noise, as rapping
table with pencil.
12:41. Same. Restless.
12:47. Quiet. Jumps clear from table when blown
upon, or upon sharp noise.
12:51. Same. Cries on being touched. Runs awk-
wardly with violent tremor.
12:53. Increased reflex excitabilit)' continues. Not
frightened by object brought rapidly toward it. Con-
dition remained as described until 1.09 when it grad-
ually became normal. Amount injected in this ex-
periment, 0.01 per kilogram.
VI. — Gmnea-pig; weight, seven hundred and thir-
teen grams.
II :45. 0.0196 gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
ii:46'i. Slight tremor. Runs around.
II :48. Violent tremor, especially on moving.
11:50. Violent tremor. Falls on side. Muscles
of body and extremities contracted and rigid. Ex-
tremities extended. Opisthotonos.
II :so'2. Gradual relaxation. Hair on fore part of
body "on end."
II :5i to II :55. Alternating tetanic spasms and re-
laxation. Breathing absent during spasm, accele-
rated during intervals.
11:56^4. Animal on side. Constant spasmodic
twitchings of head, body, and extremities, continuing
until
264
MEDICAL RECORD.
[August 22, 1896
12:05. Heart and breathing rapid. Tetanic spasms
can be precipitated by touch or irritation.
12 :o5}t. Tetanic convulsion followed by relaxation.
12:06. Gasping. Breathing gradually becomes
regular and slower.
12 -.og. Can stand on feet. Hair still "on end."
12:11. Moves around awkwardly. Recovery.
Amount injected in this experiment, 0.0275 P^"" kilo-
gram.
VH. — Guinea-pig; weight, six hundred and eight
grams.
12:00. 0.0182 gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
12:02. Tremor on moving.
12:04. Tetanic convulsion. Extremities extended.
Opisthotonos, followed by relaxation. Hair on fore
part of body "on end."
12:05 to 12:10. Alternating tetanic spasms and re-
laxation.
12:10. Gasping. Opisthotonos.
12:12. Tremor. Spasmodic tvvitchings.
12:14. Same.
12 :2o. Heart rapid, breathing fairly normal.
12:26. Tetanic convulsion brought on by touch,
followed by gradual relaxation. Breathing found to
have ceased.
12:30. Thorax opened. Heart still beating.
12:50. Heart ceases. Lethal dose in this experi-
ment, 0.03 per kilogram.
In frogs effects were produced which even more
clearly indicate the physiological action of the alka-
loid under consideration. These effects were similar
to those produced in guinea-pigs and rabbits. .\
series of experiments upon frogs was made, of which
the follow^ing may be considered typical :
VHI. — Frog; weight, one hundred and eighty-three
grams.
2:33. 0.00549 gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
2 :37. Increased reflex excitability to touch.
2 :39. Reflex excitability still more increased. Vio-
lent sudden extension of extremities on touch.
2.44. Tetanic convulsion on touch, or other slight
irritation. Animal lies perfectly quiet; when
touched, however, tetanic convulsion appears, with
contraction and rigidity of all muscles and extension
of e.xtremities, which lasts for a few seconds, followed
by relaxation and quiet until again irritated.
Condition remained same for several hours, and it
was dead upon following morning. Lethal dose in
this experiment, 0.03 per kilogram.
IX. — Frog; weight, two hundred and sixty-eight
grams.
12:02. 0.008 gram hydrochlorate of alkaloid 3 in
solution, hypodermically.
12 :o6. Increased reflex to touch.
12:08. Reflex increased. Irritation produces sud-
den violent extension of extremities.
12:11. Animal quiet unless touched, ^^len violent
tetanic convulsion occurs, as in last experiment.
I :o5. Spinal cord divided at about its middle.
Refle.x tetanic contractions persist below as well as
above point of section. Lethal dose in this experi-
ment 0.03 per kilogram.
Other experiments upon frogs were made with the
same results.
From these experiments it is evident that the third
alkaloid is much more powerful than either anhalonine
or mescaline, and differs from them also in its physio-
logical effects. Its lethal dose in frogs, guinea-pigs
and rabbits is 0.02 to 0.03 per kilogram of body
weight.
The most marked effect of the alkaloid is to in-
crease the reflex excitability of the animal. This was
produced by doses as small as 0.0136 per kilogram.
As the amount given was increased, this effect became
more marked, and when large doses were adminis-
tered violent reflex tetanic convulsions were produced.
These effects were due to action through the spinal
cord, as they persisted below the point of section, after
the cord had been divided and the parts severed from
connection with the brain.
The similarity in action between this alkaloid and
strychnine is remarkable. Experiments were per-
formed in which a frog was given alkaloid 3 and
another at the same time strychnine, and the effects
of the two drugs were compared. Almost no differ-
ence in effect whatever could be distinguished, the
third alkaloid producing increased reflex excitability
as surely and to as marked an extent as the strych-
nine.
The effect of chloral hydrate upon an animal to
which the alkaloid had been administered is also of
Interest. To ascertain this, a lethal dose of alkaloid
3 was given to one frog, and to another the same dose
of alkaloid 3, and in addition chloral hydrate in vary-
ing quantity in different experiments.
X. — 3:40. Frog A, 0.03 per kilogram hydrochlo-
rate of alkaloid 3 in solution, hypodermically.
Frog B, same, and in addition chloral hydrate, i.oo
per kilogram, in solution, hypodermically.
In frog A increased reflex excitability was noted in
four minutes. The effect deepened into reflex convul-
sions upon irritation, as in experiments already re-
ported, which continued until the death of the ani-
mal.
Frog B appeared normal at 3:45 and 4:00.
4:05. Extremities appear weak, and animal rests
upon belly. By no stimulation can any increased re-
flex e.xcitability be demonstrated.
4:07. Same. Stupid. No increased reflex. Con-
dition remained same until death at 4:20, apparently
from the effects of chloral. At no time did an;' in-
crease in reflex excitability appear.
Other similar experients were made in which, the
dose of the third alkaloid remaining the same {0.03
per kil(5gram), the amount of chloral administered was
progressively lowered. It was found that no increase
in reflex excitability appeared until the amount of
chloral was lowered nearly to 0.25 per kilogram. As
the amount was still further lowered, reflex tetanic
convulsions and the typical effects of the alkaloid ap-
peared.
Furthermore, chloral appeared to act in frogs as an
antidote in poisoning by the drug.
XI. — Frog; weight, three hundred and forty-four
grams.
11:30. Injected lethal dose of hdyrochlorate of
alkaloid 3,0.0103 in solution (0.03 per kilogram);
also 0.086 of chloral hydrate (0.25 per kilogram).
11:37. Slight increase of reflex excitability to
touch.
1 1 :48. Same, more marked. Extension of legs on
touch. Draws them up, however, and stands nor-
mally.
11:53. Tetanic convulsion on touch. Stupid. Rests
on belly. Tries to hop occasionally. Draws legs
up normally. Condition remained same for several
hours and recovery upon following morning was com-
plete.
XII. — In this experiment the same lethal dose (0.03
per kilogram) was injected, and but 0.125 of chloral
hydrate per kilogram. Animal recovered.
In these experiments the amount of chloral given
was insufficient entirely to counteract the effect of the
alkaloid, but the animals recovered from what would
otherwise have been a fatal dose of the third alka-
loid.
From the results of these experiments we conclude
that the most marked physiological effect of the third
August 2 2,
[896]
MEDICAL RECORD.
26 =
alkaloid of mescal buttons is the production of in-
creased reflex excitability, and, if the amount given be
sufficiently large, reflex tetanic convulsions; this effect
is produced by action through the spinal cord; chloral
hydrate directly antagonizes this effect of the alkaloid,
in small doses modifying the increase in reflex exci-
tability, and in sufficiently large doses counteracting
it entirely; and that the symptoms produced by the
alkaloid in frogs, guinea-pigs, and rabbits appear to
be identical with those produced by str}xhnine.
The action of the alkaloid upon the respiration and
heart appeared to be entirely secondary to its effect
upon the muscular system and the degree of involve-
ment of the muscles of respiration. The breathing
was absent during the tetanic convulsions and more
rapid than normal during the inter\al of quiet, as was
also the heart. Xo marked effect upon the pupil was
found.
Other Constituents In addition to alkaloids, mes-
cal buttons contain other ingredients, the most impor-
tant of which is a resinous substance, which may be
found to play an important part as the active prin-
ciple of the drug. It is soluble in alcohol and ether,
insoluble in water, and seems to be of a complex na-
ture, as it can be separated into two or more portions
by proper solvents. The buttons also contain other
substances which possess more of chemical than of
pharmacological interest. These include one or more
wax-like bodies, and some of the carbohydrate con-
stituents of the plant.
Therapeutic Uses.— The conditions in which it
seems probable that the use of mescal buttons will
produce beneficial results are the following: In gen-
eral "nervousness," nervous headache, nervous irrita-
tive cough, abdominal pain due to colic or griping of
the intestines, hysterical manifestations, and in other
similar affections in which an antispasmodic is indi-
cated ; as a cerebral stimulant in neurasthenia and in
depressed conditions of the mind — hypochondriasis,
melancholia, and allied conditions; as a substitute for
opium and chloral in conditions of great nervous irri-
tability or restlessness, in active delirium and mania,
and in insomnia caused by pain. In the last condi-
tion it acts to produce sleep not as a hypnotic, but bv
relieving the cause of the insomnia. In full physio-
logical doses it produces insomnia, but in therapeutic
doses it does not have this effect.
The following cases in which the drug was used may
be mentioned briefly:
I. — Gentleman, aged fifty-five years. Chronic bron-
chitis with asthmatic attacks. Much distressed by an
irritative cough which kept him from sleeping. .\
piece the size of a pea from the centre of a button was
administered in the afternoon, to be dissolved slowly
in the mouth. The irritative cough was speedily re-
lieved. He took a second similar dose at bedtime and
slept well through the night, which he had not done
before for a long time. He returned to his home in
New York and kept up the use of the drug with con-
tinued relief. In a letter received from him recently
he states that he has improved very much, being able
to sleep all night without rising, which he had not
been able to do for two years; and that, although he
has no need of it upon some days, he carries a
piece of a button in his pocket constantly, as its use
relieves the tickling in his throat at once and gives
greater relief than any other remedy which he has
ever used. It appears to have no curative effect —
merely relieves the irritative cough.
II. — Gentleman, principal of high school, aged
twenty-five years. Neurasthenia of six months' stand-
ing. The effect of the drug in this case seemed little
less than marvellous. Three buttons were adminis-
tered within an hoir. This was followed by tiie char-
acteri-stic color vi.,ions of the drug, and relief from
the bodily and mental fatigue with which he had suf-
fered for six months, and he declared that he was
" himself again, cheerful and happy." On the next
day, and for several days thereafter, he continued to
feel the beneficial effects of the drug. He has con-
tinued its use in dose of one-half a button when he
feels it to be necessary. It invariably relieves the
sense of bodily and mental fatigue.
III. — Lady, aged thirty-three years. Nervous pros-
tration. The drug was administered in this case as
in the last, but in smaller doses, with a marked bene-
ficial effect. Mental and physical exhaustion were re-
lieved and power to work was increased to a marked
degree. There was no reaction.
IV. — Lady, aged forty-nine years. Chronic phthisis
with facial neuralgia and catarrh of pharynx, larynx,
and bronchi. The fluid extract of anhalonium was
administered with beneficial effect. The irritative
cough was relieved to a marked extent, the spells of
coughing being less frequent and less violent and pro-
longed. Although she has been taking the drug but
a comparatively short time, she has suffered much less
than fonnerly from the facial neuralgia.
The following cases were reported by a gentleman
of a Western State. The drug was administered under
the supervision of his family physician:
V. — Gentleman, aged fifty-six years, large and
strong physically. " Softening of the brain," onset
dating back about a year. He was under the care of
his two brothers who were physicians in Kansas, and
was at times violent and required the constant attend-
ance of a physician and two nurses. In an attack of
violence, opium in the form of laudanum and morphine
was given, commencing on Thursday, until the follow-
ing Sunday, without beneficial effect. Upon Sunday
at 2 P.M. he was given a teaspoonful of tincture of
anhalonium. A teaspoonful was also given every half
hour from 6 until 9 p.m. At 10:30 the patient went
to sleep and awoke at seven o'clock, Monday, in ra-
tional condition. He felt so much improved that he
left the ne.xt day for his home in Texas. The course of
the original disease was not influenced by the drug,
and he died a few months later.
VI. — Sister of above-mentioned gentleman report-
ing cases. "Very low and out of her head.'' One of
the physicians above referred to used chloral to quiet
her, and, this failing, administered tincture of anhalo-
nium. It quieted her in a few minutes and she slept
well and long. It seemed to be the turning-point in
her illness, as she fully recovered.
The same gentleman reports that his wife formerly
used to take the tincture for nervous headaches and
that it always relieved her. She has them so seldom
now that she does not use it.
The following preparations are suggested : Extrac-
tum anhalonii fluidum (one hundred per cent.).
Dose, one-half to one gram (ten to fifteen drops).
Tinctura anhalonii (ten per cent.). Dose, four to
eight grams (one to two teaspoonfuls).
Anhalonium (in form of buttons or powder). Dose,
one-half to one gram (seven to fifteen grains).
The tincture should be made by the process pre-
scribed in the United States Pharmacopoeia for the
preparation of tinctures. It should be of ten-per-cent.
strength. The fluid extract should be made of one-
hundred-per-cent. strength and in accordance with the
method prescribed in the United States Pharmacopoeia
for the preparation of fluid extracts.
The taste of these liquid preparations is verj- bitter,
but may be disguised by a suitable vehicle, such as a
mixture of fluid extract of licorice and elixir of yerba
santa.
In conclusion we would say that Anhalonium Lewinii
(mescal buttons) must not be confounded with the in-
toxicating drink "mescal," used by the Mexicans and
266
MEDICAL RECORD.
[August 2 2, 1896
Others. This drink is the fermented juice of one or
more of the species of agave.
1230 Ninth Street, N. W. .
BIBLIOGRAPHY.
Dr. L. Lewin ; Ueber Anhalonium Lewinii und andere Cacteen.
Archiv fUr experimentelle Pathologic und Pharmakologie, iSSS,
x-xiv. , 401; also Therapeutic Gazette, 1SS8.
Dr. Arthur Heffter : Ueber Pellote. .\rch. f. exper. Path. u.
Phar., 1894, xxxiv. , 65.
Dr. L. Lewin: Ueber Anhalonium Lewinii und andere Cacteen.
Arch. f. exper. Path. u. Phar., 1S94, xxxiv., 374.
H. H. Rusby: Mescal Buttons. Bulletin of Pharmacy, 1894,
viii., 306.
I. M. Coulter: Preliminarj- Revision of Cacti. Bulletin U.
S. Dep't Agriculture, Washington, D. C. June 10, 1894.
Dr. L. Lewin: Ueber Anhalonium Lewinii und andere giftige
Cacteen. Berichte der Deutschen Botanischen Gesellschaft, 1894,
xii., 283.
Lumholtz: Plant Worship among the Tarahumari. Scribner's,
October, 1894.
Dr. S. F. Landry : Therapeutic Gazette, 1888.
TWO CASES OF '
OF INFANCY.
CHANGES IN
(KINGDON).'
A RARE FATAL DISEASE
WITH SYMMETRICAL
THE MACULA LUTEA"
Bv CARL ROLLER, M.D.,
NEW VliRK.
I WISH to present to you two cases of a rare and gen-
erally fatal disease or degeneration in infancy, asso-
ciated with early blindness and characteristic retinal
changes. The credit for having first observed and
accurately described such a case belongs to Waren
Tay, who in 188 1 presented the case before a meeting
of the Ophthalmological Society of the United King-
dom. Tay's report of the case, admirable for its sim-
plicity and completeness, reads as follows:
" Mrs. L brought her infant, aged twelve
months, to the London Hospital, March 7, 1881.
When the baby was a fortnight or three weeks old, it
was noticed to have little power of holding its head up
or moving its limbs. Since that time the weakness
has become more and more pronounced. The mother
brought the child to the hospital in the hope that
something might be done to strengthen it. I could
find nothing more than weakness, no absolute paraly-
sis of any part. It seemed to me that its cerebral
development was probably deficient, and I was in-
duced to examine the eyes with the ophthalmoscope
to ascertain whether there was any affection of the op-
tic nerv'es. The mother had not suspected there was
anything the matter with the sight, though when ques-
tioned closely she admitted she did not think the baby
took as much notice as other babies. I found the op-
tic discs apparently quite healthy, but in the region
of the yellow spot in each eye there was a conspicuous,
tolerably well-defined, large white patch, more or less
circular in outline, and showing at its centre a brown-
ish-red, nearly circular spot, contrasting strongly with
the white patch surrounding it. This central spot
did not look at all like a hemorrhage nor as if due to
pigment, but seemed a gap in the white patch, through
which one saw healthy structure. In fact, the appear-
ances may most suitably be compared with those we
are familiar with in cases of embolism of the central
artery of the retina. I am quite unable to arrive at
any conclusion as to the exact nature of the disease.
I believe the changes to be situated in the retina, at
any rate chieHy so. They may possibly be congeni-
tal. The family history throws no light on the possi-
bilities of the case. This is the first child. There
have been no miscarriages. There is no history of
' Read before the American Ophthalmological Society at the
Thirty-Second Annual Meeting, in New London, July 16, i8g6.
phthisis in the family. The parents have been mar-
ried two years and were not related before marriage.
Dr. Hughlings Jackson kindly saw the child with me,
and said there seemed no evidence of any definite
cerebral affection. He could only say the baby seemed
very weak. He agreed as to the local conditions pres-
ent; so also did Mr. Hutchinson and others who have
examined the child. — April 7, 1881.
" P.S. July 30th. — The baby has remained in much
the same state as when first seen. There is still no
definite sign of localized mischief, but the child lies
almost helpless in its mother's arms. It is generally
cheerful or else asleep; it is rarely cross. There is
an important alteration in one respect, however; the
discs are now undoubtedly becoming atrophic. The
changes in the region of the macula are apparently
precisely the same as before."
This child died at the age of one year and eight
months. Two more cases of exactly the same kind
occurred in this family and were described by Tay.
Since Tay's first publication in 1881 a number of
other cases have been brought to light by different ob-
sen'ers — Magnus, Goldzieher, Knapp, Sachs, Wads-
worth, Hirschberg, Kingdon, Carter — altogether nine-
teen (my own two cases included) that have been
ophthalmoscopically examined and identified as be-
longing to the same group. To this list must be added a
number of others that, according to the histories of the
parents, have occurred in the same families and liave
closely resembled the cases examined, which brings
the number of known cases up to something over
twentv-five. Recently, Kingdon and B. Sachs, both
of whom had the chance of observing a comjiara-
tively large number of the cases known, have collected
and reviewed all the cases in literature. They are
also the only ones who have made autopsies and mi-
croscopical examinations.
In reading through the histories of all the cases,
one is struck by their uniformity. The children are
born of healthy parents with no history of syphilis;
most of them, if not all, are Eastern Jews, with tlieir
well-known tendency to neurotic degeneration. Up
to the third or fifth month of age the children develop
well; nothing unusual is noticed, unless a former case
in the same family directs the attention to the ocular
symptoms, which, in fact, seem to precede the others.
Between the third and eighth month, sometimes sooner,
a peculiar weakness of the muscles shows itself. The
children are unable to hold the head up, the back is
weak, the muscles are flabby, the reflexes are present.
The further development is retrograde, both as to body
and mind. The children do not learn to walk, present
the picture of idiocy, and fall into a condition of ma-
rasmus, to which they succumi) at the age of about two
years.
The eye symptoms, although not always first no-
ticed, seem to be the very first and seem to appear in
the first weeks or months of the child's life. It is not
likely that the retinal changes are congenital, as .some
observers assume. The ophthalmoscopic picture is of
striking uniformity, and according to all observers
very similar to the changes found in embolism of the
central artery of the retina. The yellow-spot region
is the site of a whitish opacity, the centre of which
shows a cherry-red spot. The discs are mostly yel-
lowish or grayish discolored, but other^vise appear
normal and well defined; later on, atrophy develops.
Pupils react sluggishly; in most cases, at least before
the stage of complete atrophy, perception of light is
present. In some cases there is oscillatory nystagmus.
The variations from this general picture are only
slight. In many of the cases I find h\peracuity noted;
in some of them convulsive seizures.
The affection is a family disease; two, three, and
even four cases have beep obsen'ed to oncur in the
August 2 2, 1896]
MEDICAL RECORD.
267
same family. The nineteen cases reported and tabu-
lated by Sachs occurred in ten families. All ob-
.ser\-ers are agreed that syphilis plays no part in the
etiology.
So far only three autopsies have been performed —
two by Sachs of two children belonging to one family,
and one by Kingdon. Both found changes in the layer
of the large pyramidal cells in the corte.x of the brain,
and they interpret these changes as arrested develop-
ment. Kingdon found descending degeneration in
the cervical part of the cord. Sachs states expressly
that no changes in any of the blood-vessels of the cor-
tex were found. Xo satisfactory examination of the
eyes has been obtained. Treacher Collins made sec-
tions of the eyes of Kingdon's patient, " but the result
was unsatisfactory, as there was a fold of the retina
in each eye at the macular region."
The history of my own cases is this:
Mary L , then two years old, was brought to my
dispensary service on June 18, 1894. The child had
been born healthy and had developed well, until at the
age of five months it was noticed that she did not use
her eves as other children of that age do. Nystagmus
of the vibratory kind was present, which, according
to the histor}', had developed in the first few months
of the child's life. The ophthalmoscopic exami-
nation was very difficult on account of the nystag-
mus, and showed the discs in a congested state; be-
sides, I find in my record the entry that apparently
there was perception of light. There was nothing that
struck me as unusual in the general condition of the
child. The case was considered by me one of optic
neuritis from an unknown cause. A second examina-
tion was intended, but the child was lost sight of until
two years later, when an almost identical condition in
an infant sister came under my observation, ex ited
my interest, and led to the re-examination of the first
child. She was now nearly four years old, but far be-
hind others of that age in mental development. The
latter had been retrogressive rather than progressive.
At the age of one year she had been able to stand up,
but she had never learned to walk. She was weak
in her limbs and could not stand upright. At pres-
ent she crawls and finds her way in the rooms of the
institution (Montefiore Home for Chronic Invalids)
into which she has been admitted. At the age of two
years she had begun to speak a few words, but she for-
got them. She knows her parents. She is very un-
cleanly in her habits, very irascible, and subject to fits
of rage, in which she screams and scratches herself,
unless she has her own way and is taken in the arms
of her nurse, whereupon she becomes perfectly quiet.
Altogether, she gives the impression of being an
idiot. The condition of nutrition isven,'poor: sever-
al times it has seemed as if marasmus made quick
progress and would soon terminate life, but with good
care she has rallied again. Her muscles are weak
and flabby; reflexes are present. There is hyperacu-
ity and she starts at sudden noises. The eyes out-
wardly present nothing peculiar; occasionally there is
a little nystagmus, but this is very much less marked
than it was two years ago. The iris is bluish-gray:
the pupils are of medium size; they have no prompt
reaction, but become slowly narrower when exposed
to light. After dilatation of the pupils with atro-
pine the ophthalmoscopic examination is easy, the
nystagmus being only occasional. The discs are
sharply outlined, atrophic, yellowish discolored, and
present the appearance found in cases of retinitis pig-
mentosa. The retina is atrophic. The choroidal ves-
sels are visible, as in individuals having the same
color of iris. In the region of the macula there is a
slight, veil-like, milky-bluish haze, gradually fading
into the color of the surrounding retina; in the centre
of this opacity, at the site of the fovea centralis, is a
cherry-red patch, not very dark, a little smaller than
the disc, with ill-defined outlines.
The second child, Hattie L . was seen for the
first time on January 8, 1S96, at the age of two
months. When the child was three or four weeks old,
the mother, forewarned by the experience with the first
child, noticed that it had nystagmus and did not seem
to see. I found the eyes of normal external appear-
ance, oscillatory nystagmus, and pupils of sluggish
reaction. With the ophthalmoscope the media are
found clear: the discs are sharply outlined, yellowish
discolored, but otherwise appear normal. The retina
exhibits the bright reflexes usually found in young
individuals. The ophthalmoscopic examination is
very difficult, on account of the strong nystagmus.
Since the beginning of January I have examined the
child six times, but have not found any unusual .ap-
pearance of the fundus, except the yellowish coloring
of the discs. In the left eye, however, there is at the
site of the fovea a rather indistinct brownish patch;
there is none of the white opacity in the yellow-spot
region. The child begins to exhibit the signs of mus-
cular weakness, and in eveiy way, as the mother avers,
behaves like her older sister.
The examination of the parents did not furnish any-
thing of especial interest. They are both of the Jew-
ish race and appear healthy ; the mother is twenty-seven
and one-half years old and the father twenty-six and
one-half years. There is no history nor are there any
symptoms of syphilis. Inquiry into their family history
elicited nothing that could bear on the subject. They
have been married six years. Ten months after mar-
riage a boy was born, who is healthy. Nineteen
months later a second child appeared, the girl that
figures as my first case. During the seventh or eighth
month of pregnancy with this child, the mother suflered
a violent shock, her husband being brought home on a
stretcher, on account of some sudden illness. F.igh-
teen months after the birth of the second child, a third
one was born — a girl, who is in good health. Kigh-
teen months later the fourth child appeared, which is
the second subject, as related above.
These two cases differ only in some minor points
from the other cases described. As to the first child,
which exhibits all the characteristic symptoms of the
affection, she has reached the age of four years, whereas
all the others died when about two years old. From
the condition of the nutrition it appears very unlikely
that the child can live much longer: in fact, her
end has seemed near several times, but she has unex-
pectedly rallied each time. She has also reached a
comparatively higher degee of de\elopment than the
other subjects (being able to stand and to speak a few
words), so that we may conclude that the aftection in
her case is of a milder form than in the others. In
the younger child, although she has developed all the
other symptoms of the affection, the characteristic ret-
inal changes are missing, whi h proves that they are
not congenital. In this connection it is remarkable
that in Kingdon's second patient, who was seen at the
age of three months (sister of a former patient) and in
whom muscular weakness was just then beginning, the
fundus oculi was nonnal. When the child was five
months old a suspicious haze appeared at each macula;
when she was eight months old the eyes exhibited the
usual appearance.
It is to be hoped that this rare and interesting affec-
tion of the nervous system will be cleared up by path-
ological investigation with modern methods, especially
with reference to possible changes in the vascular sys-
tem. Until this has taken place, we can only state
as our opinion that the anatomical substratum of the
affection is most likely a degenerative process in the
cortex of the brain and in the retina. From the clin-
ical course of the disease, the original healthy condi-
268
MEDICAL RECORD.
[August 2 2, 1896
tion of the children, and the consequent development
of the marasmus and the characteristic changes in the
eyes, we must conclude that we have to deal less with
a condition of arrested development than with a pro-
gressive morbid process in the nervous system. The
clinical picture of this affection in infancy is one that
bears some resemblance to general paresis; general
muscular debility without outspoken paralysis, physi-
cal and mental decay, and fatal issue being common
to both.
I.ITERATUKE.
AVaren Tay: Symmetrical Changes in the Region of the Yellow
Spot in Each Eye of an Infant. Transact, of the Uphth. Soc. of
the Unit. Kingd., vol. i., iSSi.
Waren Tay: A Third Instance in the .Same Family of Sym-
metrical Changes in the Region of the Yellow Spot of an Infant,
Closely Resembling those of Embolism. Trans, of the Ophth.
Soc. of the Unit. Kingd., vol. iv. , 1884.
H. Magnus: Eigenthiimliche congenitale Bildung der Macula
lutea auf beiden .\ugen. Zehender's klin. Monatsblatter fiir
Augenheilkunde, .^csiii., 1SS5.
Goldzieher: Report of Meeting of .Society of Physicians of
Budapest. Wiener med. \Yochenschrift, No. ii.
H. Knapp: Ueber angeborene hofartige weissgraue Triibung
um die Netzhautgrube. Transact. Heidelberg Ophth. Soc, 1 885.
Idem supplemented in Transact. Heidelberg Congress, 18SS.
B. .Sachs: On .\rrested Cerebral Development with .Special
Reference to its Cortical Pathology. Journal of Nervous and
Mental Disease, vol. .\iv. , 1S87.
Hirschberg: Der graublaue Hof um den gelben Fleck. Cen-
tralblatt ftir Augenheilkunde, 18SS, January.
Wadsworth: A Case of Congenital zonular grayish-white Opac-
ity around the Fovea. Trans. .Kmer. Ophth. .Soc, 1SS7.
E. C. Kingdon: .\ rare Fatal Disease of Infancy with Sym-
metrical Changes at the Macula I.utea. Trans, of the Ophth.
Soc. Unit. Kingd., vol. .xii., 1S92. ,
E. C. Kingdon: Symmetrical Changes at the Macula Lutea in
an Infant. Trans, of the Ophth. Soc. Unit. Kingd., vol.
xiv., 1S94.
Curtis B. Carter: Knapp's Archives of Ophthalmolog)-, J.inu-
ary- April, 1894.
B. Sachs: A Family Form of Idiocy, generally Fatal and as-
sociated with early lilindness (.\maurotic Family Idiocy). New
A'ork Medical Journal, .May 30, 1896.
THE DIAGNOSIS OF THE MORPHINE DIS-
EASE.'
liv
B. MATTISON, .M.D.,
MKDICAl. niKECTOH, UKOOKLVN HOME FOR HAKlTUfes.
0-\ first thought, the title of this paper may seem
somewhat trite; but a more sober second one will be
likely to convince the reader that some cases of the
morphine disease — disease, not "' habit" — involve con-
ditions so obscure as to make the diagnosis by no
means easy; and the purpose of this paper is to pre-
sent certain facts along .somatic lines that will clear
away doubt in suspected cases. There are morphin-
ists who, so far as outward symptoms under ordinary
conditions obtain, present no proof. .\gain and
again, in my e.vperience, this fact has been noted; and
if this be so with one whose professional life is exclu-
sively given to the study of this disease, it goes with-
out saying that it is much more likely to occur with
one engaged in general work, by whom minor evidence
of this toxic condition might easily be overlooked.
I have known a doctor to take morphine fifteen years
and present himself for treatment. He was cured and
has been free six years, without showing the slightest
sign of his drug disease. Of course, this was a very
exceptional case, for usually the stamp of this neuro-
sis is soon patent; but such a case is likely to reoccur
and possibly involve such interests along medico-legal
lines as to make a correct diagnosis of more than com-
mon importance.
' Read before the American Medical Association, Atlanta, Ga.,
May 6, iSg6.
This case in point; Nine years ago the wife of a
medical man brought suit against him for divorce.
He was charged with being a morphinic. The charge
was denied, and a countercharge made that she was
an hahiiiie. This was denied, and, in proof of denial,
she was examined by two physicians, who gave evi-
dence that she was free from the disease. They were
mistaken — she had been taking morphine daily for
six years! They failed to make crucial test of her
true condition, and so erred. She lost her suit, but,
I'll passant, it may be said that the outcome was a hap-
py one; for she came under medical care, recovered,
was reconciled and reunited to the doctor, has since
added to the census, and remained well.
.Another case: In the appeal for a new trial forCar-
lyle Harris — who, you will recall, was killed for al-
leged murder of his wife with morphine — evidence
was offered to prove that she was a morphinist, and
so might have died from an overdose self-taken. The
appeal was denied, and in his opinion, refusing, Re-
corder Smyth — the trial justice — laid special stress
on his belief that had Mrs. Harris been an ka/'i/uc the
fact would have been known to her husband, in whose
behalf on the trial no such claim had been made.
I have no hesitation in saying that in this part of
his opinion Recorder Smyth made a grave judicial er-
ror. Why.' Because many a case of morphinism in
a wife has persisted for years unknown to her husband
or even her doctor. That is a fact — just such a case
of morphino-cocainism is now under my care; and,
granting that the judge's belief along tliis line was the
main reason for his refusal, if this fact had been prop-
erly presented and insisted on by competent counsel,
it might have secured a new trial for Harris; which
was, in my opinion — the claim as to the morphine be-
ing undecided — undoubtedly his due.
Many and varied as are the tokens of this toxic neu-
rosis, it is safe to say there is not a single symptom
infallible as a sign of the disease. This statement
mav be contrary to the general opinion in and out of
the profession, but it is true. Anything like a "snap-
shot diagnosis" in morphinism may be quite unrelia-
ble, and should never be made. The usual various
sequela.' — many of which may present in other disor-
ders— are known to you, and details need not detain.
The point of most value in this paper is a statement
of the fact that we have at command two tests that are
certain to detect chronic morphine taking. They are
enforced abstinence and urinalysis.
Concerning the first, so imperative is the demand
of the system for a sufficient supply of morphine at
more or less regular inter\als, when il becomes part
and parcel of the daily need, that any withholding
beyond a certain time is sure to be followed by symp-
toms that settle the narcotic status beyond doubt.
The length of this abstinence needful to deteiniine
the question varies according to temperament and con-
dition; but as patients require the drug daily or usu-
ally more often, forty-eight hours' withdrawal will
suffice for proof. Possibly, in some extraordinary-
case, a longer time may be needed; but, as a rule, two
days will do.
Regarding the renal test, various methods will
serve; but the simplest of which I know is that of Dr.
E. H. Bartley, professor of toxicology in the Long
Island College Hospital. This is the Bartley proc-
ess: To the suspected urine add carbonate of sodium
to make it alkaline. In this put a portion of chloro-
form; shake well, allow it to settle, draw off, and add a
small amount of iodic acid. If morphine be present,
a violet tinge appears.
With a consensus of symptoms usually noted, and
the time and urine test.s, the diagnosis of the morphine
disease need never be long in doubt.
Prosfbct Place, near Prospect Park.
August 2 2, 1896]
MEDICAL RECORD.
269
Medical Record:
A Weekly Journal of Medicine and Surgery.
quarter years, nine months, and five and one-half years
old respectivly, and received a single injection of
serum varying from ten to eighteen grams. The
cases were selected on account of their gravity; all
terminated favorably and two by crisis.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, August 22, 1896.
THE TREATMENT OF MEASLES WITH THE
BLOOD SERUM OF CONVALESCENTS.
The hope that the principles which govern the
employment of antitoxin in the treatment of diphtheria
could at once be applied to the treatment of other in-
fectious diseases has not yet been realized. Conced-
ing the correctness of these principles, it is obvious
that they are capable of application only in the case
of diseases whose etiology is determined and which
are transmissible to lower animals. Among the dis-
eases not yet placed in this category are a number
common among children and of which more than one
attack is uncommon in the same person, such as
measles, scarlatina, and whooping-cough. In the case
of these it is at present not possible to immunize
lower animals and employ their blood serum in the
treatment of the developed disease in human beings.
On the other hand, it is possible to utilize for this
purpose the blood serum of convalescents from the
disease. The success of such treatment, it may be
expected, will depend in a large measure upon the
degree of immunity conferred by one attack of the
disease. Measles may be included among the diseases
in which this degree of immunity is considerable, and
for this reason it furnishes a suitable example for the
observation of any influence that may result from the
therapeutic employment of the blood serum of con-
valescents. With these thoughts in mind, Weisbecker
(ZeUschrift fiir klinische Medicin, vol. xxx., Nos. 3 and
4) has adopted this plan of treatment in a small series
of cases in private practice. The first case occurred
in a girl nine months old, who presented character-
istic initial symptoms of measles without exanthem.
An injection of ten grams of blood serum from a
convalescent from the same disease was given. The
catarrhal symptoms appeared for a day to be held in
check, but they returned, and on the following day an
eruption of i^eculiar character and distribution ap-
peared. Large areas of cutaneous surface escaped,
and the face was involved last. While no radical
effect was observed, a certain favorable influence ap-
peared evident. Upon the assumption that pneumonia
occurs as a complication of measles when insuffi-
cient antitoxin is naturally developed to neutralize
the circulating toxins, the serum was employed in four
cases presenting this complication, with the happiest
results. The children were one year, one and one-
THE BICYCLE FRIGHT.
The extended use of the bicycle has brought to
light numerous physical phenomena which have
proved profitable subjects for speculation and study.
Human ingenuity has been taxed to perfect the mech-
anism of the machine in almost every direction in
which improvement is possible. Its weight has been
reduced to the lowest standard consistent with strength
and safety, the jolt is conteracted by cushioned wheels,
the saddle has been constructed on anatomical prin-
ciples, the friction has been lowered to the conserva-
tive maximum of effective power, while the entire
apparatus has been so nicely balanced to the centre
of gravity of the rider that the propelling power is as
little embarrassed as is possible under the circum-
stances of ease and surety of progression. It is not
so much the question of adaptability of the machine
to the individual as of the individual to the machine.
There is no doubt that a large number of the accidents
for which the bicycle is so often blamed is more or
less chargeable to the want of care and the lack of
skill on the part of the rider. Particularly is this the
case with many of the numerous collisions of which
we hear so much. There is one peculiar cause of
accident which appears to be particularly associated
with the bicycle, in that the latter is in itself a special
means to the end of producing a distinct and well-
recognized form of nervous perturbation, which may,
for convenience of description, be designated the
bicycle fright. Although it occurs most frequently
with inexperienced riders, it often attacks others who
have under ofdinary circumstances reasonable control
of their wheels. Under certain conditions the passive
machine becomes, by a mental perversity of the rider,
an uncontrollable and active agent of an apparently
unavoidable accident. The vehicle is thus forced to
run into the very danger that the rider would other-
wise avoid, and a direct collision is inevitable in
spite of the frantic efforts to prevent it. So far from
having any proper will force in the matter, the rider
appears to aid the perverse and calamitous tendency.
The phenomena are to be explained, however, on well-
established psychological principles, and these differ
in degree from similar ones in that they are more dis-
tinctly individual than under other and more usual
methods of travel. It is purely and simply a perver-
sion of determination on the part of the rider entirely
uncontrolled by any other counteracting agency.
The one element of safety for a frightened horseman
is the possibility of there being some little remaining
sense in the horse, some instinctive power on the part
of the latter to avert collisions, independently of the
demoralized occupant of the saddle. On the other
hand, the runaway bicycle becomes an intensified ex-
emplification of the rider's loss of individual control.
2 70
MEDICAL RECORD.
[August 2 2, 1896
It would appear to resemble stage fright in many es-
sential particulars. The intense and overwhelming
desire to do well in the face of danger temporarily
paralyzes the necessary will force and makes such a
result impossible. The untrained bicyclist who wishes
to avoid the vehicle approaching from an opposite
direction finds himself helplessly steering toward the
object instead of away from it. Under the hypnotic
influence of concentrated attention, his movements
become inco-ordinate, and in the struggle to regain his
lost grip he becomes the hopeless victim of the per-
verted reflexes of purposeless effort and the abject
subject of an optical illusion. When once attacked
with this nervous malady it is almost useless to at-
tempt to prevent its injurious tendencies. The victim
can no more help himself than can the gnat resist the
attraction of the flame. All attempts to collect the
scattering wits usually add to the original difficulty
and intensify the hysterical desperation of a lost
cause. The only hope is in immediate dismounting
and the gaining of an opportunity for the natural re-
covery of nervous equilibrium.
For obvious reasons associated with the well-known
tendency to nervous disabilities in females, such
phenomena are more frequent in that sex than in the
other, but they occur often enough in both to demand
serious attention in connection with the necessity for
lessening the number of many avoidable accidents. So
widely is this form of fright acknowledged, that teachers
of bicycle riding lay special stress upon the danger of
fi.xing the gaze upon any object necessary to be avoided,
and in proof of their point frequently demonstrate to
beginners the strange tendency, even in roomy halls, to
collide with obstacles purposely placed in prominent
positions. One of the remedies suggested is to look
away from rather than tow ard the object to be avoided,
fixing the gaze ahead and only in the direction in
which the machine should be steered. On the same
principle, it is uniformly advised that the rider should
never look at the revolving wheel or the moving
pedals.
THE HUNTER'S POINT STENCH AND THE
STATE BOARD OF HE.\LTH.
The Citizens' Organization of Brooklyn has made
a formal complaint against the manufacturing nui-
sances at Hunter's Point, and the governor has very
properly referred the matter to the State board of
health for investigation and remedy. Similar pro-
tests have been made before by various parties indi-
vidual and corporate, so that the reasons for the same
are well understood by all who have been forced to
give attention to the subject. The very name of
Hunter's Point has become a designative synonym for
offensiveness. No one has questioned the fact that
the abominable stenches that emanate from the
regions of Newtown Creek are to the most extreme de-
gree an outrageous nuisance, save the firms indirectly
interested in the manufactories. The local and State
boards have investigated the conditions for the pro-
duction of these stenches and have made elaborate
reports, but nothing further has been done. Mean-
while, the inhabitants of the large adjoining districts
of Brooklyn and New York continue to suffer from
the sickening odors. Oftentimes when the wind is
in a favorable direction for the transmission of the
obnoxious vapors the windows and doors must be
closed to prevent nausea, headache, and other evi-
dences of vitiated atmospheric influences. Particu-
larly is this the case in the dead of night, the intensity
of the foul odor being sufficient to awaken the sleeper
and deny him the commonest of all privileges, that of
ordinary ventilation for his apartments. In view of
the repeated failures to remedy this crying and de-
fiantly persistent evil, it would naturally appear that
either the State board of health has no power in the
premises, or that it does not exercise it in the face of
the strong political pull at the back of the interested
manufacturers. We have so strongly suspected the
latter element that we shall watch with becoming inter-
est the conduct of the investigation about to be made.
If the State board of health, boasting of its membership
of independent and well-qualified men, desires to
place itself on record as daring to tackle the question
in the proper spirit, it will now have the opportunity
to do so. It can soon prove which is the stronger, the
rights of the people represented in the board in ques-
tion, or the power behind that orders the pigeonholing
of any perfunctory recommendation. At best we can
only wait and see. There is no question concerning
the necessity of abolishing the nuisance, but whether
or not it can be done under the existing circumstances
of dominant political influences is altogether another
matter.
^cxus of the 'S^cch.
Fire at Montpellier University. — A fire broke out
on August i8th in the building of the Industrial Ex-
hibition in Montpellier, France, which not only caused
considerable injury to the exhibits, but also spread to
the university buildings, the damage to the latter
being estimated at 600,000 francs.
Norristown (Pa.) Hospital for the Insane. — Dr.
.\lice Bennett has resigned her position as chief
resident physician in the department for women of
the Norristown Hospital for the Insane, after a con-
tinuous service of sixteen years. The resignation has
been accepted with regret by the trustees of the hospi-
tal and a committee has been appointed to select a
successor.
Diagnosis of Glanders The health department
of New York City is prepared to furnish mallein for
the diagnosis of glanders in horses. This is prepared
by Nocard's method, and is furnished in vials con-
taining a single dose of 2.5 cubic centimetres. In
order that accurate results may be obtained, the board
has issued directions which those who use the mallein
are advised to follow.
A New Journal. — Dr. Jos^ E. Calvo, of Panama,
has established a journal to be published monthly,
entitled Rez'isia Mensual de Medicina, Cirurjia y
Farmaaa.
August 2 2, 1896]
MEDICAL RECORD.
271
Spanish Hospitals in Cuba. — Dr. Murata, a Japa-
nese army surgeon, who was sent on a mission to Ha-
vana by his government, has described in a Tokio
paper the condition of affairs which he found. He
says the Spanish army surgeons are very far behind
the times in their methods, and he describes the nurs-
ing as slovenly and negligent, the wounded soldiers
being roughly treated by the surgeons and nurses.
The latter appear to be laborers picked up in Havana
and the neighboring country districts, very dirty and
wholly ignorant of the first principles of care for the
wounded.
American Academy of Railway Surgeons. — The
third annual meeting of this society will be held in
Chicago on September 23d, 24th, and 25th. Dr. John
E. Owens, of Chicago, is president, and Dr. Webb
J. Kelly, of Gallon, O., secretary.
Vital Statistics of Philadelphia. — For the week
ending August isth there occurred in Philadelphia
838 deaths — 348 more than during the preceding week
and 280 more than during the corresponding week of
last year. Of this number 315 (40 per cent.) were of
children under five years of age. The largest number
of deaths from a single cause. — 173 (20 percent.) —
was due to insolation. Other conspicuous causes, in
the order of frequency, were as follows: Cholera in-
fantum, 106; pulmonary tuberculosis, 50; heart dis-
ease, 40; marasmus, 34; gastro-enteritis, 31 ; senility,
28 ; inflammation of the brain and convulsions, each
27. There were reported during the week 65 cases
of typhoid fever, 20 of diphtheria and 1 1 of scarlet
fever. The number of deaths from these three dis-
eases were 10, S, and i respectively.
University of Pennsylvania Plans have been
prepared and contracts awarded by the trustees of the
University of Pennsylvania for the erection of a new
building for the department of dentistry, to cost
$120,000. The exterior of the building will be of
brick and terra cotta, with a tile roof, and the floors
throughout will consist of slow -burning material.
The structure will occupy a space one hundred and
eighty by one hundred and thirty feet. On the second
floor will be a large clinic hall, one hundred and
eighty feet long by fifty feet wide, with excellent light
from the north. There will be, besides laboratories of
metallurgy and prosthetic technique in addition to
the general and demonstration laboratories, a lecture-
room for the accommodation of five hundred students,
a large students' assembly room, toilet rooms, bicycle
rooms, etc. It is expected that the new building,
which will be heated by steam and lighted by elec-
tricity, will be ready for occupancy within a year.
The Tri-State Medical Society of Alabama, Geor-
gia, and Tennessee will hold its eighth annual meet-
ing in Chattanooga on October 13th, 14th, 15th. Dr.
J. B. Murfree, of Murfreesboro, Tenn., is president, and
Dr. Frank Trester Smith, of Chattanooga, secretary.
The Therapeutics of the Parks. — The president
of the Kneipp-Verein, an association of believers in
the cold-water maxims of Father Kneipp, recently ad-
dressed the park commissioners, asking permission to
walk barefoot on the lawns of the parks in this city
during the early hours, while the dew is still on the
grass. Next to wet compresses, this is regarded as one
of the most efficacious of measures for promoting and
maintaining health.
Gift to a Hospital.— Lord Mount-Stephen and Sir
Donald A. Smith, the founders of the Royal Victoria
Hospital in Montreal, have given an additional sum
of $800,000 for a permanent endowment sum. It is
expected that the hospital will have an annual income
of $40,000.
Capture of a Hospital — Colonel Molina, of the
Spanish army, recently led an expedition against a hos-
pital of the insurgents near Colon, in Cuba. Six of
the Cuban inmates were killed and several of the at-
tendants were wounded. The doughty colonel ought
to be decorated for his victory.
Obituary Notes Dr. Robert Fleet Speir, of
Brooklyn, died at his home on August 13th, at the
age of sixty years. He was a graduate of the Univer-
sity of Vermont in 1866. He was a brother of the
late Dr. S. Fleet Speir. — Dr. Curran C. Smith, of
Waco, near Richmond, Ky., dropped dead at his
dinner table on August 13th. He was a graduate of
the medical department of the University of Louis-
ville in the class of 1850. — Dr. Joseph Augustus
MoNELL, of New York, died at his home in this city
on August 1 2th. He was born in 1826, and was grad-
uated from the College of Physicians and Surgeons in
1850. He was a member of the New York County
Medical Society, the New York Academy of Medi-
cine, the New York Pathological Society, and the
Physicians' Mutual Aid Society. His widow and a
son survive him. — Dr. William Waring, of Upper
Marlboro, Md., was stabbed to death on August 5th
during a political quarrel. — Dr. Jonathan Kay Pit-
ney died at Absecon, N. J., on August 8th, at the age
of fifty-nine years. He was a son of the late Dr.
Jonathan K. Pitney. — Dr. Emanuel F. Gerhard died
at Norristown, Pa., on August 13th, of typhoid fever,
at the age of thirty-eight years. He was graduated
from Jefferson Medical College in 1884 and at the
time of his death was a member of the town council.
— Dr. Hermann F. Guleke, of this city, died on Au-
gust 17th at Sheepshead Bay. He was born in Dor-
pat, Russia, in 1826, and studied medicine at Dorpat
and Berlin, being graduated from the former univer-
sity in 1854. Soon afterward he came to this country
and was graduated from the New York Medical Col-
lege. He was for many years visiting physician at
the German Hospital. — Professor Pajot died in
Paris recently at the age of eighty years. He was for
nearly forty years professor of obstetrics in the Uni-
versity of Paris. — Sister Mary Irene died in this
city on August 14th. She was born in London in
1823, and became a Sister of Charity in 1850. In
1869 she established the Foundling Asylum in this
city and brought it up from very small beginnings to
its present prosperous condition. She was also in-
strumental in founding the Seton Hospital for Con-
sumptives at Spuyten Duyvil.
272
MEDICAL RECORD.
[August 22, 1896
There Were 1,091 Deaths from Cholera in Egypt
during the week ending August isth, bringing up the
total number of deaths to i4»7SS-
A Loud Heart Murmur. — Dr. J. !•'. Baldwin, of
Columbus, O., writes: "In your issue of May 9th is a
report of a case of unusually loud heart murmur.
Some three years ago I was consulted by a colored
man, who, after a scuffle with a companion, had no-
ticed a cooing sound in his chest. I found he liad
suddenly developed a mitral systolic murmur which
sounded very much like the cooing of a dove. I could
hear this distinctly when he was standing at the front
door and I was at the extreme rear of my back ofifice,
a distance of about thirty-five feet. I passed the case
around among my professional friends, and we tried to
secure transmission of the sound by telephone, but it
did not possess sufficient intensity to enable it to be
heard. The patient complained of no inconvenience
whatever, and the case passed from observation."
Against the Sale of Quack Remedies.— A new
law against '" unfair competition in trade," which has
come recently into force in Germany, may, it is hoped,
be taken advantage of to restrict the sale of nostrums.
It is aimed against false descriptions and other forms
of swindling by advertisements. Not only the adver-
tiser, but the newspaper publishing the advertisement,
may be prosecuted.
Wholesale Lead Poisoning. — The Rome correspon-
dent of Tlie Lancet relates a curious instance of wide-
spread lead poisoning, especially in Milan, caused
in an unusual way. It seems that the sausage manu-
facturers have to pay the usual tax on salted articles.
As an evidence that this tax has been paid, every sau-
sage is ticketed with a leaden seal. When so labelled
the sausages are distributed to the dealers, and by the
latter are sold to the public, in most cases already
cooked, the heavy leaden seal still remaining attached.
One may readily divine the consequences. Most sau-
sages contain salts, such as nitrate of potassium, chlo-
ride of sodium, etc. ; besides this, the intestine used
as their envelope is washed with vinegar, or even
moistened in wine, which also in turn becomes acid-
ulated— all of them substances which in contact with
oxide of lead produce poison of varying intensity. In
this state the sausages are consumed by a large pub-
lic, native and foreign, while the liquor in which they
have been cooked — a liquor charged with the salts in-
dicated— is distributed to the poor. It was only after
analysis at the municipal laboratory of Milan that the
extent of the mischief was realized. The manufac-
turers are memorializing the communal and civic au-
thorities to replace the leaden seal by another made
of some innocuous metal. Meanwhile, the origin of
the unpleasant abdominal symptoms, of which there
have been so many complaints recently, has now been
discovered.
Women and Medical Societies. — A persistent effort
has been made by the women physicians of London to
gain the right of membership in the medical societies.
After being repulsed by the Royal College of Physi-
cians and Surgeons, they tried the Pathological Soci-
ety, but with the same lack of success. The Medical
Press says that it had hoped the Pathological Society
would rise superior to such petty professional jealousy
and fear of successful rivalry; "but the sexual hyper-
EESthetics had it all their own way, and as they are im-
pervious to reason and argument the ladies must e'en
wait until these become too infirm to attend the meet-
ings or until they are old enough to be superannuated.
It is worthy of remark that fellows whose voices are
never heard and whose forms are unknown under or-
dinary circumstances within these hallowed precincts,
invariably turn up to defend the society which they
profess to cherish, but which they never frequent, from
the moral contamination involved by the presence on
terms of scientific equality of the new order of practi-
tioners. Science is ase.xual, and the relief of human
suffering knows no distinction of persons. Women,
as practitioners of medicine, labor under many inhe-
rent disadvantages, but this is not a sufficient reason
for refusing to the more diligent and gifted among
them free scope for their unemployed energies. Ju.st
as we naturally respect the man who has fought his
way to the front in spite of opposition and difficulties,
so we ought to regard the woman who, in spite of
physiological burdens and social discouragement, has
acquired the right to be enrolled a member of an hon-
orable and humjne profession."
JEROME COCHRAN, M.U.,
MONTCOMERV, ALA.
Dr. Jerome Cochran, the dean of the medical pro-
fession in Alabama, died at his home in Montgomery
on August i8th, of chronic nephritis. Dr. Cochran
was born in Moscow, Tenn., December 4, 1831. He
studied medicine first at the Botanic Medical College
of Memphis, being graduated there in 1856. He be-
gan practice the following year in Fayette County,
Miss., but went soon after to Nashville and took the
regular course of lectures at the medical department
of the University of Nashville, where he received the
degree of M.I), in 1S61. He then entered the Con-
federate army as surgeon, serving there for three years.
After the war he settled in Mobile, where he built up
a large practice. He was connected with the Medi-
cal College of Alabama for ten years, occupying first
the chair of chemistry and later tiiat of public hygiene
and medical jurisprudence. Dr. Cochran was al-
ways identified with questions of public medicine and
hygiene. He was the author of the medical and
health laws of Alabama, was health officer of the
State and chairman of the State board of medical
examiners and of the committee of public health of
Alabama. He was a recognized authority on yellow
fever, having been a member of the yellow-fever com-
mission in 1878, and being also the author of many
articles on that disease in American and foreign jour-
nals and systems of medicine. He was a member of
the American Public Health Association and of many
other .societies. At the Atlanta meeting of the Amer-
ican Medical .Association he was chosen to deliver the
address on State medicine at the semi-centennial
meeting in Philadelphia next year. He was an ad-
vocate of the establishment of a national health bu-
reau, but thought this object could be attained better
by enlarging the duties and powers of the Marine
Hospital .service than by creating a new organization.
He leaves a widow and two sons.
August 2 2, 1896]
MEDICAL RECORD.
273
Society J^lcports.
BRITISH MEDICAL ASSOCIATION'.
■Si.xfy-Foitrt/i Annua/ Meeting, Held at Carlisle, July
28, 2g, JO, and 31, 1896.
CContinued from page 244.)
SECTIOX OX MEDICIXE.
Second Day — Thursday. July JOtli.
Discussion on Anaemia — Dk. F. Taylor opened
the discussion. Ananiia may be defined in general
terms as an abnormal pallor of the tissue.s, a definition
that means a good deal more than it says. It mav be
broadly divided into primary and secondary, the first
being that form of ana;mia that arises spontaneously
without any definite cause, while the second follows
such debilitating diseases as cancer.
The first or primary form is named also ciilorosis,
and is eminently a disease of the young; another
primary form is called, not very happily, pernicious
anemia, and may occur at any age.
Chlorosis is also known by the name of idiopathic
anaemia and is usually associated with constipation
of the bowels, while diarrhcea frequently complicates
pernicious anaemia, which is also more likely than
■chlorosis to be accompanied by various hemorrhages.
In pernicious anamia there is oftfen the association of
fatty degeneration of the heart.
Chlorosis is sometimes complicated by gastric
ulcer, the formation of ptomaines in the stomach and
intestines, and occurs in women from the age of
puberty to about twenty-two \ears, though instances
are recorded of chlorosis setting in at a later age, even
at forty-one years in one case; and, as a rule, it is an
affection from which the patient after a time recovers.
The speaker has noticed in chlorotic females a de-
cided preference for green colors and an objection to
anything pink or red. The cause of an attack is not
apparent; but as it is ascertained that in females the
specific gravity of the blood falls at the commence-
ment of puberty, while that of the male rises at the
same period of life, it may be that some ha;mostatic
correlation exists between the lowered gravity of the
blood and the disease. Iron is the accepted remedy in
chlorosis, but, the lecturer thought, is usually ex-
hibited in too small doses.
The degree of anaemia does not always correspond
in the young with the amount of food taken, for in
some cases the nutrition of the patient does not appear
to be interfered with.
Chlorosis very seldom indeed had a fatal termina-
tion. Pernicious anaimia might be primarv and pro-
gressive, and was often rapidly fatal ; following a
drainage of the system from bleeding piles, pregnancy,
etc., and sometimes supervening after a single attack
of hemorrhage. In pernicious anaemia there was a
great diminution of the blood corpuscles, and at the
same time an increase of ha;moglobin in the indi-
vidual corpuscles. Affections of the spleen might
produce anaemia, and not infrequently would be found
to be associated with syphilis.
The great point in the treatment of chlorosis was
perfect rest, and without it iron would often be found
to be productive of very little good; fresh air had a
beneficial effect, but exercise should be regulated by
circumstances, and might be injurious, especially if
there were any cardiac complications. In the treat-
ment of pernicious anamia the sheet anchor of the
physician was arsenic; of late stress had been laid
upon the successful exhibition of extract of bone
marrow, the action of which had not been hitherto
explained satisfactorily, but it appeared to arrest the
destruction of the blood corpuscles. How.> Well, as
the Devonport brothers said, " We don't know how we
do it, but we do it!"
'I"he inhalation of oxygen had been tried, but with-
out much benefit. Iodide of potassium occasionally
acted like a charm, but in such instances the speaker
was of opinion that there was, undoubtedly, a syphilitic
taint, for in other cases in which it was known that
there was none it was inoperative.
In splenetic anaemia great benefit had resulted from
splenectomy, but the operation was a heroic one, not
to be lightly undertaken.
Dr. Brvom Br.\.\iwell announced his intention of
referring mainly to the treatment of anitmia, chlorotic
and pernicious, although there was a great difference
between the two, for in the former it was the number
rather than the composition of the blood corpuscles
that was affected, while the very contrary obtained in
the latter. Chlorosis might exist without constipation
and the remedy was iron — Blaud's pills in large doses.
The speaker had given as many as forty-eight of these
on the fourth day, and continued them for three or four
weeks. It was necessary to keep the patient in bed in a
large airy^ room, and that was the reason hospital patients
were more apt to recover quickly than private ones.
More than one condition was included under the
term pernicious ana;mia; in one form a great deal of
iron would be found in the liver, owing to the rapid
destruction of the blood corpuscles that was going
on, and in others there was rather an imperfect forma-
tion of them, and consequently little or no iron was to
be met with in the liver or in the portal system. The
sequel of a long-continued drain, as from the uterus,
was identical with idiopathic pernicious anamia, and
the early exhibition of arsenic was advisable; it was
also desirable to continue it for some time after re-
covery, as relapses were of frequent occurrence.
Anaemia was often found to be coexistent with the
presence of worms in the intestinal tract.
Dr. J. M. Cl.\rk thought it was important to diag-
nose early between chlorosis and pernicious anaemia,
as the latter was often complicated by, if it did not act-
ually result from, syphilis, and in these cases iodide of
potassium was of extreme value. He had found per-
manent benefit to result from the inhalation of oxygen.
Dr. W. T. G.\irdxer, of Glasgow, had not found
the antiseptic treatment of anjemia in the least satis-
factory, but the administration of arsenic was followed
by the best results, whether there was imperfect forma-
tion or undue destruction of the blood corpuscles.
The speaker cited cases that had come under his ~o\vn
observation.
Dr. Affleck, thought that in some cases there was
a natural tendency to get well, and in others to get
worse, independently of treatment. In chlorosis he
advocated rest, and held that the influence of sunshine
was of paramount importance. They had none too
much of this precious commodity in Scotland, but what
they had was utilized to the utmost; the ward in which
anasmic patients were placed was in the warmest
quarter and the sufferers were made to bask in the sun
on the balcony with immense advantage. He thought
heroic doses of iron were unnecessary, a far smaller
quantity being required than had been mentioned by
some of the speakers. Pernicious anaemia was a
specific disease, and in the treatment of it he gave .i
decided preference to arsenic over bone marrow, which
he had, moreover, found patients were extremely un-
willing to take, while none objected to a few minims
of the arsenical solution, and that was by no means an
unimportant consideration.
Dr. Handford also advocated rest, but thought
that it acted differently in the case of private and
hospital patients, for it was nothing new to the former,
but was of benefit to the latter, who knew but little
2 74
MEDICAL RECORD.
[August 2 2, 1896
about it. He had met with a severe case of pernicious
ansemia in a lad of sixteen, in whom the administra-
tion of arsenic produced a temporary improvement;
when the patient stopped talcing it he had a relapse,
and this occurred several times, but ultimately he re-
covered, and was then a strong and healthy laborer.
Splenetic ana;mia differed from leucocythEemia, and
arsenic was more beneficial than bone marrow. He
usually gave from ten to fifteen minims of the arsenical
solution, but there were cases in which it could not
betaken; it all depended on the idiosyncrasy of the
patient. When arsenic could not be taken, bone mar-
row was useful. Stress had been laid upon the benefit
to be derived from sunshine, but in Stuttgart chloro-
sis was endemic, although that city was situated in a
warm sheltered valley where the sun exerted its power
to an extent inconceivable by the denizens of the
more sombre British islands; the sanitar}- condition
of the sunny valley, however, was deplorable.
Dr. .A.le.\.\nder Craig thought that chlorosis and
pernicious anasmia were caused by the presence of
uric acid in the blood ; if the uric acid were eliminated
the anaemia would cease. Uric acid could not only be
eliminated from the system, but its formation could be
prevented by attention to diet. The speaker offered to
let any one examine his blood, but no one having volun-
teered to do so, he concluded his remarks by stating
that it was then quite normal. One or two other gen-
tlemen having said ditto to those who had already
spoken, and time pressing. Dr. Taylor replied briefly,
and the business of the section was then suspended to
enable the members to witness some demonstrations in
another part of the building. The session having been
resumed after an interval, Drs. Drum.mond and Mori-
son, of Newcastle, read a paper on " Ascites Due to
Cirrhosis of the Liver Cured (?) by Operation," but
when the patient was produced some of those present
did not seem to think he was by any means saved.
Dr. Allison, of Newcastle, then read a paper on
" Deformity Treated by iione Marrow,'" and showed
cases, casts, and photographs, which were of consider-
able interest.
Drs. Samuel Wes-^ and IJradburv read papers on
"Uranium Nitrate in Diabetes" and expressed them-
selves satisfied with the results, though the drug ap-
peared to others to be, as yet, upon its trial.
Dr. John Wallace read a paper on " Kxploratory
Incision Versus Paracentesis in Ascites," which gave
rise to some unimportant discussion.
Dr. Williamson read a paper on the " Clinical Diag-
nosis of Diabetic Blood" and Dr. Robertson one on
"Diabetes Insipidus Cured by Electrization of the
Medulla Oblongata."
Dr. Savill produced an essay on the " Pathology
of Itching and its Treatment by Large Doses of Cal-
cium Chloride."
Dr. Bokenham brought forward "Statistics of Or-
rhotherapy of Diphtheria" and Dr. Aitken read a
paper on " Raynaud's Disease Associated with Ure-
mia," which brought the list of papers submitted for
this day to a close.
Third Day — Friday, July Jist.
Discussion on Tuberculosis. — Dr. J. W. Moore,
of Dublin, opened the discussion on this subject. He
began by alluding to Koch's cure, which came in on
a wave of enthusiasm and went out after a brief pe-
riod of trial on one of despair, and tuberculosis still
reigned in the midst of us, affecting not only man him-
self but the animals on which he depended for food. It
was at one time held that heredity accounted for fully
forty per cent, of all cases of tuberculosis, but that
was a position that had to be abandoned. Heredity
certainly had an influence on the disease, but it was a
limited one, for it is the tendency to the disease that
is inherited and not, as in the case of hereditary syph-
ilis, the actual di.sease itself. With regard to the in-
fectibility of tuberculosis, there is and can be no doubt
that it is essentially of an infectious character, but
without the presence of the bacillus that gives rise to
it there is no tuberculosis. Stamp out the bacillus
and you get rid of the disease. It is most important
to recognize the early signs of the disease, but these
are not of an unequivocal nature; for instance, the red
line along the gums may be due to other causes, as
may also be the clubbed finger tips and ridged nails,
which are common to other diseases resulting from
malnutrition. The same may be said of morning-sick-
ness and distaste for food, which are also characteris-
tic of the early stage of pregnancy ; but there is tender-
ness on pressure over the apex of an affected lung, less
movement of the chest walls than is natural, and an in-
tensity of the heart sounds in the same region. The
damage done by tuberculosis is practically incalculable,
and its ravages are greater in Ireland than in Scotland,
and especially more so than in Kngland and \\'ales.
Existing causes are the malign influence of town
life, dusty occupations, and such as have a tendency to
lower the vitality of those who are engaged in them.
The favorite site of tuberculosis is in the lung tissue
(pulmonary phthisis), but it also attacks the brain
membranes (meningitis), the glands (scrofula), etc.
Not many years ago tuberculosis caused nearly twice
as many deaths in Brussels as all the zymotic dis-
eases put togetiier, but owing to improved sanitation
of recent date the mortality had materially declined.
In order successfully to repel the attack it is neces-
sary to carefully study the manner in which it is car-
ried out. The doctor instanced the case of a poor
man suffering from tuberculosis in an early stage, and
who was not particular as to where he let fall his ex-
pectoration, and a child previously healthy became in-
fected tiirough crawling about the floor. There was
no fear of infection being conveyed by the breath, but
kissing consumptives on the mouth was much to be
deprecated. \\'hile in a moist state the sputum was
practically innocuous so far as non-contact was con-
cerned, but when it had dried and become pulver-
ized it was the source of infection, for the dust was
liable to fall on food and into water and was thus
conveyed into other systems. Milk in its raw state
was a frequent source of infection, and extraordinary
precautions were taken in Denmark to render it
harmless by cooking. Sunlight was one of the most
relialile disinfectants: the bacillus could no; long
survive exposure to the genial rays of the sun. Deep
inhalations of free air were of the utmost importance.
The speaker deprecated the habit of spitting into hand-
kerchiefs, but if these were used they should be at
once disinfected by plunging them into a four-per-cent.
solution of carbolic acid. Japanese pajjer should be
used and could be immediately burned. Dclenda sunt
sputa ! They must be destroyed at any cost. The too
familiar •" dusting" was to be highly deprecated; a
damp clotli should be used, and that should also be
disinfected. The foolish, almost insane, dread of
night air that prevailed so generally must be com-
bated and shown to be groundless. Wiiat was wanted
was pure air (avoiding draughts), nourishment, punc-
tuality in meals, and no stimulants. (Jeneral hospi-
tals were unsuitable for the treatment of tuberculous
cases, for which special institutions ought to be pro-
vided, and these should be classified so as to have one
place for tjie commencing case and one for those wliose
recovery was hopeless — the Friedenheim (peace
house) of the Germans. However, where such could
not be provided, special wards for consumptive pa-
tients should be set apart in the general hospitals.
With regard to long sea voyages and residence at mar-
August 2 2, 1896]
MEDICAL RECORD.
275
itime resorts, the speaker gave the preference to the
former, but thought it was cruel to send a patient hope-
lessly ill away to die among strangers. A patient once
told him that "sea air"' was too strong for him, and
the speaker thought there was something in that.
Mountain resorts had their advantages, but he advised
stoppages en route. He had heard that the climate of
Tasmania was favorable, and instanced the case of a
lady whose friends thought she would die on the voy-
age, who completely recovered there and remained well
at the age of sixty-six. A high temperature did not by
any means,- the speaker thought, debar a patient from
the use of animal food, if he cared to take it and had
any appetite. Milk was very good but required to be
sterilized, and kuniyss had its advantages, as also had
maltine; cod-liver oil, of course, was valuable, espe-
cially when combined with saccharated solution of
lime. Chloride of calcium was invaluable in cases' of
haemoptysis, the attacks of which were much diminished
by its use. Quinine made an admirable mouth and
throat wash. Cough was relieved in a most remarkable
manner by the inhalation of oxygen, and extract of
condurango had a marked effect in dyspepsia. Salol,
guaiacol, and iodoform were useful when there was
diarrhcea, and small doses of cocaine were of much
benefit in vomiting. At one time mercury was freely
employed in the treatment of tuberculosis, but it had
fallen out of repute. With regard to the question of
notifying tuberculosis as an infectious disease, the
speaker thought it would not be desirable, the dififi-
culty being where to draw the line ; but he was strongly
of opinion that eveiy case of death from tuberculosis
should be notified as such, and that the room in which
the patient had been lying, perhaps for months, should
be thoroughly disinfected.
Dr. Havilland Hall agreed generally with what
Dr. Moore had said in his very exhaustive paper, and
especially with regard to the inadvisability of treating
consumptive patients in general hospitals, except in
cases of acute laryngeal phthisis, which derived so
much benefit from the ablation of tonsils and laryn-
geal growths. It was a good plan to put a five-per-
cent, solution of carbolic acid into the spittoon, and to
use handkerchiefs of Japanese paper, which might be
immediately burnt; but he deprecated spitting into
the fire, as grates had to be cleaned and spitters occa-
sionally spit wide of the mark. The necessity of free
ventilation and sunshine went without saying, but there
was no ideal climate for consumptives ; there was some
drawback everywhere, and better results would, on the
whole, be obtained if they stared at home. He particu-
larly warned them against going to South Africa — any
part of it — particularly if there was any digestive trou-
ble. The question of temperature was not an impor-
tant one, but if anything a cold climate was better for
young subjects, and a warmer, milder one for those who
were more advanced in years. He did not consider .sea
voyages desirable, as the miserable accommodation did
more harm than the air did good. Great care must
be taken not to upset the digestion by prolonged treat-
ment with guaiacol or creosote, but the carbonates of
those drugs given in milk or coffee were admirable.
Salicylate of bismuth was most useful in the treatment
of diarrhoea.
Dr. Shingleton Smith was affected with tubercu-
losis when he was young, but was cured by a long sea
voyage. He thought it was possible to attack the ba-
cillus in its stronghold and destroy it there. If guaia-
col disagreed when taken by the mouth, it could be
injected hypodermically. He had used guaiacol to
the extent of from sixty to ninety minims daily, until
the patient fairly reeked with it. Creosote was well
borne in the early stages of the disease, but less so
afterward. He thought that tuberculin had been ta-
ken up rashly and abandoned as rashly.
Dr. Grimshaw, referring to the supposed influence
of heredity, was of opinion that the members of a
family took the complaint from each other. He ad-
vocated large windows so as to admit plenty of light.
He did not think that notification of tuberculosis was
practicable except when death had resulted, when the
true cause should certainly be given.
Dr. Affleck believed in jxjrsonal infection and
thought that if a person afflicted with tuberculosis was
admitted into a general hospital he should be strictly
isolated. He also agreed with the suggestion that
there should be separate institutions for patients in
the initial and in the advanced stages of the disease,
for it was horribly cruel, he thought, to expose even a
person suffering from one incurable disease to the
risk of contracting another.
Dr. Phillip thought it was not wise, as Dr. Moore
had done, to allow tuberculous patients to expectorate
into the fire, or rather into the fireplace. He thought
the influence of change of air on the type of the dis-
ease had scarcely been realized. Patients should be
instructed as to the value of fresh air and of fresh
water in the shape of a daily bath. He found that
breathing night air had a wonderful effect in stopping
cough and night sweats, in improving the circulation
and the digestion. With regard to specific treatment,
the foe must be met, and the system saturated with
remedies — carbonates of guaiacol and creosote. True,
these were expensive drugs, but they might be used
subcutaneously. Inunctions, too, of guaiacol and cod-
liver oil were very valuable. He advocated placing
hospitals for tuberculosis in busy centres and not in
the country, as Drs. Moore and Grimshaw had done.
It was a duty to provide dying-homes for the poor in-
curables; but the great fault of the system is that men
are not taught to diagnose.
• Dr. Frew said the question was not only how to
bring the bacillus into position, but how to pre\ent
others from coming in. He thought climate had much
influence in these cases, and mentioned the west coast
of Scotland as a favorable place to send consumptive
patients to. His own experience with hypodermic
injections had been unfortunate, but he would give the
plan a further trial. He quite believed that guaiacol
neutralized the toxin, and thought the recovery of any
patient ought not to be considered hopeless. Patients
often derived great benefit from their stay' in hospitals
but relapsed as soon as they were sent back to their
wretched homes.
Dr. Bezley Thorne said he was not an authority
on tuberculosis, but he questioned whether creosote
reached the lungs when given by the mouth ; he thought
it did not, and suggested that its action was that of a
gastro-intestinal disinfectant. He instanced cases of
subcutaneous injection of guaiacol (his own among the
number) that had gone back when the mode of ad-
ministering the drug was changed, but improved again
as soon as the injections were resumed. He was
struck with the overwhelming gravity of the mortality
in Great Britain from the various forms of tuberculosis.
A man was not admitted into a hospital until his case
was practically hopeless; there was no provision for
the treatment of the disease ; such matters were man-
aged much better abroad.
Dr. Odell thought it might be considered pre-
sumptuous on the part of a mere general medical
practitioner to give his opinion after the learned pro-
fessors who had spoken, but he thought there were
places in England to which consumptive people could
be sent with advantage — Torquay, for instance, where
they had separate hospitals for the curable and for the
incurable. The rich could go where they liked, and
the poor, as a rule, were taken care of; it was the poor
gentlefolk who suffered most. He fully appreciated
the value of the outdoor treatment of the disease and
276
MEDICAL RECORD.
[August 22, 1896
thought that the Koch treatment had been too quickly
abandoned.
Dr. Van So.merex was of opinion that the condi-
tion of life was of more importance than change of
climate; if the former was not good, the latter would
produce little benefit. It w-as all very well to e.xpress
opinions, they ought to be put into practice.
Dr. Colin Ca.mpbell thought they tried ever)-
means of getting at the bacillus except the direct one,
and yet it was perfectly easy to put thirty grains of
guaiacol into the lung; it should be mixed with glycerin
and the syringe used should be long enough to reach
below the vocal cord. He had used this mode of
treatment in over two hundred and fifty cases, and
even in some cases in which there were cavities in both
lungs, great benefit had resulted. His advice was
" to go direct for the bacillus."
Dr. Broxner had used menthol with remarkable
results, but thought the operation was not such an easy
one as the last speaker wanted to make out. He used
the menthol combined with olive oil. He considered
the tuberculin treatment unfortunate.
Dr. Moore in reply said he did not think the
bacillus could be reached directly in its stronghold,
where it was entrenched behind a triple line of de-
fences, for it was only too well able to take care of
itself. He thoroughly endorsed all that had been said
about free ablutions and believed there was a glorious
future in store for orrhotherapy.
Dr. Grimshaw moved the following resolution:
"That the government be approached by the associa-
tion to urge the infectious nature of tuberculosis and
the necessity for treating it in a separate place.'"
Dr. Gairdxer seconded and said that he was not
one of those who advocated treating all tuberculous
patients as if they were lepers; but the disease haunted
certain sites, as typhus had done and did, and he
thought it was no one's place to build houses for the
classes who willed to live like pigs; until the towns
were rendered unliveable for them there would be no
improvement.
The resolution was carried unanimously. Mr.
OwE.v read a paper on "Thymus Feeding in Ex-
oplithalmic (Joitre."
Cerebro-Spinal Fever.— Dr. Frew read a paper on
" Cerebro-Spinal Fever in Scotland," which he said
was frequently confounded with typhoid, but admitted
that the differentiation of the two complaints was dif-
ficult. It was also confounded with tuberculous men-
ingitis and with influenza. He had seen recoveries,
but death often super\ened rapidly. .\ siiort but un-
important discussion followed, and the meeting came
to a close.
SECTION OX OIISTETRIC MEDICINE .VND C.VNE-
COLOGV.
First Day — Wednesday, July 2gth.
Address of the Chairman — Dr. Halliday Croom,
of Kdinburgh. delivered a short introductory address,
in which he drew attention to the brilliant advances
made in gynecology of late years, and said that, having
raised ovariotomy to a high pitch of excellence, sur-
geons were now turning their attention to the treatment
of uterine cancer. It was estimated that there were
«ight thousand women in England and Wales alone
suffering from cancer, and that of all women who died
of cancer, in at least one-third of the number it at-
tacked the pelvic organs.
He viewed with scepticism some of the statistics
published by CJerman surgeons, showing operations
in a large percentage of cases of cancer of the uterus
■with such satisfactory remote results, as he found that
in very few of the cases which he saw was an opera-
tion for complete removal admissible. In order that a
radical operation may be undertaken, it is essential
that the uterus should be free and that the cervix can
be drawn to the vulva.
Statistics show that we may expect a duration of life
of about two years without operation, so that unless the
operation promises a longer period than this it is use-
less. He deprecated all partial operations. The
mortality of hysterectomy was not great. In his own
experience he had met with three hundred cases, and
but very few of these were suitable for operation. Pa-
tients nearly always applied too late, and in this rela-
tion the responsibility of the physician to recognize
early was great, as he believed that with early recogni-
tion and vaginal hysterectomy one should get as good
results as in cancer of the breast.
Senile endometritis and cervical inflammation and
catarrh caused symptoms which most resembled those
of cancer.
As regarded vaginal hysterectomy for other cases,
such as prolapse and fibroids, he thought it bid fair
to be overdone, as neither of these diseases were nec-
essarily fatal. He thought that it was needed some-
times for small fibroids and for persistent uterine hem-
orrhage which could not be checked by other means.
He would not advise vaginal hysterectomy for puer-
peral septic conditions, as had been done in America.
The only post-partum condition for which he would
do it would be the rare disease known as deciduoma
malignum. In chronic inflammatory diseases of the
uterus and appendages, vaginal hysterectomy offered
advantages over abdominal section, as the drainage
was complete and there was no danger of hernia.
Vaginal hysterectomy for fibroid was now heing sup-
planted by complete removal by combined abdominal
and vaginal incision, "pan-hysterectomy,'' and this
might be done when oophorectomy had been tried and
had failed. Oophorectomy had been done for some
general diseases with good effect, notably for osteo-
malacia, and some cases had lately been recorded in
whicii the removal of the appendages had been said
to arrest the growth of mammary cancer.
Discussion on Dysmenorrhoea. — Dr. Mirhoch
Cameron, of Glasgow, opened the discussion. He
thought the spasmodic form was the most common, and
he advised dilatation with solid graduated dilators.
He never used tents; he always passed a sound first,
then seized the cervix with volsella, with sound in situ,
as by doing this there was no risk of including the cer-
vical canal in the grasp of the volsella. He fol-
lowed this up by the occasional use of a white-metal
stem pessary in the intermenstrual periods.
Dr. Christopher Mariin, of Birmingham, said
that it was important to make perfectly certain of di-
agnosis, as salpingitis might be overlooked and dila-
tation done, with disastrous consequences. He would
divide the causes into intra- and extra-uterine, and of
the latter the most common were inflammation of the
tubes and chronic peritonitis; and he would distin
guish the factors of spasm, congestion, and neuralgia.
He would treat by rest, hot douches, and glycerin
plug, and, as regards drugs, would especially avoid al-
cohol and opium. He used sujipositories of the ex-
tracts of belladonna and cannabis indica, one-half
grain each. In the neuralgic form he gave antipyrin.
In other cases, potassium bromide, belladonna, and
viburnum prunifolium. He found that dilatation gave
only temporar)- relief. He had tried conservative
operations, consisting in opening the abdomen, freeing
adhesions, treating small cy.sts of ovary by ignipunc-
ture, and fixing the uterus to the abominal wall when
he found it prolapsed. With oophorectomy as a last
resource, in one or two cases he had removed the ute-
rus by vaginal hysterectomy.
Dr. I.M'.lis Parsons, of London, would advise ex-
amination under chloroform of unmarried women, as
August 2 2, 1896]
MEDICAL RECORD.
277
it was impossible to make a satisfactory diagnosis
otlierwise. He did not believe in the ovarian origin
of dysmenorrhea, and instanced cases of large ovarian
tumors in which no dysmenorrhcea had occurred. He
considered antefle.xion a cause, and treated it by dila-
tors. He thought tiiat the pain was due to obstruction
caused by the anteflexion, and found that the size of
the uterus increased during menstruation.
Dr. J. D. WiLi.i.AMS, of Cardiff, thought that there
was one class of cases in which the women, if married,
were sterile; and in these no inflammatory lesion could
be detected, but the uterus was small, anteflexed, and
excessively mobile. He believed that it would be
found that a diseased condition of the mucous mem-
brane near the internal os was present, and that uter-
ine contractions took place during menstruation. He
had found benefit to be derived from nitrite of sodium
and diffusible stimulants. He had found an intra-
uterine stem pessary to do no good and dilatation often
to fail.
Dr. Amand Routh, of London, pointed out that
dysmenorrhcea was only a symptom, and thought that
most cases were of the spasmodic variety. There was
too much done now in the way of mechanical treat-
ment. Most girls with dysmenorrha-a were consti-
pated and anaemic, and both these conditions should
be treated. He had found phenacetin in ten-grain
doses every three or four hours to give relief, and also
found good to result from antipyrin and from nitrogly-
cerin in one-drop doses of one-per-cent. solution. The
organs could be well examined per rectum, and he did
not think it was necessary to give an anaesthetic for
examination purposes. In those cases of dysmenor-
rhoia in which the pain preceded the flow, a glycerin
tampon gave relief by removing the congestion.
Dr. Lycett, of Wolverhampton, pointed out that the
rheumatic and scrofulous diatheses should be recog-
nized as causes.
Dr. Bedford Fenwick, of London, thought most
cases were due to congestion. This might be relieved
by aperients, scarification of the cervix, and glycerin
tampon. Many cases were due to rheumatism, and in
these potassium iodide did good. Dilatation was in
his opinion both unscientific and unsatisfactory, and
if anything were done to widen the cervix it should be
the removal of a good piece of the anterior lip.
Dr. Byers, of Belfast, remarked on the extraordi-
nary difference of opinion shown. He thought that
many cases had their origin in the ner\'ous system.
He was opposed to stem pessaries. He did not think
anteflexion a cause, as it was often present in a marked
form without causing dysmenorrhcea. He had found
cycling to do good in some cases.
Dr. P.\rslo\v, of Bimiingham. had found many
cases in which there was no pain during the first three
or four years of menstrual life, and then pain began.
These cases could not be due to any congenita! mal-
formation, and he thought they were neurotic. He
thought it very unwise to make vaginal examinations
or treat mechanically unless good was likely to be
done, as it was most unfortunate for a young unmar-
ried girl to get the idea that there was " something
wrong with her womb."
Miss Kettle, of Edinburgh, had also found many
cases in which the pain had not commenced at puber-
ty, and had found that the first attack frequently orig-
inated from some slight cause, as catching cold during
menstruation, overexertion, or other imprudence; and
in these cases the pain might last for a few periods
and then disappear. In the unmarried she would not
make an examination until she had tried treatment for
at least three months, and she would avoid directing
a girl's attention to her uterus.
Dr. Cameron, in closing the discussion, said that
he thought that there was one prevalent cause which
had not been mentioned, and that was the artificial
avoidance of conception.
Hysterectomy for Fibroids — Dr. A. Donald, of
Manchester, then read a paper on " Intraperitoneal
Hysterectomy and Total Hysterectomy by the Com-
bined Method, for Fibroid Tumors of the Uterus,
with a Series of Cases." He considered the whole
question and gave the preference to the latter opera-
tion, tying the broad ligaments in sections and bring-
ing the sutures down through the vagina.
Dr. Martin, of Birmingham, in discussing this pa-
per, said that formerly he left all ligatures long and
drew them down into the vagina, but now he cut off
the upper ones and brought down only the lower
one.
Electricity in the Treatment of Uterine Neo-
plasms— Dr. Herbert White read a paper on
■• Practical Observations on the Electric Treatment of
Uterine, Mammary, and Other Growths." He used a
constant current of about seventy milliamperes and
punctured the growth with the negative needle. He
showed photographs illustrating the good results, par-
ticularly in a case of rodent ulcer.
Dr. Ixglis Parsons said he had used currents of
three hundred milliamperes in tlie same w^ay, using
two platinum needles, fixing the negative one and us-
ing the positive as a pencil over the surface of the
ulcer.
Prevention of Tetanus of the New-Born. — Dr. G.
A. Turner, of Glasgow, read a paper on " The Suc-
cessful Preventive Treatment of the Scourge of St.
Kilda — Tetanus Neonatorum." He gave an interest-
ing account of the island of St. Kilda, which lies west
of the Hebrides and is rarely visited from the main-
land. For the past one hundred and fifty years as many
as sixty-seven per cent, of the children had died from
this disease, the symptoms commencing with rigidity
of the jaw on the fifth or si.xth day and the child dying
on the eighth day. V'arious theories had been brought
forward to account for this, some attributing it to the
excess of fat in the mothers' food, others to the insan-
itary, ill-ventilated dwellings. Dr. Turner's advice
was requested by the clergyman of the island. He
came to the conclusion that the germ must enter
through the stump of the umbilical cord. He ad-
vised treating the cord antiseptically with iodoform
and gauze, and strict attention to cleanliness of the
child; and these measures had proved* so efficacious
that there had been no case in the last two years.
Sccv/id Day — Thursday, July joth.
The Causation and Treatment of Secondary
Puerperal Hemorrhage.— Dr. Amand Routh, of Lon-
don, in opening the discussion on this subject, said
that he would define secondary post-partum hemor-
rhage as bleeding which took place after the doctor had
left the house. He distinguished the varieties of
■■ concealed" and " evident." In the first variety the
uterus distended, the cervix being blocked by spasm
or clot. The causes of the condition were: Suddenly
induced uterine inertia, which might be produced by
emotional disturbance; partially detached pieces of
placenta or membrane — these acted by keeping open
the sinuses at the point of attachment, and were less
dangerous when quite loose. Later in the puerperal
period too early exertion, as in getting out of bed,
might be a cause. The treatment, if the hemorrhage
was concealed, was to pass the hand into the vagina,
clear out the clots there, and then to pass the hand
into the uterus, kneading the uterus at the same time
with the other hand on the abdomen. In the mean
time a hot douche should be made ready and adminis-
tered at a temperature of 115" to 118° F. ; a hypoder-
mic injection of ergotine should be given. If the
278
MEDICAL RECORD.
[August 22, 1896
hemorrhage was external, hot douches and kneading
should be used, and, if these did not quickly succeed,
the hand should be passed into the uterus. He found
that he could pass the hand up to three days af-
ter parturition. In e.xtreme cases he would compress
the abdominal aorta. After the third day it may be
necessary to dilate the cervi.x, and this he would do
with Hegar's or bladed dilators. It was not generally
necessary to give an anaesthetic; he would be pre-
pared to plug the uterus with iodoform gauze if the
hemorrhage was severe.
Dr. Wallace, of Liverpool, said that if it was from
retained placenta he should class it as primary. He
thought that hemorrhage was sometimes due to press-
ing the uterus down too firmly into the pelvis, and he
never used the binder. He also thought that too hur-
ried emptying of the uterus was a common cause.
Dr. Vax So-NnrERKN, of New South Wales, nar-
rated a case in which all the usual means of treatment
failed to stop the hemorrhage, and he succeeded in
stopping it by compressing the abdominal aorta.
Dr. Ritchie agreed with Dr. Routh in his definition
of secondary hemorrhage. He had found fibroids to
be a cause. He had faith in prophylactic treatment,
consisting in the use of tonics in the last months of preg-
nancy, especially strychnine; in not hurrying the birth
of the placenta; and in not allowing the patient to be-
come exhausted. He mentioned the importance of
making an examination of the placenta. In reference
to treatment, he would pass the hand into the uterus
and inject hot water, and had found good to result
from introducing a crystal of ammonia, iron, or alum
into the uterus.
Dr. Bvers, of Belfast, dwelt on the importance of
carefid management of the uterus in the third stage,
and advocated turning the patient on her back imme-
diately after the birth of the child. It was the great-
est mistake to make the uterus push out the placenta
before it was really separated. He always examined
the uterine surface of the placenta and then examined
the chorion. He had found distended bladder to be
sometimes a cause of post-partum hemorrhage. Even
without dilatation he sometimes found the curette
sufficient.
Dk. Donald, of Manchester, had never seen second-
ary hemorrhage, except what had been caused by re-
tained placenta, in hospital patients. In private pa-
tients he had'sometimes seen it, due to too much food
and constipation, and in those cases he gave calomel.
Dr. J. D. Williams, of Cardiff, had used saline in-
jections in severe cases. He thought secondary hem-
orrhage extremely rare.
Dr. J. M. Kerr, of Glasgow, thought that backward
displacement of the uterus was sometimes a^ause. If
Credc's method was resorted to too soon, there was
danger of pieces of placenta remaining.
Dk. RoiTTH, in closing, said that he had not men-
tioned fibroids, though he had known hemorrhage
from that cause to come on a week after labor. He
thought that the concealed variety was sometimes due
to the use of ergot during labor, causing contraction of
Bandl's ring. He hoped that the use of perchloride
of iron had been abandoned ; if used, he would apply
it on a probe and not inject it. He did not believe
in using the curette until the finger had been first in-
troduced.
Puerperal Septicaemia. — Dr. Byers, of Belfast,
read a paper entitled " A Plea for the Early Recogni-
tion and Treatment of Puerperal Fever." He said
that puerperal fever was now more common in private
than in hospital practice. The earliest symptoms
were rise in the temperature and pulse rate. He had
found the pulse to be 75 to 80 after delivery, quicker
after forceps had been used, and the pulse rate might
rise from other causes. He had seen cases of influenza
in the puerperal period, which caused difficulty in
diagnosis. Constipation might also cause a rise. He
urged the importance of a diurnal record being kept.
If the temperature rose and no cause could be found,
sepsis should be suspected; much time was often lost
in giving quinine, antipyrin, etc. He would at once
begin local treatment. The pelvic Hoor, vagina, and
uterus should be examined, and tears of the perineum
sutured and then dusted with iodoform. Cases es-
pecially liable to infection were the ansemic and those
in whom the first stage of labor had been prolonged
after rupture of the membranes. He advised irri-
gation of the uterine cavity by a gravitation douche
of I to 4,000 perchloride solution. Antiseptic solu-
tions, if used too strong, might cause death of the
tissues and increase the danger. He used a large
quantity of the solution, eight to ten pints. If the
temperature and pulse fell, it need not be repeated;
but if not, it should be used again, or, better still,
continuous irrigation, as had been practised in France,
with carbolic or boracic acid solution or lysol. This
method had not received sufficient attention in Great
Britain. The curettage caused no harm when care-
fully done. He did not, as a rule, do it before the
fourth day of the patient's illness. Injections of an-
tistreptococcic serum had not up to the present time
shown very good results, but it might have a great fu-
ture. Saline injections had been used. He kept up
strength by stimulants and digitalis. Of abdominal
hysterectomy for sepsis, he had had no experience.
The President concurred, and said that if any rise
of temperature occurred he would wash out at once.
Fleshy Mole. — Dk. Berry Hart, of Edinburgh,
read a paper on " The .Symptoms and Nature of the
So-called Fleshy Mole."" The most marked change
in the ovum in these cases was hemorrhage beneath
the chorion. He narrated two cases: In the first,
eleven months elapsed from the cessation of menstru-
ation to the expulsion of the mass ; and in the second
eight and one-half months. Microscopic examination
showed that the amnion was healthy and the villi of
the chorion were perceptible, but the mucoid matrix of
the connective tissue of the villi was increased. Tlie
mass was expelled in two forms: ist, a piece of fleshy
tissue; 2d, a sac containing a little liquor amnii and a
shrivelled foetus. In the first variety the portion
which comes away is that which would ultimately form
the placenta. The sequence of events is: Death of
foetus, which is sometimes retained, at others expelled;
blood extravasation into the serotina, forming sub-
chorionic exudations. This happens about the sec-
ond month. In some the mass is expelled as early
as four months and a half; in others retained to the
eleventh month. \\"hen the condition was diagnosed,
the cervix should be dilated and the uterus emp-
tied.
The President said such cases used to be known
as "missed abortion."
Antitoxin Treatment of Puerperal Septicaemia.
^Dr. J. D. Wii.LiA.Ms read a paper on "The Value of
Antistreptococcic Serum in the Treatment of Puer-
peral Septicsemia." Fourteen cases had been re-
corded by various authors: the earliest day for com-
mencing the injections had been the fifth, and the
latest the fourteenth. The dose had generally been
ten cubic centimetres given by subcutaneous injection
into the abdominal wall, the skin and syringe being
first sterilized. Some good results had been obtained,
but it was difficult to judge of them, as the serums used
had not all been of the same strength.
Perforation of the After-coming Head. — Dr. Purs-
low, of ]!irminL;ham, read a paper on this subject, in
which he urged the choice of the roof of the mouth as
a site for the operation, in preference to the one usu-
ally advised, viz., behind the ear.
August 22, 1896]
MEDICAL RECORD.
279
Third Day — Friday, July jisi.
The Relative Advantages of Forceps and Version
as a Means of Extraction in Cases of Moderate
Pelvic Contraction. — Dr. Mu.ne Murray, of Edin-
burgh, opened this discussion. He said that in cases
of gener.il pelvic Contraction version was acknowledged
to be inferior to forceps, but it was said that in cases
of flat pelvis for ^jS were unsatisfactory and version
was advised, the reason given being that forceps com-
pressed the head in the antero-posterior diameter and
so caused elongation of the biparietal diameter. He
had made experiments to test the truth of this, and had
found that it was possible to squeeze the child's head
so as to reduce its longitudinal diameter one and one-
half inches widiout increasing the transverse diameter.
What happened was that a telescopic action took
place, the frontal and occipital segments of the head
slipping under the parietal, and the head also expanded
in a vertical direction. This could be noticed when
forceps were applied to the living, as the sagittal suture
could be felt to descend, giving the operator a delusive
idea that the head is descending. The explanation of
the difficulties which had been experienced in the use
of the forceps in the case of flat pelvis was that with
the ordinary long curved forceps the direction of
traction was wrong, tending to pull the head against
the pubis. And he estimated that with a pull of
fifty pounds as much as thirty-eight pounds of force
might be wasted in this way. . In the flat pelvis
this was more likely to be the case than in the normal
pelvis, because the inclination of the pelvic axis was
greater and the pubis more horizontal. The use of
axis-traction forceps avoided this, and he found that
heads could be delivered by these which could not be
extracted with ordinary forceps ; and, as pointed out
above, no amount of compression with ordinary for-
ceps can increase the biparietal diameter of the head.
He had delivered living children through pelves with
conjugate of three inches, and in one case of two and
three-quarters inches, by axis-traction forceps. He
showed and demonstrated a pair of axis-traction for-
ceps, in which he had made a modification which al-
lowed the line of traction to be altered by moving the
traction handle along a rod which projected at right
angles from the traction rod. He had called these
"adjustable axis-traction forceps." To sum up: Any
case in which turning had been advised might be more
efficiently dealt with by axis-traction forceps.
Dr. Purslow, of Birmingham, thought Dr. Milne
Murray had gone too far in absolutely condemning
version in cases of contracted pelvis.
Dr. Fothergill, of Manchester, said that it had
been urged in favor of version that the bitemporal di-
ameter was substituted for the biparietal in passing
through the conjugate. He thought that the same thing
occurred with forceps.
Dr. J. M. Kerr, of Glasgow, said that in some
cases, in which one side of the pelvis was more roomy
than the other, some labors might be easy and others
difficult in the same woman, according to the side to
which the occiput was directed ; and in such cases ver-
sion was sometimes better when the occiput was found
to be directed to the smaller side; when directed to
the large side, forceps should be used.
Dr. Murdoch Cameron, of Glasgow, thought much
depended on the shape of the head, and he divided
heads into " long" and " square." He showed an
"antero-posterior" forceps of his own invention. He
found that when forceps slipped it was generally due
to the head being occipito-posterior.
Dr. Connel, of Peebles, would never contemplate
turning in preference to axis-traction forceps, and had
found the latter also a powerful preventive of rup-
tured perineum.
Dr. Mil-NE Murray, in closing, said that the blades
should be applied fore and aft as regards the head, and
not obliquely, as the latter caused a loss of the tele-
scopic effect. He always used the axis-traction rods
throughout, and never pulled on the application han-
dles. He believed an occipito-posterior position would
come round if left alone.
Haematometra and Pyometra. — Mr. Christopher
Martin, of Birmingham, read a paper with this title.
He said these cases were due to occlusion of the cer-
vix, sc "times congenital and sometimes acquired.
In the former the patient had suffered for some time
froi. _,i-adually increasing stenosis of the cervix, and
in only one of his cases did the occlusion come on
suddenly; in one of the cases in which the occlusion
was acquired it followed amputation of the cervix for
cancer. The treatment consisted in free incision of
the occluded cervix and washing out the uterine
cavity, stitching the mucous membrane of the uterus
to that of the vagina, and allowing the patient to wear
a rubber tube afterward. \\'hen the tubes were dis-
tended he advocated the removal of both uterus and
tubes by abdominal section.
Walcher's Position — Dr. Fothergill, of Manches-
ter, read a paper on " Walcher's Position," which is to
have the patient lying on her back on a table, w ith her
sacrum on the edge, and her legs dependent, the feet
being clear of the ground. The effect of this is to
cause a rotation of the ilia on the sacrum and to in-
crease the antero-posterior diameter of the pelvic inlet,
while diminishing that of the outlet. Another effect
which Dr. Fothergill had observed was relaxation of
the perineum. He had made careful measurements
with the woman in this position, and had found that
the conjugate could be increased by as much as one-
third of an inch. This manoeuvre should always be
tried before proceeding to symphyseotomy or craniot
omy.
Hysterectomy for Fibroid Tumors. — Dr. le Dec,
of Paris, read a paper on '" Total Hysterectomy for Big
Fibroids." His method consisted in opening the ab-
domen, tying the broad ligaments in sections, stripping
off the bladder, and opening F^ouglas' pouch; and
then, after removing the tumor, turning the stumps of
broad ligament into the vagina, and stitching the per-
itoneum together over them. The paper, which the
author himself read in English, was illustrated by nu-
merous diagrams.
This concluded the business of the meeting.
Hemorrhage in Brain Surgery The control of
hemorrhage is one of the most difficult problems in
connection with the removal of cerebral tumors.
Hemorrhage from the diploe is easily controlled by
Horsley's antiseptic wax. For hemorrhage from the
vessels of the meninges the ligature is an efficient
means of control. If the dura be cut and an artery
bleeds, the cut end can be tied just as any other ves-
sel. If it be necessary to ligate a vessel in its con-
tinuity, the dura being unopened though with torn ves-
sels, it can be secured by passing fine silk thread by
means of the finest semicircular Hagedorn needle under
the dura and around the vessel, care being taken not
to wound the underlying cerebral veins themselves.
For venous hemorrhage, the best method, also, is the
ligature. Rarely can the vessel be seized by the for-
ceps and a ligature applied. Pass by means of the
semicircular needle of suitable size, a silk or cat-
gut ligature through the cerebral tissue immediately
below and around the vein, and then tie the vessel
by drawing with equal force of the two ends, not
constricting the vessel with so much force in tying
the knot as to tear through its weak walls.- — Keen,
Interuationa! Medical Magazine, March, 1896.
28o
MEDICAL RECORD.
[August 22, 1896
diwical §qjartment.
IMPREGiNATION— WHEN IS IT POSSIBLE?
Bv HENRY A. SHELLEY, M.D.,
NEW YORK.
Various views have been held by competent ob-
servers as to the time when woman may be impreg-
nated during the lunar month. Some authors say only
at the completion of the glandular function ; others
affirm that tonception may occur at various times dur-
ing the lunar month.
The illustrious Dalton thus writes in his classic
work, '■ Human Physiology:" " The mature egg, dis-
charged from the ovary, soon dies and is decomposed
like any other portion of the body separated from its
connections."
For some years I have studied the subject clini-
cally. The orthodox members of two different relig-
ions furnished the subject matter. Orthodo.\ Hebrew
women observe the Mosaic law, living apart from their
husbands for seven days after the monthly flow has
ceased, making a total of at least twelve out of twenty-
eight days in which sexual congress is prohibited.
The fecundity of Hebrew women is proverbial. We
read in Genesis: "And the Lord said unto Abram :
And I will make thy seed as the dust of the earth; so
that if a man can number the dust of the earth, then
shall thy seed also be numbered."
Bearing in mind the dictum expressed by Professor
Dalton as to the vital duration of the mature egg, it
is reasonable to say that '' ova are usually discharged
from the ovary before the appearance of the monthlv
flow."
It is a common custom of strict Catholic women of
the educated, upper classes of society to observe a
rule of abstinence somewhat similar to that of Hebrew
women. But the reason is altogether different. Such
Catholic women do not wish children, for various rea-
sons, their husbands assenting. By the way, Mr. J.
S. Mill well remarks : •' The fact itself of causing the
existence of a human being is one of the most respon-
sible actions in the range of human life." The law of
Malthus is: There is a tendency in all animated ex-
istence to increase faster than the means of subsist-
ence. This law is axiomatic, and is well worthy of
consideration in social science. As the Catholic
Church is most stringent as regards the violation or
interference with the law of nature as regards sexual
congress and its consequences, there remain but two ^
things to do in order to avoid transgression of canon
law — total abstinence from copulation or limitation
of the act sexual to certain periods of the month, " the
so-called sterile period," "a quarto dk post iiurpta
menstrua." What is the result clinically? A doctor,
a Catholic, who faithfully obser\ed this rule within
his own household, when he found his own spouse
grossesse, sadly said to me: "Doctor, that sterile
period ain't worth a d ." Frequently women w-ho
limit sexual intercourse to one or two days mid-period
I find "to be with child." Alas! there is nothing
certain in this transitory world but taxes and death.
To conclude, we may say in such cases as the above
the "sexual ongress determines the ovipont."
These facts prove that the biological history of
menstruation, bearing on impregnation, by Arthur
Johnstone, is incorrect :
" It is only at the completion of the glandular func-
tion, that is, when the nidus is completely cleared
out and cleaned and its epithelial covering removed,
that the implantation of an ovum is possible. There-
fore it is that the age and maturation of the impreg-
nated ovum are to be reckoned from the end of men-
struation."
My opinion is that whether the endometrium is-in
a morbidly hypera;mic condition or not is a potent
factor as regards conception. It is conceded that the
true predisposing cause of abortion is irritability of
the uterus.
Resume: Facts sustain the following conclusions. ■
"Ova are usually discharged from the ovary before
the appearance of the monthly flow." Sexual con-
gress often determines an ovipont (Coste). As a re-
sult coitus is often then followed by conception.
319 Easi- 0\k Hvnijkeij AM) Twentieth Siheet.
POISONING BY CANNABIS INDICA.
Bv G. G. FISCHLOWITZ, M.D.,
NEW YORK.
Owi.N'G to the rarity of cases of this nature, the follow-
ing history is sent for publication :
On March 29th, at 11 p..m., I was hurriedly sum-
moned to see Dr. L. C — — , aged twenty-nine years,
who was suffering from the effects of an overdose of
the fluid extract of cannabis indica. The patient had,
at 10:15 i'..M., taken for his troublesome cystitis a tea-
spoonful of the above drug, after wliich he went to his
office to read.
But feeling drowsy, he went to bed and awoke at
10:45 P-^'-; becau.se of very troublesome dreams. He
thought he had slept for hours, and had a feeling of
tingling all over his body, especially around the an-
gles of his jaws and in the region of his stomach, and
of intense mental discomfort.
Realizing that an overdose had been taken, he al-
lowed cold water to run over his head, which increased
the discomfort about his jaws and abdomen.
He then started to read his " Materia Medica," in
order to get an antidote: but though he found the
proper page, he could not read, being unable to con-
centrate his mind. Becoming alarmed at his condi-
tion, he aroused his household and I was sent for.
Before my arrival he had taken some mustard, which
caused him to vomit freely.
On my arrival at 1 1 :3o p.m. I found the patient ex-
citedly, though in a happy frame of mind, walking up
and down the sitting-room. After seating himself, he
spoke very garrulously upon a number of subjects, but
his memory of tilings past was very clear. He traced
his ancestry back to his great-grandmother, who was
melancholic, and he feared he himself would become
insane.
He complained bitterly of the tingling and uneasi-
ness in his limbs, and that his legs were as heavy as
lead, and that when walking he felt as if wading
through feathers. His tongue felt thick and leathery,
and, fearing that he would become dumb, while walk-
ing he would shout out aloud, in order to correct that
impression. His throat felt parched, the conjunclivze
were reddened, the pulse ranged from 100 to 118, and
respiration was very rapid. He had no idea of time,
minutes seeming hours, and voices in a neighboring
room sounded to him as if coming to him from the top
of the house. \\'ith distances he had no difficulty.
Upon attempting to drink a cup of coffee which was
placed before him, he would forget to take the cup
and would go on talking. Upon being reminded of
the coffee, he brought the cup to his lips, but would
fail to drink and continued talking.
About 1:15 A.M. I requested him to go to bed; but
though much calmer than before, he hesitated about
going to sleep, fearing that he would not awake.
At 2 :i5 A.M. he fell asleep and awoke at 5 a.m., ^ith
a severe frontal headache, but otherwise well.
In looking up the literature on this subject, I find
but four cases reported in this country since 1883,
August 22, 1896]
MEDICAL RECORD.
281
none of which ended fatally. Hamaker ' reports a
case of a physician who took forty-one drops of the
fluid extract experimentally. Prentis " reports a case
of poisoning by five drops of the fluid extract. Rusin '
reports two cases of poisoning by three-fourths of a
grain of the solid extract.
1708 Lexington AvExirE.
FOREIGN BODIES IN THE INTERIOR OF
THE EYE.'
By \V. a. fisher, M.D.,
CHICAGO, ILL.
It is quite common practice to remove pieces of iron
or steel from the interior of the eye with the magnet,
many such cases having been reported. I wish to re-
port two cases in which pieces of iron were found and
extracted from the interior of the eye, yet one is strik-
ingly different from the other.
With the literature at my command I can find noth-
ing that equals in size the large piece of iron which
remained in the eye so long without causing more
serious results.
CasE I.^J. G. Graham, aged thirty-seven. Fourteen
years ago, while he was driving spikes on a railroad, a
piece of iron struck him in the eye, causing instant
blindness. He was unable to work for about three
months. Since that time he has been troubled about
once a year, the attacks, at first lasting about a week,
becoming more severe and lasting longer with each
succeeding year.
February 13, 1896, he applied at my clinic at the
Illinois Charitable Eye and Ear Infirmary, complain-
ing of much pain, lachrymation, and photophobia.
On examination I found the right eye atrophic and
tender. Vision of the left eye was f^. There were
lachrymation and photophobia. The right eye was
hopelessly blind and there was consequently no choice
left as to treatment, enucleation being the only thing
to do. He was at once anesthetized and the right
eye removed. In cutting open the eye, the piece of
iron was found to be completely encapsulated, while
the lens was calcareous. The size of the piece of
iron was eleven millimetres long, four millimetres
wide (seven-sixteenths of an inch long, and more than
one-eighth of an inch wide), and weighed two and
one-eighth grains. The man was a scissors sharpener
by occupation, and he went to work next morning,
sharpened all the knives in the hospital, and expressed
himself as feeling better than he had felt for three
months.
This case seems remarkable when we take into con-
sideration the size of the foreign body and the time it
remained in the eye.
By way of comparison I will now report an injury
from a much smaller piece of iron I removed with the
magnet, and which caused destruction of the eye, ne-
cessitating its removal two weeks after the accident.
Case II. — J. P. Roth, aged four years and ten
months, patient of Dr. Harsha. November 9, 1895,
the right eye was injured while he was playing with
two hammers. November 1 1, two days after the acci-
dent, I saw him in my office with Dr. Harsha. There
was a scar in the ornea, also a corresponding scar in
the iris. The vitreous was completely clouded; there
was no reflex. A diagnosis was made of foreign body
in the interior of the eye. The child was asleep and
when awakened was very irritable. I was unable to
locate the foreign body on account of the restlessness
' Hamaker : Therapeutic Gazette, Detroit, iSgi.
•Prentis: Therapeutic Gazette, Detroit, 1S92.
' Rusin : Southern Medical Recorder, Atlanta, i8go.
* Read before the Chicago Society of Ophthalmology and
Otolog)-, April 14, 1896.
and the age of the child. .\s the foreign body, if left
in the eye, would in all probability destroy it and sub-
ject the good eye to great danger, I decided to remove it
and endeavor at least to save the globe, as it is often
impossible to get children of this age to wear an arti-
ficial eye. In removing the eye I realized the import-
ance of thorough antisepsis in such cases, being very
particular to sterilize the instruments, cleanse the eye,
and, in fact take every precaution as to cleanliness.
When everything was ready the patient was given
chloroform, the conjunctiva was opened, and an in-
cision made in the sclera with a Graefe knife. The
curved tip of a magnet that was attached to a three-
cell storage battery was then introduced, and with but
little effort the foreign body was located and drawn to
the surface. In trying to extract it through the scleral
opening, which seemed too small, it slipped from the
magnet and fell into the vitreous. The opening was
therefore enlarged and the piece of iron removed. As
in similar operations about the usual amount of vitre-
ous was lost. The eye was thoroughly cleansed with
I to 5, 000 bichloride solution, and the conjunctiva
stitched, cleansed again, and one-per-cent. atropine
solution instilled and the eye bandaged. The child
slept well that night, the bandage was removed the
next morning, and the eye was again cleansed with t
to 5,000 bichloride solution, the application of atro-
pine repeated, and the eye bandaged. There was no
reaction following the operation. Atropine was in-
stilled every day thereafter, and antiseptics were used as
often as practicable. Everything progressed nicely
until the fourteenth day, when a swelling appeared at
the site of the scleral opening. The globe was now
filled with pus. Evisceration being the only thing to
do. Dr. Harsha again administered chloroform and the
operation was performed. At the end of two weeks
the child was fitted with an artificial eye and has worn
it continually since. I report these two cases to show
what the eye may or may not tolerate.
It is not always possible to remove pieces of iron or
steel from the interior of the eyeball with the magnet.
It has been my misfortune to make a thorough search
for a piece of metal in the vitreous with a good mag-
net attached to a good storage battery and not find it
until I had removed the eye. In my hospital work I
have witnessed many similar failures. I think any
one who has had much clinical experience has at times
met with the same results. There are so few misfor-
tunes of this kind, however, attending the use of the
magnet in extracting pieces of iron or steel from the
eye that we are not justified in abandoning the use of
the magnet, but on the other hand it should always be
employed, unless, perhaps, the metal has become en-
capsulated and the eye is quiet. Even in these cases
the patient would often be better for an operation.
About two years ago in this society I saw two sub-
jects who had pieces of metal encapsulated in the fun-
dus of the eye. They were quiet at that time and one
of them had good vision. I have had the one that had
good vision as a private patient since that time. This
was a patient of Dr. Tilley's. July 5, 1895, Dr. Tilley
being out of the city, I was called to see this patient
(Mr. T. W. F.). He had injured his right eye the day
before with a firecracker. I recognized the patient as
the one whom Dr. Tilley had shown in the society
with the metal in the fundus and who had at that time
vision of j%. The metal had not injured the lens in
its entrance, but at the time I saw him the lens was
opaque and the eye far from being in a state of rest.
The right eye soon cleared up and I have lost sight of
him, but I am sure he would be much better with the
eye enucleated than to have it in the condition it was
in when I saw it.
If one is sure of having a piece of metal in the eye,
and the media are not clear but are without serious in-
282
MEDICAL RECORD.
[August 2 2, 1896
fiammation, it is well to wait for the media to become
clear. If there is serious inflammation and the media
are not clear, nothing will be gained by waiting.
The results of magnet operations are very various
so far as vision is concerned. Many patients who
are reported as having good vision are reported
too soon, but enough successful cases are reported
to justify us in using the magnet in all recent cases.
When the metal is in the anterior chamber the re-
sults are nearly always satisfactory. In removing
from the anterior chamber metal that has become
embedded in the iris it is best to use a flat blunt elec-
trode. The electrode should be introduced in the an-
terior chamber and the metal dislodged before connect-
ing the current. The foreign body having been dis-
lodged, the button on the handle of the electrode may
be touched and the metal removed, thus preventing
prolapse of the iris.
Churning the vitreous is to be avoided. Cocaine is
as good as profound ancesthesia in adults. Thick
blunt electrodes are to be preferred to thin pointed
ones.
Air bubbles are always a sure sign of foreign bodies
in the eye.
Sometimes a piece of metal can be located by pass-
ing the electrode over the sclera. The patient will
complain of pain only as the instrument passes over
the metal.
It is useless to probe for foreign bodies in the
vitreous.
It is not wise to try to remove a foreign body from
the interior of the eye through the opening made by
its introduction. It is better to make a larger opening
and avoid introducing the instrument so many times.
In conclusion I will say that the possibilty of pre-
serving the globe and often useful vision warrants us
at all times in using the magnet in all cases in which
metal is in the interior of the eye.
103 Stai E Stkeei.
TREATMENT OF PNEUMONIA..
By S. H. VANDOREN, .M.D.,
SAVDROOK, ILL.
Realizing that no safe and certain cure for pneumonia
is given by any medical work e.xtant in the English
language, I desire to state briefly a few facts, which, I
hope, will be instrumental in the hands of a part of
the ninety thousand of earth's humanitarians toward
lessening the fearful ravages of this chief lieutenant of
death in all countries.
I shall not enter into the symptoms or the pathology
of pneumonia, as these can be learned from many medi-
cal works of the day. Upon those points there is no
dispute.
The world to-day is without a successful treatment
and that is what I will supply. Medical men are as
suddenly struck down by it as are their patrons.
The treatment upon which in my experience most
reliance can be placed is as follows : Counter-irritation
to chest, followed by hot poultices constantly applied
until all danger is past.
Nothing new, say a thousand voices at once. No,
but wait. I do not believe any person ever had pneu-
monia when the liver and kidneys were in a normal
condition. We must establish a free secretion of all
the important organs of the system.
First we would give:
IJ Tr. aconiti,
Tr. bryoniae aa gtt. x.
Tr. digitalis 3 i.
Potassii nit 3 ss.
Fl. ext. ipecac gtt. x.
Syr. pruni virg q.s. ad J iv.
il. S. For adults, teaspoonful diluted every hour until
patient is better; tlien only as seems to be required, say every
three hours while fever lasts.
I use the best imported German tinctures. They must
be reliable.
We have now started right. In an active practice
for twenty years I never saw a case that did not need
free catharsis. I think any compound employed
should act through the blood and intestinal tube, and
be capable of emptying the alimentary canal by its ef-
fect upon the mucous membrane lining the intestinal
tube, for if these toxic ptomains remain in the system
they may destroy it, and this is why opiates of all
kinds kill the patient — they check the elimination of
those deadly poisons from the system, and cause de-
bility and irritation in the lungs to increase.
So we would give ;
^ Ext. rhei,
Ext. jalap;v et sennoe aa | ij.
Sodii bicarb.,
Potassii tart aa 3 iss.
Tr. capsici 3 ss.
Ess. menth 3 ij.
Syr. simp q.s. ad O i.
M. S. Tablespoonful diluted every three hours until the
bowels operate three or four times thoroughly; then daily as re-
quired to keep up free action.
In forty-eight hours after this treatment has been
instituted give:
1^ Syr. ferri iodidi gtt. xx.
Strychninaj sulph gr. jij.
Atropina.' sulph gr. jjjj.
M. S. Give ever)' four hours for one dose as above.
By this treatment you sweep out of the system the
poisons that if permitted to remain produce death.
The last prescription strengthens the heart and less-
ens in a very marked degree the pulmonary pressure
in the lungs, and the irritation rapidly subsides.
I was taught to depend upon about ten drops of
syrup of iodide of iron, three times daily, in such
cases for its alterative and tonic effect in assisting to
clear up a hepati/cd lung; but such small doses are
not sufficient in most cases to accomplish that result.
I frequently give in acute bronchitis, especially in the
aged, forty drops ever}' four hours, until marked im-
provement is noted. Furthermore, the careful physi-
cian will know when to lessen the dose of str}'chnine.
.As a rule, after I liave the patient on the last pre-
scription twenly-four hours, I reduce the strychnine to
about one-one-hundred-and-fiftieth grain three or four
times daily, and maintain a tolerably free circulation
all through the case.
In conclusion, I want to impress upon the minds of
members of the medical profession that it is not neces-
sary for any ordinary case of pneumonia less than
seventy years old to die if treated upon these lines.
If the above doses do not promptly control the disease,
I increase the doses until I get the system profoundly
under control and then maintain that effect.
As regards the use of alcoholic stimulants, best Hol-
land gin should be given from the start or in twenty-
four hours after the chill. Why do we give gin?
For two reasons :
ist, to maintain a better circulation of the blood.
2d, and most important of all, to assist the kidneys
to freely eliminate the various poisons that have the
natural tendency in these cases to accumulate in a
body.
Colles' Immunity. — By this is meant that which
is shown by those healthy mothers who, owing to syph-
ilis in the father, have borne syphilitic children, but
have themselves apparently escaped infection. This
immunity has been proved in thousands of cases, and
there is no longer anv doubt that it mav exist.
August 22, 1896]
MEDICAL RECORD.
283
Jiuuflical J'liggestious.
Vaginal versus Abdominal Section Vaginal sec-
tion: (i) A shallow and wide pelvis in a thin woman.
(2) Exploration of the peTvis. (3) Visceral adhesion
in true pelvis. (4) Displaced and adherent uterus.
(5) Smaller ovarian cysts, especial !)• the intraliga-
mentous and parovarian. (6) Smaller fibroids, espe-
cially the soft. (7) E.\tra-uterine pregnancy, up to
seventh month and after death of fcttus. (8) Pelvic
haeniatocele. (9) Puerperal hysterectomy. (10) Acute
inflammation of the appendages, with peritonitis, in-
volving cul-de-sac. (11) Inflammator)' destructive dis-
eases of the appendages, including tuberculous disease.
(12) Pelvic abscess pointing downward. (13) Conser-
vative operations on appendages that lie in the true
pelvis.
Abdominal section: (i) A narrow and deep pelvis,
especially if deformed. (2) Explorations above the
true pelvis. (3) Visceral adhesions in false pelvis or
above. (4) Large ovarian cysts, especially multilocu-
lar, with colloid contents. (5) Large fibroids, espe-
cially the firm and hard. (6) Extra-uterine pregnancy
at time of rupture and of term. (7) Extra-uterine preg-
nancy, with tumor wholly above the brim of the pelvis
and not in relation with the uterus. (8) Pelvic abscess
pointing upward. (9) Conservative operations under
conditions unfavorable to vaginal section, such as nar-
row and deep, or a deformed pelvis, that is contracted.
— WiLLiA.M M. Polk, Canadian Practitioner, February
8, 1896.
Malignant Disease of Uterus. — i. Cancer of the
cervix uteri, if left without surgical interference, al-
ways kills. 2. The disease in most instances is pri-
marily a local process. 3. Early hysterectomy will
cure quite a percentage of these cases. 4. The micro-
scope, while a great diagnostic aid, is not infallible in
its findings. 5. The experienced surgeon is warranted
in resorting to hysterectomy, even in doubtful cases.
6. Every malignant gravid uterus should be removed
before the disease has advanced beyond the period of
a probable cure. — Cordier, Tri-State Medical Society,
Chicago, April, 1896.
Club Foot. — In infants who have not walked on
a congenital equino-varus the deformity can be easily
cured by manipulation by correcting first the varus and
later the equinus, and holding the foot in plaster-of-
Paris dressing after each manipulation until overcor-
rection is obtained. The child should then wear a
retention apparatus for a year after it has learned to
walk. — T.WLOR, Maryland Medical /(Hinial, April 11,
1896.
Nocturnal Emissions. — The cause of impotency, of
abnormal seminal emissions, and of premature ejacu-
lations is in most cases an intense hyperfcsthesia of
the deep urethra. Nocturnal emissions occurring with
greater frequency than once in ten days are indicative
of some pathological condition which requires treat-
ment; seminal discharges taking place in the daytime,
when the patient is awake, are of serious import, how-
ever infrequent they may be ; true spermatorrhoea is
very rare. — Lamphear, American Journal of Surgery
and Gynecology, Februar}' 18, 1896.
Drainage of Abdominal Cavity. — Drainage of the
abdominal cavity is an expression of the present im-
perfect state of surgery. It is often an unavoidable
evil. It should be limited to appropriate cases, and
it is therefore well that the indications for it should be
laid down clearly, so that we may have eventually
some definite rules that will guide the surgeon in his
abdominal work. There are now no fixed rules. Some
surgeons avoid drainage whenever possible; others
drain as a rule. If 1 were permitted to pass my judg-
ment on this question as a whole, I would say that the
surgeon who has the ambition to operate quickly, to
make an impression on the bystanders, should drain
frequently; while, on the other hand, the surgeon who
proceeds with his work carefully, step by step, with
plans well laid out, with his practical knowledge rest-
ing on a firm pathological basis, will drain only in
exceptional cases. — Senn, American Gynecological and
Obstetrical Journal.
Floating Kidney. — (1) Operate on all movable
kidneys which are diseased, varying the operation ac-
cording to the condition present. (2) When mechani-
cal troubles or pain are present, try a supporting ban-
dage. If the symptoms disappear, then give to the
patient the opportunity of choosing between operation
and mechanical support. If a bandage does not give
a good result, operate. (3) When hysterical or neu-
rasthenic symptoms are present, then try the bandage,
and do not operate unless it fails to give satisfactory
results. (4) In cases of general abdominal relaxation
employ the abdominal supporter, and do not operate
unless the movable kidney itself is the cause of dis-
tressing symptoms. After the operation it is still
necessary to use the bandage. (5) When a movable
kidney does not give rise to serious symptoms, advise
the use of a bandage. — Albarran, An. des Mai. des
Org. Genito-Urinaircs, vol. iii., p. 577.
Bacterial Products — Drs. Vaughan and Novy have
determined the chemical products of bacteria to be: i.
Ptomains, which are either toxic or non-toxic. 2.
Toxalbumins. 3. Ferments. 4. Acids. The pto-
mains are transitional products and resemble the veg-
etable alkaloids. Vaughan says : " The genn produces
toxins by splitting up pre-existing compounds." An
example of toxins is the typho-toxins, and of the non-
toxic ptomain methylamin. The toxalbumins are al-
buminous substances. In this class of products are
the active principles of the various toxin serums, as
tuberculin and tetanin. The principal ferment is the
peptonizing ferment already mentioned. All these
have a part in pyogenesis. When the toxins are ab-
sorbed and carried to the nerve centres we get the fever
and other constitutional disturbances of suppuration.
— Duncan, Kansas Medical Journal, April 18, 1896.
Dressings. — Any surgical wound dressing should
be absorbent, to admit of the ready impregnation with
medicinal substances and to absorb discharges. The
substances in most common use are lint, absorbent cot-
ton and gauze, tow, oakum, jute, wood wool, moss,
peat, and pine sawdust. — American Te.xt-Book of Sur-
gery, p. 1,159.
Profeta's Immunity.—- La loi de Profeta," accord-
ing to Fournier, is the immunity of the children of
syphilitic parents, either or both of whom are syphilitic.
— American Text-Book of Surgery, p. 134.
Hip-Joint Disease. — There has been a diversitj' of
opinion as to the tissue in which the disease exists
primarily, some surgeons asserting that its frequency
of commencement is first in the synovial membrane ;
others in the capsule; others in the ligamentum teres;
and -Still others, constituting the largest majority, con-
tend that its primary manifestation is in the develop-
ment of a tuberculous ostitis in the head of the femur
or the cancellated bone tissue at the bottom of the ace-
tabular cavity, the same principle holding true here
as elsewhere in the predominance of the epiphyseal
affection. The examination of a large number of
specimens after resection of the hip-joint favors the
supposition that an ostitis, resulting from an iniplan-
284
MEDICAL RECORD.
[ August 22, 1896
tation and development of the bacillus tuberculosis in
the cancellous tissues of the bony elements of the joint,
is the starting-point of this disease most frequently by
far, in children at least. In adults the synovia Imem-
brane of the joint is often the first tissue to be affect-
ed.— Charles T. Parkes, Clinical Lectin es, pages 457
and 202.
Tuberculous Meningitis Dr. Lamphear has advo-
cated an operation in tuberculous meningitis which,
so far as I know, has never been tried — namely,
opening the skull and washing out the meningeal
spaces, as we do the belly in tuberculous peritonitis.
He reasons that the peculiar disappearance of the tu-
berculous process in peritonitis treated by flushing the
abdomen, leads to the conclusion that a similar result
might be anticipated in tuberculous meningitis when
complicated with hydrocephalus. — American Journal
of Surgery and Gynecology, vol. ii., p. 143, January,
1896.
Rupture of the Quadriceps Extensor. — Dr.
Walker {American Journal of Ihc Medical Sciences, p.
647), in a paper on the aforesaid subject, draws the fol-
lowing conclusions: I. In recent cases in which there
is not much effusion and the joint is apparently not
opened, and in which the separated ends can be ap-
proximated and detained by suitably adjusted pads,
the mechanical treatment may be carefully considered.
In the hands of the intelligent general practitioner this
method may be expected to bring about a complete
recovery in the larger number of cases. From nine
to twelve months will be required to re-establish fully
the normal functions. 2. A too prolonged fixation in
bed is unfavorable to an early recovery; therefore
early massage and passive motion are strongly advised.
3. The skilled aseptic surgeon who primarily resorts
to the operative method in suitable cases (but the age
and vitality of each patient must be most carefully
considered) may quite reasonably hope to obtain a
better result in a larger number of cases and save his
patient three to six months' time. Catgut, kangaroo
tendon, or silkworm gut should be used, and when
there is much effusion drainage should also be em-
ployed. 4. When the separation is greater than one
and one-half inches, or when the case has not recovered
under the mechanical treatment, the operation is in-
dicated. 5. As the length of time required for treat-
ment is a very important consideration, so the opera-
tive method, which has diminished this period and
also succeeded in a larger number of cases without
increasing the danger, will be more often indicated
and more frequently applied in the hands of the
skilled surgeon.
Treatment of Puerperal Sepsis — i. Suspected in-
fection of the birth canal should be confirmed when
possible by a bacteriological examination of vagin?il
secretions, and every means of differentiating from
other affections be resorted to, that they may be treated
rationally either by medicine or by surgery. 2. Irri-
gation and antiseptics destroy the nutrition of the parts
when continued and, furnishing increased moisture,
improve the field for the development of micro-organ-
isms, aside from the danger of death resulting from the
antiseptic used. 3. The birth canal can be kept com-
paratively dry by absorbent dressing, removing the cul-
ture media and arresting the development of germs and
infection until the abraded parts have healed. — Mil-
ler, American Journal of Obstetrics, November, 1895.
Chronic Rhino-Pharyngitis. —
'S, Menthol i
Oil of sweet almonds, or
Liquid vaselin 10
M. .S. Apply locally with a brush.
— Hamon iik Fou(;er.4v.
OUR LONDON LETTER.
(From our Special-Correspondent. )
OMNIU.M GATHERU.M FRO.M CARLISLE.
London, .-August 7. 1896.
The lapse of a week since leaving Carlisle has not
sufficed to turn professional gossip into its accus-
tomed grooves. Wherever we meet, one of the earliest
questions is, "How did you like Carlisle?'' or '"What
did you think of the meeting of the B. M. A. ? " or
something equivalent. A very nice place to visit is
the border city, with its wide, well-kept streets, sub-
stantial buildings, and hospitable, big-hearted North-
ern inhabitants. Carlisle, too, has a history of which
it may well be proud and offers archaeologists no slight
attractions. It has, further, a medical history, which
history and that of the worthies of the district were
well told in the address of the president. Some diffi-
dent people feared the meeting might be a failure, as
coming after London, but the event has justified the
courage of the Cumbrians, who may continue to boast
in the words of their old song:
" Canny au'd Cumberlan* caps *em a' still."
The district around the border city is one of great
interest and well worth full exploration. A number
of excursions were arranged by the local commit-
tees, including one to the "Land of Scott" and an-
other to the lake district. Cricket, lawn tennis, golf,
etc., were accessible. A conversazione and a dance,
garden parties, and other entertainments galore were
provided by the Cumbrians, and the 1896 meeting may
fairly be cited in support of the frequent taunt that
these congresses are attended more for the sake of
dissipation than science. I should mention that par-
ties were conducted through the cathedral, the castle,
and Tullie House by Chancellor Ferguson, and the
splendid collection of birds in the museum was a
great attraction, as to which the Rev. H. A. Macpher-
son acted as the kind cicerone.
Dr. Barnes is an excellent president, and the choice
of the subject of his address was most appropriate. It
must be confessed, how-ever, that his voice could not
adequately fill the room, and many were therefore un-
able to follow all His utterances. I hear, however,
that your special reporters secured good places and
have sent you a full abstract. The local press was
by no means gratified with the treatment meted out to
its representatives, who were excluded from the most
lively proceedings. (Jentle hints, not to say remon-
strances, were thrown out about " meetirrgs with closed
doors" and the curious "traditional reserve" of the
doctors being perhaps connected with their " prover-
bial differences."
It was very amusing to see the energy of a door-
keeper in clearing the room of reporters at some of
the general meetings. He included in his orders the
representatives of medical journals, assuring them the
meeting was private and out they must go. The ab-
surdity of thinking the doings could be kept secret
when so many members were present should have
been manifest to the managing clique. .As a member
I could not be excluded, and I write shorthand, as no
doubt many other members can, besides which, with
ever)' dinner table discussing the secrets, they were
all "open" ones indeed. It was natural, perhap.s, for
these managers to wish to avoid all discussion of their
conduct in the libel action, Kingsbury v. Hart, but
Dr. Kingsbury had taken effectual means to prevent
this. He had printed a pamphlet containing his his-
tory of the case ah initio and a full report of the trial.
August 22, 1896]
MEDICAL RECORD.
285
in which he triumphed and which the council con-
fessed to have cost j(^,' 1,300, and yet they were not
manly enough to acknowledge any mistake. It was
very laughable to see Mr. Hart making anvil and
hammer of his fists to emphasize the assertion in stac-
cato falsetto, " I — would — do — the — same — again —
in — the — same — case." No, no, Mr. H., not if you had
to pay the costs! Dr. Kingsbury's pamphlet was freely
distributed and is very caustic. It asserts that agents
were set to work in Blackford, Manchester, Liverpool,
and Preston " to try by hook or by crook to hunt up wit-
nesses against him, but they failed to find one honest
man in all Lancashire whom they could induce to give
evidence," while "twenty-one of the leading professors
and consultants of the county volunteered their ser-
vices and were in court to support him." But the de-
fendant did not appear. He started on the yacht trip
which he advertised in the Times the day before the
trial, and Dr. Kingsbury speaks of him as "the gen-
tleman who had only the courage to run away." It
was suggested at the trial that he was ill, but no evi-
dence was given; in the debate at Carlisle it was said
that an.xiety lest he should be asked the name of his
informant prompted his non-appearance. These ex-
planations do not agree, but what matters? The case
is over. Dr. Kingsbury has vindicated his conduct
and shown that the enormous influence of the associa-
tion cannot crush an independent man who has noth-
ing to be ashamed of. The lesson was needed, and
it is to be hoped will be laid to heart in in both the
editorial and advertisement offices of the Journal.
How the evidence of Sir D. Duckworth, Sir T.
Stokes, and Dr. Cousins broke down at the trial was
duly recorded in your columns at the time. . The
fuller light shed on the matter in Dr. Kingsbury's
pamphlet confirms the opinion then expressed. As to
advertising, the lesson will now perhaps be learned that
what is sauce for the general practitioner is sauce for
the consultant.
Dr. Kingsbury scored a success, for although he
had to modify a resolution he submitted, he carried
that part of it which invited the council to draw up
a code of ethics to be submitted to the association.
It might seem that some of the council were scarcely
suitable persons to entrust with this task, but no doubt
their recommendations will soar above their practice.
Ignorance of ethics was openly professed by some
and a definition demanded. But on Wednesday a
section of ethics was opened under the presidency of
Dr. r.Xnson, who told his audience in his address that
"their ethics were comprised in their duty to their
brother practitioners, their patients, and the world at
large." This is comprehensive enough, though surely
"the world at large" includes brethren and patients.
But the president went on to particularize by adding
to his statement " and the necessity of upholding by
any and every means in their power the honor and
dignity of their profession." I do not desire to criti-
cise these rather loose expressions ; the subsequent
discussions would have been more edifying if some
of the speakers had conformed to the president's de-
scription. For it cannot contribute to our honor and
dignity to give way to temper in discussing burning
questions, and I am sure it is contrary to so-called
ethics for speakers to hurl opprobrious epithets at one
another.
The annual dinner went off with the usual eclat.
The bishop was present and returned thanks for the
toast of the clergy and ministers of all denominations.
He humorously pretended that he nearly fell " into a
trap " by speaking in an assembly of doctors of the
other denominations as " irregular practitioners," and
then, referring to the next toast, the military one,
claimed them as "auxiliary forces" and paid them
full compliment as brothers in arms.
Surgeon-Captain Witchurch, who won the Victoria
Cross for his heroism at Chitral, also spoke and was
received as enthusiastically as when the gold medal
was presented at the general meeting.
The temperance breakfast is now regularly looked
for. For some twenty-five years the National Tem-
perance League has invited the members to a break-
fast. This league is devoted to the spread of temper-
ance by moral suasion. Sir Wilfred Lawson, who is
the leading advocate of legislative suasion, was also
present, and some delightful humorous passages were
exchanged between him and the bishop, making this
one of the most successful entertainments of the kind.
The journey back to London on Saturday was much
retarded by the crowded state of the line carrying
thousands in the opposite direction. Members who
stayed until Monday, the bank holiday, were doubt-
less much more inconvenienced. Not a few took the
opportunity of a few days in the lake district.
The Third International Congress of Dermatology
has been sitting in London all the week, but notes
of its proceedings must stand over and for once the
metropolis give place to the border.
OUR BERLIN LETTER.
(From our Special Correspondent.)
RENAL DIABETES — URIC-ACID DIATHESIS HOT-AIR
FIXATION OF BLOOD SPECIMENS DIPHTHERITIC
MVELOCYTH^MIA.
Beklin, August 8, 1896.
A RECENT lecture upon renal diabetes by Dr. Klem-
perer aroused a more than usually interesting discus-
sion. The views enunciated by Dr. Klemperer may
be summarized briefly as follows:
In the healthy person, sugar is stored up in the
liver as glycogen, but if excessive quantities of carbo-
hydrates have been taken a certain amount passes the
liver, enters the blood unchanged, and is excreted by
the kidneys as sugar.
This alimentary glycosuria is practically of a regu-
lating nature. If we e.xcite an artificial diuresis, we
may produce a glycosuria, when even very moderate
quantities of arbohydrates are ingested. In the cases
described by Klemperer as renal diabetes, we find a
permanent excretion of sugar, though the quantity of
carbohydrates ingested is not increased and the circu-
lation is not accelerated by diuretics. In the discus-
sion. Dr. A. Fraenkel opposed the idea of a diabetes
strictly renal in character. According to his view the
arrest of a glycosuria upon the appearance of a chronic
granular nephritis maybe readily explained by assum-
ing that the diseased kidney retains the ferment se-
creted by the pancreas and this ferment in return
enables the tissues again to assimilate the sugar. Dr.
Fiirbringer had seen three patients with diabetes in
whom glycosuria ceased as albuminuria appeared.
Magnus-Levy had administered phloridzin hypoder-
mically and found that, after doses of even only twenty
centigrams the healthy as well as diseased kidneys
would excrete sugar, but the largest amount would be
excreted by the contracted kidney. These results are
diametrically opposed to Klemperer's statements, who
says that contracted kidneys excrete no sugar after the
administering of phloridzin. The general conclusion
of the discussion was that Klemperer failed to sustain
his theory of a renal diabetes. Dr. Klemperer also read
another paper before the Berlin Medical Society on
the prophylaxis of uric-acid concretions in the kidney.
The treatment of such concretions in the urinary tract
must be principally surgical, because a solution of
these concretions by internal remedies is utterly im-
286
MEDICAL RECORD.
[August 2 2, 1S96
possible, on account of the firmness of the combina-
tion of the urates with the organic constituents. Pro-
phylaxis, therefore, is what we must aim at. The
kidney should be well irrigated, food substances
which aid in the formation of uric acid (as nucleins)
must be avoided, and as little meat as possible should
be taken, milk, eggs, and vegetables being preferable.
Not all nuclein-albumin, however, is turned into uric
acid as a final product, for in the case of some its
transformation is effected into urea. Certain drugs,
such as caffeine, have a strong tendency to increase
the formation of uric acid. Muscular exertion also is
followed by an increased formation of uric acid. The
elimination of uric acid is favored by an excretion of
neutral or alkaline urine. Of remedies favoring this
Klemperer recommends bicarbonate or citrate of so-
dium. Urea especially has this property. It may be
given in daily doses of twenty grams. It not only
increases diuresis, but also is a solvent of uric acid.
Piperazin, lysidin, and uratropin are more expensive
than urea and of less therapeutic value than it in cases
of the uric-acid diathesis.
Of interest was a demonstration at the same meet-
ing by Strauss, who diagnosed a mediastinal tumor
with the aid of the .v-rays. In the photograph a
shadow was to be seen in the thorax as large as a fist,
situated to the left of the spinal column. According
to Strauss this was a cancerous enlargement of a bron-
chial gland occurring thorough metastasis, the pri-
mary lesion having been in the stomach. Attempts
made to locate by means of the a-rays the position
of the large cur\'ature of the stomach, after passing a
metal sound, have not been successful. During the
discussion Boas stated that by his method it was not
at all difficult to locate the position of the large curva-
ture by passing a tube. He considered any compli-
cated apparatus for this purpose unnecessary.
At a meeting of the Society for Internal Medicine
Kronig read an interesting paper concerning certain
new methods of blood examination. One novel pro-
cedure was the fixation of blood specimens in hot-
air baths. Kronig has constructed a small and a
large air bath. The small apparatus is a square
metal box, with a receptacle for four specimens. It
is placed over a gas flame; a thermometer is attached
to show the temperature. With a temperature of 150°
C, the fixation of the specimens is obtained in four
or five minutes.
In the large air bath the preparations remain for
one hour at a temperature of 115^ to 120 C .
At the same meeting Engel reported the discovery
of certain peculiar conditions of the blood in diph-
theritic children. He examined thirty-t\vo children
seriously ill. He found the so-called myelocytes al-
most entirely absent in those children who recovered.
All those (seven) died who had a large number of
myelocytes in the blood. Engel calls this condition
"myelocythamia" of diphtheria. All the children
were treated with antitoxin. Engel believes that the
poison of diphtheria acts injuriously upon the blood-
forming structures just as it acts in producing par-
enchymatous inflammation in various internal organs.
Lacerated Wounds of Fingers. — In cases of severe
injury to the fingers by laceration or contusion, put the
entire hand into a very ample soaking-wet dressing.
Do not trim off any pieces of flapping skin. Incision
for drainage is all that is allowable until healing
is very well under way. Vou may then look over the
ground and see whether it is necessary to sacrifice any-
thing. A half-inch of boneless finger may be of great
value to its possessor. — International Journal of Sur-
gery, May, 1896.
Beiu iustvutncuts.
A PORTABLE STERILIZER AND DRESSING
RETAINER.'
By JOHN PRENTISS LORD. M.D.,
OMAHA, NEB.,
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERV, CREICHTON MEDI-
CAL COLLEGE; ATTENDING SURGEON, ST. JOSEPH'S HOSPITAL, AND CON-
SULTING SURGEON, PRESB^TERIA.N HOSPITAL.
In the summer of 1894 the author conceived the es-
sential features of the portable steam and hot-air ster-
ilizer and dressing retainer herein described. Think-
ing that the market would aft'ord something of this
character, a search was accordingly made, but with
negative results. Sterilizers were too large or too
small; the larger were cumbersome and ill adapted to
convenient use outside of a hospital ; the smaller were
inadequate for major operations and necessitated the
carrying of a previously prepared aseptic roll for
gowns, bandages, cotton, etc., which, as a consequence,
were an extra incumbrance, and, furthermore, did not
sufficiently simplify the technique of antisepsis in sur-
gical preparations.
It was considered a first essential feature to have a
portable receptacle sufficiently large to retain dress-
ings required for any major operation {i.e., gowns for
operator and assistants, towels, gauze, cotton, silk,
drainage tubes, bandages, etc.), ready packed and
primarily sterilized by steam, rendered dry by hot air,
and retained in a dry aseptic condition, ready for use
in ordinary emergency cases and in convenient order
for resterilization in cases of major degree or when
extraordinary precautions are desired.
Second, to have an adequate independent heating
apparatus for both steam and dry heat, to be used in
emergency, but not required when the ordinary means
of heating are at hand.
Third, to make the pan for the water not only sup-
ply the steam but answer for boiling instruments,
either simultaneously with sterilization of dressings or
independently, without in any way disturbing the con-
tents of the sterilizer, and also ser\e as a tray for the
instruments, thereby relieving the satchel of this en-
cumbrance.
The apparatus herein described has been in actual
use more than a year and a half, with such results as
to justify me in presenting it to the profession for
their consideration.
The sterilizer, as represented in Fig. i, is nine and
one-half inches wide, ten and one-half inches to the
top of the handle, and si.xteen inches long. It is
made of copper and brass, nickel plated. The handle
is hollow. The handle post contains a perforated
lork for the reception of a thermometer,- after remov-
ing the mill-headed cap, A. The partial unscrewing
of the cap B permits the steam to escape, when dry
heat replaces the steam. The cover is secured by
' Read before the Medical Society of Missouri Valley at Sioux
City, la.. March 20, 1895.
August 2 2, 1896]
MEDICAL RECORD.
287
clasps or hooks, as represented in the cuts. The pan
is fastened to the bottom of the apparatus by hooking
its handles over the pins upon the ends of the body of
the sterilizer.
Fig. 2 represents the top removed, showing the gal-
KlG.
vanized-wire basket which retains the dressings.
This basket is removable and has a double bottom of
copper, which prevents scorching of the contents when
dry heat is used. It .serves also as an aseptic retainer,
especially convenient in the absence of plenty of
bowls, basins, etc.
Fig. 3 is sell-explanator)'. .A second pan with a
wide flange is nested with this and is used as a cover
for the instrument boiler, and also as a second tray.
Fig. 4 illustrates the manner in which the flame is
Fic.
limited by the slides in the cover of the alcohol stove.
By closing these slides the flame is extinguished.
When the stove is used for steam the whole top is re-
moved.
Fig. 5 represents the application of dry heat, with
Fig. 5.
thermometer introduced through the handle.
It is not to be inferred that the sterilizer requires
the use of the alcohol stove. Any heat may be used
when at hand. The independent heating apparatus is
intended for emergency.
The alcohol stove is four by ten inches and one
incli deep. It contains a mat of asbestos wool, which
requires twelve ounces of alcohol to saturate, and will
burn forty to fifty minutes. Two quarts of water will
boil in six minutes, and a steam heat of 212"^ F. is at-
tained with the sterilizer in ten minutes The stove
is readily packed in the pan, as is also the tin alcohol
bottle. The bottle holds one pint, and the remaining
four ounces of alcohol, not used for the stove, may be
used for disinfecting hands, wounds, site, etc.
The whole makes a compact, capacious combination,
all the parts of which are useful and necessary ad-
juncts to a surgical outfit.
The construction is simple, the apparatus is light
and very portable. No new principle is claimed.
The apparatus is simply a convenient combination of
necessary utensils, all of which are required in emer-
gency work.
The steam heat is abundant and efficient. Under
steam is used, but, the air being allowed to pass off
through the handle during the first minute or two, per-
fect saturation and sterilization of the contents by
steam takes place, the same practical results being
secured thereby as in other sterilizers, which are more
complicated and bulky, heavier and less roomy. Be-
sides, they do not furnish pans, etc., which are espe-
cially convenient to have in emergency work.
A small size is made for oculists and those who do
minor work. Its small size yet considerable capacity
commend it to a class of men who are wont to operate
without up-to-date asepsis, for the reason that their
work is of such a minor character that these extra
pains are not deemed necessary in order to get results
in the majority of cases; yet bad results are sure to
follow this neglect of the only safe course in all surgi-
cal procedures.
The small-sized sterilizer is twelve and one-half
inches long, five and one-half inches wide, and six and
one-half inches high, including the handle; it will
hold sufficient gauze, cotton, bandages, drainage tubes,
silk, etc., for any minor operation.
The sterilizers are supplied with canvas or telescope
covers, and are of moderate cost.
The writer has long considered it necessary for gen-
eral practitioners, and surgeons as well, to break away
from the old and too frequent custom of using gauze
and various other dressings from their several pack-
ages, which have occupied the dusty shelves of the
office for a variable period, and have, perhaps, been
opened repeatedly. Gauze should be supplied in less
expensive retainers, furnished in blotting paper for
instance, with an outer covering of a less permeable
character, which latter, when received, could be re-
moved and the gauze with its porous covering kept in
the sterilizer ready for use, and resterilized as often as
contaminated by opening or using from the retainer.
If all physicians would inaugurate these reforms in
the care of their dressings, their results would be
much improved and operative surgeons would see
fewer cases of septic wounds — the legitimate off-
spring of a practice much too common, in view of our
present knowledge of asepsis. It would seem super-
fluous to make these remarks to readers of this journal,
but all will admit that asepsis in ofiice and general
practice has not yet been rendered as simple, effective,
practical, and easy of attainment as it should be. It
has, therefore, been my aim to simplify it, so far as im-
mediate dressings for the wounds are concerned, by
having them all together in one retainer, both conven-
ient for office use and ready for transportation and re-
sterilization at a moment's notice; so that, instead of
using gauze from one or more different packages, silk
from another, drainage tubes from another, cotton from
the roll, and bandages from the bottom of a dirty
satchel, etc., they are ail from one clean, reliable
source, absolutely to be depended upon.
288
MEDICAL RECORD.
[August 22. i8g6
Therefore, with sterile dressings, gowns, and towels,
boiled instruments, sterile hands, and a clean wound
site, no man need fear to make a wound within the
range of his ability. And let me here add that if we
take away the fear of sepsis our general practitioners
will be less loth to cut. My obser\'ation of this class
of men has been that they usually know when and how
to operate, but that the complex and complicated time-
robbing methods of preparation, together with their
uncertain results, cause them oftentimes to refer their
cases to others. At the present day, with the present
state of our knowledge, there should not be a hamlet
or crossroads where accidental and surgical wounds
are not treated aseptically. To simplify and render
easy such an attainment is a service to our fellows and
a blessing to mankind.
ptecUcat Stcttxs.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending August 15, 1896:
Deaths.
Tuberculosis
Typhoid fever
Scarlet (ever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-po.\
Vaginal Irrigation without Wetting of Clothes.
— A. E. Bradley, Captain, Medical Department, U. S.
A., now at Fort Yellowstone, \Vy., writes:
" One occasionally meets with a new method of ac-
complishing some certain end; it comes often as a
surprise and is so simple that one wonders it had not
occurred to him before. It may be that the surprise I
received recently is not, to many, a new method of ac-
complishing vaginal irrigation, but it was to me.
■' In obtaining a history the following conversation
occurred :
"'Do you use, or have you ever used, hot-water
douches?'
"' Oh, yes; but I thought they only helped me for a
time.'
'" Did you take them lying down?'
" ' Yes. I used a bed pan formerly, but I always got
my clothes wet and the bed too, so that it was a per-
fect nuisance. But after I used a hammock it went
better.'
"' A hammock!'
" ' Yes. I hung the hammock in my bedroom, got my
fountain syringe ready, placed a tub under the ham-
mock ; then I lay down, and could use all the water I
wanted without getting anything wet. You know the
water will run right through hammock meshes.'
'"Who told you how to do this?'
"' No one; I thought it out myself.'
" I refrain from comment. This method has advan-
tages appreciated by my patient at least."
Henry Dunant, founder of the Geneva Convention
and the Red Cross, his life work, and the part taken
by women in this work, was the title of an address
delivered by Dr. Jordy before the Berne Good Samari-
tan Union, November 24, 1895. We are told that
Dunant came of a good Geneva family; like all noble
men he owed much to a superior mother. At the bat-
tle of Solferino, in 1859, he distinguished himself in
the care of the wounded, and through his little book,
•• Un Souvenir de Solferino," interested Queen Au-
gusta of Prussia, the Empress Eugenie, and other high
personages, and finally succeeded in getting together
the Geneva Conference of 1864 and in founding the
Society of the Red Cross, the members of which care
for the injured, more particularly in times of war, but
also in times of peace, and are recognized as non-
belligerents by the several nations who have adopted
the rules of the convention. Dr. Jordy thinks George
Sand's desire to credit Arrault, a Frenchman, with
being the originator of the Geneva Convention is due
to chauvinism. While a number of persons had sug-
gested the idea of recognizing the wounded in battle
as neutrals, he thinks there cannot be the least doubt
that Dunant's work and writings first led to practical
results and finally to the Geneva Convention. In
1867 Dunant had the misfortune to lose his own prop-
erty and that of relatives in some venture in Algiers,
and he is now living in obscurity and poverty.
Advice to Bicyclists. — Dr. Rocheblave gives the
following advice; i. No one should ride until after
an e.xamination by a physician. This examination
should be made both before and after a walk or run,
for some cardiac lesions manifest themselves only
after a state of fatigue. 2. Ride no faster than twelve
kilometres an hour. 3. As far as possible guard against
the desire to ride any faster. It is very difficult not
to give way to the "delirium of swiftness." With a
light machine on a good road an amateur may easily
make twenty-five kilometres an hour. This is too
much, for the pulse is increased to 150, even at four-
teen and sixteen kilometres an hour. — Pacific Medical
Journal.
Pure Milk for Brooklyn. — Health Commissioner
P^mery has appointed a dairy inspector, whose duty
will be to investigate the sources of the entire milk
supply of Brooklyn. He is charged with the duty of
examining the cow stables, the number of animals
therein, their sanitary condition, the water they drink,
and the drainage of the stables. If in his opinion any
feature of any of the dairies is unsatisfactory, he has
power to prohibit the sale in Brooklyn of the milk
from that establishment.
Venereal Disease a Sufficient Cause for Divorce.
— The Paris Court of Appeals recently decided that
the fact of marrying before being cured of a venereal
disease and knowingly communicating it to the other
party in the marriage, is sufficient cause alone to allow
a divorce. — Scmaine mc'd.
The Bicycle should be prohibited to women during
menstruation.
While the Medical Record is pleased to receive all new publi-
cations which may be sent to it, and an acknowledgment will be
promptly made of their receipt under this heading, it must be iviti
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it which in the judgment of its editor will not be
of interest to its readers.
Sterility. By Robert Bell, M.D. 8vo, 88 pages. Illus-
trated. I'. Blakiston, Son & Co., Philadelphia, Pa. Price, $1.75.
Tra.nsactions of the American Association of Obste-
tricians A.ND Gyn.«cologists. Volume VIII., for the year
1895. 8vo, 404 pages. Illustrated.
A System of Medicine by Many Writers. Edited by
Thomas Clifford .Mbutt, M.D. Volume I. 8vo, 978 pages.
Macmillan & Co., New York. Price, $5.00.
A Treatise on Appendicitis. By John B. Deaver, M.D.
8vo, 168 pages. Illustrated. P. Blakiston, Son & Co., Phila-
delphia, Pa.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 50, No. 9.
Whole No. 1347.
New York, August 29, 1896.
$5.00 Per Annum.
Single Copies, loc.
SOME STUDIES OF THE BLOOD IN THY-
ROID FEEDING IN INSANITY.
By MIDDLETON L. PERRY, M.D.,
MORRIS PLAINS, N. J.,
ASSISTANT PHYSICIAN AT THE NEW JERSEY STATE HOSPITAL.
That decided changes in the mental state maybe pro-
duced by thyroid feeding is now a well-recognized fact.
This has been demonstrated in numerous cases of myx-
oedema and cretinism which have made marked im-
provement under continued treatment with this drug.
Recently there has been a number of cases of insanity
reported as improved, and some have gone on to com-
plete recovery on a similar line of treatment.
In the first class of cases (my.\oedema and cretinism)
the treatment by the administration of some prepara-
tion of the thyroid gland is entirely rational. The
gland in the patient is either defective or absent, and
it is simply sought to restore to the system some prin-
ciple which it has lost thereby, and which is essential
to health. But the use of this remedial agent in men-
tal diseases in patients who have apparently healthy
thyroid bodies is as yet entirely empirical. Several
theories have ' been advocated as to the manner in
which the drug probably acts, but as yet very little has
been done toward placing this form of treatment on a
scientific basis. So good an authority as H. C. Wood,
in a recent lecture on animal extracts, delivered at the
University of Pennsylvania,' merely says on this sub-
ject: "Thyroid extract is sometimes useful in melan-
cholia, but how it acts we do not know."
The object of the work reported below has been to
endeavor to throw some light upon the physiological
action of this agent. If the result has been such that
it will induce others to pursue the subject further, that
facts may be established which will place this method
of treatment on a more rational basis, the writer will
feel that his work has not been in vain.
The present paper is a report of a study of the blood
in a number of cases before and during a course of
treatment with thyroid. I have made no attempt at
a chemical analysis, but have restricted my observa-
tions to the numerical and morphological aspect of the
corpuscles. And in consideration of the fact that the
function of the red blood cell is largely, if not wholly,
as an oxygen bearer, I have devoted the most of my at-
tention to the leucocytes.
The only reported study of the leucocytes in thyroid
feeding with which I am acquainted is a report of a
case of infantile myxoedema by M. Labraton." In this
case the author makes only two examinations in a pe-
riod of time covering more than a year. This is far
too small a number of observations to establish any
facts in the case.
The method which I have pursued in making the
examinations is as follows: The number of red and
white blood corpuscles in a cubic millimetre of blood
was first determined by the Zeiss-Thoma apparatus.
' University Medical Magazine, April, 1896.
' Gazette Medicale de Paris, January 19, 1895.
It has been my aim to obtain as nearly accurate results
as possible. To do this I have in all cases used a di-
lution of I to 200 for the red corpuscles and counted
the number of cells in one hundred squares; for the
white cells a dilution of i to 20 was used, and the en-
tire number in the four hundred squares was counted.
Frequently several counts would be made at one ex-
amination and the average taken as the result. By
reference to Abbey's table of probable errors in count-
ing the blood corpuscles, it will be seen that by the
above method the greatest probable error would be
less than two per cent. To avoid error from digestion
leucocytosis and to insure a similar condition in each
case, the counts were all made between eleven and
twelve o'clock, and several hours after a meal.
A differential count of five hundred leucocytes was
then made. The films of blood on a cover glass, be-
ing dried, were fixed in absolute alcohol from two to
five minutes and subjected to a contrast stain. The
staining fluid used in the beginning was the triple stain
of Ehrlich, but this was discontinued for one of hse-
mato.xylin, orange, and fuchsin, which has been much
more satisfactor)'. The formula used is:
Hsematoxylin, Delafield's sol gtt. viij.
Orange G, ^ sat. aqueous sol gtt. x.
Fuchsin S (after Weigert), Yz sat. aqueous
sol gtt. i.
Water cc. -xv.
The covers are passed immediately from the alcohol
into this fluid and allowed to remain fifteen minutes,
washed in water, and mounted in balsam. The stain
should be fresh, as it soon deteriorates. Owing to the
varying strength of hematoxylin, slight modifications
of the above formula are at times necessary to obtain
the best results.
I have followed Ehrlich's classification of the differ-
ent varieties of white corpuscles into: i, small mono-
nuclear, or lymphocytes; 2, large mononuclear, in-
cluding the transitional forms; 3, multinuclear neu-
trophiles; 4, eosinophiles. He gives the relative
number of each variety in normal blood as: Small
mononuclear, i^ to 25 per cent.; large mononuclear,
6 per cent.; multinuclear, 70 to 75 per cent.; eosino-
philes, I to 5 per cent.
Some recent authorities are inclined to give the
percentage of lymphocytes somewhat higher and the
multinuclear form slightly less than the above, and this
has been my own observation. Dr. Walter A. ^^'ells,
in an article in the Medical A'cws of March 14, 1896,
places the normal number of lymphocytes as high even
as twenty-eight per cent.
In each of the cases given below one or more counts,
both numerical and difi'erential, were made preliminar}-
to the course of thyroid, and during the treatment, gen-
erally lasting from a week to ten days, a count was
made every second or third day.
Case I. — M. M , female, aged thirty-four. A
case of mania of puerperal origin and nearly one year's
duration. Emotional state decidedly exalted. Physi-
cal condition very good. Temperature, 99.2" F. : pulse,
65. Patient was put to bed and two blood counts
were made on different days, and the average was taken
to establish a preliminary count, which was: R. B. C,
4,832,000; W. B. C, 11,000. Differential count:
290
MEDICAL RECORD.
[August 29, 1896
Small mononuclear, 18.4 per cent. ; large mononuclear,
9 per cent.; multinuclear, 70 per cent.; eosinophiles,
2.6 per cent.. She was then put on thyroid extract, ten
grains three times a day. The extract was of such
strength that fifteen grains represented one sheep's
thyroid.
Second day of treatment: Mental condition un-
changed. Pulse, 95; temperature, 99.2° F. Blood
count: R. B. C, 6,272,000; W. B. C, 9,000. Differ-
ential count: Small mononuclear, 17.2 per cent.;
large mononuclear, 8.2 percent.; multinuclear, 74.2
per cent.; eosinophiles, 0.4 per cent.
Fourth day: Pulse quickened; skin flushed; tem-
perature, 99.6° F. General condition good. Mentally
e.icalted. Thyroid extract increased to forty grains a
day. Differential count: Small mononuclear, 25 per
cent.; large mononuclear, 8.8 per cent. ; multinuclear,
64.6 per cent.; eosinophiles, 1.6 per cent.
Seventh day: Patient quiet, but still mildly exalted.
Pulse, 106, somewhat irregular; temperature, 99^ F.
Taking thyroid extract, fifty grains a day. Blood
count: R. B. C, 4,520,000; W. B. C, 5,200. Differ-
ential count: Small mononuclear, 37.6 per cent.;
large mononuclear, 11.6 per cent.; multinuclear, 50
per cent. ; eosinophiles, 0.8 per cent.
Ninth day: Twenty-four hours after thyroid was
discontinued the patient was still decidedly impressed
with the drug. Pulse, 105 ; temperature, 99 F. Much
more quiet. Differential count: Small mononuclear,
26.6 per cent. ; large mononuclear, 12 per cent. ; multi-
nuclear, 60.4 per cent.; eosinophiles, 1 per cent.
A note made five days later states that she was more
quiet and rational than for months past. Patient con-
tinued to improve with an occasional period of a few
hours' excitement, and made a complete recovery.
Case II. — S. A , male, aged forty. A case of
mania of six months' duration. Emotional state ex-
alted. Talk rambling and disconnected. Has had
double hsematoma auris. Physical condition very good.
Temperature, 98° F. ; pulse, 65. Preliminary blood
count; R. B. C, 5,616,000; W. B. C, 8,600. Differ-
ential count. Small mononuclear, 31 percent.; large
mononuclear, 6.8 per cent.; multinuclear, 61.4 per
cent; eosinophiles, 0.8 per cent. He was then put on
thyroid extract, thirty grains, the equivalent of two
sheep's thyroids, a day.
TRird day of treatment: No change whatever men-
tally. Temperature, 98.6° F. ; pulse, 75. Thyroid
increased to thirty-six grains a day. Differential
count: Small mononuclear, 32.6 percent.; large mo-
nonuclear, 5 per cent; multinuclear, 59.8 per cent.;
eosinophiles, 2.6 per cent.
Fifth day: Patient decidedly impressed by the drug,
of which he is taking forty-five grains a day. Pulse,
84; temperature, normal. Mental state decidedly ex-
alted; talking constantly. Blood count: R. B. C,
5,440,000; \V. B. C, 9,200. Differential count:
Small mononuclear, 45.6 per cent. ; large mononuclear,
6.6 per cent.; multinuclear, 45.8 per cent.; eosino-
philes, 2 per cent.
Seventh day: Somewhat more quiet, but still mania-
cal. Pulse, 85, tension ver)' much diminished; tem-
perature, 98.2° F. Taking thyroid, fifty grains a day.
Differential count: Small mononuclear, 43 percent.;
large mononuclear, 6.4 per cent.; multinuclear, 50.2
per cent. ; eosinophiles, 0.4 per cent.
Eleventh day : Patient markedly under the influence
of the drug. Pulse, 102, and quite characteristic;
temperature, 98.4° F. He is quiet and his facial ex-
pression is much brighter. Thyroid has been dimin-
ished to thirty-six grains a day. Differential count:
Small mononuclear, 34.6 per cent.; large mononu-
clear, 10.2 per cent. ; multinuclear, 54 per cent. ; eosin-
ophiles, 1.2 per cent.
Eighteen hours after last dose of thyroid : Patient
quiet but rather disconnected in his talk. Tempera-
ture, normal; pulse, 96. Blood count: R. B. C,
4,368,000; W. B. C, 5,200. Differential count : Small
mononuclear, 37.2 per cent.; large mononuclear, 7.2
per cent; multinuclear, 53.4 per cent.; eosinophiles,
2.2 per cent.
Five days after treatment was discontinued there
was a very decided change in his mental condition.
Emotional state entirely normal. An extract from the
case records says he was ver}- much better and talked
quite rationally. He took a lively interest in things
about him and read the newspapers, something he had
not done for a long time before. Blood count : R. B.
C, 5,136,000; W. B. C, 6,800. Differential count:
Small mononuclear, 45.6 percent.; large mononu-
clear, 7.2 per cent.; multinuclear, 45 per cent;
eosinophiles, 2.2 per cent. The change in the mental
state and the improvement noted above, while quite
pronounced, was of only a few days' duration, when
the patient relapsed into a maniacal condition, very
similar to that before the course of treatment was be-
-, female, aged thirty. Case of
gun.
Case III.— K. S-
simple melancholia of five and one-half months' stand-
ing, this being the second attack. Some improvement
had been made, but it was slow and her mental state
had been unchanged for some time past. Mildly de-
pressed. General health good. Pulse, 60 ; tempera-
ture, 98.2° F. Average of blood counts made on
three successive days preliminary to treatment: R. B.
C, 4,832,000; W. B. C, 8,800. Differential count:
Small mononuclear, 25 per cent; large mononuclear,
8.4 per cent. ; multinuclear, 63 per cent. ; eosinophiles,
3.6 per cent. Desiccated thyroid, twelve grains of
which represented one sheep's thyroid, was given in
doses of ten grains three times a day.
Fourth day of treatment: No change mentally.
Temperature, 99.6° F. ; pulse, 98, rather quick. Com-
plains of pain in the extremities. Thyroid has been
increased to forty grains a day. Differential count:
Small mononuclear, 35.2 per cent. ; large mononuclear,
1 1.6 per cent.; multinuclear, 48.8 per cent; eosino-
philes, 4.4 per cent.
Fifth day: Mental condition remains unchanged.
Temperature, 99.4" F. ; pulse, 112. Complains of
pain in the extremities. Rather restless at times.
Quite well under the influence of thyroid, of which she
is taking forty grains a day. Blood count: R. B. C,
5,656,000; W. B. C, 8,000. Differential count:
Small mononuclear, 37.6 per cent. ; large mononuclear,
12 per cent.; multinuclear, 45.2 per cent.; eosino-
philes, 5.2 per cent.
Sixth day: General condition same as on day pre-
vious. Temperature, 99.4"' F. ; pulse, 128, weak and
compressible. Thyroid has been increased to fifty
grains a day. Differential count : Small mononuclear,
36 per cent.; large mononuclear, 12.2 per cent.; mul-
tinuclear, 46.4 per cent.; eosinophiles, 5.4 per cent.
Ninth day: No appreciable change in the mental
condition. Still mildly depressed. Temperature,
99.2' F. ; pulse, 125, weak, tension low. Thyroid
was discontinued to-day. Blood count: R. B. C,
6,464,000; W. B. C, 6,000. Differential count:
Small mononuclear, 34.4 per cent; large mononu-
clear, 12.6 per cent.; multinuclear, 48.6 per cent.;
eosinophiles, 4.4 per cent.
The patient's mental condition appeared to be in no
wise affected by the course of treatment. The symp-
toms produced, however, were quite characteristic of
the drug. It is of interest to note that the range of
teni])erature in this case was much above the average
noted in the other cases.
Case IV. — P. B , female, aged forty-nine. A
case of chronic melancholia of four years' duration,
having the appearance of partial dementia. She was
August 29, 1896]
MEDICAL RECORD.
291
quite dull, rarely ever speaking or taking any notice
of anything. General health poor. Temperature,
normal; pulse, 100. Physical examination revealed a
well-marked insufficiency of the mitral valve. Prelim-
inary blood count: R. B. C, 5,432,000; W. B. C,
8,200. Differential count: Small mononuclear, 10.8
per cent.; large mononuclear, 3.6 per cent.; multinu-
clear, 79.2 per cent.; eosinophiles, 6.4 per cent. Pa-
tient was put on desiccated thyroid, thirty grains a
day, which was increased to forty grains on the second
day.
Third day of treatment: No change whatever men-
tally. She is getting well under the influence of thy-
roid, of which forty grains are given a day. Temper-
ature, 99° F. ; skin flushed and moist; pulse, 105.
Differential count : Small mononuclear, 20.2 per cent. ;
large mononuclear, 4 per cent. ; multinuclear, 70.8 per
cent.; eosinophiles, 5 percent.
Sixth day: Taking forty grains a day. No marked
change in mental state. Seems a little more irritable
and talks more. Is thoroughly under the intiuence of
the drug. Pulse, 120, weak and rapid; temperature,
99.2^ F. Skin moist. Blood count: R. B. C, 5,312,-
000; W. B. C, 8,800. Differential count: Small
mononuclear, 15.4 per cent.; large mononuclear, 4.2
per cent.; multinuclear, 79.2 per cent.; eosinophiles,
1.2 per cent
Ninth day: Still taking thyroid, forty grains a day.
Temperature, 99.8 F. ; pulse, 132; tension vervMiiuch
diminished. No change in the mental state; still dull
and stupid. Blood count: R. B. C, 5,288,000; VV.
B. C, 7,200. Differential count: Small mononu-
clear, 17 per cent.; large mononuclear, 7 per cent.;
multinuclear, 75 percent.; eosinophiles, i percent.
A short time after the treatment was discontinued
there was seen to be a very marked change in the
mental condition of the patient. She began to take
much more interest in her surroundings; would talk
more, and her will power, which had been almost en-
tirely abolished, began to reassert itself. There was
no change of any consequence in her reasoning pow-
ers, however, and she soon drifted back into her appar-
ently hopeless state.
Case V. — P. V , male, aged thirty. Had been
insane three months. Emotional state very much ex-
alted. Talks constantly in a disconnected manner.
Has a general feeling of well-being. Physical condi-
tion fairly good. Temperature, normal; pulse, 85.
Secretions appear to be normal. Preliminary blood
count: R. B. C, 5,104,000; W. B.C., 11,100. Differ-
ential count: Small mononuclear, 17.2 per cent.;
large mononuclear, 5 per cent.; multinuclear, 77.2 per
cent.; eosinophiles, 0.6 per cent.
Thyroid extract, thirty grains, was given on the first
day. It was increased to thirty-five grains on the
second, and on the third day forty grains were given.
Third day of treatment: Somewhat more maniacal
and quite irritable. Skin moist and flushed. Tem-
perature reached 100.2° F. in the afternoon; pulse,
100. Blood count: R. B. C, 5,048,000; W. B. C,
4,400. Differential count: Small mononuclear, 29.6
percent.; large mononuclear, 5.8 per cent. ; multinu-
clear, 64.4 per cent.; eosinophiles, 0.2 per cent.
Fifth day : Patient more quiet but very emotional.
Influence of thyroid on blood pressure quite apparent.
Pulse, 102; temperature, 99.8° F. He is taking thy-
roid extract, forty-five grains a day. Differential
count: Small mononuclear, 29.4 per cent.; large mo-
nonuclear, 5.8 per cent.; multinuclear, 64 per cent.;
eosinophiles, 0.8 per cent.
Seventh day: Thoroughly impressed with the drug
and apparently quite sick. Temperature same as on
previous day: pulse, no. Still rambling and discon-
nected in his talk. Blood count: R. B. C, 5,988,000;
W. B. C, 6,600. Differential count: Small mono-
nuclear, 29.6 per cent.; large mononuclear, 5.6 per
cent.; multinuclear, 63 per cent.; eosinophiles, 1.8
per cent.
Tenth day, fifteen hours after last dose of thyroid :
Spent a comfortable night and is much more quiet this
morning. Effect of the drug is still marked on the
pulse. He has lost considerable flesh, although his
appetite has been good. Blood count: R. B. C, 5,-
376,000; W. B. C, 5,800. Differential count: Small
mononuclear, 27.2 per cent.; large mononuclear, 7.4
per cent. ; multinuclear, 63.8 per cent. ; eosinophiles,
1.6 per cent.
Ten days later the patient has improved very
much physically and has about regained his former
weight. There is also a very apparent change in his
mental condition; he is much more quiet and his emo-
tional state is only slightly exalted. Is still quite de-
lusional, however, and incapable of reasoning. It
was decided to give him another course of treatment
similar to the first. He was accordingly put to bed
again and another preliminary blood count made,
which gave the following result : R. B. C, 5,368,000;
\V. B. C, 7,800. Differential count: Small mono-
nuclear, 26.8 per cent. ; large mononuclear, 6 per
cent.; multinuclear, 66.4 per cent.; eosinophiles, 0.8
per cent. Patient put on thyroid extract again, thirty
grains a day.
Third day of second course of treatment: Took
thyroid, sixty grains. Pulse, 120; temperature, 99 F.
No marked change mentally. Blood count: R. B.
C, 5,338,000 ; \V. B. C, 6,000. Differential count:
Small mononuclear, 26.8 per cent.; large mononu-
clear, 7.4 per cent.; multinuclear, 65.4 per cent.;
eosinophiles, 0.4 per cent.
Sixth day: Thyroid extract, sixty grains a day, is
continued, and the patient is thoroughly under its
influence. Temperature, 99.2° F. ; pulse, 124, weak,
and tension decidedly diminished. He is quiet but
mildly exalted. Differential count: Small mononu-
clear, 26 per cent.; large mononuclear, 8.4 per cent.;
multinuclear, 65.2 per cent.; eosinophiles, 0.4 per
cent.
Eighth day : Treatment was discontinued. He has
lost several pounds in weight and is quite weak.
Continues to be quiet. Blood count: R. B. C, 5,296, -
000; W. B. C, 7,000. Differential count: Small mo-
nonuclear, 30.6 per cent. ; large mononuclear. 9.8 per
cent.; multinuclear, 58.8 per cent.; eosinophiles, 0.8
per cent.
Patient soon regained what he had lost physically.
The improvement in his mental condition was contin-
uous and very rapid. A note on the case made two
weeks later says: "He now talks rationally and en-
gages readily in conversation. Is no longer noisy and
incoherent. Talks rationally on all subjects, and
spends considerable of his time reading and seems to
appreciate w hat he reads. He now sits- up most of the
day, but his pulse is still very rapid and not strong."
Recovery was complete and has been permanent.
For the sake of brevity in the remaining cases only
the preliminary count and another when well under
the influence of the drug will be given. The numer-
ical count of the red and white corpuscles is omitted
in some cases where it was of no especial interest.
Case V^I. — I. H , female, aged thirty-one.
Chronic melancholia of a mild type, complicated with
hysteria and hypochondria. Had been insane two
years. Preliminary count: Small mononuclear, ^j^
percent.; large mononuclear, 4.4 per cent.; multi-
nuclear, 59.4 per cent.; eosinophiles, 3.2 per cent.
Large doses of thyroid extract were given and pushed
until at the end of the fourth day the pulse was so fee-
ble and rapid that it could hardly be counted. Pa-
tient complained of severe pains in various parts of
the body, and could with difficulty be kept in bed.
292
MEDICAL RECORD.
[August 29, 1896
This case was much more thoroughly impressed by
the treatment than any of the others. Treatment had
to be discontinued at the end of the fourth day. A
differential count made then gave the following in-
teresting result: Small mononuclear, 55.4 per cent.;
large mononuclear, 9.2 per cent.; multinuclear, 34.6
per cent.; eosinophiles, 0.8 per cent.
The result in this case was entirely negative.
Case VII. — J. G , male, aged sixty-two.
Chronic melancholia of sixteen months' duration.
Preliminary count: R. B. C, 5,008,000; W. B. C,
7,200. Differential count: Small mononuclear, 27.4
per cent. ; large mononuclear, 9.2 per cent. ; multinu-
clear, 55.4 per cent.; eosinophiles, 8 per cent.
Thyroid was pushed until a very decided effect was
produced. Temperature at one time reached 100.4*^ F.
A count made while patient was well under treatment
gave: R. B. C, 5,240,000; W. B. C, 8,600. Differ-
ential count: Small mononuclear, 32.6 per cent. ; large
mononuclear, 16.8 per cent.; multinuclear, 47.2 per
cent.; eosinophiles, 3.4.
No change was observed in his mental condition
when treatment was discontinued, nor for several
weeks thereafter. About one month after the course
of thyroid he began to improve and clear up rapidly,
and was discharged as recovered. Some doubt exists,
however, as to whether or not his improvement was
the result of -the course of treatment, as recovery in
his case was quite different from the others.
C..\SE VIII. — E. W , female, aged twenty. A
mild type of mania of thirteen months' standing. Pre-
liminary count: Small mononuclear, 24 per cent.;
large mononuclear, 14 per cent.; multinuclear, 61 per
cent. ; eosinophiles, i per cent.
Differential count made on the seventh day of treat-
ment: Small mononuclear, 31.2 percent.; large mo-
nonuclear, 9.6 per cent.; multinuclear, 58.2 per cent.;
eosinophiles, i per cent.
There was apparently no change whatever produced
in her mental state.
Case IX. — E. M — — , male, aged eighteen. A case
of insanity of pubescence of eighteen months' duration.
Preliminary count: Small mononuclear, 38.2 per cent.;
large mononuclear, 6 per cent. ; multinuclear, 54.4 per
cent.; eosinophiles, 1.4 per cent.
Differential count made on the eighth day of treat-
ment, when the patient was very thoroughly impressed
with thyroid, resulted as follows: Small mononuclear,
5 1.6 per cent. ; large mononuclear, 9.4 per cent. ; mul-
tinuclear, 36.8 per cent.; eosinophiles, 2.2 per cent.
Result entirely negative, no change being produced.
Case X. — C. C , male, aged thirty. A case of
paresis in the first stage. Duration of disease, about
four and one-half months. Symptoms well marked.
Preliminary count: Small mononuclear, 19.8 per cent. ;
large mononuclear, 11.5 percent.; multinuclear, 66.7
per cent.; eosihophiles, 2 per cent.
On the sixth day, when the effect of the treatment
was very marked, a count was made, as follows: Small
mononuclear, 28.2 percent.; large mononuclear, 14.8
per cent. ; multinuclear, 54.8 per cent. ; eosinophiles,
2.2 per cent.
There was quite an apparent change in the patient's
mental state when the thyroid was discontinued. He
continued to improve until in the course of a few
weeks he had lost delusions and talked rationally.
Although four months have now elapsed since he was
taken off treatment, there has been no return of his
mental symptoms. Many of the physical signs of his
disease have also disappeared. He is evidently en-
joying a period of remission, such as is sometimes
found in cases of paresis. This condition was un-
doubtedly produced by the course of thyroid.
From the examination made of these cases, as well
as others, the study of which was more or less incom-
plete and therefore not reported, it appears that the
number of red blood corpuscles is not materially
affected by the administration of thyroid. In the
stained specimens there is no deviation in the appear-
ance of these cells from the normal.
There is also to be found no decided, constant, or
characteristic change produced in the total number of
white blood cells by the administration of this drug.
In some cases the leucocytes are found to be increased,
in others diminished in number, and my observation
has been that the latter condition occurs more often.
In no case have I seen anything approaching a leuco-
cytosis nor any marked increase in the number of
white corpuscles.
In the differential count, however, we see a very de-
cided change produced in the relative number of the
different varieties of leucocytes during a course of thy-
roid feeding. This change consists in the increase of
the percentage of the small mononuclear cells or lym-
phocytes, and a corresponding diminution in the mul-
tinuclear neutrophiles. By referring to the above ta-
bles, it will be seen that this condition exists in every
case. It will also be seen that the increase in the
lymphocytes bears a fairly regular ratio to the in-
crease in the dose of the drug. It is quite reasonable
to suppose, therefore, that this condition is a result
produced by the administration of thyroid. This
effect begins to be apparent on about the third day
from the beginning of the course of treatment, and
continues several days after it has been discontinued.
It is in the small mononuclear variety of lympho-
cytes that we see the only change in the appearance
of the leucocytes in stained specimens. The lympho-
cytes in a specimen of blood taken from a patient
thoroughly under the influence of thyroid extract are
found to be much smaller, and the nucleus beccome
stained more deeply than in a specimen taken from the
same patient before treatment. This difference may
be assumed to be the indication of the difference of the
age of the cells. Uskow, of St. Petersburg, as the re-
sult of a prolonged and very close study of the blood,
comes to the conclusion that the small lymphocytes
with deeply stained nuclei are the youngest elements
in the blood. This being the case, we are forced to
the conclusion that the drug acts as a direct stimulant
to tho.se tissues of the body whose function is the
production of the lymphocytes, namely, the lymphatic
or adenoid tissues.
The blood of a patient who is taking large doses of
thyroid extract also appears to undergo some chemical
change. This is manifested by the very much more
tardy manner in which the blood flows from a prick in
the skin, making it at times difficult to obtain enough
to fill the tubes of the hematocytometer without mak-
ing quite a large puncture. The blood also coagu-
lates more readily than under ordinary circumstances.
What the nature of this chemical change is I cannot
say, for, as previously stated, I have attempted no
chemical analysis.
Now, let us see what bearing these cases may have
upon the various theories advanced to account for the
action of thyroid in' mental disease.
Some writers upon the subject of thyroid therapy
have advanced the idea that the good results obtained
by it might be explained by the tonic line of treat-
ment, with an increased appetite, more nourishing
diet, etc., following the course of treatment. That
this theory is entirely illogical and insufficient to ex-
plain the results obtained, will be apparent to all
whan we consider that the most decided improvement
is often seen during the administration of the drug
and before the tonics have been given. It has been
so with some of my own cases.
Bruce, in his excellent article on this subject in the
Journal of Mental Science iox January, 1895, is inclined
August 29, 1896]
MEDICAL RECORD.
293
to the opinion that it acts by producing a febrile state
with its resulting reaction. I very much doubt that
this is the true explanation; and, in fact, his paper
itself would contradict the theory, for some of his pa-
tients made decided improvement in whom there had
been a very slight if any rise of temperature. The
highest temperature reported as due to thyroid feeding
is no very marked deviation from the normal.
In Case I. it will be seen that the highest tempera-
ture recorded 1599.6" F., w^liile the temperature before
the patient w'as put on treatment was 99.2" F., an in-
crease of less than o.^"^, and yet she began to improve
immediately and made a rapid recovery.
In Case III. the temperature was normal at the pre-
liminary examination, and registered 99.6° F. on the
fourth day of treatment. In this patient there was ab-
solutely no change in her mental state. The other
cases will also show a similar lack of ra»io between
the increase of temperature and the mental change
produced.
If the improvement noted in cases of insanity treated
with thyroid extract is due simply to the febrile state
produced, then why do we not have an equally high
percentage of recoveries following intercurrent disease
accompanied by high temperature? That such recov-
eries do occasionally occur is an undisputed fact, but,
compared with the whole number of febrile diseases
occurring among the insane, they can be considered
only as interesting phenomena.
\n. \he. Journal of Alcntal Science, iox October, 189 1;,
Dr. Bruce reports sixty additional cases treated with
thyroid. As a result of this work, he, while still ad-
hering to the theory advanced in his first paper, comes
to the further conclusions that thyroid is a direct cere-
bral stimulant and that the ingested thyroid supplies
some material to the body which the gland is supply-
ing in deficient quantities.
That this drug is a cerebral stimulant, direct or in-
direct, would certainly appear from its awakening the
higher cerebral centres to functional activity in some
cases of dementia in which the intellectual powers had
been dormant for a long period of time.
That thyroid supplies some principle to the blood
and thereby to the body is the most plausible explana-
tion of its action. The cases cited show that it has a
constant and decided effect upon the corpuscular ele-
ments of the blood by a stimulating action on the ade-
noid tissues. I am led to believe that it is by this
action on the adenoid tissues that some principle is
added to the organism which is being supplied in a
deficient amount. It has been my observation that
those patients do best on thyroid whose preliminary
blood counts show a low percentage of lymphocytes.
In Cases I. and V., in which recovery was complete
and undoubtedly due to thyroid, it will be seen that the
preliminary counts of lymphocytes were 18.4 per cent.
and 17 per cent., respectively. Case X., which made
the most marked improvement of any that did not en-
tirely recover, had 19.8 per cent, of lymphocytes on
preliminary count. The lowest percentage of lympho-
cytes found in any case before treatment was in Case
IV., which had only 10.8 per cent. This patient, as
will be seen, was partially demented, but still showed
a decided mental change under treatment.
On the other hand, in Cases III., VI., VIII., and
IX., whose preliminary counts of lymphocytes were
respectively 24, },},, 24, and 38.2 per cent., absolutely
no change was produced in their mental condition.
From these facts it is very plausible to suppose that
in some forms of insanity there is a sluggish action of
some of the tissues intimately connected with the
function of haematosi-s, which tissues, being stimulated
by a vigorous course of thyroid, elaborate and turn
into the circulation some principle which has a bene-
ficial action on the cerebral cortex.
While I thoroughly appreciate the fact that the
number of cases studied has been too small to allow of
a positive statement of the effect of this remedial
agent, certain of the results obtained have occurred
with such uniformity in every case that I am led to
hope that by a more extended use and careful obser-
vation we may yet arrive at the true manner of its ac-
tion.
In conclusion, I wish to acknowledge the valuable
assistance of Dr. Thomas P. Prout, of the hospital
staff, in the study of these cases.
HYPNOTISM AND SUGGESTION, WITH A
CASE OF SPASMODIC STRICTURE OF THE
CESOPHAGUS.'
By S.\MUEL brothers, Pii.G., M.D.,
NEW YORK-,
ATTENDING PHYSICIAN TO THE COLUMBUS DISPENSARY.
In the following paper I use the terms hypnotism
and suggestion collectively, but I do so because I be-'
lieve it more practicable to speak of both together, since
psychological suggestion merges imperceptibly into
hypnotism and vice versa, and both probably affect
the same portions of the cerebral mass, although with
different degrees of intensity.
The words hypnotism and suggestion, in short, mean
nothing more nor less than the processes which make
a person believe what is not true, or what at the time
he does not believe is true. This hypnotic state is ex-
plained by the fact that once a person having been
made to think that he or she is asleep (for he may be-
lieve so when the eyes are not even shut), the phenom-
ena of ordinary sleep will continue the natural time,
during which the suggestions made will have profound
effects. This is corroborated by the fact that persons
can be hypnotized during natural sleep. Evidently,
then, if" we can prevent ourselves from shocking a
sleeping person to wakefulness, and if at the same
time we can induce the belief that we are the opera-
tors, the process is just the same. In natural sleep, a
person has no operator, no supreme controller; in hyp-
notism he has: this is the difference. I have had
subjects in the lethargic state who said after me
that a long wooden rod was a pen, who wrote on
my hand when I called it paper; and yet on open-
ing their eyes they said they knew it was not true, but
had to say so because I told them it was so. I have
often said to waking patients, "Go to sleep again,"
and they have immediately fallen into slumber.
Webster defines hypnotism as follows : " Sleep,
especially a kind of sleep or somnambulism said to
be produced by means of animal magnetism ; also a
similar condition produced in persons of very delicate
organizations, by gazing at a very bright object, as a
metallic ball highly polished and strongly illumi-
nated."
Dunglison defines it under "Animal Magnetism"
as " Mesmerism, Pathetism, Psycheism, Neurogamia,
Biogamia, Biomagnetismus, Zoomagnetismus, Exo-
neurism, Anthropomagnetismus, Gargale, Gargalismus,
Gargalus. Properties attributed to the influence of a
particular principle, which has been compared to that
which characterizes the magnet. It is supposed to be
transmitted from one person to another, and to impress
peculiar modifications on organic action, especially
on that of the nerves. The discussions to which this
strange belief has given rise are by no means termi-
nated [1868]. There is no evidence whatever of the
existence of such a fluid. Highly impressible persons
can be thrown into a kind of hysteria or magnetic sleep
and somnambulism, designated by Mr. Braid hypno-
' Read, in part, at a meeting of the Eastern Medical Society,
February 7, 1896.
294
MEDICAL RECORD.
[August 29, 1896
tism, neurohypnotism, and nervous sleep, and at times
called, after him, Braidism : but farther than this, the
efforts of the magnetizer cannot reach. It is a mode
of action upon the nerves through the medium of the
senses.''
Suggestion, separate from hypnotism, seems to have
received little notice in our medical literature. Dana
gives, as synonyms of hypnotism the terms trance,
artificial cerebral automatism, and electro-biology.
Gradle gives the additional synonyms, provoked
somnambulism and artificial trance, and he charac-
terizes it as a state interfering with or entirely suspend-
ing the free will and judgment, together with readi-
ness to obey the most unreasonable suggestions of
others. Its effects, he says, resemble catatonia, etc.,
but differ from them in being transitory. Dana says,
in defining hypnotism, that the state is one in which
the phenomena allied to those of perturbed sleep
(somnambulism) are e.xhibited, and considers it as a
morbid mental state characterized by (i) perversion
or suspension of consciousness; (2) abeyance of voli-
tion; (3) automatic response to commands or external
impressions; and (4) intense concentration of the
nervous force in some particular direction.
It seems to me that our whole lives must be ine.x-
tricably bound up with psychical auto-suggestion
(apart from hypnotism), since imitation seems to be
the basis of its effects, and our every action seems to
be the result of some impression, the outcome of cer-
tain imitative reminiscences.
What is the e.xact relation between the imitative
faculty and "suggestion".'' The child tries to imitate
its guardian and its surroundings; and yet an advice
or a command is followed or not, according as it
is pleasing or the reverse. The same may be said
of adults, although duty and civility modify the re-
sults. Has auto-suggestion anything to do with the
urinary or other secretions, with defecation, with co-
ition or with parturition? Is the attraction" of the
se.xes hypnotic in nature? The thoughts are certainly
concentrated in this condition. We might go further
and ask if all animals, all plants, including even the
single-celled animal or the bacterium — we might ask
if all these are subject to the same force! Are all
our actions the result of auto-suggestions? Is au-
tomatism unconscious suggestion ? Are our reflex
actions connected with hypnotism ? We dream during
sleep, and remember it after we awake. In the same
way, the hypnotized subject dreams of some things
which occur to him and not of others. Why should
some impulses reach the centres of consciousness and
memory and others not? We touch a hot stove and
draw our finger away by a reflex action ; then we first
become conscious of what has happened. Hut the
hypnotized subject does the same thing; tell him that
he is sitting on a red hot stove and he not only jumps
up, but he rubs himself! Is this merely automatic?
A young girl follows the mental commands of her
father to the letter, and yet not a word is spoken.
Can the hypnotic be educated in certain directions?
If an animal or a human being receives a great injury,
he becomes unconscious, and we say that he is suffer-
ing from shock : but very often we get the evidences
of so-called shock from a trivial injury, and even this
may result in death. Now, what relation has this
shock to mental suggestion? Has the subject's fright
or fear of the consequences, or have the abhorrent
actions of bystanders, brought on the condition? We
know that the sudden receipt of very bad news, or
similar circumstances, may throw a susceptible person
into a cataleptic condition. Can some of our " heart
failures" be attributed to the same cause? Can we
make a person die by hypnosis? We can kill an
animal by it!
A woman, even during (or after) the most difficult
version or instrumental delivery (with or without an
anaesthetic), rarely becomes profoundly shocked, and a
death from shock under such conditions is very-
rare.
In what way, again, do drugs act on the system?
Why is one drug a cerebral excitant and another a
depressant or hypnotic? How is it that sulphonal pro-
duces sleep on the second and even on the third day
after it has been taken ? Is there any hypnotic sugges-
tion in this?
Dana claims that the understanding of hypnotism
gives a key to all the cerebral automatic states. A
certain portion of the cerebral cortex, he says, re-
mains inactive during this process. This is caused
by transitory inhibition of these functions. A steady
monotonous impression is made on one of the senses
to the exclusion of the others. This dulls the percep-
tion of the rest; during battle wounds are frequently
not felt.
When an image is formed on one point of the ret-
ina, the sensibility of the other portions is reduced.
If we fix our eyes on a luminous point, the surround-
ing objects become invisible. Suggestions are acted
upon without the judgment based on the total evidence
of the senses and on the remembrances of past ex-
perience. (It is thus, by the suggestive power of a
lawyer, that a justice may be forced to take a wrong
view of a case before him.)
Any slight irritation produces general spasms in
strychnine poisoning, because the natural resistance
to the nervous connections is diminished in the
spinal cord. We must therefore infer that in hypno-
tism this resistance is increased and even blocked
entirely in certain directions, but the opposite may
also be made to occur.
Heidenhain and Bubnoff, on testing the galvanic
excitability of the cortical motor centres in the dog,
found it increased for a few seconds by every previous
stimulus, even when the latter was too feeble to excite
a muscular contraction. An electric stimulation of
insufficient strength could also be rendered eftectual
by any slight irritation in the region of the niu.scles
under the control of the centre experimented upon.
Thus the excitability of the motor centre of the fore-
leg could be distinctly raised by stroking the leg.
On the other hand, the cortical excitability could be
reduced in numerous ways. For instance, the con-
tracture sometimes following stimulation of the corre-
sponding centre could be checked by blosving on the
leg. In short, they found that the excitability of the
cortex was in anything but a stable condition, and
that it fluctuated in either direction from remarkably
slight causes.
The hypnotic anomalies of the motor system are
shown by the researches of Tschiriew and Momsen,
who have shown that the skeleton muscles are not in
any state of tonic contraction until a muscle or its
tendon is put on the stretch. When this occurs, as
by tension of the antagonistic muscles, a gentle reflex
tonic contraction is immediately produced. We get in
this way the tendon reflex, a sudden jerk. This is in-
creased often in the trance, show ing hyper-excitability,
and is also shown in the cataleptic condition. This ex-
alted sensibility of the spinal centres must be attrib-
uted to the influence of the cerebral centres upon them.
In the contractures the cortical motor centres are in-
volved, for Munk and others have shown that these
centres must be closely connected, if not identical
with, those presiding over the "'muscular sense," and
the ner\-es of this sense — the tendons, aponeuroses,
and other deep structures near the muscles, as well as
the probable sensory nerves of the muscles — are the
ones excited.
Locke, the poet, described the will as the '" power
to begin or forbear, continue or end the several actions
August
!9, 1896]
MEDICAL RECORD.
295
of our minds and motions of our body, barely by a
thought or preference of the mind."
Dana, in the " Reference Handbook of the Medical
Sciences," says that our reflexes may be classed as
follows: ((?) The simple reflexes of the spinal cord
and medulla. (/') The dexterities: riding, playing,
dancing, walking, playing on instruments and even
suckling at birth (which is acquired without prac-
tice), and we might add a great many others to
these; />., even lecturing becomes in a degree auto-
matic. These are called the machine-like (or automat-
ic) actions; the centres are located in the lower gan-
glia and hinder part of the brain. (<■) The third or
highest system of reflexes : ideation, perception, etc.
These include emotions of fear, etc., and ideas. Thus,
a single frightful sight may give rise to prolonged
feelings of terror.
In hypnotic conditions the entire phenomena are
reflex, undisturbed by the will ; these cause, no doubt,
changes in the vascularity of the brain, with rapid
breaking down of nerve tissue.
The peculiarity of hypnotism seems to be that, un-
like the normal state, when a suggestion may be fol-
lowed or not (according as it is received favorably
or unfavorably), in this state it must be followed
because the control of the will is absent. Patients
will sometimes hesitate before following a com-
mand, but this must be ascribed rather to igno-
rance than to resistance; and yet, in the first stage,
resistance is frequent. Can resistance be present in
the more profound states of hypnotism .' If a patient
vomits in spite of commands to the contrary, can this
be called resistance.'
I will now describe a case of spasmodic stricture of
the CESophagus, in which I tried the value of hypno-
tism. I must admit that the case is rather incomplete
in some respects, but as this complaint is not specially
noticed in our literature I undertake to describe it.
Before beginning, though, I would like to say that the
mass of my experiments have been on gynecologcial
cases.
On August 27th of last year, Mr. A. C , aged
thirty-one, called upon me with the following history:
He had been ailing three months; had been married
twelve years; no children; no specific history obtain-
able; said that his difficulty in deglutition became
more and more profound as time progressed. At first
he could eat solid food, but with difficulty; then he
could swallow only pasty food, then liquids only, and
finally even these were regurgitated. I failed to pass
even the finest semi-elastic urethral catheter (they were
the only ones at hand, but were made pliable in hot
water, the wire staffs being discarded). He said: "I
can take nothing since a long time but milk; any-
thing like meat or bread first goes down and then
comes up through my mouth and nose; sometimes
when the bread is very soft a small crumb goes down ;
when I begin to swallow water it goes out again
through the mouth and nose; and I have no appetite
to eat."
This looked a little like hysteria, but still the pre-
vious history seemed to point clearly to an organic
stricture of some kind. I made another attempt to
pass a catheter, but failed even with a No. 9. The
throat seemed to be very sensitive, and he gagged and
vomited with each effort. He succeeded in swallow-
ing a No. 9 soft-rubber bougie and also about eight
inches of the stomach tube. I ordered boiled chopped
meat and the following prescription:
^ Ilydrargjri chloridi corrosivi gr. -^.
Potassii iodidi gr. •''•
.Syrupi sarsaparillse compositae 3 i.
M. S, Take the dose three times a day.
He said he could eat very soft spring chicken.
August 28th I passed a No. 1 1 catheter, and ordered
the mercury, etc., to be continued. He wanted to know
if he should consult a professor. I gave him a note to
Dr. Howard Lilienthal, in order to determine posi-
tively if there was any stricture.
On November loth, three months later, I saw him
again, when he related to me the following story:
He had shown my note (addressed to Dr. Lilienthal)
to a druggist who was a friend of his, and was advised
by the latter to see another physician by whom he was
treated for a time, but was finally sent to the German
Hospital.
At this time again, although I could not pass the
smallest semi-elastic catheter, he could swallow, of his
own accord, the large soft-rubber stomach tube. The
case was therefore plainly a spasmodic stricture of the
oesophagus.
I ordered:
1} Spiritus aetheiis compositi,
Tincturae valerian.Te ammoniatae aa 3 ss.
Mistur« asafoetidae,
Aquce „ . aa 3 ss.
This he was directed to take every four hours, and also
beef tea or kumys.
November iith there seemed to be some gastric ir-
ritability, so I ordered:
IJ Sodii bicarbonatis gr. x.
Magnesia ponderosae gr. v.
Sacchari lactis gr. v.
Olei anisi gtt. ss.
The stomach tube was not retained so well as the
day before, although the smaller semi-elastic ones
passed and were retained, as were the smaller soft
ones.
November 1 2th he said he felt better, but had had ten
passages the previous day and one on this day. I made
the No. II semi-elastic catheter pass by distracting his
attention; this was done by inducing him try to pull
his hands apart. He then swallowed the No. 13 without
trouble. I ordered Hoffman's anodyne, valerian, and
asafoetida in doses of ten drops of each, t. i. d., after
meals, in a wineglass of water.
On November i8th the valerian mixture was con-
tinued, but the powders were changed a little by add-
ing five grains of saccharated pepsin in place of the
heavy magnesia; barley, farina, and milk were
ordered.
On the 20th he said that "the food stops and then
goes down with a gurgling sound." I gav'e him potas-
sium bromide in half-drachm doses, with syrup, citric
acid, and water. I tried a soft-rubber tube larger than
the stomach-tube, but saw no signs of blood stains on
the tube and desisted.
On November 2 2d I passed a flexible steel tube
with fangs that could be spread apart by pressing the
opposite end; this was withdrawn open. I ordered raw
chopped meat.
November 24th he complained that he gagged after
eating raw meat and had to put his finger in his throat,
which caused part of the meat to be vomited. I tried
to pass a No. 9 wooden rod, but had to desist for fear of
doing harm. I ordered the compound spirit of ether
and valerian in twenty-drop doses, t. i. d., and bromide
at night only.
On December 5th I decided to hypnotize him, as he
seemed to be tiring of his prospects. I told him to
look in my eyes, and made passes across his forehead
and down his face for about ten minutes, suggesting
sleep all the time. He showed a tendency to smile
when I began, but he finally fell off into a deep state
of hypnotism. Before treating him I made a few ex-
periments. Under the suggestion that his chair was a
hot stove, he jumped up in a natural manner, rubbing
his trousers. He showed natural excitement when I
told him that a child was falling out of a window; he
296
MEDICAL RECORD.
[August 29, 1896
went on all fours and trotted about at my suggestion
that he was a horse. Impersonating a cat for me, he
caught a pencil in a natural way, taking it for a rat.
He was a Russian Pole and understood very little
English. He imagined himself an actor on the
Hebrew stage, even recognizing his friends in the
audience; he spoke in the German-Jewish jargon and
sang in the same strain. Then he was made to be-
lieve that the theatre was an English one, and he tried
to imitate Booth to the best of his ability; French, of
course, he did not understand, but my limited voca-
bulary" of the language he imitated admirably. He
believed himself in heaven or in sheol, according to
my desire, but showed that he had only his ordinary
impressions about them. He played the piano har-
moniously, under the impression that he was Paderew-
ski, using every finger and at my demand playing
slow or fast; he had probably never touched a piano
before. He shot an imaginary bird, thought it was
winter or summer, and felt correspondingly hot or cold.
He found a needle, although I had to direct his move-
ments, as he seemed unaware of things in his way and
would undoubtedly have fallen over everything ob-
structing him. He sat down and played with imagin-
ary toys when I told him he was a baby, or acted like
an old woman or giddy female at my desire. He im-
personated Corbett at my request and did well with
Fitzsimmons. His limbs became rigid or mobile in
any part or in any position; or some became mobile
and others rigid at the same time, as when he thought
he was a pump, the rigid left upper extremity being
worked like a pump handle. Then, again, a clean
needle was passed through the loose skin of his hand,
while he exhibited a pleased expression. While he
believed a part immovable, the greatest force would
hardly overcome the rigidity, yet a single suggestion
made it lax again.
Now I began to make use of the therapeutic proper-
ties of hypnotism. I made passes over the oesophagus,
telling him that he would be able, when he awoke, to
eat food of any kind without any difficulty. In order
to emphasize this, I gave him imaginary food, which
he appeared to eat and drink with ease. After awak-
ening him, which I accomplished only after consider-
able clapping of hands, combined with suggestions for
him to wake, I asked him what had happened, and he
said " I ate zwieback."
December 6th I hypnotized him more readily this
time and told him that zwieback and everything else
would go down without any trouble. I made ascend-
ing ■' passes" and told him to wake up. After a time
he came out of tHie condition, opening his eyes with a
start.
December iith I invited a number of neighboring
physicians in his presence, but he seemed to have got
frightened, and would not enter the hypnotic state
under any consideration; he pleaded that he was not
at all sleepy. I ordered Hoffman's anodyne and vale-
rian in forty-drop doses. I ordered also fifteen drops
of saturated solution of the bromide every four hours.
Perhaps the gaslight or the comparative want of quiet
disturbed him also.
December 12th he said that "farina goes down
but milk sticks and is spit out again; the pill goes
down without water but not with water." Since the
first seance he seemed to be suffering from some out-
side depressing influence, as shown by his actions and
apparent fear, and also from the fact that solicitous
friends appeared on two occasions to ask about him.
I failed to hypnotize him.
In the evening of December 14th he was again
hypnotized. From this out he was hypnotized regu-
larly until he became delinquent and finally disap-
peared altogether. At one time I ordered him men-
tally when he failed to appear punctually, and he
came; but this may have been merely a coincidence.
.\t another time I learned that he was taken to
Brownsville to prevent him from coming, and finally,
after hypnotizing him in the presence of his wife, it
seemed to have a still worse effect and he was kept
away altogether. I ordered him by postal card a
week later, but his wife appeared instead, evidently
determined to keep him away at all hazards.
Let us see what other authorities have to say on the
subject.
Gradle makes the following statement: "When
a susceptible person stares at some bright object,
like a button, without being disturbed otherwise,
or when the forehead is stroked by an operator, the
subject appears to become drowsy in the course of
a few moments. . . . The first time it may require a
persistence of some fifteen minutes or more. Gradu-
ally the object appears indistinct to the subject, his
eyelids droop, and he seems to fall asleep. Occasion-
ally more of a dazed condition occurs than actual
sleep."
The subject may be awakened by shaking him.
The reaction of the pupil to light is usually not abol-
ished although the subject may be sightless. The
person indicates that he sees, but does not interpret
correctly what he sees. The sense of hearing may or
may not be interfered with. The taste is usually,
the smell sometimes, abolished. Carpenter mentions
a young woman who found the owner of a glove, in
a company of sixty, by the smell. Very frequently
subjects have the ability to perform delicate move-
ments without the sight. They have been made to
write with the eyes bandaged. They may row or
ride horseback, or dance. They will recall inci-
dents in their past which they do not remember in
their normal state.
Gradle says further that a certain number of
patients will recall some of their experiences, but as
if in a dream. The muscles can be thrown into steady
contraction by pressure on them or their nerves, with
the finger or any instrument, as precisely as by elec-
tricity. Some of these contractures may persist, in
hysterical patients, even after the subject's return to
the normal condition, but by a gentle rubbing of the
antagonistic muscles the contractures can readily be
stopped. In another phase, the cataleptic, the entire
body presents the wax-like flexibility of catalepsy.
Charcot found three stages in hyterical patients, leth-
argy, catalepsy, and somnambulism. The lethargic
state is produced by staring or by gentle pressure on
the eyeballs. It is characterized by mental stupor
and hyperexcitability of the motor system. Contrac-
tures produced on one side of the body can be trans-
ferred to the corresponding parts opposite, by holding
a magnet near the part to be affected. This effect is
prevented by making the limb anxmic with an
Esmarch bandage. If we apply pressure to muscles
through the bandage, the contracture will be sure to
follow its removal; even while the bandage is applied,
the contracture can be transferred back again by the
magnet.
The lethargy gives way to the cataleptic state on
opening the eyes, and especially on exposing them to
a strong light, or by suddenly producing a loud noise.
(Most of my subjects have been awakened by these
means.) The features of this state are plasticity of
the muscles and of the mind, the latter revealing itself
by the miens and gestures of the subject on suggest-
ing any train of thought. By keeping open only one
eye this side will be cataleptic, but the other will re-
main lethargic. The somnambulistic state may then
be induced by gentle rubbing of the forehead. In
this latter state the delusions, hallucinations, and
imitative tendencies predominate. In those not af-
flicted with hysteria, these separate stages are not evi-
August 29, 1896]
MEDICAL RECORD.
297
dent. The derangements of circulation, respiration,
and other involuntary functions are merely the result
of the intense emotions experienced. These " stages"
give the erroneous impression that they are transfera-
ble only by following the directions given, whereas,
as a matter of fact, these changes are more subservient
to "suggestion"' than to anything else.
Dana says that by cultivation almost any one can
train himself to enter the state at will ; he further states
that the person who has been hypnotized at first sits or
lies quietly in the position he assumed during the
manipulations of the operator. Some of my subjects
have fallen back when asleep; one of them stood with
difficulty, he seemed to be so sound asleep, and, al-
though I suggested repeatedly that he was not sleepy,
he suddenly fell (fortunately in a rocking-chair), the
shock waking him up. No notable changes, Dana
says, occur in the pulse, respiration, temperature, pu-
pils, or skin. Some increase in the cerebral blood
supply, though, is said to be present.
The patient will now, at your command, talk, walk,
run, gesticulate, assume e.xpressions of fright, anger or
joy. Outside of these he hears, sees, smells, tastes,
and feels nothing. He can be made cataleptic, som-
nambulistic, or paralytic. This state is termed som-
nambulistic trance. If left to himself, he gradually
sinks into a deep sleep, from which he can with diffi-
culty be .roused. After rarely more than one or two
hours he awakens as from an ordinary slumber; this
state is called trance coma or lethargic hypnotism.
The three forms of the French writers are hardly pos-
sible, according to Dana. Sensitive subjects can be
thrown at once into any one of these states (including
the cataleptic).
The best method of inducing this state, he says, is
to hold for five or ten minutes some bright object at a
distance of from si.\ to eight inches from the eyes, and
a little above the horizontal plane of vision. (I some-
times induce it by making them look at the quick-
silver in a thermometer bulb while facing a bright
gaslight and simultaneouslv 1 nking into their eyes.)
It is self-induced by fi.\ing tlie attention rigorously
upon some object, says Dana, as in the ecstatic
states of the saints and the nirvana of the Budd-
hists, as well as the states of some clair\'oyants,
spiritualistic preachers, and "mind healers," and it
enters also into rational therapeutics. He refers
undoubtedly to the use of suggestion, independent
of hypnotism, for he adds, that '" the capacity of
the human mind for hypnotism or .semi-hypnotic
states is, therefore, a most curious and important
fact." .\fter a time even a word of command is
sufficient to hypnotize a subject. The practice is in-
jurious, he claims, tending to e.xhaust the nervous
force and weaken the will. Faith-healing institutes,
Dana thinks, are more pernicious than ginmills.
This seems to indicate that it would be better to take
up this matter in its incipiency and make some at-
tempt to obtain legislation before it has gone too far.
The subject is dehypnotized by command or pass of
the hand, or by any impression that the patient e.xpects
for the purpose. Under the spell they have been ob-
served to have a diminution of the spinal reflexes and
a muscular hypere.xcitability. They sometimes show
a most extraordinary exaltation of the visual, auditory,
or other special sense, although the statement of Luys
that medicines in sealed vials can be made to act is
hardly credible.
To distinguish malingering of hypnotism, which
sometimes is done for purposes of injury or crime, the
following rules are laid down : (i) Careful examina-
tion of the subject by an expert is necessary to note
the general actions. (2) The muscular hyperexcita-
bility is tested by percussing the motor points. (3)
The alleged anasthesia is tested by unexpected burn-
ing, or pinching, or injury. (4) Testing the tetanic
rigidity by the revohing tambour. In conscious
states a tremor soon appears when the hand is kept
extended at arm's length. (5) The subject may be
tested with eyeglasses and other apparatus to deter-
mine anaesthesia of the special senses.
It is very aggravating at times to have a subject
almost completely under the influen e and then have
him awakened by some disturbance. When the sub-
ject shows a tremor of the eyelids or makes motions as
of swallowing saliva, or sighs, or motions with the
hands, or wipes tears from the eyes, in spite of contin-
ued efforts, he will not be hypnotized at this seance
beyond the first (the lethargic state). He will talk to
you and tell you anything you ask of him, hearing and
knowing meanwiiile everything that is going on around
him. In spite of this, however, suggestion will have
a marked effect, although occasionally it requires
some persistence. For instance, once in a while a
patient will insist for some time that she does not ex-
perience what you tell her. In the end, however, you
will generally succeed. I have often been successful
in hypnotizing even when the subjects plainly did not
wish to be hypnotized, and I have given marked relief
to numbers by suggestion without asking them to sleep
at all.
One advantage of direct suggestion, apart from
hypnotism, is that it can be used ad libitum, as it
produces no apprehension on the part of the patient.
Some cases of profound hysteria in males are
very obstinate toward the influence of hypnotism.
These are especially the patients who feign almost
every symptom known. A large percentage of sub-
jects can (with sufficient patience) be brought under
the influence. Liebault states that in one thousand
and four persons, twenty-seven could not be hypno-
tized, three hundred and thirt}--five became sleepy,
while all the rest passed into the trance. While hys-
terical females yield more readily than any others,
Heidenhain noticed that strong muscular develop-
ment is also favorable to its production. Infants and
idiots could not be hypnotized by him.
Dana says that about one in every ten or fifteen
adults is susceptible. It is said that the " magicians"
in India hypnotize a whole audience, and I ha\-e
demonstrated the po'-'^ibility of this by hypnotizing a
whole group without moving from the centre of the
room. In my experience in dispensary practice, the
large majority do not get beyond the first stage (al-
though I have succeeded better of late). The worst
drawback which I have had to contend with in my
experiments is the great distrust which the attempt usu-
ally engenders, although I do better now bv group-
ing subjects together. The foreign Hebrew element,
especially, is extraordinarily superstitious. One young
man was mortally afraid that I was going to use a
knife on him when he was asleep. .Another patient, a
middle-aged woman, seemed to be afraid that I had
evil intentions.
I became acquainted with hypnotism while a
chemist nearly fifteen years ago. Dr. Parrish at that
time was the first I met who understood the subject
practically, he having taken a course of instruction
from two professional lecturers. I made no practical
use of it, however, until recently.
It has been frequently claimed that by fixing the
attention upon a person unseen, he or she will be at-
tracted by it. I concentrated my attention recently
upon a subject separated from me by two glass doors.
She had .seen me pass in from the street to the vesti-
bule and apparently thought I went on upstairs. Al-
though she turned and looked at me, I have little
doubt that she became aware of mv presence and saw
me .staring at her.
If in a theatre, vou concentrate vour attention on
298
MEDICAL RECORD.
[August 29, 1896
a person in front of you, he or she will often turn
around; but this is caused by the fact that other
people, noticing your unusual actions, draw his or
her attention to you. We all know that there is a
language in looks and actions. Bend your head
forward suddenly in a car and look at something
— all the passengers will look after you. Your ac-
tions have said plainer than words, "There is some-
thing unusual there," and they all want to see what it
is. It must be remembered, when people see things
without looking at them, that although the macula
lutea with its fovea centralis retinae is most powerful
in sight-giving properties, still the surrounding parts
of the retina can also produce mental impressions,
and, considering that we have two eyes, this gives us
a very large range of vision; although looking
straight ahead, we can see objects on both sides of
our heads. We have all been the subject of attention
in assemblages at times, and yet have felt no particu-
lar attraction ; that was because we are accustomed to
it. In other instances we have felt embarrassed, and
have tried therefore to avoid such congregations.
The old method of hypnotism, says Dr. Luys, was to
cause the subject to look one steadily in the eye, while
the operator's hands were continuously passed about
his head. To be successful by this method, he says,
the subject must feel that he is going to be hypnotized
and must not offer the slightest mental objection.
(My e.xperience does not agree with this.) The
principle of his hypnotizing machine is a constantly
moving, glittering surface.
The great requisite for successful hypnotization is
unbounded self-confidence and fearlessness. If you
are afraid that the patient may laugh at you, you will
never succeed. I have hypnotized the very patients
who were forced to smile at first. I was asked re-
cently by a man of apparently strong will-power if I
thought I could hypnotize him. "Why," said I, "you
would be the easiest of subjectsl" Still I did not be-
lieve so myself at the time, and yet the effects of my
answer could have been observed in the patient's sub-
sequent demeanor.
Dr. Abbot Combes, who was a student under Char-
cot, claims that every advanced physician nowadays
should know how to hypnotize. He takes a hen and
bends the neck to one side and then draws up one of
the wings over the head. Holding her in this posi-
tion, he whirls her around twice and then sets her
down. With eyes wide open, she sits perfectly rigid;
placed upon her back, she makes no effort to regain
her upright position; when one of the wings is spread
out, it remains there. This is the second or cata-
leptic stage, in which she remains for several minutes.
Other birds of smaller varieties are handled in the
same way, with similar results.
A young man is seated by him in a chair and he
doctor points his finger at him, keeping it about five
inches away from the subject's head and on a level
with his eyes. The young man's eyes droop and in a
very few seconds he is in the first stage (somnolency).
By pushing open the eyelids (and pressing slightly
upon the eyeballs?) the second stage, or cataleptic
condition, is reached. Placed in any position, no
matter how uncomfortable or ridiculous, the subject
remains there. When needles are introduced into the
tlesh, tlie man never winces; he is deprived of all
feeling. A minor surgical operation, as the amputa-
tion of a finger, could be performed without the least
difficulty, but a major operation, as that of removing
the arm, would produce such a shock to the nen'es as
to bring the subject out of the trance.
By stroking the middle of the forehead with the
finger he produces the third and last stage, hypnotic
suggestion. (He thus calls the stages bj- the more
appropriate terms, somnolence, catalepsy, and sugges-
tion— or still better terms would be insomnolence,
catalepsy, and servility.) All the stages are fre-
quently present at the same time, in varying propor-
tions. "He will remain under my control," says the
doctor, " unless I suggest that he is under the control
of some one else or awaken him: if I place him under
the control of any other person, I have no control over
him until the governing party suggests again that he
should be under my control." The subject is burned
with cold iron, and drinks water, thinking it is milk.
If a woman has hysteria, he suggests that she will not
have another attack until she sees him again: the
effect is generally very satisfactory. The length of
time the influence lasts depends upon the number of
times she has been hypnotized, how susceptible she is
to the influence, and what her capability for receiving
the suggestion is; as a general thing it lasts for from
two to four weeks. The patient is awakened by blow-
ing in his or her face. When a disease is long-con-
tinued, says Dr. Combes, as in functional epilepsy
of from fifteen to twenty years' standing, it is hardly
possible to cure it in this way. In alcoholism, you can
keep a man from drinking by suggestion, but it will
not reduce the inflammation of the brain cells in de-
lirium tremens, ^^'hen patients complain of pain as
the result of an operation accomplished two years pre-
viously, with no foundation for such comjilainl, they
are cured in this way. Alcoholics are told that if
they drink in the future it will make them sick, and it
does generally make them vomit; this suggestion lasts
for two or three weeks. Sometimes we say, " Don't go
into a saloon." The same is done for the smoking-
habit, when necessary. If they complain of headache
after continued hypnotism, the treatment is usually
suspended for a while.
The doctor does not believe that a man who is thor-
oughly moral and principled could he induced to com-
mit a crime, nor could a virtuous woman, according to
him, be made to surrender herself. (Can they resist
without the presence of the will?) Still, he admits
that subjects have engaged in antics which would have
made them feel disgraced in the normal state. It is
claimed that a subject would forget to do a criminal
act as soon as he had left the jiresence of the oper-
ator.
In producing the hypnotic state artificially in man,
Dana says, his attention is fir.st fi.xed upon some partic-
ular object, as a bit of glass, which is held slightly
above the level of vision, so as to put the ocular mus-
cles upon a certain strain; after a few minutes, in
sensitive subjects, the nervous force seems to lose its
equilibrium, and to concentrate itself in one particu-
lar direction; the whole mental life of the subject is
narrowed into one field. The equilibrium of nervous
force being once overturned, it remains unstable, and
can be turned in one direction or another, at the will
of the operator. The subject is told that he is a mur-
derer and must die, and he is overpowered with fear
and remorse. The hypnotic is to all intents and pur-
poses ana;sthetic (unconscious to feeling) and blind
and deaf to everything except an expected suggestion
from the ojaerator, who is the only link between him
and the external world at this time. The concentra-
tion of his ner\ous force upon some particular func-
tion, such as that of sight, hearing, or touch, exalts
these senses, so that vision is clearer, hearing more
acute, and tiie touch more sensitive.
Certain persons of a highly sensitive, nen'ous tem-
perament, are liable to spontaneous attacks called
trance, which is nothing more than a day somnambu-
lism. These individuals are generally hysterical, and
their attacks may be accompanied by or complicated
with catalepsy, ecstasy, or various other hysterical phe-
nomena. In some cases this is said to be congenital,
any excitement of the brain producing a spell : in others
August 29, 1896]
MEDICAL RECORD.
299
it may be acquired, after the subject has been mesmer-
ized. A case is reported of a patient with chronic
periodical tic douloureu.\ who fell in a stale of "som-
niloquence" after each attack; her religious eloquence
was a modern illustration of the prophecies of the
priests of the Delphic oracle. If the hypnotic is left
alone, his condition passes after a few hours into true
sleep. Those periodically hypnotized can recall in
one se'ance what occurred at a previous one.
The slighter degrees of hypnotism resemble pro-
found reverie or abstraction ; the absorbed reverie of
the student, however, is different from the absorbed
contemplation of the hypnotic. The student is con-
structing and building under voluntarj- direction; the
latter is going automatically over old ground.
Gradle claims that hypnotism can be more easily pro-
duced in functionally nervous patients than in healthy
subjects. The patient, he says, stares at a bright object,
in a quiet room, or listens to a monotonous noise like
the ticking of a clock; or having his forehead or nape
of the neck warmed by means of the hands of another
person, or the radiant heat from warm plates held at a
short distance, will answer the same purpose in some
instances.
It is true that the action of a mesmerizer who has
had experience in producing this state facilitates its
occurrence, but the popular idea that it requires a
mesmerizing operator is not fully accurate. This
state can be produced more readily the oftener it is
accomplished. Susceptible and credulous subjects
have been mesmerized at a stated time, even in the
absence of the operator. A direct mesmeric influence
is an unsupported myth, not bearing rigid criticism.
The touch of a magnet may be used for producing
hypnotism, but there is no other connection between
them. Usually certain muscles are kept on a strain
in its induction.
Braid's method of treatment by hypnotism was to
direct the attention during the trance upon the parts
depressed in function and to direct it from the organs
supposed to be in a state of exxitement.
He suggested its use for surgical operations, and
quotes Esdaile as having performed three hundred oper-
ations under it. Wiebe obtained encouraging results in
cases of hysterical spasms and tremors and in hysteri-
cal hemiana;sthesia; also in non-hysterical neuralgia.
Voisin obtained good results in the management of in-
sanity. He found it useful to calm excitement, to feed
obstreperous patients, and to elicit their history.
Pritzl put a girl into a trance during her first labor;
the birth was accomplished in one and one-quarter
hours without pain; she recollected nothing about it.
Its therapeutic indications are, then, prolonged pain,
as neuralgia, or the passage of a calculus; if other
methods are available it is not prudent to take the
chance of failure (though this is not so essential now,
since its use is becoming popularly understood). Tor
surgical anasthesia it is too uncertain. A good field
is hysteria, somnambulism, catalepsy, ecstasy, and
some fonns of insanity. .Since some individuals com-
plain of mental stupor and physical lassitude after hyp-
notization, it is probably not safe to repeat such exper-
iments often (its effects cannot therefore be altogether
imaginary).
It must not be forgotten that a good deal of time is
unconsciously expended on these cases, and herein
may lie part of its value. A young woman thus de-
scribes her own cure from neuralgia by pure sugges-
tion. She was shown into a pretty room and placed
in an easy chair; a silk cushion was placed under her
head, a footstool supported her feet. The attendant
lighted a small spirit lamp under a vaporizer and put
a dainty bib under her chin. With a soft sponge
moistened in wami water and some sweet-smelling
material, the masseur made the application, and man-
ipulated the aching spot with firm, cool fingers.
Vigorously, but gently, she rubbed the surface with
the soft, practised cushions of her finger tips. This
brought the blood to the surface with a peculiar
sensation of refreshment. After this treatment some
fragrant cream, medicinally treated, was rubbed in.
The cream that did not penetrate was washed off with
cold perfumed water, to prevent taking cold from ex-
posed pores. The final step was a mild application of
electricity by means of a soft kid pad over the face.
After three-quarters of an hour of this enforced leisure
and dallying with creams and perfumes, a week-old
neuralgia was chased away.
Hewitt and Sims, in their treatise on the "Diseases
of Women," devote four chapters to the subject of the
hystero-neuroses, which are very interesting in this
connection.
Chambers' Encyclopedia, edition of 1883, gives the
following description of the subject; " From the Greek
hypnos, sleep, a term invented by the late Mr. Braid, of
Manchester, to designate certain phenomena of the
nervous system which in many respects resemble those
which are induced by animal magnetism, but which
clearly arise from the physical and psychical condition
of the patient, and not from any emanation proceed-
ing from others. The following are his directions for
inducing the phenomena and especially the peculiar
sleep-like condition of hypnotism; Take a silver lan-
cet case or other bright object, and hold it between
the fingers of the left hand, about a foot from the eyes
of the person experimented on, in such a position
above the forehead as to produce the greatest strain on
the eyes compatible with a steady fixed stare at the
object. The patient must be directed to rivet his
mind on the object at which he is gazing. His pupils
will first contract, but soon dilate considerably, and
if, after they are well dilated, the first and second fin-
gers of the operator's right hand, extended and a little
separated, are carried from the object toward the eyes,
the eyelids will most probably close with a vibratory
motion. Aften ten or fifteen seconds have elapsed, it
will be found that the patient retains his arms and
legs in any position in which the operator places
them. It will also be found that all the special
senses, excepting sight, are at first extremely exalted,
as also are the muscular sense and the sensibility of
heat and cold. But after a time the exaltation of
function is followed by a state of depression far
greater than the torpor of natural sleep. The patient
is now thoroughly hypnotized. The rigidity of the
muscles and the profound torpor of the nervous sys-
tem may be instantly removed, and an opposite condi-
tion induced by directing a current of air against the
muscles which we wish to render limber or the organ
we wish to excite to action : and then by mere repose
the senses will speedily regain their original condi-
tion. If a current of air directed against the face is
not sufficient to arouse the patient, pressure and fric-
tion should be applied to the eyelids, and the arm or
leg sharply struck with the open hand.
" From the careful analysis of a large number of ex-
periments, Mr. Braid is led to the conclusion that by
a continued fixation of the mental and visual eye upon
the subject, with absolute repose of the body and gen-
eral quietude, a feeling of stupor supervenes, which
renders the patient liable to be readily affected in
the manner already described. As the experiment
succeeds with the blind, he considers that it is not so
much the optic as the sentient, motor, and sympathetic
nerves, and the mind, through which the impression is
made."
We see from the above that hypnotism was con-
sidered at this time to be entirely distinct from mes-
merism or animal magnetism, which is described
in a separate article, being defined as "a supposed
300
MEDICAL RECORD.
[August 29, 1896
inriuence or .emanation by means of which one per-
son can act upon another, producing wonderful ef-
fects upon his body, and controlling his actions and
thoughts. It was fancied to have some analogy to the
magnetism of the lodestone," the article goes on to say,
and hence its name. " Electro-biology, odylism, table-
turning, spirit-rapping, table-talking, and spiritualism
have been classed as only modifications of the same
phenomena. The art of inducing the magnetic state,
as practised by its discoverer, Mesmer, involved the
use of apparatus — the baqiiet or magnetic tub, iron
rods, etc., but the more common means have been
passes made by the hands of the magnetizer from the
head of the subject (or patient) downward, or simply
making him fi.x his eyes on the operator.
" He then generally feels a creeping sensation steal-
ing over the surface, and shortly falls into the mes-
meric sleep — a state more or less resembling somnam-
bulism or sleep-walking.
■■ About one person in ten is found capable of being
thus affected to a greater or less extent.
"While in this state, the functions of the body are
liable to be much affected; the pulsations of the heart
and the respirations are quickened or retarded and the
secretions altered, and that chiefly at the will of the
operator. [It might thus be useful in dropsy.] One
liquid tastes as the other, and is hot or cold, sweet or
bitter, as the subject is told.''
According to this mesmeric theory, the nervous
energy of the operator has overpowered that of the
subject, as a powerful magnet does a weak one, and
the two are en rapport, as it is termed. In some cases,
the mesmeric trance assumes the form of clairvoyance.
The author goes on to say that " it Jias been clearly
established, however, that the notion of a force of any
kind whatever, proceeding in such cases from a per-
son or from a magnetizing apparatus, is a delusion."
Where it is to be looked for was indicated, though
not followed up, as early as 1785, in the report of the
commissioners, one of whom was Franklin, appointed
by the king of France to examine these pretensions of
Mesmer. They reported that "on blindfolding those
who seemed to be most susceptible to the influence,
all its ordinary effects were produced when nothing
was done to them but when they imagined that they
were magnetized, while none of its effects were pro-
duced when they were really magnetized but imagined
that nothing was done; that when brought under a
magnetized tree [one of Mesmer's modes of operating]
nothing • happened if the subjects of the experiment
thought they were at a distance from the tree, while
they were immediately thrown into convulsions if they
believed they were near the tree although really at a
distance from it; and that, consequently, the eft'ects
actually produced were purely imaginary."
Braid traces the whole thing to the brain of the sub-
ject acted on by suggestion, a principle long known to
psychologists, though never made so prominent as it
ought to be. In reviewing the subject Dr. Carpenter
traces the operation of this ^xmc\\>\e. {Quarterly Rc-
7ie7c< for September, 1853) through the most ordinary
actions, which no one thinks wonderful, up to the
most miraculous of the so-called "spiritual" mani-
festations.
.\ train of thought is internal suggestion (auto-sug-
gestion), but impressions from without originate and
modify these trains, constituting external suggestion
(direct suggestion). These phenomena enable us to
explain the physical excitement attendant on " re-
vivals," " camp meetings," etc.
No wish of the mesmerizer, or of any other person,
was ever known to affect the " subject," until it was
conveyed to him by voice or otherwise (unless we ac-
cept the cases recently reported). If he is more sub-
ject to the will of the operator, this is because he was
impressed with that idea. He is thus made to lose
and recover memory, or even his own identity.
The manifestations of table turning, such of them
as are genuine, are explained by the operation of ex-
pectant attention. A number of individuals sit around
a table with their hands resting on it, having the idea
in their minds that it will or may move, the direction
of the expected movement being also agreed upon.
Accordingly, if none of the party are very sceptical,
it generally does move after a time, all declaring, and
in perfect good faitli, that they did not press upon it.
And yet it has been proved by a contrivance of Fara-
day that there always is pressure, though without the
will or consciousness of the performers.
The wonders related by believers are to be received
with suspicion, but without accusing the relators of
bad faith (because they are suffering from the effects
of auto-suggestion).
The mysterious indications of the divining rod and
of an oscillating body, such as a ring suspended from
the finger, are all to be accounted for by uninten-
tional muscular movements.
Beard and Rockwell, in their treatise on " Nervous
Exhaustion," 1888, say that "morbid states of the
nervous system which we call trance, but which are
popularly known as hypnotism, somnambulism, cata-
lepsy, all being special varieties of the special generic
condition, trance, is one of the interesting, though per-
haps not most frequent or the most serious of the
sequels of neurasthenia."
Neurasthenia is not, by any means, they say, the
most common of the e.xciting causes of this state. In
the middle ages, among many wild, savage, and semi-
barbarous races, trance existed, and in modern times
it has spread as a mental contagion, even among per-
sons who have great strength of constitution, or at
least who have but very little of the nerve element in
them.
Trance of this variet)', in its psychical form, is
found to-day among certain classes of people, but the
majority of the cases of trance, among our better
classes, are seen in women who have entered the state
through the doors of neurasthenia. Our so-called
starving girls, with their ecstasies and visions, are
oftentimes neurasthenic for years before they develop
trance phenomena.
The time may be near at hand when we shall be able
to observe these mental phenomena by actual sight.
We can photograph the skeleton through the body al-
ready, and who knows but with the aid of multiple in-
stantaneous chromo-micro-photography we shall think
nothing some day of looking at the brain-cells in ac-
tion, in natural colors?
In connection with general hypnotism, another
question presents itself, and that is this: In view of
the fact that this state has a tendency to depress the
mental faculties, should parents, guardians or teachers
be allowed to load the minds of children with fairy
stories or with mythological religion? Since religious
mania takes such a prominent place in our works on
mental disease, it seems only natural that all but real
historical religion should be excluded from the studies
and the libraries of children. Would it not be more
advisable to teach them psychology and its laws in an
appropriate form?
.\lthough .Spitzka, 1889, in his " Insanity," has noth-
ing to say on hypnotism or its allied conditions, I ab-
stract the following paragraph as being of interest in
this connection.
" In private practice, melancholia, particularly of
the lighter grades, is very common, and is not unfre-
quently treated as neurasthenia — whatever that may or
may not be — and dyspepsia, and, thanks to the self-
limiting tendency of the lighter forms of the psy-
chosis, it is frequently cured on either theory."
August 2g, 1896]
MEDICAL RECORD.
301
It has been said that every genius is to a certain ex-
tent, insane. I believe ni3self tiiat it would be truer to
say that every person who concentrates his mental fac-
ulties in one particular direction, is more or less hyp-
notic, at greater or smaller intervals, and for varying
lengths of time.
Brown in his " Medical Diagnosis," 1890, speaks of
somnolence, among other causes, as being the result
of a "'natural aptitude for sleep possessed by persons
of a lethargic temperament."
Howe, in his treatise on " Excessive Venery," 1889,
under ■■ Mental Emotions," cites: '"'A powerful imag-
ination will create that which it imagines ' in a short
space of time." A new mental creation, without a
basis in fact, obscures and distorts that which is real.
The records of hospital and private practice show
that there is little limit to the power of this influence
in creating organic changes, when the nervous system
of the patient is abnormally sensitive. (This being
the case, why not reverse the emotions by opposing
impressions?) He goes on to describe a case, while
he was an interne at Bellevue Hospital, in which an hys-
terical patient developed peritonitis with tympanites
and later an apparent mastitis with swelling of the
breast, through being placed in proximity with patients
suffering from these affections; twelve months after, to
his great surprise, he found the same person, who was
supposed by the staff to be dying from inflammatory
softening of the brain.
Hamilton, in his " Medical Jurisprudence," says
that it is very rare that trance can be given as an
excuse for the active commission of a crime. It might
be possible to account for the ignorance of an indi-
vidual by the fact of his being unconscious or being
thrown into a state of suspended consciousness through
fright or a strong moral impression.
A case is related of a theft claimed to have been
committed in the mesmerized state. In court the man
appeared to be in a sound sleep and did not under-
stand the questions put to him by the magistrate. It
was stated that he fell in this state after his arrest,
although before this he had given an account of him-
self. No medical aid could arouse him. Even his
brother, who was a lecturer on mesmerism, could not
arouse him, although he answered questions readily.
The brother said that he was susceptible for a long
time, and that on one occasion he became violent and
had to be restrained. The prisoner subsequently re-
covered, after going for several days without food or
drink. He was sentenced to fine and imprisonment.
An act of violence, Hamilton says, had it been com-
mitted, would have suggested criminal irresponsi-
bility, but theft implies personal benefit. The verdict
was probably a righteous one.
Dana (Mcilical Annual, 1889) states that the doc-
trines of Bernheim are far more correct than those of
Charcot. The operator talks to the subject in a firm
voice, assuring him that he will go to sleeep in a short
time, telling him to make no resistance — that his sleep
will be natural, that nothing will be done to worry or
fatigue him, that he will dream pleasant dreams, that
he will wake up feeling better; then that he is feeling
drowsy, objects seem confused, the lids are falling,
they are closed — in a moment more the patient goes
off to sleep. This is the persuasive or suggestive
method. It requires from five to fifteen minutes. The
method is applicable to neuralgias, neurasthenias,
hysterical, convulsive, and paralytic troubles, alco-
holic and morphine habits, amenorrha-a, rheumatic
troubles, etc.
Tuckcy {Aledical Annna/, 1890) says that Lie-
bault hit upon the value of suggestion in the hypno-
tic state. Intelligent artisans he found to be the
best subjects, especially when tired out by the day's
work, .\najmic and phthisical patients, and adoles-
cents of both sexes, are also easily hypnotized. Even
if the patient has been frequently hypnotized, mental
emotion, such as fear, will prevent it succeeding.
Lie'bault finds in 100 — uninfluenced, 5; slightly
influenced, 15 ; sleepers, 65 ; somnambulists, 15. The
same proportion is foimd among the phlegmatic Dutch
and many sonmambulists are found among the Swiss.
A larger proportion of English is uninfluenced (two
per cent.), and there are fewer somnambulists (eight
per cent.), but this may depend upon coincidence.
The condition is analogous to but dift'ers from sleep;
in sleep imagination has full play and runs riot in
dreams, whereas in hypnotism it can be controlled, so
as to influence even the heart and circulation, the
vasomotor centres, and intestinal and uterine secretions.
In hysterical paralysis, aphonia and amaurosis, neu-
rasthenia, spinal irritation, railway spine, brain fag,
sleeplessness, functional derangements of the genito-
urinary organs, such as o\arian irritation, vaginismus,
impotence, nocturnal enuresis, headaches of nearly all
kinds, even migraine or neuralgias, and even in gouty
sciatica in old men it is useful.
In menstrual difficulties, whether dysmenorrhoea,
amenorrhoea, or menorrhagia, not only when depen-
dent on functional causes, but even sometimes when
there is structural change, i\g., subinvolution; in occu-
pation neuroses, as writer's cramp (for which hypno-
tism is often combined with massage) ; in painful local
affections, as cramp, torticollis, and lumbago; in some
cases of epilepsy, and especially in hystero-epilepsy,
it will modify the attacks even in the traumatic forms.
In ner\'ous dyspepsia, colic, and some forms of con-
stipation and diarrhcea, it may be employed ; also in the
sympathetic and functional troubles of organic dis-
ease, as palpitation and sleeplessness in cardiac dis-
ease, or constipation and lightning pains in locomotor
ataxia. As an anaesthetic during labor it may some-
times be useful, as well as to relieve after-pains. In
hypochondriasis and in melancholia it may be tried,
but it is difficult to influence patients with mental dis-
ease. In acute mania it may succeed, but great pa-
tience is necessary. It effects wonders in dipso-
mania, the morphine habit, masturbation, and other
vices; these cases should be kept under observation
for twelve months to prevent a relapse.
The rules laid down by Beaunais are as follows:
( I) Never hvpnotize except with the patient's free con-
sent and if necessary that of friends. (2 ) Never make
any experiment without the knowledge and consent of
the patient. (3) Never operate except in the presence
of a third person. (I consider these rules altogether
too stringent.)
Q3 Madison Strem,
Syphilis in Infants and Young Children. — If
" snuffles'" are present, irrigation with boric-acid or
thymol solutions, or bichloride of mercury (i to 1,000),
or with a one or two per cent, aqueous solution of
ichthyol, will be suitable. For mucous patches, mild
solutions of nitrate of silver, or of mercuric chloride
are of benefit, while for the condylomata, cleanliness,
dryness, the use of nitrate of silver, or of calomel in
powder form, five to twenty per cent., are indicated.
Fissures at the angles of the mouth I have seen much
benefited by balsam of Peru, painted on in full strength,
ichthyol ointment, ten per cent., or by touching with
the nitrate-of-silver stick. — Elliot, New Orleans Meiii-
iirl and Suixiial /iinrnal. May, 1896.
Disinfection of Hands. — It seems conclusive that
the great enemy to all surgery, the hand of the oper-
ator, is best disinfected as first taught in Baltimore,
by the use of solutions of pennanganate of potassium
and oxalic acid. — Hknrv O. Marcv.
;o2
MEDICAL RECORD.
[August 29, 1896
WHAT IS THE BEST OPERATIVE PROCE-
DURE FOR RETRODEVIATIONS OF THE
UTERUS?
By AUGUSTIN 11. GOELET, M.D.,
:»F GVNECOLOGV IN THE NEW
-MEDICINE.
YORK SCHOOL OF CLINICAL
In considering the treatment of retrodeviations of the
uterus, the maintaining cause of the displacement
must be borne in mind, and the existence or absence
of an associated disease of the adne.xa must be de-
termined. We may divide these cases into three
classes:
The first class will include those in which the organ
is freely movable and will admit of replacement, but
in which the displacement recurs upon the removal of
the support which replaces it. In these cases a metri-
tis and an endometritis or their result are the maintain-
ing cause, the relaxed uterine supports being a secon-
dary consideration, at this time, though in the beginning
they may have occupied a more prominent etiological
position.
Th J second class will include those cases in which, in
addition to a metritis and an endometritis, adhesions
or surrounding exudation bind the fundus of the organ
immovably in Douglas' cul-de-sac. In these cases
a previous or perhaps an existing inflammation of the
adnexa is the cause of the fixation, though moderate
fixation from adhesions may occur independently of
inflammation of the appendages.
In tiie third class may be included those movable
retrodeviations complicated by prolapsed, enlarged,
and sensitive ovaries, which preclude the use of a
vaginal support for maintaining the uterus in a cor-
rected position.
Now let us consider the objections to and the dis-
advantages of some of the operations which have been
devised for these displacements, and see if they are
necessary or justifiable, and, if so, when they are
indicated.
The Alexander operation is the least objectionable,
since it seeks to restore the organ to a normal position
in the pelvis. Its chief disadvantages are: (i) the
tim.e which the operation requires; (2) the doubt
about finding the ligaments sufficiently strong in their
long overstretched and atrophied condition to bear
the strain to be put upon them; (3) the prolonged
convalescence necessary before the shortened liga-
ments can be regarded sufficiently strong to support
the uterus; (4) the risk of hernia: (5) the cicatrices
which may become the seat of keloid. (Several cases
of this kind have come under my observation and have
proven very disagreeable and intractable.)-
The shortened ligaments do not interfere seriously
with subsequent pregnancies, though in two cases
which came under my observation considerable pain
in the region of the wounds and shortened ligaments
was experienced in the later months of pregnancy.
The actual indications for this operation may, in
my opinion, be regarded as very circumscribed. It
would .seem to be particularly applicable to the cases
belonging to the third class mentioned above, viz.,
when a movable retrodeviation is associated with
prolapsed, enlarged, and sensitive ovaries which can-
not bear the pressure of vaginal support, but which are
not sufficiently diseased to require removal. In ordi-
nary movable retrodisplacements when the operation
is supposed to be indicated, it is unnecessary. This
operation may be done for fixed retrodisplacements,
the adhesions being previously broken up through
a vaginal incision opening Douglas' pouch. Hut
when the adhesions are extensive I believe it will be
more satisfactory to separate them from above through
an opening in the abdominal wall, and when they are
not firm or extensive .Alexander's operation is unneces-
sary, as the malposition can be satisfactorily overcome
by a procedure to be described farther on.
Ventrofixation as ordinarily done may hardly be
regarded a justifiable operation. It draws the uterus
up out of the pelvis and fixes it in an abnormal posi-
tion. These patients sometimes suffer considerable
pain resulting from the strained and unnatural position
of the organ. This unnatural position must prove a
complication to subsequent pregnancies. Several un-
favorable cases have been reported.
The suspension operation of Kelly, in which the ute-
rus is suspended by its posterior face from the anterior
abdominal wall and in which it is not fixed perma-
nently, but is merely suspended and eventually recedes
to the distance of about an inch and swings in an easy
position of anteflexion, is certainly less objectionable
and is more rational. It should, however, be limited to
those cases of firmly fixed retrodisplacements associ-
ated with diseased adnexa which require removal. It
is unnecessary in movable retrodeviations. \Mien the
uterus is firmly adherent, I believe it is safer and more
satisfactory to open the abdomen and break up the
adhesions from above than from below through a
vaginal incision.
I cannot see that intraperitoneal shortening of the
round ligaments possesses any advantage over sus-
pensio uteri, and the operation consumes more time.
\'aginal fixation should not, in my opinion, be re-
garded as a justifiable operation. It substitutes an
exceedingly awkward fixed anteversion for a movable
posterior displacement. The complications during
labor following this operation which have been report-
ed should be sufficient to condemn it. It has already
been abandoned by its originator, Mackinrodt.
It will be admitted, I think, that if the intra-ab-
dominal pressure can be brought to bear permanently
upon the posterior face of tlie uterus, it will be held
anteverted. It must, likewise, be admitted that if the
maintaining cause of the displacement when the organ
is or has been made movable (the metritis and endo-
metritis) be at the same time overcome, a positive
cure must result. This will, of course, presuppose the
possibility of a cure of such disease of the uterus and
also retraction of the relaxed suspensory ligaments.
I believe that ninety per cent, of all the cases of
movable retrodeviations are amenable to a very sim-
ple procedure wiiich I have employed with success for
the past ten or twelve years. I have employed it also
in cases of moderate fixation when the adhesions
could be separated by manipulations through the
vagina and the abdomen without opening the peritoneal
cavity, the patient being under anesthesia to secure
absolute relaxation. This should, of course, be under-
taken only when we can be certain that there are no
pus accumulations in the pelvis. When the adnexa
are incurably diseased, it is wiser to open the abdo-
men, and, after removing such diseased structures as
is necessary, suspend the uterus from the anterior ab-
dominal wall.
Tile procedure to which I refer aims at a cure of the
metritis and endometritis, which may be regarded as
the most prominent etiological factors in maintaining
movable displacements. It consists of careful dilata-
tion of the canal, thorough curettage of the cavity, fol-
lowed by frequent irrigation to promote and hasten the
formation of a healthy endometrium. Immediately
following the operation of dilatation and curettage, a
glass drainage tube is inserted, which in the case of
flexion, acts as a splint, holds the organ straight, and
converts it into a version. It will then be an easy
matter to adjust vaginal tampons of iodoform gauze so
as to throw the uterus into a position of anteversion
and hold it there. It is very necessary to adjust these
tampons daily and keep the patient confined to bed.
August 29, 1896]
MEDICAL RECORD.
At the same time the tube is removed and cleansed,
the cavity irrigated, and it is reapplied.
I have found that if this is kept up for a week, in
the majority of cases a vaginal pessary may then be
adjusted to hold the uterus in an anterior position
without the aid of the glass tube in the canal, even in
old fle.xions with considerable induration of the walls.
In some cases, however, it will be necessary to retain
the tube in the uterus for a few days longer after the
vaginal pessary has been inserted. When it is found
that the pessary will maintain the organ in an anterior
position, and the tube can be dispensed with, the
patient is permitted to get up. She must, however, be
kept under close observation for a time, to make sure
that the pessary is maintaining a correct position;
and the cavity should be irrigated from time to time
until a healthy condition of the endometrium has
been restored. Measures to promote retraction of the
rela.xed uterine supports (faradization, for instance)
should likewise be eir'ployed. This will very materi-
ally aid in bringing about a cure, which I consider is
secured when the vaginal pessary can be dispensed
with.
This procedure brings about rapid softening of the
uterine walls and favors the retention of the uterus in
a normal position by the vaginal support.
In cases of retroversion, when the organ is in a
state of subinvolution in the soft stage of metritis,
after the dilatation and curettage the cavity is packed
with iodoform gauze for a week, to stimiilate contrac-
tion and depletion. The gauze, however, is removed
and renewed every twenty-four hours, the cavity being
freely irrigated at the same time. Vaginal tampons
are inserted to hold the uterus in a position of ante-
version, and at the end of a week a vaginal pessary is
inserted and the patient is permitted to get up.
The only disadvantage of this procedure is the time
and trouble which the after-treatment necessitates in
order to accomplish a satisfactory result, but this is
more than counterbalanced, it seems to me, by its
absolute safety and the restoration of the organ to a
normal position in which its function is not interferred
with. As compared with shortening of the round
ligaments, which is so often done for movable dis-
placements, the chief advantage in favor of this pro-
cedure is the shorter confinement to bed and the
quicker convalescence. It is also, I believe, more
certain and more rational.
To recapitulate, .Vle.xander's operation is not neces-
sary in movable retrodeviations unless they are com-
plicated by prolapsed, enlarged, and sensitive ovaries
which do not require removal.
Ventrofi.xation substitutes a fixed abnormal position,
for some reasons more objectionable than the original
displacement.
Suspension of the uterus from the anterior abdomi-
nal wall is indicated for firmly fixed retrodeviations,
especially when the adne.xa are diseased, and it yields
a very satisfactory result.
Intraperitoneal shortening of the round ligaments
possesses no advantages over suspensio uteri.
Vaginal fixation is never indicated and should be
discouraged.
The operation of dilatation with curettage, and tiie
subsequent use of a glass drainage splint for the
correction of the flexion, is indicated in the large ma-
jority of movable retrodeviations, and is more rational,
since it restores a normal position of tlie organ without
submitting the patient to any risk, and does not entail
prolonged confinement to bed.
351 West Fiftv-Seventh Stkeet.
The Horseless Carriage is now used by I'rench
country physicians.
NOTES FROM THE LABOR.VrORY AND DIS-
PENSING-COUNTER.
By .\CGU.ST DRESCHER, A.B., Ph.G.,
NEWARK, N. J.,
CMEMIM TO THE NEW JEHSEV ST.ATE BOARD OF HEALTH.
Dispensing Calomel with Sugar of Milk — For years
all of us have dispensed calomel, together with "cane
sugar,'' in the form of powders, and no fault niav have
ever been found with this combination. VN'ithin the
last few years it has been found by many of our phv-
sicians to be necessary to follow the " progressive
line" — that is, to change the " old-fashioned" cane
sugar to milk sugar, in the case of admixture with cal-
omel, and even with more delicate and more easily de-
composable chemicals. " Milk-sugar fame" came from
abroad, and we here naturally ape European fashion,
whether rightly or wrongly. In my experience calo-
mel and milk sugar, safely ensconced in a good pow-
der paper, as is the common practice among pharma-
cists, will not keep so long as a mixture of "cane
sugar" and calomel, without showing signs of decom-
position (turning gray).
This is generally not noticed, because of the large
quantity of sugar of milk present, the e.xcess hiding
the discoloration : but when, as in my store it is often
the case, small amounts of sugar of milk are wanted
with calomel, so that the powder can be placed dry
upon the tongue or into the mouth of a small child,
the metamorphosis of the calomel can be easily no-
ticed before the administration of the dose.
Calomel with Sodium Bicarbonate. — Quite re-
cently a graduate of pharmacy asked me to account for
the " black streaks" in the mortar in which he had
been triturating calomel with sodium bicarbonate.
He knew well enough that sodium carbonate, heated
with certain metallic salts, eff'ected reduction, but of
its effect in the cold or that of the bicarbonate he had
no idea.
The same thing happens to us almost every day,
when we triturate calomel with sodium bicarbonate in
various quantities, to form " tablets" (this new curse
of pharmacy). The reaction is simply this:
Hg„Cl, + 2 NaHCO^
= Hgp + 2 NaCl -f up + 2 CO,,
and the tablets turn gray. In mixing powders we had
the chance of pulverizing finely each ingredient in the
mortar by itself, and then mixing them all together
upon paper with a spoon or spatula; but tablets must
be moistened, even if only with alcohol and a little
water, in order to bring the particles more nearly to-
gether. The alcohol cannot be supposed to act in the
case, conceding to it all its powers of afiinity.
Incidentally, I would here say that among the au-
thorities on chemistrj' there ought not to be a differ-
ence of opinion as to the formula for calomel. Even
good authorities on chemistry have quoted HgCl.
The majority is, it appears to me, in favor of Hg.,Cl.j.
Logical reasoning suggests at a glance the latter to
be the more correct. For, when we construct the for-
mula of a compound, we naturally first of all look at
the oxides capable of formation. Upon their formuUt
we generally base the whole series of possibly fornui-
ble salts. Thus we have: Hg,,0" = mercurous ox-
ide, and Hg"0" = mercuric oxide, showing Hg t(f be
both a monad as well as a dyad. In accordance, the
formula of calomel must be :
Hg'.cr. or Hg' - cr i
I '
Hg' - cr.
Were we to adopt the formula of HgCl, we would
not ac-ount for the oxide, except that we accepted
304
MEDICAL RECORD.
[August 29, 1896
HgO„, involving a fraction of a unit, contrary to our
custom at present.
Copper Arsenite (Scheele's green). — H'^ (AsO,)'"
(arsenious acid), being a tribasic acid, admits of the
fonnation of tliree series of salts by saturation with
monadic basic radicals. With copper arsenite (in
tablets) the writer has had an e.vperience quite re-
cently, and the salt was prepared and the tablets were
served, all made in his own laboratory, in less than
one hour's time. The article in question is well
known to chemists, but there are many druggists or
pharmacists who do not know it as a drug. It was
made in a hurry in the following manner (as chemists
apply the Cu test for arsenic), taking proper care to
have stoichiometric equilibrium established for this
purpose. The reactions:
As,0^ + 2 CuSO^ + 3 H..O.
2(Cu"HAs03) 2 H.^SO..
(Scheele's green.)
(Sulphuric
acid.)
The atomic weights were used in round numbers:
As, 75; S, 32: O, 16; Cu, 63.
Since then I have selected another relatively more
productive progress, which, however, does not produce
real " Scheele's green" but saturated CUj(AsO,).,,
which physicians, it seems, prefer. It can be made
just as the other salt, by applying more C'uSo^. Thus :
Asp, + 3 H,0 + 3 CuSO,.
Cu(AsOJ, + 3 H,SO,.
For the production of the CuHAsO, a great deal of
skill is required, as the liquid out of which it is to be
precipitated must be critically neutral, the least ex-
cess of either acid or base acting as a direct solvent,
resulting in loss of yield.
In closing, I would remind my readers of the dif-
ference between copper arsenite and " Paris green"
of the trade. Paris green, French green, Schweinfurth
green, are all mi.xtures of Scheele's green with more
or less copper subcarbonate or subacetate, such color-
shades as may be required for technical purposes.
progress 0f
Ulcdiatl
.i-cicnce.
Puerperal Pulmonary Thrombosis. — At a recent
meeting of the Isdinburgh Obstetrical Society, a report
of which is published in The Lancet, Dr. J. Lomond
Lackie read a paper on '" Puerperal Pulmonary Throm-
bosis," with an illustrative case. The patient was a
strong, healthy primipara, aged twenty-six. She en-
joyed good health during pregnancy, but during the
last few weeks of gestation suffered from considerable
anasarca of the legs; there was no trace of albuminu-
ria. The labor was easy and there was an unusually
small ciuantity of blood during labor and after the sep-
aration of the placenta. The puerperium was practi-
cally normal. On the twelfth day she walked from
the bed to a chair, a distance of twelve feet, and as
she reached the chair she exclaimed she was dying,
complained of shortness of breath, and collapsed on
the floor. Her face became livid, she struggled for
breath, and speedily became unconscious. Dr. Lackie
saw her within six minutes of the onset, when she was
dyitig; the extreme lividity of the face was very
marked. Restoratives and ether were used, but she
died two minutes later. On post-mortem examination
the uterus was found to be normal in size, the fundus
being just above the brim of the pelvis, and it was
somewhat flabby. The cavity was normal and aseptic.
There was no indication of clotting in the veins of the
pelvis or in the femoral veins, at least in their upper
part. All the organs of the body seemed healthy; but
on opening the pulmonary arterj- there was found a
thrombus, white, dense, and fibrinous, adherent to es-
pecially one side of the vessel, and extending into
both branches and their ramifications for some distance.
On the surface of this clot there was more recently
coagulated blood. The right ventricle of the heart
was also occupied by a recent dark purple clot. There
were absolutely no premonitor}' symptoms to lead one
to anticipate this result. The small amount of blood
lost during labor was unusual, as this condition seems
to occur more easily in those weakened and ana;mic
from hemorrhage. A few cases of recovery have been
recorded. Ammonia and diffusible stimulants can be
given, and, if life is prolonged, inhalation of oxygen
may be of service.
Bismuth Naphtholate. — Dr. Edmond Chaumier re-
gards beta-naphthol as the best of all intestinal anti-
septics, although it has a disagreeable taste. It can
be prescribed as a mixture with some bismuth salt or
as a combination — beta-naphthol bismuth, which has
no burning taste. The last in the alimentary canal
decomposes, breaking up into naphthol and bismuth
oxide. It is a gray powder, slightly aromatic, and
contains 26.5 per cent, of beta-naphthol. In infantile
diarrhoea the fetid stools lose their odor, the watery
evacuations become thicker, and the green color disap-
pears under the influence of this drug. It can be ad-
ministered in two to five per cent, solution in quince
syrup, of which the dose is one teaspoonful. In diar-
rhoeas of larger children and of adults the remedy acts
quickly, and with a sufficient dose — seventy-five to one
hundred and fifty grains in wafers— they disappear
within one or two days. If the pain is severe opium
may be added. For both infants and adults it is well
to continue the remedy for some time after the diar-
rha-a has stopped. The diarrhoea of the tuberculous
is of great importance, because it interferes with nu-
trition, emaciates the patients, causes them to lose
strength, and prevents the administration of proper
remedies. The remedy has been used as well in the
temporary diarrhcta, which in a few days will undo the
benefits of several months, and in the chronic form,
which is almost continuous and constitutes the princi-
pal lesion. In the first case the creosote carbonate,
the only active and safe drug against tuberculosis,
should be stopped and naphthol bismuth given, not
only during the disease, but for several days after.
In the chronic cases, when the diarrha-a has existed
for several months or vears, the abdomen is painful
upon pressure and the appetite is very much dimin-
ished. .\fter prolonged use of the drug these symp-
toms disappear and the creosote can again be admin-
istered. In typhoid fever (two cases) the intestinal
disinfection was perfect, the tongue was always clean
and moist, and the convalescence was brief. — Ameri-
can Journal of the Medical Sciences.
Appendicitis. — (i) All cases do not require oper-
ation ; on tiie contrary, some cases are best treated
without operation. (2) In cases requiring operations
the appendix should be removed; {a) when there is no
pus; (b) when an endo-appendiceal abscess is present;
{c) as a rule, when there is a ])eri-appendiceal abscess
that requires drainage through the general abdominal
cavity; and (V) when there is general peritonitis with-
out adhesions, with the exceptions noted. (3) A sim-
ple incision should be made and drainage provided in
cases with circumscribed abscess, when this can be
done without opening the healthy peritoneal cavit}'.
An exception should be made to this rule in cases in
which the removal of the appendix will not add to the
gravity of the operation. — Porter, Aledicat JVercs,
September 14, 1895, p. 290.
August 29, 1896]
MEDICAL RECORD.
305
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, August 29, 1896.
RECTAL EXAMINATIONS IN THE DIAGNO-
SIS OF ABDOMINAL DISEASE IN CHIL-
DREN.
It has been truly said that more mistakes in diagnosis
are made from failure of observation than from lack
of knowledge or misinterpretation of facts. This is
more especially true in the case of children and in-
fants, in whom subjective manifestations are not to be
depended upon even when intelligently conveyed. It
is for this reason that any addition to our diagnostic
resources will be hailed with satisfaction, and in such
a light must be viewed the recommendations con-
tained in a communication dealing with the subject
of rectal e.xploration in the diagnosis of abdominal
disease in children presented by Dr. George Car-
penter at a meeting of the East Sussex Medico-Chi-
rurgical Society {The British Gynaecological Joui-nal,
May, 1896). His first e.\perience in this connection,
he relates, was acquired in the discovery by a senior
colleague of a myeloid sarcoma of the anterior surface
of the sacrum in a little girl who had long suffered
from constipation. " Not satisfied with firing off all
the drugs in and out of the phannacopcjeia,'' this prac-
tical man determined to use the '" hands and brain
that nature had provided him with '' and " proceeded
to make a rectal examination." Influenced by this
e.^ample, Dr. Carpenter began the systematic employ-
ment of rectal examination in the diagnosis of ab-
dominal and other obscure disease in children. He
cites a number of illustrative cases in whicii this mode
of procedure rendered the utmost service. Thus, in
the case of a small boy, three years old, presenting an
umbilical fistula and enlargement of the mesenteric
glands, rectal examination disclosed the existence of a
f)ea-sized nodule in the position of the prostate gland
and extending from it slight enlargement of the semi-
nal vesicles on either side. A probe introduced into
the sinus reached the prostatic enlargement, and it was
concluded that a tuberculous abscess of the prostate
had burrowed along the urachus and had found vent
at the umbilicus.
In the diagnosis of tuberculous peritonitis digital
examination through the rectum, in conjunction with
bimanual palpation, is capable of yielding conclusive
information, disclosing, especially in the early stages,
a lumpiness due to matting of the intestines. An
anaesthetic facilitates the exploration, but is not al-
ways absolutely necessary. VVitii the patient's legs
well drawn up, the thighs flexed on the abdomen, the
pelvis raised on a cushion, the left hand of the exam-
iner on the abdomen and the right index finger in the
rectum, the right side of the abdomen can be explored.
By reversing the hands the left side can be examined
up to a level depending upon the length of the exam-
ining finger and the size of the child. If the intra-
abdominal tissues that can be included between the
finger in the rectum and those upon the abdominal
wall are inconsiderable in thickness, peritonitis can
be safely excluded. If, however, the thickness of the
tissues is considerable, it is probable that the perito-
neal coat of the bowel is thickened by lymph. Bi-
manual palpation is capable of disclosing not only
intestinal matting, but also peritonitis without definite
abdominal nodules, or a thin plaque of omental thick-
ening perhaps coarsely granular. At the same time
glandular involvement if present can be appreciated.
The partially filled bladder must not be mistaken for
a peritonitic exudate, and conversely a localized col-
lection of pus or other fiuid may simulate a distended
bladder. The use of a catheter will aid in the differ-
entiation. If doubt exi.st as between fecal lumps on
the one hand and glandular enlargement or intestinal
matting on the other, an enema will make the distinc-
tion. Intestines involved in peritonitis tend to move
cii masse when pressed upon, and do not yield so
quickly to the fingers as in health. Small empty and
constricted coils of intestine may yield a sensation
similar to that of infiammatory thickening of the in-
testine, but the mistake is not likely to happen more
than once and will be avoided if such a condition is
borne in mind.
Rectal examination may thus not only give valuable
positive information in a doubtful abdominal case, but
it may throw a totally different light upon a case of
abdominal disease which may appear to admit of but
one interpretation. In the case of a child presenting
broncho-pneumonia and an abdominal tumor following
whooping-cough it was feared that tuberculous peri-
tonitis existed; but rectal examination, with bimanual
palpation, disclosed the tumor to be a horseshoe kid-
ney. Malignant disease, and especially sarcoma, may
give rise to nodules which can sometimes be detected
only by rectal examination or by bimanual palpation.
Intussusception, likewise, may be discoverable only
by this means. Simple inflammatory affections of the
peritoneum may simulate tuberculous or other lesions
by the formation of abdominal tumors. Abdominal
abscesses are often tuberculous, but occasionally they
have a different origin, sometimes starting from the
vermiform appendix, rarely from an antecedent pneu-
monia or following typhoid fever, and are sometimes
of unknown origin. A not common variety of abdomi-
nal tuberculosis is attended with involvement of the
mesenteric glands, in the absence of other complica-
tions. Even less commonly the intestines are sur-
rounded by tuberculous false membrane, which can be
readily stripped off. The invaginated portion in case
of intussusception conveys to the examining finger a
sensation like that of the os uteri advanced in preg-
nancy. With a knowledge of this fact the differen-
3o6
MEDICAL RECORD.
[August 29, 1896
tiation from tuberculous peritonitis may sometimes
be made.
In children the sacrum as well as the rectum is al-
most straight. The infantile bladder is egg-shaped,
with the larger end downward, and as the pelvis is
shallow it is almost entirely an abdominal organ. .As
soon, however, as the child begins to walk, the blad-
dar sinks more into the pelvis, though even then its
attachments are so loose that it readily rises wholly
into the abdominal cavity when distended or otherwise
displaced — a feature observed almost until the period
of puberty. The child's uterus consists almost en-
tirely of cervi.\ and it lies in the upper part of the
pelvis. At birth the ovaries have descended as far as
the brim of the true pelvis, but in children a few
weeks old they are found close to the e.xternal iliac
arteries at the side of the pelvis. The ovaries are for
the most part elongate oval in shape; occasionally
more or less rounded organs are found. The falciform
or utero-sacral ligament forms a guide to the oviduct.
The former pursues a sickle-shaped course surround-
ing the rectum, being attached behind to the sacrum
and in front to the lower part of the cervix. Using
this structure as a guide, the tubes and ovaries, which
are on a higher plane, can be readily manipulated be-
tween the exploring finger and the bony wall of the
pelvis, or bimanually. The ureters can be examined
at the same time. It is sometimes possible to detect
in the ovaries the small cysts or dropsical ovisacs not
infrequently found post mortem. The uterus, on ac-
count of its mobility, is not readily detected in this
way, but if the bladder be emptied any marked ab-
normality can be appreciated by bimanual palpation.
In young children the uterus can be rolled between
the finger and the symphysis pubis, and its contour
made out with ease. Ovaries and tubes may be dis-
placed into the inguinal and crural openings. A case
is on record of a child three months old in whom an
ovary and oviduct that had descended into the inguinal
canal were removed. Tuberculosis of oviducts, uterus,
and ovaries is extremely rare in children. Inflamma-
tory disorders of the tubes and ovaries in children
have received but little, if any, attention. A case is
on record of a little girl in whom symptoms of pelvic
peritonitis developed in the sequence of an attack of
gonorrhoea. Salpingo-oophoritis sometimes compli-
cates vulvo-vaginitis in children. The inflammation
may subside into latency and be revived at the period
of puberty.
With the knowledge tlius far gained, as indicated
in the foregoing delineation, an agency of practical
value is placed in the hands of the clinician in the
employment of rectal examination in the diagnosis of
abdominal and other disease in children.
Fat Witness Fees. — At the Carlisle meeting of
the British Medical Association it was stated that Sir
Thomas Stocker received $1,000, Sir Dyce Duck-
worth §600, Mr. Ward Cousins $300, and Dr. Bate-
man $200 for their services in testifying in behalf of
the editor of the Association Journal during the suit
brought against him by Dr. Kingsbury.
THE TREATMENT OF ACNE.
The lesion in acne is an inflammation of the sebaceous
glands and adjacent tissues. All writers upon the
subject agree that the causes are to be divided into
three classes : the overproduction of sebum, impedi-
ments to the escape of the sebum, and irritation of
the gland by foreign matters, such as pyogenic organ-
isms from outside or drugs eliminated through the
glands. These three general causes represent the
fundamental factors in causing the disease. We find
that a further analysis of the etiology, however, such
as is given in an article on the subject of acne by
Dr. R. A. McDonnell ( Vale Medical Journal), in-
creases the number of causes to eighteen or tvventy;
and one concludes from a study of the list that acne
can be produced by almost anything, from indigestion
to a state of exalted self-consciousness.
The article by Dr. McDonnell gives a resume of
some of the modern methods of treating this trouble-
some disorder. In the acutely suppurating forms,
incision, so as to allow free bleeding, followed by
washing with antiseptics and the application of
aristol powder is indicated. In perhaps the more
numerous class of suppurating cases, in which the
suppuration is slight and the number of pustules very
great, incision is impracticable, and the application
of some preparation which will produce desquamation
is recommended. A preparation containing ten parts
of beta naphthol, fifty of sulphur, twenty of green soap,
and twenty of vaseline is recommended. This is to
be spread thickly over the affected surface, allowed
to remain on for about three-quarters of an hour, and
then wiped off. This application is made every
day in the evening, for five days. As a result, the
surface desquamates in thin epidermal scales. A
soothing paste is then applied every evening and
allowed to remain all night. The well-known Lassar
paste, composed of salicylic acid, oxide of zinc, starch,
and vaseline, is recommended for this. In the milder,
non-suppurating cases, in which firm red papules
abound, the application of the Lassar salicylic paste is
often sufficient, so far as external medication is con-
cerned. Return of the trouble is prevented by the use of
cleansing lotions, which keep the gland ducts open.
For this purpose a five-per-cent. resorcin soap is recom-
mended. But the ordinary measures of bathing in
very hot water and thorough friction of the skin are
often efiicient. Some dermatologists use ichthyol
soap and others advise soap linament, some antiseptic
being incorporated with it. Reinold prescribes, for
example, bathing the face night and morning with hot
water applied on a sponge previously kept in a one-per-
cent, sublimate solution. The face is rubbed for
several nights with black potash soap, the latter being
left on till morning. The face is then washed with
warm water and dusted with starch. After a few
days emollient applications, such as boric-acid solu-
tions or glycerin and water with sulphur, are applied.
The internal measures necessarily depend very
much upon the age and condition of health of the
patient. .-Vcne in a period of adolescence is due to
the physiological stimulation of the sebaceous glands,
August 29, 1896]
MEDICAL RECORD.
307
produced by the sudden increase in the growth of the
hair. But this is often aggravated, as is well known,
by reflexes, ancemia, and sexual neuroses. Dr. Mc-
Donnell thinks that, as a routine prescription, the
pill of aloin, belladonna, and strychnine is to be
recommended. The aloin, undoubtedly, is the only
one of these constituents that does any particular
good. A good many people find that they cannot eat
certain foods without the development of acne. Oat-
meal, cheese, butter, bananas, and candy are some of
the substances which affect the sebaceous glands
unfavorably. Internally, arsenic may be given also,
and, empirically, ichthyol, in doses of five to seven
grains, and sulphide of calcium are recommended.
The latter drug had, at one time, much vogue, but its
reputation has hardly been sustained.
The number of remedies, external and internal,
which have been recommended and which can be ad-
vantageously employed in the treatment of acne is
very great, and it is most important, after all, there-
fore, that the physician discover the cause underlying
each case of acne, in order that he may treat it in-
telligently and prevent a recurrence.
^ciojs ot the 'Smccfe.
Dr. C. H. Hughes, of St. Louis, has been ap-
pointed honorary president of the section of neurology
and psychiatry at the Pan-American Medical Congress.
All who intend to present papers in this section are
requested to communicate with Dr. Hughes.
Cattle Plague in Jamaica. — A very serious plague
has broken out among the herds of cattle in the island
of Jamaica, and the government has sent for Mr. Wil-
liams, the cattle expert of Scotland, to study the dis-
ease and, if possible, to prevent its further ravages.
Picric Acid is recommended by Thiery, of Paris, in
the treatment of burns. He immerses the part for
five minutes in a solution of the strength of one part
to sixty of water and then wraps the part in wadding,
protecting it, if excoriated, by iodoform gauze.
Just an Employee. — Among the widely advertised
attractions of a new shop in this city is to be a hospi-
tal for the benefit of any of the shoppers who may be
taken ill. There will be a resident physician, and it
is announced that his services will be gratuitously ren-
dered to any of the patrons of the establishment, " just
as those of any other employee of the house."
Roentgen Rays for Cancer. — Dr. Despeignes claims
to have had a measure of success in treating a case of
carcinoma of the stomach with the a--rays. They
were passed through the part twice a day for half an
hour each time and by the end of a week the patient's
condition was markedly ameliorated and the tumor
was evidently smaller.
Need of Caution in the Use of the Roentgen
Rays. — Dr. W. V. Gage, of McCook, Neb., writes: '• I
wish to suggest that more be understood regarding the
action of the .r-rays before the general practitioner
adopts them in his daily work. Several cases of alo-
pecia and erythema have followed its use in Omaha
and Lincoln, and in one case of my own, when the
rays were utilized in trying to determine the presence
of a foreign body in the stomach of a child, erythema
and finally sloughing took place, leaving a lesion over
the region penetrated by the rays, which is at present
the size of the hand."
Treatment of Pneumonia. — In the article with this
title by Dr. Van Doren, in the issue of August 2 2d, the
second formula was incorrectly printed. Instead of
sodii bicarb., potassii tart., aa 3 iss., it should have
read: sodii et potassii tart., 3 iss.
The Unwritten Law. — Commenting upon the pro-
posal to draw up a code of ethics of the British Med-
ical Association, T/ie Lancet says that " professional
ethics cannot be put into written form. They are es-
sentially 'unwritten.' To write them would be to
spoil them. They are like the aroma of some flowers
— an aroma which when concentrated becomes offen-
sive."
The Medical Practice Law in Hawaii. — No one
is permitted to practise medicine in the Republic of
Hawaii without a license. A person wishing a li-
cense must pass an examination before the board of
medical examiners, and if this is done successfully
the board of health is notified, and recommends the
minister of the interior to issue a license. All appli-
cants must pay to the minister of the interior a fee of
ten dollars. Any violation of this act entails a pun-
ishment by fine of not more than $250. A license
may be revoked at any time by the minister of the in-
terior for professional misconduct, gross carelessness,
or manifest incapacit)'.
Smoking and Intellectual Labor — Dr. Drysdale,
writing to the British Medical Journal, a propos of
certain recently published statistics of smokers among
the students of American colleges, recalls some facts
discovered by Bertillon in 1855. He found on in-
quiry made by him concerning the pupils of the Poly-
technic School of Paris that 108 of the pupils smoked
and 52 did not smoke. He then arranged the 160 pu-
pils into eight divisions, according to the place they
held in examination, 20 in each rank, and found that
of the 20 who stood highest, 6 were smokers and 14
non-smokers. Of the next 20, 10 were smokers and
10 non-smokers; of the next 20, 11 smoked and 9 did
not smoke; thus showing how much higher the non-
smoker stood intellectually than the habitual smokers.
He also found that the mean rank of the smoker, as
compared with that of the non-smoker, deteriorated
from their entering to their leaving the school. As a
result of Bertillon's inquiry, the minister of public in-
struction of France issued a circular, addressed to the
directors of schools and colleges, forbidding the use
of tobacco and cigars to students.
Bichloride Injections in Leprosy.— Dr. H. Rad-
cliffe Crocker reports in The Lancet for August 8th
two cases of leprosy in which very marked improve-
ment followed deep injections of one-fifth of a grain
of corrosive sublimate made once a week for a long
period.
3o8
MEDICAL RECORD.
[August 29, 1896
Navy Department — Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the Medical
Corps of the U. S. Navy for two weeks ending August
21, 1896. August 9th, Assistant Surgeon M. K. John-
son detached from the U. S. S. JVein York and ordered
to the Coast Survey S\.QZ.mex £ac/ie. August 12th, P.
A. Surgeon G. A. Lung ordered to the receiving ship
Vcrt?wnt. August 12th, P. A. Surgeon E. R. Stitt de-
tached from the receiving ship Vermont and ordered
home on waiting orders. August 2 :st. — Passed Assis-
tant Surgeon A. M. D. McCormick detached from the
Bancroft and ordered to the Naval Academy. Passed
Assistant Surgeon E. M. Shipp detached from the
Monongahela and ordered to the Bancroft.
Patients Poisoned in a Hospital. — .\ nurse in the
City Hospital at San Francisco went out one evening
recently, leaving the patients in his ward in charge of
one of their own number. This man gave two of the
patients a draught from a bottle containing poison in-
stead of the medicine prescribed for them, and they
died from the effects of it.
American Microscopical Society. — The nineteenth
annual meeting of the American Microscopical Society
was held at Pittsburg, on August 18, 19, 20, 1896,
under the presidency of A. C. Mercer, of Syracuse.
An address of welcome was delivered by Dr. W. J.
Holland, chancellor of the Western Universit)'.
Among the papers read were the following: "Com-
parative Histology," by Prof. Edith J. Claypole;
" Courses in Histology and Methods of Conducting
Them," by Prof. S. H. Gage, of Ithaca; " Photomicrog-
raphy by the Use of an Ordinary Objective Prac-
tically Considered, with Specimens of Work," by
Thomas J. Bray, of Warren, O. ; " On Astronomical
Photographs, with Photomicrographic Apparatus,"
showing pictures of a partial eclipse of the sun taken on
an eight-inch focus, by President Mercer; " The Anti-
vivisection Bill," by Pierre A. Fish, of Chicago;
" The Acetylene Light as Applied to Photomicroscopy,"
by William H. Walmsley, of Chicago; '"What is the
Best Method of Teaching Micro-Science in Medi-
cal Schools?"' by Dr. Vida A. l^atham, of Chicago;
"The Structure of the Teeth and Spines of Some
Fossil Fishes, Mazada and Ctena Canthus," by Prof.
E. W. Claypole, of Akron, O. ; " The Development of
the Brain in Soft-Shell Turtles," by Susanna Phelps
Gage, of Ithaca, N. Y. ; " The Rotifera in Sandusky
Bay," by Prof. E. W. Claypole, of Akron, and D. S.
Kellicott, of Columbus, O.; " On the Public Water-
Supply for Small Towns," by Dr. M. A. Veeder, of
Lyons, N. Y. ; "The Requisites of a Pure Water Sup-
ply," by Dr. William C. Krauss, of Buffalo, N. Y.
The International Congress of Psychologists,
which was held this month in Munich, will meet
again in Paris in 1900.
Obituary Notes. — Dr. J. C. Worthington, a sur-
geon in the United States army, died in Louisville on
August nth, of acute articular rheumatism. — Dr.
Armand Despr^s, of Paris, died during the first week
of August, at Interlaken. He was born in 1834, and
was graduated in medicine in 1861. He was a good
surgeon of the olden times, but was such an obstinate
Chauvinist that he would never accept the principle of
antiseptic surgery, since it was not a French discov-
ery.— Dr. C. M. Kittredge, of Fishkill-on-the-Hud-
son, died suddenly at his country home in New
Hampshire, on August 19th. He was a graduate of
the College of Physicians and Surgeons in this city
in 1863. — Dr. A. Sydney Roberts, of Philadelphia,
died at Newport, R. I., on August 17th, after a brief
illness, at the age of forty-five years. He was at one
time a promising orthopa'dic surgeon, but he retired
from the practice of his profession a number of years
ago, and had since, until recently, been living abroad.
— Dr. Andrew Fleming, of Pittsburg, died at Mag-
nolia, Mass., on August i8th, at the age of si.\ty-eight
years. He was a graduate of Jefferson Medical Col-
lege and a successful practitioner. — Dr. William F.
Hertzog died at Friedensling, near Reading, Pa., on
August 20th, at the age of forty years. He was a
graduate of Long Island Medical College and was at
one time active in county politics. — Dr. John B.
Haines died at South Bethlehem, Pa., on August 15th,
at the age of sixty-seven years. He was formerly en-
gaged in the practice of his profession in Philadelphia,
where he at one time occupied a seat in city councils,
and where he had also been assistant physician to the
county prison.
The Cumberland County (N. J.) Medical Society
held a meeting at the Hotel Cumberland, liridgeton,
N. J., on July 14, 1896, with the president. Dr. Oliver,
in the chair. A paper on " Penetrating Wounds of
the Abdomen " was read by Dr. Cornwell. Dr. S. M.
Wilson read a paper on " Hydrophobia," in which he
questioned the value of Pasteur's method of treatment
and emphasized the importance of prophyla.\is by
means of strict supervision of the dog. Dr. The-
ophilus Par\'in, of Philadelphia, will address the next
meeting of the society, w-hich w-ill be held the second
Tuesday in October.
©bitiiarij.
WILLIAM HENDERSON WILKES,
WACO, TEX.
Dr. William Henderson Wilkes died at his home
in Waco, Tex., .August 14th, after an illness of six
weeks. Dr. Wilkes was born at Raymond, Miss.,
in 1833, and was graduated at the University of Nash-
ville, in the class of 1855. He enlisted as a private
in the Confederate army, and gained rapid promotion
for gallant conduct, being retired with the rank of
colonel and acting brigadier-general. In 1868 he
began practice in Waco, Tex., in which place he had
since lived, except for a period of one year, during
which he held the chair of obstetrics and diseases
of children in Kansas City. In 1882 he was elected
mayor of Waco and was reelected in 1885. In 1888
he was appointed professor of the theory and practice
of medicine in the Texas Medical College at Gal-
veston, but declined to remove from Waco again. In
189 1 he was chosen president of the Texas State
Medical Association. In April of the present year
he was again elected mayor of Waco, which office he
held at the time of his death.
August 29, 1896]
MEDICAL RECORD.
309
Society glepforts.
BRITISH MEDICAL ASSOCIATION.
Sixty-Fourth Annual Meeting. Held at Carlisle, July
28, 2g, JO, and J I, i8g6.
(Continued from page 279.)
SECTION ON SURGERY.
First Day — H'ednesday, July 2gth.
The Surgical Treatment of Prostatic Hypertro-
phy.— Dr. David MacEwan, of Dundee, opened the
discussion. He referred to the work of Sir Henry
Thompson and Mr. Reginald Harrison in connection
with the advances in surgery of the bladder, es-
pecially its drainage, and to the occasional observa-
tion that the symptoms of cases of enlarged prostate
had been ameliorated by removal of portions of the
prostate gland during the operation of lithotomy.
He then spoke of the elaboration of the operation of
prostatectomy. The mortality of operations on the
prostate undertaken under the usual conditions being
still high, attention had been largely directed during
the last three years to the results of castration for pros-
tatic hypertrophy, the introduction of which was largely
due to Dr. White, of Philadelphia, and whose cases,
especially the series published in 1895, showed great
success. Owing to lack of time he passed over physio-
logical considerations about the function of the pros-
tate and its relations to the testes, and went on to the
clinical experience of the effects of castration and
vasectomy. In castration, although the results were
valuable, they were not perfect: and then au.\iliary
methods, such as catheterization and caustics directed
to the state of the urine, and sometimes puncture of
the bladder, were often employed at the same time.
It was difficult to say how much of the benefit was
due to these measures. In the record of one series
(Ferich's) drainage was used in addition. Of fifty-
two operations, forty were successful; eight patients
died, and in si.\ no diminution in size was apparent.
He had studied the records of thirty-seven cases of re-
section of the vas, and in twenty-si.x a good result was
noted.
Personally, he had performed double castration for
enlarged prostate three times, and resection of the vas
for the same cause twice, but had never done single
orchidectomy. In the cases of double orchidectomy
all the patients had been leading a complete catheter
life for some time ; in two cases as long as seven years.
After operation all were improved, but one patient still
used the catheter every twenty-four hours. After two
months shrinkage of the prostate was noted, in two
cases to one-half the previous size. Also shortening
of the urethra was noticed.
He thought that probably the rationale of the
shrinkage was a reflex reduction of hypera;mia with sub-
sequent real atrophy. The theories brought forward to
explain the exact effect on the gland were discussed, and
he leaned to the theory that the changes were due to
the medium of the nervous system, but at present the
evidence was conflicting. Anyhow, the amelioration
of the symptoms, including the return of vesical con-
tractility, was remarkable. He thought that the large
soft form of hypertrophied prostate was more amenable
than tiie smaller hard fibroid form.
One objection that had been brought against
White's operation was that in certain cases mental
disturbances resulted from the operation. With tiiis
he did not agree, but thought these symptoms were
due to uraimia from the state of the urinary tract and
not to the operation itself.
If resection of the vasa deferentia were followed
by equally good results to orchidectomy, then the less
severe operation would be the better. But at present
the statements of results did not agree. .As to the re-
sults of experiments on animals: In dogs Griffiths
found that the testicles were not affected by vasectomy,
while others observed atrophy of these organs. White
says there is a loss of weight after eight days. The
inference was that although in some cases atrophy fol-
lowed, in most it did not. At present there was no evi-
dence of the result of vasectomy in man, on a normal
prostate. He had twice performed the operation ; one
subject died of ura;mia. The other, who had been
leading a catheter life for seven years, still required
to use the catheter, but some diminution had taken
place in the size of the prostate and the symptoms were
ameliorated. But the diminution in size was not so
marked as in orchidectomy.
He had found no mention of mental disturbances
following this operation, save once. He thought it
equally difficult to explain the shrinking in this, as in
White's operation. White says it is due to certain
nerves being included in the ligature. Probably the
explanation was to be found in engorgement of the
testis from obstruction to its outflow, with subsequent
atrophy. In doing the operation both testicles had
better be removed at one sitting.
He concluded that in a certain proportion of cases
castration was needed, and might be done with good
results. In many the hypertrophy was much dimin-
ished, and all the symptoms relieved. Vesical con-
tractility may often be restored, but even if contractility
did not return relief was obtained. Lastly, vasectomy
showed slower and more uncertain results.
Mr. Reginald Harrison spoke chiefly of division
of the vas deferens in cases of hypertrophy, as an
alternative to orchidectomy. His method of reasoning
appeared to be as follows : Removal or atrophy of the
testes in man is followed by atrophy of the prostate.
Then in cases in which the vas was destroyed by injury,
atrophy of tire testicle followed. Therefore, divide
the vas deferens rather than remove the testicle, since
the operation would be less dangerous.
He divided his own cases into two groups — one
group of twelve cases, in which he did single vasec-
tomy ; a second group of ten cases, in which the
double operation was performed. Of the first group,
seven received permanent benefit, and five either
showed negative results or were lost sight of. The
cases were not of the severest character, but the im-
provement in symptoms w-as marked. Of the second
group, five received considerable, and he thought, last-
ing benefit, while the remaining five were either too
recent to judge or not benefited. In the double opera-
tion he preferred to wait a month or so after the first
vasectomy before operating on the opposite side.
The points gained were, diminished frequency
of micturition, a lessened use of the catheter, an im-
proved condition of the urine, while the actual
catheterization was easier and vesical spasm less
marked. He considered that many cases were helped
by White's operation or by vasectomy, but some were
not amenable to either. He was not opposed to cas-
tration; he believed that ill mental results did some-
times follow. He thought that at present we had not
sufficient information for selecting cases, and hoped
the discussion would help to determine when orchidec-
tomy and when vasectomy would be more suitable.
Mr. Mansell Moullin thought that all statistics
as to the results of operation were valueless. He
did not refer to any particular series, but thought no
comparison between the cases was possible, even with-
out the still further disturbing elements of different
surgeons and different nationalities. He would him-
self rely on individual experience alone. He then
3IO
MEDICAL RECORD.
[August 29, 1896
went on to point out that the operation of prostatec-
tomy seemed in danger of neglect. This might be
due to the high mortality (twenty per cent.) of the
earlier cases. But Mayo Robson had done eleven
cases with one death, and he himself had had five
cases with no death. If septic cystitis and pyone-
phritis were present at the time of operation, the
mortality must be high, but if suprapubic prostatec-
tomy were done while the urine was still healthy the
mortality would fall and relief be given. Castration
should be reserA-ed for cases which could not with-
stand suprapubic prostatectomy, or when age was
sufficiently advanced to do away wnth the very real
if sentimental objection. He did not believe in
unilateral orchidectomy, and gave the case of a gentle-
man with one testis atrophied from infancy who had
a median outgrowth in the neck of the prostate, and
in whom no difference in size could be detected in the
lateral lobes.
Dr. L.\ndberg, of Bergen, spoke in favor, both of
White's operation and of vasectomy, but thought tlie
first was the more certain. He believed that the
nervous theories of the relief were right. As to com-
plete ligature of the whole cord, he recorded a case
of gangrene of the testis when such had been done.
He dwelt on the difficulty of exact differential diag-
nosis of all cases, but did not fear that the operations
in question would be abused in Norway.
Mr. Chiene said he had an intense respect for the
testis, and believed orchidectomy should be done only
after all other means of relief had been tried and had
failed. He believed the treatment could be summed
up into, first, a proper use of the catheter; then, if
more were required, suprapubic cystotomy should be
perfo -med. If the urine were sweet, a lobe of the
prostate might be removed if necessary. If the urine
were found septic, the indication would be for drain-
age, for six weeks, combined with rest: then subse-
quent removal of a lobe if required. Lastlv, he
would recommend a perineal tube. But he would
advise a man to wear a perineal tube and his testicles,
rather than no tube and no testicles.
Mr. South.^^m, of Manchester, thought that active
measures were required in only a small proportion of
all cases. He believed in irrigation of the bladder,
the use of substances to render the urine antiseptic,
and an earlier recourse to the catheter. If supra-
pubic prostatectomy w^ere employed, a pendulous
easily removable middle lobe was often found. If
not, a ring or collar of prostatic tissue might be re-
moved, or enucleation (which was a serious operation)
of the gland might be attempted. He also advocated
drainage through a suprapubic opening for several
weeks, or the making of a permanent fistula. Of
double castration he thought the results sufficiently
encouraging, but all patients did not regain a complete
power of voluntary micturition. He had had no
actual experience of vasectomy.
Mr. Morton related a case of double castration,
in which, although the gland atrophied, about twelve
ounces of residual urine remained in the bladder.
He believed that the operation of election dej^ended
largely on the means and intelligence of the patients.
Mr. Jordan Lloyd thought that there was much
nonsense talked and written about the whole subject.
Although when younger he had been animated by a
burning desire to operate on the prostate of everv
man who attained the age of fifty-five years, his views
had since become modified. He had had a large ex-
perience of the ailments of old men, as he was sur-
geon to the Birmingham Workhouse, and he had been
struck by seeing how well these old men with large pros-
tates went on, if let alone. He thought that there was
great difficult)- in determining the actual condition of
the gland, and the treatment must depend on that.
The different varieties of prostatic enlargement were
referred to, and he thought that the cases in which
prostatectomy succeeded were those of polypoid en-
largement, while it did not answer so well when the
hypertrophy was general.
In passing he wished to speak most highly of the
value of the simple soft Jacques' catheter. It was
quite harmless, easily cleansed, and if it could be
used no operation was needed.
Again, in examination of the growth the mere rectal
examination w-as a fallacy. Often rectal signs of
enlargement were present, but no prostatic symptoms,
or no signs of hypertrophy were noted per rectum
while symptoms were present. A sound in the bladder
and finger in the rectum were much more useful.
Cystoscopy might or might not be of use. It gave a
limited view- only, but should be tried.
Perineal drainage he never used, and he had a pa-
tient at present who had worn a suprapubic tube with
comfort for eight years.
Dr. Ca.merox, of Toronto, agreed in the main with
Dr. MacEwan's and Mr. Harrison's papers. He pre-
ferred the low operation for drainage, since the result as
regards the atrophy of the gland was better. He spoke
of the possibility of removing the prostate by mor-
cellement per perineum. Also polypoid growths
might be dealt with by this method. The researches
of Johnson, of Cincinnati, on the production of the
menopause by inclusion of nerve fibres in the broad
ligaments by ligature were mentioned, and the possi-
bility of good results of interfering with the nerves
of testes might be similarly explained.
He had done orchidectomy in nineteen or twenty
cases, with one death. The results in all the others
except two were good. In these mental symptoms
developed, and in one case, in view of the results of
Brown-Se'quard's investigations, he administered the
extract of fresh sheep's testicle with a good result.
The other ca.ses got well in a few days. He drew
attention to the excellent work of American sur-
geons.
Dr. MacEwax, in closing the discussion, said that
Mr. Harrison's cases of vasectomy were the largest in
number he had seen, and, as the results were so good and
the operation so harmless, he should in future be in-
clined to do that first and ca.stration subsequently, if re-
quired. He quite agreed that prostatectomy was the
most suitable for intravesical growths, but general en-
largement must be treated by orchidectomy. In reply
to Mr. Chiene's arguments, he did not find that the pa-
tients had any sentimental objection to parting with
their testicles, but were glad to grasp at any means of
relief for the condition. Drainage of the bladder was
very useful indeed when patients were too feeble
or too reduced to stand any more radical proceed-
ing.
Subphrenic Abscess. — Dr. Lai-exstei.\ read a
paper on ■" Subphrenic Abscess Lnd its Treatment."
He spoke of the first diagnosed case by Dr. Barlow,
then of one which came under the care of Dr. Williams
in the same year, and finally the more recent work on
the subject by Leyden. He defined the condition as
a collection of pus beneath the arch of the diaphragm.
Its origin might be primary or secondary to affections
of neighboring viscera, f.^-, stomach, duodenum, kid-
ney. It might be metastatic or due to extension of
disease from the thorax or ribs. The general symp-
toms were not characteristic, and the diagnosis had to
he made from local signs — pain, sense of oppression,
increased sensitiveness to touch along the side and
above the diaphragm. Possibl)^ there might be signs
of pleurisy above or of adhesions to intestines below.
The diagnosis might be confirmed by exploratory
puncture. He discussed the natural method of termi-
nation by perforation into the stomach, lung, etc., and
August 29, 1896]
MEDICAL RECORD.
311
considered that the prognosis depended on whether or
not surgical aid were given. He found that only six
cases of those left alone recovered, while thirty-nine
out of seventy treated surgically lived; so that, as
the chance of self-healing was remote, the treatment
should be prophylactic in cases in wiiich the condition
might be suspected. Here he thought medical treat-
ment was needed. But when it was once developed
the surgeon should take charge of the case and the ab-
scess be thoroughly opened and drained, a thick double
drainage tube being left in. He gave details of si.\
cases of his own.
Carcinoma of the Mamma Dr. Snuw read a
paper on three hundred cases of operation for malig-
nant disease of the breast. He drew special attention
to the insidious marrow lesions, and showed photo-
graphs of cases in which the prominence of the sternum
was well marked. He gave details of cases, in one
of which a woman was operated on for pure scirrhus
of si.K months' growth, and had remained immune uj)
to the present, si.xteen and a half years. Another h.id
been free for eleven and a half, another for eight
years.
The appearance of carcinoma in the second breast
he considered to be always simultaneous with general
infection, and although he had removed a second
breast in one patient he would never again do so,
either simultaneously or subsequently.
The great obstacle to the radical cure was the in-
sidious infection of the marrow, and the practical
point was a wide and free dissection of the subcuta-
neous tissue. Such operations as amputation at the
shoulder-joint for the sake of clearing the axilla were
necessarily too late, and therefore useless.
Skiagraphs. — Dr. Davidson gave a demonstration
of the .r-rays. He showed numerous photographs.
In one case the heart of an adult was w-ell shown. An-
other was a photograph of a case of coxa vara. In
another, of the leg and foot, the tendo Achillis, out-
lines of muscles attached to the tibia, tarsal bones,
and articular cartilages were easily seen. The chief
points about the practical working were to have a
large and powerful induction coil — one ten inches in
diameter was required — and to so arrange the electrodes
by manipulating them that the current just takes the
lamp, instead of jumping across the space between
the electrodes. This was got by placing the ends
close and then separating them until the spark no
longer passed and the lamp glowed. This he had
learned from an interview with Professor Roent-
gen, who said that thus the maximum photographic
effect was got. Also by means of the fluorescent
screen the members present were able to see a bullet,
lodged somewhere in the thorax, on the left side below
the ninth rib in a young adult. It had been in the
patient's body about three years.
Oxygen in Surgery. — Dr. George Stoker read
this paper, and showed the apparatus required for the
use of oxygen in surgery. The progress of the cases,
both naked eye and microscopical, was illustrated by
slides projected on the screen. The chief points were
the very good effect in chronic ulcers of the leg,
severe burns, baldness, alopecia areata, and eczema.
He showed actual patients. Also the effect on the
organisms present in the wounds was detailed. This
seemed to be in the nature of getting rid of mixed
cultivations and leaving only a pure cultivation of
certain organisms which Dr. Stoker found by experi-
ence to be harmless, as the patients in whom they were
present rapidly got well. The methods for the appli-
cation in eczema, otitis media, and ulceration of the
cornea were also exhibited. The strength of oxygen
used was usually twenty-five per cent. The applica-
tions, so far as could be judged, were attended with
•narked success.
St'coiiii Day — Tliursday^ July JO//1.
The Surgical Treatment of Appendicitis. — Dr.
M.\cDouG.ALL opened the discussion on this subject,
devoting his time chiefly to the clinical aspects of the
affection. It had been asserted that no prognosis
could be got from the symptoms. With that he did
not agree. The cases could be classed from a clinical
point of view as mild simple appendicitis, appendi-
citis with abscess, appendicitis with perforation, and
relapsing cases.
The symptoms to which attention should be directed
were pain, tenderness, muscular rigidity, tympany,
condition of the temperature, tone of the pulse, pres-
ence or absence of vomiting, facial aspect, and, about
the third day of the disease, tumor. Examination per
rectum should be always practised, and especially gave
help in children's cases.
The treatment was absolute rest in bed, fluid diet,
leeches, the use of ice bag, but opium only when pain
demanded it. Aperients should not be used for fear
of risk to any adhesions present. Sometimes enemata
were useful, and intestinal antiseptics, such as salol
and naphthalin, should be tried. If the case were going
on well, a fall of temperature, diminution of tender-
ness, and lessening of the swelling would follow.
If abscess supervened the symptoms were more se-
vere, the swelling was more acute, and the temperature
was higher or rose steadily. The abscess might re-
main localized or simulate closely general peritonitis.
Or there might be suppuration and no local tumor be
discernible.
Acute perforative peritonitis was attended by symp-
toms which cannot be overlooked. Such often came
on in persons of previous good health, and with no
history of former attacks. These cases were rare, but
the liability to perforation gave need for much watch-
fulness.
The fourth kind showed symptoms similar to simple
appendicitis, but there seemed to be a curative process
underlying these attacks, as they often became less
severe and ceased.
The treatment must in first attacks be prophylactic.
The recognition of the cases was often difficult, as
the onset was so insidious in character. Then sub-
peritoneal perforation might give rise to doubtful signs.
A case was related in which the temperature gradually
rose to 103° F. Signs of septic poisoning supervened
and a retroperitoneal abscess was found containing
two and a half ounces of pus. It was impossible to
say when the pus commenced to form. The necessity
of early rest to prevent perforation and general peri-
tonitis was absolute.
If the symptoms justified it, after a careful local
examination, an incision should be made for explora-
tory purposes.
In children appendicitis was by far the most com-
mon cause of abdominal inflammation. The speaker
related a case in which, in a young girl, operation had
been undertaken for what was thought to be a perfo-
rated gastric ulcer. None was found, but at the post-
mortem a large abscess in the iliac region with general
peritonitis was discovered. The moral was, when in
doubt think of the appendix. Cases of inflammation
and even fibroid of the right broad ligament had been
mistaken for appendicitis, but usually a bimanual ex-
amination would clear that up.
The prognosis depended largely on an early recog-
nition, followed by careful treatment.
As to the treatment, a large number of cases got
well without any surgical intervention at all. Of
course in the third group of cases there was no ques-
tion as to the line to be adopted. But in a case of
average severity, if the symptoms after forty-eight
hours did not show a tendency to increase, then one
312
MEDICAL RECORD.
[August 29, 1896
should watch and wait. If a quick, thready pulse,
vomiting, more pain, and depression came on, with in-
creasing abdominal distention and thoracic breathing,
then surgical intervention should not longer be delayed.
In children it should be the rule to operate earlier, as
their condition changes so rapidly.
In fact, each case must be considered on its own
merits, and we must be ready to recognize that we might
be sadly deceived. Such a case might seem to be get-
ting well, when sudden symptoms of perforation might
come on and in less than forty-eight hours all be over.
He instanced a case of a man aged twenty-seven years,
who was admitted into a hospital on the third day of
the disease. Within twenty-four hours the condition
was hopeless and he died in less than four days.
Then in cases of strangulation of the appendi.x it
might be impossible to judge from the symptoms how
severe the condition was.
As to the technique of operation, usually the ob-
lique incision was best; but the appendix might be
found bound down out of reach by adhesions. The
appendi.x might be removed: the wound closed usually
without drainage.
In all cases of septic peritonitis the iliac fossa
should be carefully explored. Through a median in-
cision the abdomen may be well flushed with saline
solution at a temperature of 110° F. if the state of the
peritoneum called for it, and the appendix should be
removed if the patient could bear it. In some bad
cases the patient might be so weak that a general ana-s-
thesia would be fatal. In such local anaesthesia should
be used, such as freezing with the spray, and the pus
evacuated and abscess drained.
Experiment showed that in many cases the perito-
neum did not readily become infected during opera-
tion, which was a fortunate fact, since removal of the
appendix earlier, during the third or fourth day, was
difficult to do without soiling the peritoneum.
Is removal of the appendix absolutely necessary?
No. The part might be plugged with gauze and shut
off from the general abdominal cavity, and drained
with success. To search for and remove every appen-
dix in this condition was poor surgery. The welfare of
the patient must be primarily considered and com-
pleteness of the operation after.
In deep-seated posterior collections the incision
might be well back and the peritoneum easily avoided.
If the abscess were well localized, and after incision the
appendix was found involved in the abscess wall, it was
often best to leave it alone. Of course if intestinal
obstruction were present from adhesions, these must be
broken down, and protection of the peritoneum by
careful disinfection and gauze packing employed.
The various methods of removing the appendix in
chronic cases were discussed. He preferred an ob-
lique incision and covering the stump with a perito-
neal flap if possible.
He hoped to bring out an opinion as to what
were the most valuable signs indicating early opera-
tion. The initiation of early operation in these cases
was largely due to the work of .\merican surgeons, who
drew attention to the statistics of the comparative mor-
tality of cases early operated on and those left alone.
From the records of one hundred and fifty-one cases,
extending over three years, at the Edinburgh Royal
Infirmary, grouped under the headings of appendicitis,
typhlitis, and perityphlitis, the mortality was thirty-
seven. The mortality at St. Bartholomew's and St.
Thomas' was twenty per cent. There were cases
without peritonitis and without perforation.
Much depended on the early differential diagnosis,
and one should endeavor to make out the stage the
lesion had arrived at, as the treatment to be adopted
depended on that.
One question was, what would the mortality be if it
became the general practice to operate early ? Might
not too great precipitation rob the patient of his
chance of spontaneous recovery? The operation it-
self was not a light one: it needed competent assist-
ants and favorable surroundings. The cases were not
always straightforward and difficulties often arose.
The aid of the surgeon should always be early in-
voked in these cases by the physician, especially in
acute cases.
Mr. Southam said he had operated ten times on
the recurrent form. He found the appendix bent and
bound down twice, distended twice, in two cases con-
taining hard facal masses. In four cases suppuration
had taken place — three locally, one generally. The
appendix was removed eight times.
Medicinal measures he thought powerless to prevent
recurrence; the only radical cure was to remove the
appendix. And that should be done in the quiescent
interval after an attack.
He would not operate after a first attack, but if
two well-marked seizures had taken place and any
local signs were left, he would proceed to operate.
Three of his operations had been after a second at-
tack.
As a rule the appendix would be found either con-
stricted, twisted, thickened, or distended, and there
was always a risk of ulceration. In general the result
of perforation was fatal.
As to the method of procedure, if possible the stump
should be covered with a peritoneal flap.
Mr. Rutherford Morison took the following as
guides to operation :
1. After a second attack.
2. Cases accompanied by abscess.
3. All cases of perforation.
4. The sudden onset of urgent symptoms in quies-
cent cases.
He objected to the incision being made through
the linea semilunaris, as the drainage was difficult and
paralysis of segments of the rectus muscle resulted
from division of its nerves. If in operating an ab-
scess were found quite outside the peritoneum, he
would only drain. If the peritoneum were opened the
appendix might be found lying on or behind the
caecum and it ought to be removed if possible. He pre-
ferred a big incision and packing off the lower end
with gauze and sponges. In the female with pus in
the pelvis, it should be drained per vaginam.
In peritonitis with pus free in the cavity, simple
drainage should be employed. In cases of pocketed
pus he spoke of evisceration of the intestines, by
means of a large incision from the ensiform cartilage
to the umbilicus, and giving the bowels an antiseptic
bath.
Mr. Morton, of Bristol, said he would operate in
every severe case for fear of general peritonitis. He
mentioned Murphy's records of one hundred and forty-
one cases, and maintained that without operation cer-
tain subjects were bound to die. He had personally
operated on two cases. It was impossible from the
symptoms to tell the condition of the appendix. As
to the risks of operation. Murphy lost only two and
Norris had no death in fifty-nine cases. Mr. Treves
gave the mortality as eleven per cent, in non-suppu-
rative cases; it was thirty to forty percent, if suppura-
tion occurred early. He strongly advocated early
operation and did not believe any clinical classifica-
tion possible.
Mr. JORn.\N Li.ovD agreed with the last speaker.
He said the clinical phenomena were puzzling, but
this was because the appendix was of considerable
length, and its blind end was free to swing in any di-
rection. He thought that the varieties of the disease
depended on the position of the tip rather than on any
thing else. The following varieties might be made out
August
29, 1896]
MEDICAL RECORD.
313
1. The tip in the iliac fossa.
Here the symptoms were classical, and in these
cases the iliac swelling might be made out.
2. The tip in the pelvis.
Here there was no iliac swelling, but a finger in the
rectum revealed the state.
3. In the lumbar variety there were no iliac or rectal
signs, but the swelling appeared in the loin.
4. The tip in these cases swings forward into the
abdomen, and these he should call the umbilical
variety. There would be a localized swelling or ab-
scess surrounded by a resonant area.
As to treatment, having located the trouble, the op-
erator should make the incision accordingly. The in-
cision will vary with the particular kind of abscess
present. He agreed with Mr. Morison as to the great
value of a vaginal opening in pelvic cases. In an
ordinary iliac case, whether or not he would remove
the appendi-x depended on the condition of the pa-
tient. In the lumbar cases, which were the most
fatal variety, the incision should be far back, in the
abdominal kind over the swelling. If diffuse general
peritonitis were present, the middle line was the best
place for the incision.
No hard and fast rule could be laid down about
early operation, but he had never yet had to regret
having operated early.
Dr. Renton said that catarrhal subjects should get
well with rest and did. But this should be prolonged
from five to seven weeks at least. In relapsing cases
the appendix ought to be removed.
He believed in small incisions, to lessen the ten-
dency to hernia. The appendix should not be labori-
ously hunted for to the detriment of the patient.
Curiously enough, in some cases the pain complained
of was in the side opposite to the lesion. He thought
that in intense cases of suppurative peritonitis, many
were lost because the operation was done too late.
In cases where the vitality of the patient was low he
strongly advised local anaesthesia, washing out of the
pus, and getting the patient back to bed as soon as
possible.
Mr. Verrall said that in catarrhal cases the physi-
cian should give early relief. The relapsing cases
became less and less dangerous, but more and more
difficult to treat. He believed that the only satisfac-
tory termination of the operation was when the appen-
dix was removed. The total mortality according to
two hundred and sixty-four cases collected by Haw-
kins was fourteen per cent. Murphy in two hun-
dred and seven cases had a mortality of 9.93 per
cent., with early interference. Thus an early oper-
ation lowered the mortality and saved pain, further
attacks, and loss of time, this latter being an im-
portant element to poorer patients who could not
afford to be frequently lying up for lengthy periods.
He preferred a long incision with plenty of room to
see the parts, and packing could be used to shut off
the peritoneum if necessary. He did not agree about
hurrying the actual operation for the sake of getting
the patient back to bed soon and trusting to the chance
of all being well. He believed in removing every
atom of pus by extensive flushing. He emphasized
the danger of mistaking a lull in the symptoms for a
termination of the disease.
Mr. Paul Bright, of Bristol, said he would like to
know exactly when and in how many of the cases Dr.
MacDougall proposed to remove the appendix. In his
experience the less done in the way of surgical inter-
ference— in the early stages, when there was much
suppuration — the better, and when the condition was
grave neither chloroform, ether, nor any but local ana-s-
thesia should be used.
Mr. Mitchei.i, Banks questioned whether the
.\mericans had not overdone matters, especially in
the way of statistics. He had never seen such a
large number of cases of appendicitis, yet it ought to
be quite a common condition to allow such a number
of operations being done for it. He used to see
cases of typhlitis, but now the cacum seemed to be
suffering from neglect, while the appendix was in high
favor. He thought that many of these cases had
nothing at all to do with the appendix. If the ap-
pendix were so often at fault, what became of it when
it had not been customary to remove it ? He thought
the colon and ca:cum might yet be taken into favor
again. As to the operation, no rule could be made.
The collection was either outside the peritoneum, lo-
calized inside the peritoneum, or gave rise to diffuse
peritonitis. In his experience all cases of diffuse
peritonitis terminate fatally. He rather favored a
long horizontal incision. He was much against all
unnecessary mystification. The object of the op-
eration was to find pus and let it out. He thought
that in some cases the pain complained of was due to
the formation of adhesions.
In Dr. MacDougall's reply he pointed out that the
mortality after operations done during the acute stage
was greater than if the cases had been left to them-
selves: that is, when operation was done as a rou-
tine practice and not on selected cases. He agreed
with those speakers who preferred a free incision.
Intestinal Anastomosis. — Dr. Mitchell Banks
read a paper on some experiences with Murphy's
button. The points to be cleared up were : Whether
it was the quickest and best method of joining the in-
testine, and whether any serious consequences had
followed its use. He gave details of six cases :
Case I. was a stricture of the ileum close to the
caicum. Owing to the enormous distention of the
ileum above the stricture, after the excision of the
narrowed portion had been done it was found very
difficult to adjust the ends of the bowel. However,
by means of stitches at doubtful points it was finally
accomplished. The girl died in twenty-six hours from
shock, but at the post-mortem it was found that the
union was quite efficient.
Case II. — The patient had a fistula above the iliac
crest, through which almost all the bowel contents
passed, very little escaping per anum. The condi-
tion was one of great distress. The fistula was ex-
cised and an end-to-side apposition of the ileum to
the crtcum done. The patient did well and lived six
to eight months in comfort.
Case III. — Done for stricture of the colon; the pa-
tient died of shock.
Case IV. — Operation was performed for vesico-in-
testinal fistula. The affected intestine was excised
and the ends were approximated by button.
Case V. — A very good case, in which an intussus-
ception in a boy was excised.
Case VI. was that of a woman who had a fa:;cal fistula
left after strangulated hernia. This was cured and the
intestine united by means of a button, but she refused
subsequently to part with the button. In all the other
cases the button was passed within four or five weeks.
Mr. Banks showed a skiagraph of this patient, in
which the locality of the button was seen by means
of the .v-rays.
In reviewing his cases he decided that the opera-
tion was easy, quick, satisfactor)-, and followed by no
ill results.
Mr. a. H. Tubby read a paper on metatarsal neu-
ralgia, a painful condition of the foot first described
and explained by Morton (Morton's disease). The
pain was often very severe, quite incapacitating the
patient. It appeared to be due to squeezing of the
digital branches of the ner\-es to the toes between the
heads of the metatarsal bones on either side of these
nerves. The diagnostic points were pain of peculiar
314
MEDICAL RECORD.
[August 29, 1896
character, usually some prominence of the head of
a metatarsal bone, as if it had been partly pushed out
of place, and the otherwise healthy character of the
feet. Relief was obtained in minor cases by a tight
instep band squeezing the waist of the foot, com-
pressing the bases of the metatarsal bones, causing
the digital ends to diverge and separate, and so take
pressure off the nerve. This should be combined
with a boot made tight at the instep but broad and
roomy for the toes.
In some cases operation was needed, and the head
of a metatarsal bone, generally the second, should be
excised. The result was good, all pressure on the
nerves being removed and symptoms alleviated. De-
tails of cases were given.
Hepatic Abscess. — Mr. Morton reported a case of
abscess of the liver discharging through the lung.
Many attempts were made with the exploring needle
and subsequently by operating to get at the abscess.
The difficulty seemed to be due to its having more
than one cavity. The point in the discussion was
that Dr. Powell was much against exploratory punc-
ture. He said so common was it to find abscess
some little time after the exploratorj' introduction of
the needle, that he had come to regard it as cause and
effect. He believed in exploratory abdominal inci-
sion with examination of the liver. He gave de-
tails of his cases. Certainly in one case with a
small abscess the size of a walnut on the under sur-
face of the liver, it would probably take a serious
amount of needling to discover it.
Third Day — Friday, July jisf.
The Surgery of the Subperitoneal Tissue. — Mr.
William .\xderson, of London, opened the debate
on this subject. He said that although cases of the
surgery of this structure were common enough, the
literature of the subject was very scanty; that is, the
subject taken as a whole. The knowledge on this
point was scattered very widely, and he had had to go
through a large amount of surgical literature, not only
European and American, but even to collect cases
from as far away as Japan in order to get the materials
for the paper. It was not so much to bring forward new
facts, as to collect together what was already known
but not systematized, that was the function of his
essay.
He was often asked the question. What is the sub-
peritoneal tissue? Generally speaking, it might be
defined as the structure between the peritoneum and
the abdominal wall. It was a mesoblastic develop-
ment starting from the neighborhood of the spine, in
company with the great blood-vessels, and- being car-
ried with them and their subdivisions into various
situations. Thus, where the vessels escaped from the
abdominal cavity, a process of subperitoneal tissue
went with them as their sheath.
The structure was highly elastic connective tissue,
with more or less fat, also planes or bands of invol-
untary muscular fibre. It enclosed veins, arteries,
lymphatic vessels and glands, spinal and sympathetic
ner\'es. From its complex character and many con-
nections, it followed that infection of this tissue was
one of the commonest developments in surgery.
It had a special relation to the intestine. The gut
for about four-fifths of its circumference was en\eloped
by peritoneum, but about one-fifth — the mesenteric
border — is not covered by peritoneum, but was in direct
contact with the superitoneal tissue. In the surgery
of the intestine that must be borne in mind. The
tissue might be directly infected by a leakage from
the intestine at this spot. There was a similar ar-
rangement in the broad ligaments, and a salpingitis
might thus directly infect the subperitoneal tissue.
When the peritoneum became closely applied to a
viscus, it ceased to be any longer demonstrable, e.g.,
in the four-fifths of the intestine. But every viscus of
the abdomen was somewhat in direct contact with it.
The tissue might be affected either from the perito-
neum or from the viscera. The best way of grouping
its affections was as follows:
I. — Inflammation.
Etiological grouping.
1. Idiopathic.
2. Tuberculous.
3. Syphilitic.
4. Anasthetic.
5. Traumatic.
6. Consecutive.
Regional grouping.
1. Retroperitoneal.
2. Subphrenic.
3. Perinephric.
4. Iliac.
5. Pelvic, parametric.
6. Prevesical.
II. — New Growths.
Primary. — i. Lipoma and fibro-lipoma.
2. Fibroma.
3. Myoma.
4. Sarcoma.
5. Cysts.
Secondary. — i. Sarcoma.
2. Carcinoma.
III. — Hemorrhages.
IV. — Lymph exudations.
V. — Extravasation of secretions or excretions.
VI. — Gaseous infiltration.
VII. — Atrophic and degenerative changes.
He thought that grouping according to causation
was more scientific than mere regional classification.
The tuberculous and syphilitic forms were rather rare.
The traumatic was common, it seeming that almost no
injury was too slight to set this up. In other cases the
traumatism is set up surgically during operative inter-
ference. The consecutive form was the most exten-
sive of all. The inflammation might spread from the
parietes, the bones, viscera, etc., and might closely sim-
ulate that due to other causes. The following gener-
alizations might be permitted:
Inllanimation might arise in the tissue itself, or it
might start from neighboring structures, or even in
structures outside the abdomen. Thus, from the oper-
ation of varicocele, infection might reach the subperi-
toneal tissue along the process accompanying the
veins — in hernia direct extension along the process
of subperitoneal areolar tissue forming one of its
layers; in castration along the tissue of the cord.
Also it might spread from the thorax along structures
passing from the thorax to the abdomen.
Then, whatever might be its origin, any or every part
of the subperitoneal space might be involved. Thus,
a case was recorded in which an abscess opened in the
left groin, was followed by one in the right iliac fossa,
then by another in the left iliac fossa, and finally an
ischio-rectal abscess super\ened.
The mode of implication of the tissue might be di-
rect, it might be by perforation into it, or it might be
by necrosis of its overlying peritoneum.
Its tendency, once inflammation had .set in, was al-
ways toward the surface. A localized intraperitoneal
abscess usually opened into a viscus. A subperitoneal
abscess rarely did so.
\exy little was known about its new growths. Pri-
mary lipoma in this region was ver)- remarkable. Thirty
or forty cases had been recorded, and their tendency
was to become enormous in size. They often attained
the weight of forty pounds, and the growth was rapid.
From this rapid growth the patient might become so
August 29, 1S96]
MEDICAL RECORD.
315
cachectic as to give rise to a suspicion of malignant
disease. Owing to the extent of the tumor and the
great implication of important vessels, attempts to re-
move these had been very fatal indeed. Sometimes
the lipomata, starting inside the abdomen, might follow
along the subperitoneal tissue out of the cavity by one
of its openings. Thus, he had published a case of a
man with a subperitoneal scrotal lipoma which was of
such a size that the scrotum had to be supported on
another chair in front of the patient.
The fibromata had mucli the same peculiarities.
The myomata were usually found in the parametrium.
Sarcomata usually spread so rapidly and such exten-
sive infiltration was set up that nothing could be done.
Fifteen or twenty cases of gaseous infiltration had
been recorded; they had usually been in connection
with diseased lungs and pleura; or perforated appendix.
The atrophic form was interesting in connection
with the genesis of movable kidney.
Dr. MacDoug.\ll spoke of the light the paper
shed on those extensive cases of infiammation and
suppuration of the subperitoneal tissue following ap-
pendicitis. He related a case of ovariotomy, in
which after the operation the symptoms closely simu-
lated those of severe intra-abdominal hemorrhage.
On examination of the pedicle a large subperito-
neal abscess was discovered, and evacuation of this was
followed by recovery. He referred also to the case of
a fistula on the left side of the rectum with a collec-
tion of pus high up. This was probably due to dis-
ease of the appendix, with extensive burrowing along
the subperitoneal tissue.
Mr. Ogston related a case in which a girl of
twenty years had such an enormous lipoma that she
could not raise herself in bed. It was diagnosed
as ovarian, but was larger than any ovarian tumor.
On exploratory examination the real state was made
out and nothing could be done. In this case there
was no cachexia. He also related another case of a
lipomatous condition of the omentum simulating an
ovarian tumor, and in which the diagnosis was very
difficult. In a third case operation was undertaken
for a retroperitoneal tumor the size of an ordinary-
potato. It was found to be a myoma involving the
ureter. He removed the tumor and had much diffi-
culty in getting the divided ureteric ends together.
They were too short to do an end-to-side union in
the usual manner. Finally he successfully brought it
together by tucking the upper end inside the lower
one and suturing it in position.
Dr. Lauexstein related a case of a gentleman, the
subject of old right hip-joint disease. Fluctuation
could be made out from the rectum to the right iliac
region. It was evidently a sinus opening into the
subperitoneal space. He spoke also of the hopeless-
ness of cases in which sarcomata growing from the
peritoneum had infected the tissue in question.
Intussusception — Dr. Renton read the notes of
three cases of intussusception in which he had oper-
ated successfully.
A. B , aged ten months. Intussusception of the
ileo-CJEcal valve. The abdomen was opened, the in-
tussusception reduced, and the child recovered un-
interruptedly.
E. L , aged eleven months. Intussusception at the
splenic flexure of the colon. Operation and recovery.
M. W , aged three months. Intussusception
twenty-four hours in duration, easily made out per
rectum. It was found at the operation that one and a
half feet of bowel were intussuscepted. Result good.
These cases were all taken in hand early, and the ope-
ration was done as rapidly as possible. They encour-
aged him to advise operation in all cases. It must be
undertaken promptly and before adhesions had been
formed.
Clinical §epctrtmcnt.
MASKED APPENDICITIS.
Bv
ESTILL MILLER, M.U..
I'lTTSFIELD, ILL.
I REPORT the following case for the purpose of demon-
strating the obscurity of symptoms in some of the
severer forms of appendicitis, upon which our text-
books are uniformly silent.
Mr. S. H., aged twenty-six, rather slender and of
sickly aspect, came to my office July 9th, complaining
of feeling badly: he said he had not been well for two
years. He had no particular pain, but general weak-
ness, malaise, and loss of appetite. I found his temper-
ature under the tongue 100° F., pulse 80, bowels fairly
regular, no tympanites, tongue dry and covered with a
yellow coat. I told him I thought he had malarial
fever and advised him to go to bed. Under treat-
ment with laxatives and quinine he did not seem to
improve, so July 17th I decided to give him a more
thorough examination. I found the stomach, liver,
spleen, heart, and lungs about normal; on palpating
the abdomen I found in the right lumbar region just
above the iliac crest an enlargement about the size
and shape of a goose egg, with moderate tenderness
over McBurney's point on deep pressure. There was
no distention of the bowels. There was another point
of tenderness above the sacro-iliac synchondrosis.
Morning temperature, 99' F. ; evening, 100° to no"
F. ; pulse, 80 to 90. I advised him to keep quiet, take
nourishing and easily digested food, and apply hot
hop poultices.
The patient had a profuse sweat followed by a chill
on July i8th, and the evening temperature the follow-
ing day was 100.5° F. ; pulse, 88. The enlargement of
the abdomen was slightly more prominent and there
was a little more tenderness on deep pressure. I told
the family that I thought there was an accumulation of
pus and advised an operation. I prepared to operate
next morning, but found the patient greatly improved,
temperature normal, pulse 68, no tympanites, enlarge-
ment not so marked, only slight tenderness, bowels
regular; so I postponed operating, as I did not know
the cause of the enlargement and thought it might be
absorbed. My friend. Dr. Dunn, who was called in
consultation, thought it perityphlitis, but later said it
might be necrosis of the ilium or vertebral caries.
He did not think an operation was indicated. On
July 2ist I introduced a small aspirating needle, but
found no pus. The symptoms remained about the
same during the following three days, viz.: morning
temperature, normal; evening, 99.5° to 100° F. ;
pulse, 68 to 76; appetite fair. The patient slept well:
at times he had slight distention of the bowels. On the
morning of July 25th, as the temperature was 100 ¥.
and the pulse 80, I decided to operate, so I took the
patient to Dr. Jno. A. Prince at Springfield. After
careful examination he concluded there was an accumu-
lation of pus, although he was in doubt as to its origin.
He advised an operation for its removal. With my
assistance he operated the same afternoon, making the
lateral incision parallel with the iliac crest. He found
the peritoneum dark and congested over the enlarge-
ment; the adjacent coils of intestines were glued to-
gether by intlammator)' adhesions, the appendix was
indurated and adherent, the tip had sloughed off and
was surrounded by a pus sack situated deepl}, just
above and internal to the psoas mu.scle, thus produc-
ing the pain and tenderness in the back. The abscess
contained about four ounces of thick creamy pus.
The patient is now making a good recovery. Under
the circumstances it was very fortunate that we used
3'6
MEDICAL RECORD.
[August 29, 1896
the lateral incision; otherwise the operation would
have been rendered far more difficult, if not impossi-
ble, on account of the position of the appendix and
the extensive inflammatory adhesions.
Some tell us to operate if the pulse runs above 1 16
or below 60 or when there is high temperature with
distention and great tenderness; or, if the attack is
mild, to wait and operate after the inflammation has
subsided. This is good advice when applied to the
proper cases. But what are we to do and what is to
be our guide in cases like the above, in which symp-
toms are so masked and misleading.' I firmly believe
the patient would have died without the operation.
At no time during his illness did the temperature go
above 1 10° F. or pulse above 90.
REPORT OF A CASE OF
HEMORRHAGE FOLLOWING
OMY.
SECONDARY
TONSILLOT-
Hv K. A. BOTTOMi;. M.I).
NEW YORK.
The subject of secondary hemorrhage following the
operation of tonsillotomy is an interesting one, and
increases in interest in proportion to the length of
time elapsing between the operation and the appear-
ance of the hemorrhage.
With adults we naturally expect a rather sharp hem-
orrhage at the time of the operation, especially if the
tonsils removed are of the hard type and large in size.
If, however, the bleeding stops after a few moments
(which it usually does), we feel relieved; and this
feeling is intensified if a day has elapsed without a
recurrence.
Bosworth gives a very complete resume of this subject
of secondary hemorrhage. In most of the cases quoted
bv him from current literature the hemorrhage occurred
a few hours after the operation, and in only two cases
after a lapse of twenty-four hours; namely, in Nela-
ton's case, forty hours; and St. Yves', in which the
hemorrhage came on four days after the operation.
I have a history of the case of a boy at my clinic
who stated that he had a hemorrhage two days after
I had removed the tonsils; but I was not able to sat-
isfy myself that the bleeding was from the tonsils and
not from the nose, in which I found a small ulcer.
The following case, however, is, without doubt, one
of true secondary hemorrhage, and the length of time
intervening between the operation and the appearance
of the hemorrhage warrants my reporting the case.
I. D , aged thirty-one. Parents both living;
also several brothers and sisters, and all in-good health.
He has been a hard-working man all his life, without
sickness since childhood, except two attacks of tonsil-
litis, several years previously. There was no specific
histor)', and there were no bleeders in the family.
He applied for treatment because he wished to join
the police force; and, although he passed the physical
examination, the examiner informed him that he must
have the tonsils removed to avoid the possihilitv of
frequent attacks of tonsillitis.
Examination showed both tonsils hypertrophied and
of the hard variety. From the fact that they were of the
hard type, and therefore liable to bleed freely if re-
moved by the tonsillotome, I advised the use of the hot
snare. But the patient objected, and I therefore used
the tonsillotome.
The left tonsil was removed on May id, and the onlv
interesting feature connected with its removal was the
fact that the blade of the Mathieu tonsillotome broke
when it had penetrated only half of the tonsil. This
might have been embarrassing but for the fact that a
MacKenzie tonsillotome was readv bv mv side, and
with this I renioxed the tonsil with the broken blade
buried in it.
The bleeding following the removal was unusuallv
slight and stopped entirely in a moment. I decided,
however, not to remove the right tonsil at the same
sitting, and he returned for the second operation on
the following Monday, May 4th, at g .a.m. He stated
that there had been no bleeding nor pain, and he had
little discomfort in swallowing.
The right tonsil was removed with no difficulty, and
no bleeding to speak of followed the operation.
On May 7th the patient returned with the following
history: There had been no bleeding nor discomfort
after the removal of the second tonsil, and he had con-
sidered himself well until 3 a.m. of Thursdav, May
7th, when he awoke to find blood flowing from the
mouth and the bed linen saturated with blood. He
had tried to stop the hemorrhage with cold water, but,
failing, sent for a physician in the neighborhood, who
worked on him for an hour before he succeeded in
stopping the flow. Even at this hour, 10 a.m., he was
still expectorating a little blood.
Examination showed that the right tonsil was covered
with a black coagulum, evidently from the application
of iron; and from the anterior edge of the tonsil be-
hind the anterior curtain there was slight oozing.
This point I cauterized and then gave him a solu-
tion of tanno-gallic acid, which .stopped the bleeding
effectually. There was no recurrence.
The history of this case shows clearly that it was
one of secondary hemorrhage, after an intenal of si.xtv-
six hours.
4: Wkst Onk Hlnukeu and Twen rv-SixTH Stkeei.
A CASE OF CENTRAL LACERATION OF
THE PERINECM.'
liv SlliNKV I. SM.M.I., M.l).,
SA(.INAVV. MKM.
Ox the evening of July 8, 1891, I was called to at-
tend Mrs. S , aged thirty-three years, in her first
labor. Reaching the patient at eight o'clock, I found
she had been suft'ering moderate pains for several
hours, and an examination showed a roomy pelvis, the
OS dilated, and the head well down. The labor
seemed to progress very favorably, and at the end of
three-fourths of an hour the pains had increased
somewhat in force and frequency, but still were not
especially severe. Then came one more severe than
any previous one, followed quickly by another, and the
second stage was over; but in a most astonishing way.
The child had gone straight through the perineum,
making a wound as though by a cannon ball and leav-
ing the vulva and anterior portion of the floor intact.
I had never seen a case of central laceration. I had
probably read the three or four lines which some of
the text-books devote to it, but I know that when I
saw the condition of things I was sorely surprised.
The child was of medium size, and it seemed impossi-
ble that it could have passed through so small a space
with .so little apparent force, for at no time were the
pains ver)' severe. .Vfter the placenta had been de-
livered through the same abnormal channel, I made a
careful examination of the parts. The laceration ex-
tended, with irregular outline, from a point in the cen-
tral line near the posterior commissure to and in-
cluding the rectal sphincter, and denuding the lower
end of the bowel for half its circumference and about
an inch high. There was not much hemorrhage, and
I decided to wait for daylight in which to make re-
pairs. F.arly in the morning, with the assistance of
' Read before the .Michigan State Medical Society, June 5,
1896.
August 29, 1896]
MEDICAL RECORD.
i^7
Dr. Davis and the late Dr. White, I repaired the
laceration, using catgut for the deeper sutures, and
silk for the rest. The patient made an excellent re-
cover}', and on subsequent examination the parts were
found to have healed perfectly throughout. May 17,
1895, I was summoned to the same patient, in her
second confinement. The labor progressed much as
it had in the former case, and, having in mind my
previous experience, I was on the lookout for trouble;
a pain somewhat harder than usual coming on, I
found the head pressing the pelvic floor and threat-
ening a repetition of the accident. I took a blade of
the forceps, passed it under the head, and, using it as
a vectis, was master of the situation. I expected a
laceration, but was determined it should be in the
legitimate way. In this, however, I was agreeably
disappointed, for the head kindly accepted the way I
had provided, the parts yielded with uncommon readi-
ness, and in a short time the child was delivered, and
witiiout any laceration. Convalescence was unevent-
ful, and the woman has remained in good health. In
regard to the cause of the liability to this accident, I
only know that in the case recited there was a large
pelvis, in which the coccyx, because of its shortness
and slight curve, offered little resistance to the de-
scending head.
OTITIS MEDIA PURULENTA ACUTA AND
CHRONICA.
By J. H. McCASSV, A.M., M.D.,
DAVTON, O.
Suppuration in the temporal bone, involving some
of the most important structures in the human body,
should receive the best attention of the general prac-
titioner as well as that of the aural surgeon. The
importance and the danger of this very common
affection have undoubtedly been underestimated, and
the result is a very large number of deaf-mutes and
persons with defective hearing, with perforated drums
and with chronic suppuration of the middle ear with
its attendant evils. The person who temporizes
with a menacing discharge of pus constantly flowing
from his ear, without putting forth his best endeavors
to have it stopped, voluntarily slumbers on a volcano.
It is like a magazine of dynamite, which is inert till
percussed. The victim of this latent but dire malady,
by slight exposure to cold, may precipitate a fatal
mastoiditis, meningitis, or septicaemia.
A superstition of the laity is that running from
the ear is beneficial to the individual, giving exit to
poison which, if checked, might be followed by other
maladies more disastrous in their consequences.
Many persons succumb to aff^ections which would
otherwise have passed them by had it not been that
they were so reduced by constant discharge from the
ear. The mortality of acute and chronic otitis media
is about two and one-half per cent., and is nearly as
fatal a disease as typhoid fever. Of the twelve thou-
sand deaf-mutes in the institutions of the United
States and Canada, in about fifty per cent, the condi-
tion is attributable to acute inflammation of the middle
ear in infancy; scarlet fever of itself being responsible
for about thirty per cent, of these cases. The hearing
as well as the lives of many individuals are lost an-
nually through neglect and ignorance of the proper
management of suppurating ears. Meningitis, mas-
toiditis, and other fatal complications originate fre-
quently from otorrhcea, and render the patient mori-
bund before the gravity of the situation is appreciated.
There seems to be great diversity of opinion re-
garding the treatment of chronic suppuration in the
middle ear, some contending that any interference
with the ossicles is fraught with evil consequences,
while others scarcely await the results of three weeks
of conservative local treatment until they dig out the
ossicles and tympanum. Sound surgical judgment is
necessary at this moment in order to adopt a happy
medium between the two extremes. The cause of the
trouble should be sought and removed. Free drain-
age should be established. Caries or necrosis in the
tympanum should be dealt with in the same manner
as in other parts of the body. Carious ossicles, ne-
crosed bone, and other obstructions to free drainage
should be removed. It is reprehensible to continue
to pack the auditory canal and middle ear full of boric
acid, alum, or other powders, and thereby imprison
decomposing material. The person that facilitates the
flow of such fetid products into the sewer is deserving
of the laurels.
I will now give the history of a few cases in practice
to illustrate my method of management of the three
most common types of suppurative inflammation of
the middle ear, viz. :
(i) Acute otitis media purulenta.
(2) Chronic otitis media purulenta without caries
or necrosis.
(3) Chronic otitis media purulenta with caries or
necrosis of the ossicles or of the wall of the tympanum.
Case I. — Acute Otitis Media Purulenta. My son,
aged six years, contracted a cold and pharyngitis by
riding his bicycle while bareheaded and exposed to in-
clement weather. He complained of fulness in his left
ear, impairment of hearing, and tinnitus. The more
serious involvement of his middle ear was indicated
by pain in the ear and head, which radiated to the fron-
tal and occipital regions and to the pharynx along the
Eustachian tube. After he had suffered with '"earache"
in his left ear by spells for a few days his temperature
rose to 101° to 102' F., and once or twice it reached
103° F. The temperature was taken every few hours.
His pulse ranged from no to 130. He could hear
the watch only on its being pressed against his ear.
By the fourth day the pain in his ear, in the side of his
head, and along the angle of his jaw on the same side
was quite severe. The membrana tympani at first
was quite hypera;mic, then it became lustreless and
opaque. The long handle of the malleus became
obscured and the sharp white point of the short process
of the malleus was the only landmark that could be
seen. The membrane became sodden and bulging.
With the aid of a bright light reflected from the head
mirror upon the drum, I made a paracentesis in the
posterior and inferior segment by passing a spear-
shaped knife through a speculum into the membrana
tympani; whitish, creamy, inoffensive pus flowed
freely. The ear was syringed out twice or thrice
daily with warm soda or sublimate solution (the latter
I to 5,000). It would be well to say at this point that
the sublimate should not be used too- often, or in very
strong solution, because it is an irritant in a slight de-
gree, and the drug may pass through the ear and down
the Eustachian tube into the phar)'nx and cause mer-
curial poisoning. A solution of boric acid, carbolic
acid, sodium chloride, permanganate of potassium, or
any of the antiseptic washes may be used. In fact
water, and particularly rainwater, that has been
boiled is a good antiseptic and cleansing agent, even
without any of the so-called antiseptic medicaments.
After the ear was cleansed each time a few drops of
warm solution of boric acid, fifteen grains, and sulphate
of zinc, one grain to one ounce, were dropped into the
ear and the external auditory meatus was closed with
a pledget of absorbent cotton. Politzerization was
practised once daily to keep the Eustachian tub^
patulous. The little patient said he " could feel the
water come into his throat'' while his ear was being
syringed. The perforation in the drum closed about
3i8
MEDICAL RECORD.
[August 29, 1896
the middle of the second week, but a discharge of
mucus continued a week longer, when it ceased. As
soon as the perforation closed, boric acid or aristol
was blown into the external auditory meatus. (Pow-
ders should not be blown into the ear when the drum
is perforated, especially if the perforation is small or
high up, because they are liable to form into crusts,
lodge in some inaccessible crevice, and cause irrita-
tion.) Four weeks after the ear trouble began the
watch could be heard at a distance of fourteen inches,
and full hearing power was not restored until the end
of four months.
Case II. — Chronic Otitis Media Purulenta. A
young man, aged eighteen, had for ten years suffered
from a discharge of pus and muco-pus from his right
ear as a result of scarlet fever. Hearing in the right
ear for the tuning-fork was four inches; ordinary con-
versation could be heard at a distance of one foot..
There was tinnitus aurium, which was not constant, and
an occasional attack of vertigo and earache. The vi-
brating tuning-fork placed on the vertex was heard
quite well in the right ear. The posterior half of the
membrana tynipani was gone. The ossicles were vis-
ible and intact, and granulations were numerous. In-
flation yielded the " perforation whistle."
Retention of secretion in the middle ear being the
most frequent local cause of the persistence of the sup-
purative process, the ear was cleansed twice daily with
a warm soda or sublimate solution. The granulations
were touched with a solution of nitrate of silver, from
twenty to forty grains to the ounce, every two or three
days, and in less than one month's time all that could
be reached were removed. Then two or three drops of
absolute alcohol were instilled daily and were retained
for two or three minutes, the patient inclining his head
to the opposite side, but considerable pain and vertigo
followed this operation, and it was abandoned. Then
a solution of boric acid, fifteen grains, and sulphate of
zinc, one grain to the ounce, was instilled after each
cleansing operation, but the discharge did not wholly
cease. The external auditory meatus and the skin of
the ear was painted with a ten-per-cent. solution of
iodide of potassium, which protected the ear from dis-
coloration by nitrate of silver; and five to ten drops
of a five to ten per cent, solution of silver nitrate was
dropped into the ear daily and the patient turned his
head in various directions so that the solution could
reach every portion of the middle ear possible. On a
few occasions this drug passed through the Eustachian
tube into the pharyn.x, which did no harm. I usually
syringed the ear after using the silver, to wash away the
white coating, consisting of albuminate of silver formed
on the diseased mucosa. Under this treatment sup-
puration ceased in ten days.
.Some years ago I gave peroxide of hydrogen a trial
in the treatment of suppuration of the middle ear, but
it decomposes on heating, which necessitates its em-
ployment at the temperature of the surrounding atmos-
phere. It is an unstable drug, and is often a positive
irritant. I rarely use it, except as a test for the pres-
ence of pus.
In other ca.ses a saturated solution of chromic acid
or trichloracetic acid, applied by means of cotton on
a cotton carrier, successfully destroyed granulation-
tissue masses. The air douche, either Valsalva's
or Politzer's, at each syringing was used so as com-
pletely to evacuate the pus. This treatment carried
out carefully twice daily will cure nearly all, if not
all, cases of chronic suppuration of the middle ear in
from one to three months, provided the stippurative
process is not dependent upon caries or necrosis.
Case III. — Chronic Otitis Media Purulenta with
Caries and Necrosis of the Ossicles. M — — , aged
twenty years; occupation, nickel plater; the family his-
tory was good. He had had a purulent discharge from
his right ear since he was two years old, origin un-
known. He had scarlet fever and measles during his
sixteenth year, but the discharge from his ear was nei-
ther increased nor diminished thereby. The patient had
made the rounds of a great many general practitioners
and had taken a great deal of patent medicine without
being benefited. The patient alleged that most of the
physicians put him to work syringing his ear twice or
thrice daily and packing it full of a white powder (boric
acid) and cotton. On November 5, 1895, the patient
came to my office. Examination revealed a discharge
of offensive yellowish pus from the right ear, charac-
teristic of caries or necrosis. The superior and pos-
terior two-thirds of the drum membrane was gone.
The handle of the malleus was shortened through ne-
crosis. The osseous ring was roughened. There was
tinnitus and occasionally earache and vertigo. His
hearing power was diminished amid noises. He oc-
casionally experienced difficulty in ascertaining the
direction whence sound came. The vibrating tuning-
fork placed on the vertex was heard rather better in
the right ear. The watch was heard at a distance of
six inches.
The treatment described in case No. 2 was employed
for two months, as the patient wished to try the effects
of systematic local treatment for two months before
submitting to surgical operation. Local treatment
failed to stop the discharge.
Under a general anjesthetic'the rest of the drum
membrane, the necrosed incus and malleus were re-
moved with some cholesteatomata, and also a mass
of granulations from the attic. The osseous ring
was scraped with a ring curette. The operation
did not last longer than three minutes, as the hem-
orrhage was slight. The identity of the malleus and
incus was almost destroyed by necrosis.
After the operation, the ear was cleansed daily with
a mild antiseptic solution, dried with cotton, and a few
drops of borolyptol were instilled. The ear was closed
with a pledget of absorbent cotton. All discharge had
ceased in three weeks, and the patient was dismissed.
His hearing was improved. He could hear the watch
at a distance of two feet.
The history of the foregoing cases represents fairly
well the three prevailing types of suppuration of the
middle ear. The line of treatment employed in each
class of cases has been successful in my hands.
The frequent earaches of children, which prevail in
winter and spring, when sudden changes occur in the
temperature, are often the forerunners of suppuration
of the middle ear. Since 1889, owing to the preva-
lence of the grippe, the list of ear troubles has been
enlarged. A large number of cases of suppuration of
the middle ear is caused by diving or ducking the
head. Even hunting-dogs that dive have otitis media
and become deaf. Naso-pharyngeal catarrh, dentition,
scarlet fever, measles, diphtheria, whooping-cough,
phthisis, etc., are among the most frequent causes of
suppuration in the middle ear.
Pott's Disease — Dr. Lovett, in his article in the
Medical Neii's, advocates treatment of this disease by
recumbency, rather than by ambulator}' measures, dur-
ing the acute stage. He considers that apparatus is
intrinsically imperfect, and that it is incumbent upon
the surgeon either to insist upon treatment by re-
cumbency or to transfer the responsibility of ambu-
lator)- treatment to the parents. This is carried out by
having the child lie upon its back upon a frame.
The addition of traction to the head and legs he be-
lieves to be of benefit, and that it hastens recovery by
quieting muscular spasm and improving the position
of the spine.
AugTiSt 29, 1896]
MEDICAL RECORD.
319
^tirgical Suggestions.
Chronic Leucorrhcea. — In a large proportion of
cases, more distinctly beneficial results have been de-
rived from the long-continued employment in small
doses of arsenical preparations or combinations, such
as Donovan's solution, than from any other class of
medicine used in the constitutional treatment of
chronic leucorrhoeal cases generally. — More Madden.
When Shall We Trephine? — (i) In any fracture
of the skull, either simple or compound, when there
are symptoms of intracranial mischief. (2) If there
is much localized depression, indicating the proba-
bility of either immediate or remote consequences.
(3) In all cases of punctured fracture. (4) For the
removal of foreign bodies. (5) In cases of compres-
sion of the brain from blood, pus, or tumor, when the
offending cause can be located with a reasonable de-
gree of certainty. (6) In cases of epilepsy, when the
traces of the injury originating the disease can be rec-
ognized.— BuECHNER, Iiiternntioniil Journal of Sur-
gery, May, 1896.
Objections to Whitehead's Operation. — Dr. Mat-
thews read a paper upon this subject before the Marion
County Society (Indiana) recently, and his conclusions
were as follows : (i) It cannot be advised e.xcept in se-
lected cases; (2) an ansesthetic is necessary in order to
do the operation ; (3) full and complete paralysis of the
sphincters is necessary ; (4) the operation is difficult,
tedious, and bloody; (5) if union does not take place
by first intention, pus accumulates and the result must
be an ugly one, if not dangerous, and invites sepsis;
(6) it is recommended in doing the operation to re-
move the whole of the hemorrhoidal plexus which is
not necessary to the curing of piles; (7) it can be
maintained that secondary hemorrhage is niore likely
to occur than after the ligature; (8) the function of
the parts is greatly impaired.
To Open an Abscess. — Do not use the old-fashioned
curved bistour}- in opening the simplest abscess. It
is unsurgical, because you proceed from within outward
— from the unknown to the known. This is a false
principle in philosophy, in surgery, and in everything.
Cut from the surface inward and you can deal with
difliculties in the order in which they occur. .Always
work with the aid of sight and do not pin your faith
on anatomy. — International Journal of Surgery, May,
1891.
Purulent Ophthalmia and affections of the cornea,
syphilides, etc. :
IJ Salicylate of cadmium ^. iss.
Aquae fl. 3 iiss.
M. S. Use as a collyrium.
Malarial Haematuria, so called, is antimalarial;
that is to say, some substance freed or formed by the
dissolution of the blood, possibly the ha;moglobin it-
self, is antimalarial. The facts bear out this state-
ment clinically. — E. R. Martin, Memphis Medical
Monthly, 1896.
Varicocele. — Dr. Rand gives the following as the
three principal causes: First, anything that impairs
the general vigor of the part, as: i. Lack of proper
support from relaxed scrotum; 2, masturbation; 3,
abuse of venery, ungratified desires, etc. : 4, chronic
orchitis or repeated attacks of acute orchitis. Sec-
ond, anything that produces pressure: as: i, abdomi-
nal tumors; 2, enlarged inguinal glands; 3, hernia: 4,
trusses or belts worn around the waist; 5, accumula-
tion of fat in the omentum and mesentery. Third,
anything that produces prolonged muscular effort; as:
I, prolonged riding on horseback; 2, prolonged row-
ing; 3, prolonged exercise in running or waltzing; 4,
excessive and violent muscular effort; whooping
cough, sometimes.
Injection in Gonorrhoea and Vaginitis. —
I^ .'Salicylate of cadmium 3 ss.
Aquce dest | vi.
M.
— Cesaris.
Tracheotomy. — The necessity for performing tra-
cheotomy may arise when the surgeon is unprovided
with tracheotomy tubes. Disinfect a fairly large hair-
pin, and bend both ends at a rather acute angle at
about the middle of their length. The ends of the
branches may then be twisted into small hooks or
rings, to which tapes may be attached. The blunt end
of the hairpin is inserted in the trachea, and the
branches tied by tapes fastened behind the neck.
This will ser\'e until proper tubes can be procured.
Failing a hairpin, take a stitch on each side of the
opening in the trachea with stout silk, and tie the
ends behind the neck. .\ny piece of iron or copper
wire, of suitable size, may serve as well or better than
the hairpin. — Alaba7na Medical and Surgical Age,
-April, 1896.
Amputations. — Beyond the saving of blood and as
much of the limb as possible, I have never practised
any fixed rules as to how to amputate, even in the for-
mation of flaps. We should make the flap always with
a view of saving as much as possible of the limb. —
Dr. Wyeth.
Ulcer of Stomach — When perforation does take
place, one of three conditions obtains: (i) If ad-
hesions are scanty, the stomach contents escape into
the general peritoneal cavity, and a general peritonitis
results. Such is apt to be the case in anterior perfora-
tions in which adhesions are the exception, on account
of the mobility of the anterior stomach wall or of the
adjacent hollow or solid viscera; (2) Adhesions may
form and the abdominal contents escape slowly. In
these cases there is a localized peritonitis which may
advance to an abscess, or the barriers of lymph may
yield, especially if on the anterior wall, and a general
peritonitis follow, as often happens in appendicitis.
If the perforation presents itself posteriorly, the lesser
peritoneum may become involved, and a large food of
abscess result — subphrenic abscess. Very rarely it
has happened that an adherent perforation has pro-
duced an abscess in the liver, without other lesion.
Abscesses in the spleen are more frequent. (3) .Ad-
hesion of the stomach and discharge of its contents
into a hollow organ may occur. This is a very infre-
quent complication, which needs only to be men-
tioned.— Drs. Weir and Foote, Aledical Neu'S, April
25, 1896.
Fracture of Patella. — Dr. Geo. R. Fowler's method
consists in exposing the fragments as an intermediate
procedure, i.e., after the immediate effects of the
injury have subsided and before ligamentous union
has occurred, for the purpose of clearing their surfaces
of intervening soft parts, and the application of fixa-
tion hooks resembling Malgaigne's, though a single
and not a double pair is employed. The incision is
made either vertically, transversely, or U-shaped, as
indicated, and the hooks are inserted in the line of
incision when possible, to avoid separate skin wounds.
.\fter carefully removing everything from between the
fragments and applying hooks, the parts are stitched
with subcuticular silk suture, sterile gauze and cotton
are applied, and the limbs are enveloped in plaster-
of-paris splints for three weeks, at which time the
hooks are removed.
320
MEDICAL RECORD.
[August 29, 1896
©orrcsponiTence.
OUR LONDON LETTER.
< From our Special Correspondent. )
GLEANINGS FROM CARLISLE THE " JOURNAL" AND
LIBELS — PUBLIC HEALTH SERVICE VACCINATION
NIGHT SHELTERS — ARMY MEDICAL SERVICE — THE
VACCINATION REPORT— THE LATE SIR J. MILLAIS
THE THIRD INTERNATIONAL CONGRESS OF DERMA-
TOLOGY, HELD AUGUST 4 TO 8, 1 896.
London, August 14, 1896.
A WRANGLE abou nhe/our/in/\s the new diversion with
the British Medical Association, and at Carlisle was
expected to be more piquant than usual in consequence
of the recent action for libel against the editor. No
one doubts his general astuteness and his ability as a
journalist, and it must needs be that discontent will
here and there be manifested. But the usual difficul-
ties do not necessitate a perennial crop of grievances.
The reference committee seems to have failed. It was
said that the libel action would not have been taken
had this committee been appealed to, which looks like
a confession that an apolog)' would have been ten-
dered. But libels ought not to be uttered, and then
apologies would not be required. It is a common im-
pression, too, that no redress is obtainable for any
wrong done by the Jounial unless it is extorted by
legal means. There is a number of men in London
who are glad that the libel case was tried, because
they have in the past been, as they think, victims of
similar injustice.
Dr. Kingsbury proposed that no anonymous attack
on any individual should appear in the Journal with-
out the approval of the president of the branch of
which he is a member. The editor said they could
" pass such a resolution if they pleased, but then they
mio-ht as well tear up the Journal and close the associa-
tion." This is an amazing confession, suggesting that
the words must have been misunderstood, but they have
been duly printed in the Journafs own report of the
speech. Surely the Journal and the association do
not exist on anonymous attacks on individuals.
In the section of public medicine there was a dis-
cussion on " The Profession and the Public Health
Service," by Drs. Nasmyth, McVail, Sykes, Ross, Scur-
field, Paget, and others. Most of the speakers were
employed in the service and it was natural we should
hear of some of their grievances and also their defence
about the excess of zeal whicii has been charged upon
them. No doubt they have difficulties to contend with,
which occasionally cause friction with other medical
men. This has especially been caused by the pre-
sumption of a few in visiting other men's patients.
It has been decided by the local-government board
that they have no right to do so except with the atten-
dant's consent. It is to be hoped, therefore, we shall
have no more cases of this excessive zeal.
Dilatoriness in notifying was charged against some
practitioners, but the officers of health should remem-
ber the difficulties of attendants. It is necessary to
avoid mistakes, and the earlier the stage the more un-
certain the diagnosis of most infectious diseases.
Some speakers admitted that the notification certifi-
cate ought never to be questioned, though one or two
thought exceptional cases would occur in which a
consultation with the attendant should be sought.
Dr. J. A. Dick, of Sydney, gave an account of the
failure of an attempt to obtain a voluntary notification
of diseases by a medical society of Sydney. A circu-
lar was sent, requesting a table to be filled up with
certain details which could not be objected to by any
one. But the response was a complete disappoint-
ment. He hoped this might not damp the enthusiasm
of Dr. Newsholme for a national system of registra-
tion of sickness.
Dr. C. R. Drysdale read a paper advocating vacci-
nation and revaccihation with animal vaccine, as is
required in Germany. He gave a large amount of in-
formation and statistics of various countries to demon-
strate that vaccination in infancy followed by revacci-
nation at twelve years of age or thereabouts would rid
the country of the ravages of small-pox, and that it
would hasten this desired end if calf lymph alone
were to be employed.
Drs. Gaustang, McVail, and Greves supported Dr.
Drysdale's views, and the section passed a resolution
that calf lymph should be universally available from
a department of State.
Drs. Waldo and Walsh had a joint paper on night
shelters, in which the Salvation Army plan was sub-
jected to critical examination with respect to its in-
fluence on the public health. It appears that these
shelters entail a considerable expense on ratepayers.
In one case the direct cost to ratepayers througii
shiftless paupers being attracted to the locality was
stated to be over ^800 and to entail the further bur-
den of maintaining some of these paupers for the rest
of their lives. A resolution was carried that all night
shelters should forthwith be placed under the common
lodging-houses act — a view I have previously advo-
cated on other grounds.
Lord Wolseley has been to Netley and distributed
the prizes. It was thought he might have an an-
nouncement to make about the promised new warrant.
But no — he applied unlimited " soft soap" to army
surgeons in general and declared of one that he knew
no one he would rather have with him in a storming
party. Expectation was on tiptoe for the natural cor-
oUar}', but it came not. Lord Wolseley is a "com-
batant officer " and would keep down " non - comba-
tants." Even one he would like with him in a storming
party is after all a mere civilian, and as such must be
denied military rank or position. A natural result of
such .stupidity is seen in a revelation in parliament
the other day, that the government has been able to
secure only five candidates more than the actual vacan-
cies to compete for appointments on the medical staff.
Competitive, indeed! Must the marking be lowered
to fill the appointments.'
The vaccination report is said to be signed. It will
be issued very shortly and the air is full of contra-
dictory rumors as to its contents. It ought to be of
value after seven years' preparation.
I have just heard that Sir John Millais died yester-
day afternoon. As president of the Royal Academy
of Art, his illness was regarded with much sympathy
by the public. His disease was epithelioma of the
larynx, which remained in a chronic state for a con-
siderable time, but lately assumed a more active form
with attacks of hemorrhage. On Wednesday night
the temperature rose to 104 F., which was considered
due to septicarmia, and he died the next afternoon.
August 17, 1896.
This year the dermatologists swept down upon
London and during the first week in August occupied
the spacious examination hall of the Conjoint Col-
leges of Physicians and Surgeons on the Thames Em-
bankment. As usual, the work of the meeting was
split up into sections, of which the clinical demon-
strations and the museum were perhaps the most
important. Patients were shown every forenoon from
9 to 10:30, and every afternoon from 2 to 3, while
four hours dailv were set aside for papers and discus-
sions. If we add the time taken up by odd"ients, such
as lantern demonstrations and general meetings, it will
be evident that the scientific pabulum supplied by the
congress was of a plentiful and solid nattue.
August 29, 1896]
MEDICAL RECORD.
321
As one would expect, the address of the president,
Mr. Jonathan Hutchinson, was broad and philosophi-
cal. He pointed out that a generation ago the pure
dermatologist was a ranx avis in terris, whereas he
was now to be reckoned by the score. This result he
attributed in part to the existence of cheap printing
and cheap travelling. Not only were the originals and
translations of scientific books within the reach of
every one, but it was also easy to visit such historic
shrines as the Hopital Saint Louis or the clinics of
Vienna. After all said and done, however, Mr.
Hutchinson doubted whether dermatolog)' had more
than embarked upon its fuller mission. Many con-
siderations of the utmost value to general pathology
could nowhere be more readily worked out than in the
skin. From the study of lupus we learned that a
tuberculous process may be localized in one patient for
a lifetime, progressing only at the borders and never
becoming generalized. Still, in the first stage of
lupus there was frequently a potency for remote infec-
tion, and in such cases the affection was multiple.
Diagnosis should be based on essential nature and
not upon external appearance. One of the great wants
of the specialty was a natural classification of diseases
of the skin. The great problem before dermatologists
was undoubtedly that of etiology. With the latter
proposition every one acquainted with the inwardness
of this branch of study would at once cordially agree.
An enormous mass of facts had been garnered, and
masterly clinical descriptions abounded. But notwith-
standing the great advances that had been made, a
vast term incognita still awaited the explorer. In Eng-
land the study of dermatology had never been disasso-
ciated from that of general medicine.
The clinical demonstrations were crowded daily by
members, many of whom were men of world-wide
fame. Naturally a number of the cases, by reason of
their rarity, had little interest except to dermatologists.
On the other hand, not a few had a practical general
value, both as types of disease and as illustrating the
effect of various modes of treatment. Thus, Mr. Mal-
colm Morris showed a case of extensive lupus cured
by scraping and the external application of pyrogallic
acid. He applied the drug at first in ten-per-cent.
ointment, changed every six hours, and rapidly re-
duced its strength to one per cent. This plan, how-
ever, could be carried out only w'ith the patient under
observation, as several cases of poisoning from ab-
sorption of the drug had been recorded. The indica-
tion to stop the acid was smokiness of urine. For out-
patients it might be used cautiously in a two-per-cent.
strength. Dr. Payne showed a woman who four years
since suffered from a severe lupus erythematosus of the
face. The disease had entirely disappeared, leaving
some inconspicuous scars. Treatment consisted in
large doses of quinine (thirty grains daily), and, what
most people will regard as of more importance, the
external use of a collodion containing five per cent, of
salicylic acid. Dr. Radcliff Crocker exhibited a
patient in whom a number of granulomatous tumors
the size of small marbles had vanished under the in-
ternal use of salicylate of soda. In another case a
leprosy of the face had very considerably improved
under hypodermic injections of corrosive sublimate.
During six months forty-five such injections had been
given. Dr. Abraham showed a case of Kaposi's
disease, the diagnosis of which was confirmed by the
distinguished discoverer in person. In another in-
stance Bazin bore out the demonstrator of the disease
which bears his name. These incidents afford a strik-
ing evidence of the value of such international gather-
ings. As a matter of course, many curiosities were
exhibited. Dr. Walsh showed three cases of linear
and arborescent atrophodermia. In two it was asso-
ciated with rheumatism, and in a third with necrosed
bone. The condition was anomalous. There were
several other cases for which the united wisdom of the
congress failed to find a name. Dr. Connor brought
two twins, eight or nine years of age, who two years
before suddenly developed a crop of black freckles
round the mouth and also on the mucous lining of
the lips and the hard palate. Dr. Eddowes exhibited
his own legs, which had well-defined eczematous
patches caused by Primula obconica. He applied
leaves of that plant for six hours, and a rash followed
after an interval of fifteen days while sweating freely
in a hot room. Dr. Waldo showed a curious lichenoid
form of lupus, which is figured in Mr. Hutchinson's
■■ Smaller Clinical Atlas." Indeed, many of the cases
were familiar from various published illustrations.
Patients were also exhibited by Dr. Colcott Fox, Dr.
Pringle, and other well-known dermatologists. These
demonstrations were attended by a number of non-
specialist physicians. It is interesting to note that
little mention was made of thyroid gland, although it
is being extensively used in the treatment of many
skin diseases.
The next great educational feature of the congress
was the museum, which included both general and
bacteriological exhibits, under Dr. Sims Woodhead as
director, and Dr. Galloway and Mr. Plimmer as secre-
taries. Of the collection thus brought together one
can hardly speak too highly. On all sides one heard
the complaint that it was impossible to mark, learn,
and inwardly digest more than a limited part of its
closely packed contents. There was a capital show of
pictures, some of which, for execution and artistic
handling, apart from subject, might have graced the
line at the academy. Photographs were there in hun-
dreds, notably a magnificent collection from Professor
Fournier, of Paris. These sun pictures show what can
be done by the photographer in the way of illustrating ■
diseases of the skin. Certainly, in that direction Eng-
land is far behind several continental countries.
Neisser, of Buda-Pest, sent a number of lifelike
photographs of morbid conditions. Viewed through a
stereoscope, they stood out in bold and sometimes in
startling relief, and showed what a valuable aid to
teaching might be found in this simple instrument.
A fine case of wax models came direct from the col-
lection of the famous Hopital Saint Louis, while
various London medical schools contributed a number
of models, specimens, and casts. The microscopes
were in hundreds, and their slides were constantly
changed. A living filaria sanguinis hominis nocturna
was shown, and the same parasite was shown in the
thoracic muscles and in the stomach of a mosquito.
The organisms of seborrhcea, a disease which is now
attracting universal attention, were shown by Van
Hoorn, of The Hague, who has isolated three forms,
two of them for the first time. There were many slides
of leprosy, madura foot, framboesia, as well as of the
commoner diseases of the skin. The literature of the
subject was illustrated by a large collection of pam-
phlets, books, and atlases of all shapes, sizes, and peri-
ods. But the pervading, prominent feature of the con-
gress was undoubtedly ringworm. An afternoon was
devoted to the discussion of that interesting fungus,
to say nothing of various lantern demonstrations.
Saboraud, the pioneer of the subject, sent a magnifi-
cent collection of cultivations of various kinds of
tinea, both from the human subject and from the lower
animals, such as the cat and the horse. There were
also two similar Italian and two English sets. Of
the last mentioned Dr. Adamson's was notable and
extensive. His work has been chiefly among the
large-spored varieties, which furnish only about ten
per cent, of the total number of cases in man, the rest
being of the small-spored kinds. At present the study
of the tinea' fungus is in its early stages;- but there can
322
MEDICAL RECORD.
[August 29, i8g6
be no doubt that the rapid accumulation of facts will
soon enable observers to arrive at important conclu-
sions. The more we know about this harmful parasite
the sooner shall we be able to exterminate it. The
matter affects the whole civilized world, and its solu-
tion has a special bearing on the medical advisers
thereof.
As to papers and discussions, they were manifold,
and delivered in a polyglot that was not always con-
fined to the three "official" languages of the congress,
namely, English, French, and German. He who
would learn what was said will find it written in a
volume of proceedings to be issued shortly to mem-
bers.
So much for the work of the congress, and, sooth to
say, its play was nearly as varied and arduous. On
Monday the foreign members were informally received
at the Cafe Monico. On Wednesday there was a re-
ception by the lord mayor at the Mansion House, on
Thursday a recepton at Dr. Stephen Mackenzie's.
On Friday a brilliant banquet to the visitors was held
at the Hotel Cecil. Among the speakers were Pro-
fessor Kaposi, Besnier, Lassar, Unna, White,
Schwimmer, Campana, and Tarnow^ski. On Saturday
the president invited members to his country house at
Haselmere, where they had a further invitation to the
house of the late poet laureate. Lord Tennyson.
It was agreed to accept the invitation to hold the
next congress at Paris in the exhibition year, 1900.
On the whole, the generally expressed opinion is
that the London congress has been the most success-
ful gathering of the kind that has yet taken place,
whether regarded from a scientific or from a social
point of view.
JleuT Instviimcnts.
A DIRECTOR FOR THE STOMACH TUBE.
By .mark
KNAPP, M.D.
NEW YORK.
This instrument is practically a metal tube cur\'ed
at the distal end and cut in two horizontally, the
lower part of the curved portion being absent. Thus
the instrument consi-sts of three parts: A, the pala-
tal; B, the pharyngeal, which is united to A by the
hinge £ ; and £>, the glossal part. ££ are pro-
jections soldered to A to prevent the glossal part
between the left thumb and index finger, its catch /I is
brought within the hook of the trigger, and then it is
opposed to the palatal part within the projections y^/^
Then the right thumb presses upon the trigger, which
brings the glossal part backward, and after the pharyn-
geal part has been brought down with the left little
finger and so held, the right thumb releases its hold
from the trigger, which springs the glossal part for-
ward, the bolts G entering the notches in £ and clos-
ing the instrument. Simply touching the trigger with
the thumb opens the instrument instantly.
The chief advantages of this instrument are two in
number: first it may be used as a director and sec-
ondly it enables us to dispense entirely with the
will of the patient. As a director it absolutely
prevents the stomach tube from going anywhere else
but into the tesophagus, thus excluding the possibility
of its entering the larynx, an accident that every now
and then occurs. All that is to be done to insure
safety is to bring the director with the tube in.serted
well back to the posterior pharyngeal wall, and the
tube, which must be previously lubricated with warm
milk, is then pushed down with the left hand. The
time required for arranging the director and getting the
stomach tube into the stomach should hardly exceed one
minute. This director, dispensing with tiie will of the
patient, at once suggests its utility in children and in
nervous patients. Its chief value is in cases of at-
tempted suicide, in which the stronger the patient
bites the better the instrument holds after the mouth
had once been opened.
In ordinary cases the director could be removed as
soon as the stomach tube is about one inch beyond the
epiglottis: i.e., as soon as the sensitive parts of the
fauces, pharynx, and epiglottis are passed. (The
choking and gagging of the patients, especially in
nervous cases, are due only to the tube passing those
parts and irritating them, which is overcome by the
director.) But in cases of suicide, the director must
be left in the mouth during the whole washing, when
it acts at once as mouth gag, tongue depressor, and
director. This director could also be used as specu-
lum for topical applications.
This instrument is made in two sizes, one for adults
and one for children.
380 BR00.ME Street.
-^
from moving laterally. The bolts 6^ at the
distal end of the glossal part fit into corre-
sponding notches of the pharj'ngeal part B.
The handle is firmly united to the palatal
part and has attached to it the trigger C,
which ends in the shape of a hook. This
hook works on the catch //, which is at-
tached to the glossal part. A silk cord
unites the glossal part with the handle.
The cut represents the instrument closed.
This closure is effected in the follow^ing manner. First,
the pharyngeal part B is raised ; (hen, the handle being
held with the right hand and the thumb placed on
the lower lever of the trigger, the glossal part is taken
Tight Lacing. — Dr. F. Schuman Leclercq ( Virginia
Medical Scmi-Moiitlily, May 22, 1896, p. 103) says
that according to Naunyn there is found constricted
liver from lacing in from 20 to 20.5 p)er cent.,
but Schroeder states this malformation to be present
in 59.5 per cent. When we stop to consider that
even moderate lacing impedes considerably the flow
of bile without necessarily giving origin to an ana-
tomical groove of constriction, we can claim even
a higher percentage of gall-stone disease as being
called forth by lacing. However, even the tying
of skirts around the abdomen will in due time at
least relax the abdominal muscles and interfere
with the abdominal pressure, or bring forth other
active etiological agents, such as tractions on the gall
ducts, on the ligaments, interference with the physio-
logical gall-bladder contractions, causing floating kid-
ney, etc. Any corset and any tight lacing of skirts
around the waist must needs in time dislocate at least
the liver, or stomach, or colon to a more vertical posi-
tion, and tractions between these organs will ulti-
mately loosen the protective, complicated, ligamental
apparatus of nature. We cannot, therefore, praise
enough the honest and noble efforts of the reform
corset movement with skirt suspension from the shoul-
ders.
August 29, 1896]
MEDICAL RECORD.
323
pictUcal Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending August 22, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-pox
Gastric, Intestinal, and Rectal Hemorrhage —
Dr. Manley says that while bleeding through the anus
is in a general way not to be viewed with the same
alarm as that coming from the lungs or stomach, when
the hemorrhage is considerable in quantity or persis-
tent it should not be viewed with indifference. The
effects upon the stomach are quite invariably emetic;
upon the bowels, purgative. Pathological lesions
which open the way for gastric hemorrhage are simple
ulceration, tuberculosis, or cancer. It is a common
clinical observation that large gastric hemorrhage is
common among females at puberty and the menopause,
and is rarely fatal. Per contra, such hemorrhage is
e.xtremely rare and also of very serious import in a
male, e.xcepting that type of haemoptysis so general
among hard drinkers. In the case of a female, preced-
ing these large hemorrhages there is usually a period
of indigestion, anaemia, and loss of strength. Recov-
ery seems to be complete. If the cardinal lesion in
these cases is tuberculous ulceration, the bleeding
would seem to be a specific. Malignant disease of the
stomach is rarely attended by large bleeding. In
young men of good habits, sudden or repeated gastric
hemorrhage is a most suggestive sign of sarcoma. In
the incipient stage of this disease the most pronounced
symptom is a severe anaemia with rapid wasting of
flesh. It is only when the disease advances upward
and reaches the peritoneum that suffering begins.
Hence it is that cancer of the viscera becomes recog-
nizable only when it has advanced so far that relief
by operation is out of the question. Sarcoma of the
stomach is widespread, and is unlike malignant epi-
thelial infiltration (which primarily almost invariably
attacks the pylorus) ; bleeding from the intestine — as
in the course of typhoid — is manifest only when evi-
dence of mortal e.xsanguination, or a state close to it,
is apparent; deep shock, collapse, and syncope, all
appear in rapid succession. Tuberculous ulceration,
though common enough, rarely gives rise to hemor-
rhage. Malignant disease of the small intestine is
rare as a primary' affection. Hemorrhage, except at
the rectal terminus of the large intestine, is uncom-
mon, if we e.xclude dysenteric ulceration. As a symp-
tom of surgical lesion it is found in cases of invagi-
nation in young children. Any t}'pe of ulceration may
give rise to bleeding, though this part of the alimen-
tarj' canal, being devoid of lacteals or pe^ac glands,
is the least vascular.
Traumatic hemorrhage of the colon is extremely
rare. When it occurs the blood is ejected in consid-
erable amount undigested and imperfectly coagulated.
The colon is so placed that it is well protected against
the effect of traumatism. Rectal and anal hemorrhages
usually occur from areas close to the verge. By digi-
tal examination it is possible to reach into the rectum
as far as the insertion of the peritoneal coating or the
beginning of the sigmoid flexure. This marks the ut-
most limit of direct surgical manipulation. Among
predisposing causes of anal and rectal hemorrhage are:
the mechanical impediment to circulation peculiar to
this situation, the almost vertical direction of the effer-
ent vessels in the standing position, the absence of
valves, and the irregular habits of life among human
beings — for it does not appear that rectal disease is
anything other than very rare in the lower animals.
The most common cause is a hemorrhoidal or varicose
state of the vessels about the anal verge. Tuberculous,
next to simple, ulceration of hemorrhoidal walls is
the most prolific cause of exhausting hemorrhage from
the anus. Cancer ranks third in frequency. Cancer
of the rectum, like the visceral type elsewhere, is not
very painful in the beginning, and, with unusual ex-
ceptions, large or frequent hemorrhage is not present
even when the disease is making most rapid headway
and is spreading into contiguous parts. The immedi-
ate cause of hemorrhage from the anus is through
straining at stool, when a thin-walled, widely distend-
ed tumor ruptures. Arterial papillomata of the rec-
tum are not uncommon causes of most exhausting de-
pletions. In these cases the mucous membrane of the
rectum investing the external sphincter is studded
with minute raspberry papilla;, which are apparently
devoid of an epithelial investment and bleed on the
least irritation. Operative bleeding from the rectum
is a most serious complication in those whose general
health is enfeebled, who have become ana;mic, or who
have been exsanguinated by previous vascular drains.
When profuse operative hemorrhage ..rises on division
of large, thick-walled veins, and the momentary gush
for an instant floods ever}thing, moderate compression
will promptly subdue it. In operating here, as else-
where, the divided arteries give issue to the greatest
loss of blood. If operating within the lumen of the
bowel, nothing less than a thorough and complete di-
latation of the external sphincter will enable one to
expose those arteries which ramify through an area of
loose connective tissue and quickly retract far up out
of sight. The best way to provide security against
dangerous hemorrhage in operative manipulation is to
be well prepared for it, and close every bleeding point
as we proceed with each stage of the operation.
Hemorrhage in all operations on the rectum for malig-
nant disease is often quite unmanageable. In these
cases the coagulation is enfeebled. In opening up
through an osseo-ligamentous structure like the sacrum
in posterior sacral resection, we will note that the
vessels are thin-walled, and many of them ramify
through tortuous canals or paths in cancellous bone
tissue, or through the inter-ligamentous spaces, in
places where it is very difficult if not impossible to
secure the mouths of spouting vessels. Post-operative
or secondary hemorrhages after operations on the rec-
tum are comparatively rare. The rule should be al-
ways to secure bleeding arteries before returning the
prolapsed bowel w ithin the sphincter. By the adoption
of such measures as will insure prompt and safe hae-
mostasis, there will be but little danger of a large sec-
ondary oozing, though, unless all arterial leakage is
arrested by ligation, torsion, or the thermo-cautery at
the time of operating, dangerous secondary hemor-
rhage may follow'. After the sphincter has contracted
and the dressings are applied, the blood, instead of
making its way outward, may drain into the empty in-
testine. The evidence of its presence there is only
made manifest by a death-like pallor of the patient,
with a thready pulse and impending syncope. The
surgeon must judge from constitutional symptoms as
to whether hemorrhage is occurring. In many small
angeiomatous papilla with sessile bases and deeply
embedded vascular rootlets, the thermo-cauterj^ is in-
valuable; with vessels of larger bore, secure ligation
324
MEDICAL RECORD.
[August 29, 1896
constitutes our main reliance. The patient should
always be watched for se\eral hours after operations
within the sphincter. Should hemorrhage ensue, pal-
liative treatment maybe adopted for a while, and, this
failing, the patient must be put upon the table, the
sphincter redilated, and the bleeding point found and
secured. Symptomatic hemorrhage from the rectum
in persons of full habits must not be confounded with
the presence of local lesions. It is nature's way of
seeking an outlet for overdistended vessels, and may
be avoided by the use of purgative medicine and care
in regard to diet. Hemorrhage from tuberculous ulcer-
ation is sometimes ver)- profuse. These ulcers usually
lie in the posterior wall of the gut. Cancer of the rec-
tum, at least in the early stages, is seldom attended
with bleeding. In all these cases pain is a prominent
symptom during the act of defecation, but hemorrhage
is seldom seen. Gummatous masses usually infiltrate
the non-vascular stratum of lymphoid tissue, which
near the outlet of the rectum is of unusual thickness.
The hyperplasia which they cause may produce steno-
sis, but rarely ulceration or hemorrhage. Hemorrhage
succeeding tuberculous ulceration of the rectum should
be treated by local applications and attention to the
general health.
The author concludes: Hemorrhage from the rectum
may be symptomatic of constitutional or organic dis-
ease, as plethora or hepatic congestion. In conse-
quence of a lesion of some part of the digestive tube,
anywhere from the fle.xure to the cardiac end of the
stomach, blood may escape, changed or unchanged,
through the rectum. The local lesions, in their order
of frequency as a source of hemorrhage in the ano-
rectal outlet of the intestine, are: (i) hemorrhoids;
(2) simple or tuberculous ulceration; (3) malignant
disease. Treatment includes constitutional and local
measures. Hemorrhage from simple, tuberculous, can-
cerous, dysenteric, or typhoidal ulceration in any part
of the digestive tube above the rectum, is quite beyond
relief from direct surgical methods, and hence its treat-
ment must, for the present at least, remain within the
domain of medicine. Surgical treatment of hemor-
rhage of the rectal pouch and anus, when non-malig-
nant, is generally practicable, safe, and permanent in
results. In order, however, to be rendered effectual
and definite, thorough dilatation of the anus and ever-
sion of the rectum are imperative, that the bleeding
points or source of hemorrhage may be brought under
the immediate eye for direct and effective treatment.
When bleeding succeeds hemorrhoids for the first
time, or when its quantity is small, moderate catharsis
with simple astringents in the form of suppositories
will favor its arrest without recourse to radical or se-
\'ere methods. — The Therapeutic Gazette,
Innervation of the Intestines. — Pal states that not
only the stomach, the small intestine, and the upper
third of the colon are inner\'ated by the vagus, as
hitherto accepted, but also the whole of the colon and
rectum. He e.xperimented on curarized dogs, endeav-
oring to determine whether there were any controlling
motor centres for the intestines below the splanchnic
centres in the spinal cord. Simple section of the dor-
sal portion of the spinal cord (from the sixth to the
tenth dorsal vertebra;), causes more violent movements
when stimulus is applied to the vagus. If the lower
dorsal or lumbar vertebra; are removed, the intestines
assume a different appearance. (Animals from one-
half to one and a half years are best for these experi-
ments.) The vessels become fuller, the intestinal
w^alls thicker, and the intestine itself begins to move
with a peculiar motion resembling the pendulum
swing of a rabbit's intestines. Stimulus applied then
to the vagus produces a much stronger action than be-
fore, with a noticeable shortening of the time between
the stimulation and the response. If, however, the
lower part of the spinal cord is removed and the ner\'i
splanchnici are severed, the intestines also assume the
above conditions. When then the vagus is irritated,
violent peristalsis ensues, but this movement is con-
trolled by applying stimulus to the stump of the
splanchnicus, which proves the existence of other
centres in the spinal cord belov the splanchnicus,
controlling the peristaltic action of the intestines. —
Ccntralblatt fiir Physiologic.
Late Phlebotomy Best Lady (who has a sick
husband). — Don't you think, doctor, that you ought
to bleed my husband ?
Doctor (absent-minded). — No, madam. Not until
he gets well.
La Societe d'Autopsie Mutuelle, of Paris, was or-
ganized in 1876, and has about one hundred members,
all scientists of note, several of whom are women. It
has for its purpose the placing of the brains of its
members at the disposal of surviving members for ex-
amination and dissection. Fourteen brains, neatly
catalogued, are now contained in a glass case at the
end of the meeting-room, and the fifteenth, which was
during life the property of M. Abel Havelacque, rector
of the Anthropological Societ)', now rests immersed in
alcohol on the table of the dissecting-room, where the
man's former associates will meet to weigh, probe, cut,
and discuss it. — Medico- Surgical Bulletin.
Dental Forceps. — There are about two hundred
different styles of forceps made for dentists' use, vary-
ing in the sizes and forms of the beaks and in the
shapes of the handles. They are made not only to
suit ever)' need in practice, but every personal require-
ment of the practitioner.
It Makes Them Tired — Foster, the physiologist,
says: "The blood of the tired animal is poisoned, and
when injected into another animal causes the phe-
nomena of fatigue."
Hasty Delivery of the foetus is a frequent cause of
post-partum liemorrhage.
While the Medical Record is pleased to receive all new pubH-
eations which may be sent to it, and an acinowledgmeni will be
promptly made of their receipt under this heading, it must be with
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion receipted by it which in the judgment of its editor iirtU not be
of interest to its readers.
Twentieth Centlrv Pr.actice. An International Encyclo-
pedia of Modem Medical Science. By leading authorities of
Europe and America. Edited by Thomas \.. Stedman, M.D.
In twenty volumes. Volume VIII., Diseases of the Digestive
Organs. 8vo, 667 pages. Illustrated. Muslin, $5.00; leather,
$6.00; half morocco, $7-50. \Vm. Wood & Co., New York.
The American Academy of Railway Surgeons. Re-
port of the .Second Annual Meeting. i2mo, 221 pages. Illus-
trated.
Manial of Midwifery for Use of Students and
Practitioners. By \V. E. Fothergill. i2mo, 484 pages.
Illustrated. The Macmillan Company, New York. Price,
$2.25.
A Manual of Obstetrics. By W. A. N. Dorland, M.D.
l2rao, 760 pages. Illustrated. W. B. Saunders, Philadelphia,
Pa. Price, $2.50.
Practical Points in Nursing for Nurses in Private
Practice. By Emily A. M. Story. i2mo, 456 pages. Illus-
trated. W. B. Saunders, Philadelphia, Pa. Price, $1.75.
A System of Surgery. Edited by Dr. F. S. Dennis,
assisted by Dr. John .S. Billings. \'oIume IV. 8vo, 970 pages.
Illustrated. Lea Brothe'rs & Co., Philadelphia, Pa.
Medical Record
A JVeekly Journal of Medicine and Surgery
Vol. 50, No. 10.
Whole No. 1348.
New York, September 5, 1896.
$5.00 Per Annum.
Single Copies, loc.
(Driginal JVrticIcs.
THE DIAGNOSIS OF TUBERCULOSIS FROM
THE MORPHOLOGY OF THE BLOOD— AN
ORIGINAL RESEARCH, WITH REPORT OF
CASES.'
Hv A. M. HOLMES, A.M., M.D., .
DE.N\'EK, COL.,
LECTURER ON H.CMAT01,0GY IN UNIVERSITY OF COLOR.\DO ; H.€MATOLOCIST
TO ST. Joseph's hospital; .member of Denver and akapahoe and
COLORADO state MEDICAL SOCIETIES.
It is well known that if the diagnosis of tuberculosis
be delayed until it is confirmed by the discovery of
tubercle bacilli in the sputum, the most important pe-
riod has been neglected. When bacilli are found, the
patient is already in the active state of the disease,
and, in many cases, it is then too late to check it.
Therefore the first step in the prevention of tubercu-
losis should be an early diagnosis. If this can be
done before the active state begins, or at its begin-
ning, many may avoid or at least delay the destructive
results which otherwise would soon follow.
Authorities quite agree that in tuberculosis there
e.xists a shorter or longer latent or pretuberculous
state. This may be inherited or acquired. They also
agree that the leucocytes of the blood are tissue-
formers. During this so-called latent period the body
is undergoing retrograde changes. The body tissues
are being constructed of the leucocytes of the blood.
Hence it occurred to me recently that, before the dis-
integration of the gross tissues of the body begins, the
blood would show distinct and characteristic signs of a
similar nature: and, if so, that a study of these appear-
ances could be made a valuable means of diagnosis in
this disease. With this in view I selected a few pa-
tients with pronounced tuberculosis, and carefully
studied a specimen of blood from each. With each
specimen I used absolutely the same technique with
reference to taking the films, fixing, staining, and
mounting.- .\fterward cases with similar blood
characteristics were grouped together, and to my sur-
prise I found a remarkable similarity in the histories
and clinical symptoms. Hence these studies have
convinced me that in tuberculosis the condition of
the individual can be interpreted from the appear-
ances of the leucocytes of his blood.
Whether the tuberculous condition be inherited or
acquired, we find in such persons a tendency to a
more or less extensive tissue disintegration. In tu-
berculous blood I have found cell disintegration abun-
dant, and especially so in young and middle-aged
leucocytes.
Hence the fundamental principle upon which this
thesis is constructed is the hypothesis that every in-
dividual has a biological prototype in the leucocytes
' .\bstract from paper read before the Colorado State .Medical
Society, June \U, iSqO. A full report of the cases is given in the
proceedings of the society.
• It would require too much space to enter into the technique
in this paper. I propose to devote a paper especially to this sub-
ject at some future time.
of his own blood. What is true of the larger organ-
ism is true of the smaller. What is true of man is
true of the leucocytes of which man is constructed.
And conversely, what is true of the cell is true of the
individual.
The laws of life are universal. There is no break
in their continuity. They vary in degree and not in
quality. There are degrees of simplicity and com-
plexity, according to the level upon which the par-
ticular organism rests, with reference to its evolution-
ary ascent. From the primordial, non-differentiated,
homogeneous protoplasm of the protozoon, and from
the protozoon to homo, vital laws present an unbroken
continuity. They do not e.xist in the cell and cease
in the individual. They do not e.xist in the individual
and cease in humanity. But the laws of sociology are
the laws of biology, and the laws of biology are the
laws of the cell. Hence, upon this hypothesis I shall
attempt to show a relation of diagnostic value between
certain morphological appearances in the leucocytes
of the blood and certain conditions in the patient.
For this purpose I shall attempt to show certain
Analogies Between the Leucocyte and the Indi-
vidual— Analogy in Growth and Decay. — It is the
opinion held by the majority of observers, Uskow,
Gullard, Ehrlich, and others, that the various forms of
leucocytes are mere stages or transitional forms in the
life history of the cell. As the child develops by in-
sensible stages to maturity and then declines, so the
stages in the life history of the cell pass insensibly
one into another.
The characteristics which point to the growth of
leucocytes, and from which their ages may be approxi-
mately ascertained, are based upon two important
phenomena: first, a differentiation or division of the
'nucleus; second, the appearance of granules in the
ceil protoplasm.'
First. As a young leucocyte develops, the nucleus
attempts to divide. It first changes from tlie sphe-
roidal or oval form, by extending a portion of itself
in various directions. The forms seen in this stage
are characterized as "transitional forms." As the
cell continues to develop, many ot these nuclei com-
pletely divide. The cell then contains two or more
nuclei and is called a polynuclear leucocyte.
Second. A very young leucocyte possesses very lit-
tle cell body, being almost all nucleus. But as it de-
velops the cell body increases in size. The cell body
in young cells is non-granular, but is either trans-
parent or basophile. As it develops we often observe
a tendency to granulation, the granules at first being
transparent or faintly basophile. In health they de-
velop in tlie cell protoplasm simultaneously v. ith the
characteristic transitional changes in the nucleus.
-A.S the nucleus reaches the transitional or polynuclear
form, the granules become more numerous and change
from transparent or basophile to oxyphile. Hence, in
health oxyi^hile granules are never seen except in
transitional or polynuclear leucocytes or in mature
cells. When they are observed in lymphocytes, or
young cells, it indicates a prematurely developed cell
' The majority of staining-methods are useless in bringing out
these characteristics of leucocytes. Hence they are of very little
value in the study of tuberculosis.
326
MEDICAL RECORD.
[September 5, 1896
protoplasm, or a nucleus endowed with low vitality
and unable to divide.
Again, when leucocytes reach maturity and begin to
decay, the granules of the cell protoplasm become less
oxyphile and often faintly basophile. Hence, when
phagocytes or mature leucocytes are observed with
granules which are only slightly oxyphile, or with a
basophile tint, we have a cell that is undergoing disin-
tegration— a cell that is returning to its second child-
hood. Its granules were first basophile, then became
oxyphile, and if the cell lives long enough they again
become basophile.
But all cells do not pass through each of these
stages. Neither do all children live to maturity and
die in old age. As a person may die at any age, so
may a leucocyte. As a child with a frail organism
rarely reaches maturity, so frail leucocytes often die
in their infancy. Leucocytes come from preexisting
leucocytes, and here, as well as with the more special-
ized sperm and germ, the characters of the parent are
handed down to the offspring. Hence, if it is correct
to claim that an indi\-idual has inherited a strong pre-
disposition to disease, it is certainly equallv true of
his leucocytes. For, as are his leucocytes, so is the
individual.
Analogy in Structure. — The histology of the leuco-
cytes, studied microchemically, shows that they con-
sist of four tissues : chromatin and achromatin, tis-
sues of the nucleus; spongioplasm and hyaloplasm,
tissues of the cell body. Professor Ehrlich discov-
ered that each of these tissues gives a specific reaction
to stains, and that they react differently in health and
in disease.
The spongioplasm is a network of delicate proto-
plasm in the cell body, which surrounds and encloses
the globules of hyaloplasm, in the same manner that
the skin, mucous membrane, and layers of fascia sur-
round and enclose the larger animal organism and its
anatomical parts.
The chromatin is also a network of extremely deli-
cate nuclear protoplasm, which encloses and protects
its more delicate tissue, the achromatin, in the same
manner that the external membranes of the brain and
nerves surround and protect the delicate tissues within
them.
Analogy in Functions. — Von Recklinghausen and
Cohnheim demonstrated that the leucocytes possess'
distinct and independent functions. They receive
food, grow, migrate, construct, generate, and elimi-
nate. Hence we find in them functions exactly anal-
ogous to those in the larger animal.
Analogy in Disease. — If the physiological processes
are analogous, why not also the pathological.' In
gross pathology, when the tissues are changed in their
morphological appearances their functions are al-
tered. Therefore, when the cell tissues are changed
in their appearances and reactions to stains, their func-
tions are also changed.
Analogy in Tuberculosis. — In tuberculosis of the
individual we find a rupture, or evidence of commenc-
ing rupture, of the continuity of the enclosing mem-
brane, skin or mucous membrane, according to whether
it is surgical or pulmonary tuberculosis. When the
membrane is ruptured we find a discharge of broken
down or disintegrating tissue.
In tuberculosis of leucocytes an identical process is
observed. There is a rupture of or an attempt to rup-
ture the spongioplasm. When this is ruptured a por-
tion of the cell is obser\ed passing out, or it has already
passed out, leaving a depression in the cell corre-
sponding to the amount of tissue lost.
When the spongioplasm has not yet broken the cell
is distorted, with irregular contour and a portion of
the cell protoplasm protruding at various points.
Hence, the law that brings about disintegration in the
tuberculous patient brings about the same process at
an earlier date in the tuberculous leucocyte. The
cells show all degrees of disintegration. The blood
serum is loaded with debris from these disintegratins;
cells, ^\■ith marked disintegration of lymphocytes, or
the young cells, we can safely predict adult cells of
weakened vitality. Consequently, the phagocytes or
tissue formers will be feeble and inactive. Therefore,
with marked disintegration in the leucocytes, it is
with absolute certainty that we can predict a similar
condition in the larger organism. When this condi-
tion exists bacilli find a congenial culture medium in
which to lodge and develop, with very little resistance
on the part of the phagocytes.
Analogy in Percentage. — Perhaps the most impor-
tant analogy is between the leucocytes of an individual
and the individuals of humanity. Each particular
class or type in the normal state represents a definite
percentage of the total number. In other words, each
leucocyte, whether infant, middle-aged, or adult cell,
bears such analogous relation to the totality of cell
aggregation w'hich constitutes the individual as ef.ch
individual bears to the totality of individual aggrega-
tion which constitutes the more highly complex organ-
ism— humanity.
The statistics of any people will show that there is
a fairly uniform percentage of the total population for
childhood, for middle age, and for adult life. When
these percentages are materially changed, we have rea-
son to suspect something wrong in tiie vital economy.
The same law holds good in the leucocytes of blood.
The consensus of opinion among ha-matologists is quite
uniform as to the
Percentages of Leucocytes in Normal Blood. —
Neudorfer's classification is approximately as follows:'
Small lymphocytes,- twenty-six percent,; large lym-
phocytes, eight per cent, ; phagocytes, sixty-five per
cent. ; eosinophile leucocytes, one per cent. In nearly
all pathological conditions there is more or less varia-
tion from these percentages. Hence, when we find a
marked variation from the above percentages, we may
be quite certain that we have a pathological condition
somewhere in the organism. The following table
prepared from the cases studied will show a variation
from the normal percentages of considerable diag-
nostic significance. And, furthermore, a study of the
table will also show comparatively uniform percen-
tages for each type of the disease.
I am indebted to many of the physicians of Denver
for numerous cases furnished from their private prac-
tice, and I wish here to express my gratitude for
their valuable aid in this laborious study. The thirty-
five presented represent, as nearly as possible, every
stage in the tuberculous condition — those in various
stages of the active disease, those who have inherited
a strong predisposition, and those in various stages of
convalescence.
Summary of Cases. — Incipient pulmonary tuber-
culosis, I to 7.
Incipient laryngeal tuberculosis, 8 and 9.
Convalescent pulmonary tuberculosis, 10 to 14.
.'\dvanced pulmonary tuberculosis, 15 to 21.
Fatal cases of pulmonary tuberculosis. 22 and 23.
Fatal case of tuberculous meningitis, 24.
Last stage of pulmonary tuberculosis, 25.
Tuberculous periostitis, 26.
Tuberculous necrosis of spinal vertebra, 27.
Tuberculous hip-joint, 28.
Tuberculous knee-joint, 29.
Tuberculous adenitis, 30.
Pretuberculous and non -tuberculous, 31 to 35.
' To estimate the percentage of each variety of leucocytes, live
hundred or more cells should be counted and an average taken.
' The method of distinguishing and classifying the varieties of
leucocytes will be given in a later paper.
September 5, 1896]
MEDICAL RECORD.
327
TAHLL I.
7.
<
t
It
E
t!
^1
it
0
c
V 3
C V
0 ^•
oil
Condition -Ascertained from a Study
of the Patient.
Condition .Ascertained from a Study
of the Rlood.
Attending Physician.
I
*>
Mr. H.
MissX.
Mr. H.
Miss S.
Miss N.
Mr. B.
Mr. C.
Mr. J.
Mr. M.
.Mrs. F.
Mr. U.
Mr \\
18
23
26
38
5S
27
25
56
25
32
32
23
32
55
38
28
24
30
22
21
16
58
25
16
•■
5S
I
7
13
16
II
13
] 15
12
12
16
26
23
31
37
32
8
7
7
8
8
10
9
5
6
9
9
35
7
23
21
17
14
9
II
12
23
12
12
12
13
20
16
6
8
13
8
5
16
10
10
8
9
6
12
17
II
II
12
15
II
73
71
74
77
74
69
74
74
70
51
59
63
53
53
81
87
74
81
80
80
82
89
81
73
80
52
80
60
59
2
2
I
I
I
2
4
2
2
I
3
2
2
2
3i
I
3
I
I
2
0
0
h
0
2
2
9
i
Incipient pulmonary tuberculo-
sis; little sputum; few bacilli.
Incipient pulmonary tuberculo-
sis; very little sputum.
Incipient pulmonary tuberculo-
sis; sputum and bacilli.
Incipient pulmonary tuberculo-
sis. Beginning convalescence.
Strong tuberculous predisposi-
tion. Had tuberculosis and
recovered. Now threatened
with relapse.
Incipient pulmonary tuberculo-
sis; severe cough; little spu-
tum; no bacilli.
Incipient pulmonary tuberculo-
sis. Beginning convalescencfe.
Tuberculous laryngitis; little
sputum; bacilli. Improving
slightly.
Tuberculous laryngitis and in-
cipient pulmonary tuberculo-
sis; very little sputum; bacilli.
Incipient pulmonary tuberculo-
sis; no sputum; very little
cough. Convalescent.
Pulmonary tuberculosis. Con-
valescing. No cough, no
sputum.
Pulmonary tuberculosis. Con-
valescent. No cough; no
sputum.
Pulmonary tuberculosis. Con-
valescent.
Pulmonary tuberculosis. Con-
valescent.
Advanced pulmonary tuberculo-
sis; abundant sputum, cavity;
bacilli.
Advanced pulmonary tuberculo-
sis; large cavity; abundant
sputum; bacilli.
Advanced pulmonary and laryn-
geal tuberculosis of long stand-
ing. Slightly better.
Advanced pulmonary tuberculo-
sis; abundant sputum; bacilli.
Advanced pulmonary tuberculo-
sis; abundant sputum; bacilli.
Advanced pulmonary tuberculo-
sis; abundant sputum, bacilli.
Advanced pulmonary tuberculo-
sis; abundant sputum; bacilli.
Last stage, pulmonary tubercu-
losis. Died two days after
taking blood films.
Advanced pulmonary tuberculo-
sis. Died one month after tak-
ing blood films.
Tuberculous meningitis. Died
soon after taking blood films.
Advanced pulmonary tuberculo-
sis; purulent sputum; bacilli.
Last stage.
Tuberculous periostitis. Ampu-
tation. Recovery. Blood e.x-
amination five weeks after am-
putation.
Tuberculous abscess of spine
with necrosis of vertebra;
constant suppuration.
Tuberculous hip-joint disease.
Improvement slow.
Tuberculous knee-joint; no sup-
puration.
Tuberculous condition marked.
Recuperative power good.
Tuberculous condition marked.
Fair recuperative power.
Marked tuberculous condition.
Strong recuperative power.
Marked tuberculous condition.
Fair recuperative power.
Tuberculous condition marked.
Strong recuperative power.
Tuberculous condition well
marked. Two weeks later
much improved.
Tuberculous condition marked.
Strong recuperative power.
Tuberculous condition marked.
Slight recuperative power.
Marked tuberculous condition.
Moderate recuperative pow-
er.
Tuberculous condition well
marked. Strong effort to
recuperate.
Tuberculous condition moder-
ate. F'air recuperative power.
Tuberculous condition slightly
marked. Strong recuperative
power.
Tuberculous condition very
slight. Strong recuperative
power.
Tuberculous condition marked.
Fair recuperative power.
Marked tuberculous condition.
Little recuperative power.
Marked tuberculous condition.
No recuperative power.
Granules with basophile tint.
Tuberculous condition marked.
Slight recuperative power.
Marked tuberculous condition.
Slight recuperative power.
Marked tuberculous condition.
Slight recuperative power.
Marked tuberculous condition.
Fair recuperative power.
Marked tuberculous condition.
Slight recuperative power.
Marked tuberculous condition.
No recuperative power.
Granules with basophile tint.
Marked tuberculous condition.
No recuperative power.
Marked tuberculous condition.
No recuperative power. -Ab-
sence of eosinophile cells;
granules basophile; myelo-
cytes.
Tuberculous condition well
marked. Very little recu-
perative power. Granules
slightly basophile.
Slight tuberculous condition.
Strong recuperative power.
Marked tuberculous contlition.
Slight recuperative power.
Marked tuberculous condition.
Slight recuperative power.
Marked tuberculous condition.
Hone probably involved.
Dr. E. R. Axtell.
Dr. F. E. Waxham.
3
4
5
6
7
S
Dr. E. R. Axtell.
Dr. IL W. McLauthlin.
1st count.
2d count
two weeks
later.
Dr. S. G. Bonney.
Dr. F. E. Waxham.
9
It
i:
10
Dr. Henry Sewell.
Dr. S. G. Bonney.
Dr. Henry Sewell.
13 Mr. X.
14 Mr. D.
n Mr K
Dr. Chas. Denison.
do.
16
I 7
Mr. .M.
Mr H
Dr. \V. W. Grant.
Dr. I. B. Perkins.
iS Mr. X.
Dr. H. C. Crouch.
19 Mr. C.
20 Mr. L.
I
21 Mr. H.
Dr. H. H. Bucknum.
22 Mr. T.
23
24
Mr. E.
Miss C.
Mr. U.
Mr. S.
Mr. R.
Mr. H.
Mr. B.
1
I
Dr. C. B. Lyman.
Dr. E. P. Hershev,
Dr. J. T. Eskridge.
2fl
27
2S
\
Dr. \V. \V. Grant.
Dr. S. I). Van Meter
2q
Dr. John Boice
328
MEDICAL RECORD.
[September 5, 1896
TABLE \.— Continued.
. V
f^
0 &
4» 0
a* p
fX
S>.
¥^
g
't-^
iSJ
z
z;
<
.2
30
Miss M.
22
9
13
77
31
Mr. X.
25
25
13
57
32
Mrs. X.
2S
22
II
65
33
Mr. S.
53
8
21
70
34
Mr. H.
41
12
13
74
35
Miss L.
24
21
6
70
2 &•
c o
Condition Ascertained from a Study
of the Patient.
Tuberculous adenitis of cervical
glands. Severe form.
Strong tuberculous history. Sub-
ject in perfect health.
Strong tuberculous history.
Marked tuberculous predispo-
sition.
Tumor in left side. Diagnosis
not made
Strong tuberculous predisposi
tion. Not yet broken down
Malarious anajmia. No tuber-
culous history.
Condition Ascertained from a Study
of the Blood.
.attending Physician.
Tuberculous condition welliDr. Chas. Denison.
marked. Feeble recuperative
power.
Tuberculous condition slightly Dr. C. B. Lvman.
marked. Very' strong recu-
perative power.
Marked tuberculous condition. Dr. \V. W. Grant.
Strong recuperative power.
Tuberculous condition. Strong
recuperative power.
Tuberculous condition marked
.Strong recuperative power.
Dr. Chas. Denison.
Tuberculous
present.
condition n o t
Dr. E. R. Axtell.
Of these thirty-five cases six were test cases : 1,3,5,
32, 33, and 35. In each of these the blood was exam-
ined and diagnosis made without any itnowledge of
the history or physical condition. These six cases
are classified as follows:
Incipient pulmonary tuberculosis, i, 3, and 5.
Pretuberculous, not yet having reached the active
stage of the disease, 32 and 33.
Non-tuberculous, 35.
The diagnosis made from the blood was in each of
these cases confirmed by the attending physician.
It will be observed that there is no single charac-
teristic in tuberculous blood which, if once learned,
will enable us to diagnose the disease. We may have,
and generally do have, except in well-advanced cases,
three conditions of the cells existing at the same time
and found in the same specimen : cells in (<?) the nor-
mal condition, (/■) beginning disintegration, and (r)
advanced disintegration. It must be remembered also
that there is no distinct dividing line between them.
They blend insensibly into each other. Experience
alone will enable us to educate the eye to distinguish
these varieties.
In the study of tuberculous blood we should not
only ascertain the percentage of each type of leuco-
cyte, but also classify each type according to the
Degrees of Disintegration. — Beginning disintegra-
tion is characterized by a rupture in the contour of
the cell, with globules of hyaloplasm passing out,
leaving a depression in the cell corresponding to the
amount of tissue lost — cell contour partly destroyed.
Complete disintegration is characterized by a com-
plete breaking up of the cell into small masses, and
these scattering — cell contour entirely destroyed.
Many leucocytes in tuberculous blood do not show
evidence of either of these forms of disintegration,
but possess characteristics which a study of the fore-
going cases has caused me to interpret as meaning
lowered vitality, weakened functions, and
Diminished Recuperative Power.— These charac-
teristics are; ill) poorly stained or transparent nuclei ;
(/') granules of phagocytes diminished in number,
poorly stained, and scattering: and {<) a decrease in
number or a marked disintegration of the eosinophile
cells.
In many cases these characteristics predominate,
while in others they are present in only a small per-
centage of the leucocytes.
Although the eosinophile cell continues to be en-
shrouded with much mystery, the recent researches of
Kanthack and Hardy, of Cambridge, have undoubtedly
given us much light upon the subject. They claim
that the eosinophile cells are the advance guards of
the phagocytes. The eosinophile cells first surround
the bacilli and throw off some of their granules, or
secrete a substance which renders the bacilli inactive,
and while they are in this state the phagocytes sur-
round and devour them. Therefore, with this interpre-
tation of their function, in any germ disease where
there is a decrease in the number of eosinophile cells,
or a marked disintegration going on in them, the re-
cuperative power of the organism is greatly dimin-
ished. Hence a study of tuberculous blood should
reveal two important points: first, the degree of the
tuberculous condition ; second, the degree of the re-
cuperative power.
Although the first of these is important, yet we must
grant that it is equally important both to the patient
and to the physician if we can ascertain the amount
of recuperative power possessed by the patient, for
upon this depends the probable chances of recovery or
ability to combat the disease. If our fundamental hy-
pothesis be correct; if the individual has a true proto-
type in his leucocytes; if the condition of the one can
be ascertai.ied from the appearance of the other; if
the leucocytes are tissue formers; if it is true that as
are the leucocytes so is the individual, then the real
source of the recuperative power should be sought for
in the leucocytes.
.-\fter a careful study and comparison of the blood
appearances in all varieties of tuberculosis I have ob-
served that the nearer the blood characteristics ap-
proach the following, the greater is the
Contraindication of Tuberculosis.— Normal or ap-
proximately normal percentages of all varieties of
leucocytes. Absence of giant lymphocytes. Absence
of myelocytes. Very little cell disintegration. Very
little debris from disintegrating leucocytes, \^■ell-
stained nuclei. Phagocytes with cell-body clearly de-
fined and granules rich in number and well stained.
Uniformity in size and appearance of the phagocytes.
While, on the other hand, the following are the
Characteristics of Tuberculous Blood, which vary
according to the severity of the case. Marked devia-
tion from the normal percentages of all varieties of
leucocytes. Great decrease in percentage of small
lymphocytes. Great increase in percentage of phago-
cytes. Usuallv, a marked increase in percentage of
large lymphocytes. Many giant lymphocytes with ir-'
regular contour and protruding globules of hyalo-
plasm. Eosinophile cells absent or few in number
only in severest cases. Myelocytes occasionally pres-
ent. Marked cell disintegration. Many groups of
de'bris fiom disintegrating leucocytes. Phagocytes
with indistinct cell contour, and granules few in num-
ber, poorly stained, and scattering. Marked irregu-
September 5, 1896]
MEDICAL RECORD.
329
larity in size and appearance of phagocytes, dwarf
•phagocytes as small as small lymphocytes, giant phago-
cytes double the usual size with five or more nuclei.
Often a clear, narrow, and sharply defined ring sepa-
rating the nucleus from the cell body in small and
large lymphocytes. Phagocytes with granules taking
a basophile tint, evidence of approaching dissolution.
Grouping together of a large number of phagocytes ob-
served before dissolution. Very little disintegration
in red cells.
From a review of blood appearances in the fore-
going cases I have made the following
Deductions. — First, that the degree of the tubercu-
lous condition can be estimated by (n) the amount of
deviation from the normal percentage of each variety
of cells; and by (/') the amount of cell disintegration
in each variety.
Second, that the degree of the recuperative power
is estimated by (a) the staining power of the nuclei;
(/') the percentage of leucocytes with no evidence of
disintegration ; (c) the abundance of well-stained gran-
ules of the phagocytes; and (1/) the abundance of
eosinophile cells rich in granules.
Differentiation. — With reference to the differentia-
tion of the stages of tuberculosis, much could be given,
but time and space will not permit it in this paper. I
will give a few points which are most prominent, and
probably may be the means of differentiating the pre-
tuberculous, incipient, advanced, and convalescent
stages. But in the first place sufficient blood charac-
teristics must be observed to justify the opinion that
the tuberculous condition exists. It is then time to
look for those points which are characteristic of, and
will enable us to designate with reasonable certainty,
the class in which the patient is to be placed.
The following tables will show quite plainly the
peculiar percentage variation for small lymphocytes
and phagocytes in the various stages of the disease.
TABLE V.
Incipient Cases.
I.
2.
3.
4-
5-
6.
7-
8.
9-
Normal
Percentages.
Percentage of small lyrn-
7
73
13
71
16
74
II
77
13
74
9
66
12
74
12
74
16
70
26
Percentage of phagocytes. .
65
T.ABI.E VI.
Advanced Cases.
Percentage of small lym-
phocytes
Percentage of phagocytes.
15-
16.
■7-
18
19. 20.
21.
27-
3°-
8
7
7
8
8
10
P
7
f)
81
87
74
81
80
80
82
80
77
Normal
3°' Percentages.
26
65
TABLE VII.
Cases in Last Stage.
1
j 22.
23.
*24-
25.
Normal
Percentages.
Percentage of small lympho-
cytes 5
Percentage of phagocytes ... ,89
6
81
9
73
9
80
26
65
* Tuberculous meningitis an exception. Percentage of phagocytes lower.
TABLE VIII.
Showing Range of Percentages for the
OF THE Disease.
Active St.\ges
Percentage of
Small Lymphocytes.
Percentage of
Phagocytes.
Normal state
26
7 to 16
7 to 10
5 to 9
65
Incipient tuberculosis
.'Advanced tuberculosis
Last stage of tuberculosis . . .
66 to 77
74 to 87
So to 89
TABLE IL
Fretuberci-ilous Cases.
Percentage of small lympho-
cytes
Percentage of phagocytes . . . .
57
32
33-
34-
Normal
Percentages.
22
65
8
70
12
65
26
65
In pretuberculous cases, those which have not yet
developed an active lesion, the percentage of small
lymphocytes is normal or subnormal; and simultane-
ously with the decrease in the percentage of small
lymphocytes there is an increased percentage of pha-
gocytes.
TABLE in.
Convalescent Cases.
Percentage of small lympho-
cytes
Percentage of phagocytes ....
Normal
^^- Percentages.
26
65
In convalescent tuberculosis the percentage of small
lymphocytes is appro,\imately normal or above normal;
and simultaneously with the increase there is a de-
creased percentage of phagocytes.
TABLE IV.
Showing Range iif Percentages for Pretcberculous
and Convalescent Stages.
Normal state
Pretuberculous condition .
Convalescent tuberculosis.
Percentage of
Small Lymphocytes.
26
8 to 25
23 to 37
Percentage of
Phagocyte;;.
65
57 to 74
51 to 63
Deductions. — From the tables we make the follow-
ing important deductions: first, as the tuberculous
condition becomes more marked and the gravity of
the case increases, the percentage of small lympho-
cytes decreases and the percentage of phagocytes
increases.
Second, as the tuberculous condition becomes less
marked and the convalescence increases, the percentage
of small lymphocytes increases and the percentage of
phagocytes decreases.
Many other deductions might be made from the
tables with reference to the physical condition of the
patients. For example, in all cases in which the
blood shows the usual tuberculous characteristics to-
gether with an increase in the phagocytes to eighty
per cent, or over, it is quite safe to diagnose advanced
pulmonary tuberculosis with cavity, profuse expectora-
tion, and abundant bacilli ; or, if surgical tuberculosis,
an abscess with more or less discharge of pus.
I do not wish to be understood as saying that all of
the appearances that I have described are necessarily
present in each case of tuberculosis. Neither do I
wish to say that many of them are not found in other
diseases. But I do claim that a peculiar combination
of blood appearances is characteristic of this disease,
to the extent that they will enable us to make a diag-
nosis at an earlier date than by any other means that
we now possess. It is quite probable that the near
future w'ill justify a stronger statement: that from the
blood condition we will not only be able to diagnose
tuberculosis, but that in many cases it will enable us
to distinguish the various stages of the disease, and
hence will be a valuable means of following the
course of the disease under \arious methods of treat-
ment.
Summary. — In conclusion I will review this study
330
MEDICAL RECORD.
[September 3, 1896
with the following summary: That the diagnosis of
tuberculosis, from the morphological appearance of
the blood, rests upon the hypothesis that each indi-
vidual has a biological prototype in the leucocytes of
his own blood. That leucocytes are independent or-
ganisms with functions analogous to those of the larger
organism. That they pass through stages of growth
and decay. That disintegration of leucocytes may
occur at any age. That the leucocytes are tissue
formers. That as are the leucocytes so is tlie indi-
vidual. That tuberculosis is a disease characterized
by tissue disintegration. That in tuberculous blood
there is abundant cell disintegration, premature de-
velopment, premature decay, and more or less devia-
tion from the normal percentages of the various types
of cells. That if there is marked disintegration in the
leucocytes, it is with absolute certainty that we can
predict a similar condition in the larger organism.
That tuberculosis possesses a combination of blood
appearances, from which a diagnosis may be made
earlier than by any other means that we now- possess.
That these may be recognized by appropriate micro-
chemical stains and under a high power. That they
can be recognized even before the disease manifests
itself in the individual. That they are sufficiently
marked in tuberculous persons, or even in those with
a strong tuberculous predisposition, to enable a diag-
nosis being made from the blood alone, without
knowledge of the history or physical condition. That
the real source of the recuperative power is to be
found in the leucocytes. That thus far no other
pathological condition has been found which presents
similar blood appearances. That to secure an early
diagnosis would enable many to avail themselves of
favorable climatic changes, and thereby delay or even
prevent the destructive results which would otherwise
inevitably follow, And, finally, that if future investi-
gations confirm these deductions, we may look forward
to a no distant day when, if we expect to detect tuber-
culosis in its incipiency, we must study the leucocytes.
25, 26 Barth Block.
THK MICROSCOPICAL PROOF OK A CURA-
TIVE PROCESS IN TUBERCULOSIS; OR
THE REACTION TO TUBERCULIN EVI-
DENCED BY BLOOD CHANGES HITHERTO
UNRECOGNIZED.'
Bv CHARLES DEMSON, .A.M., \l.lt.,
DESVF.R, t\>l .
There is urgent need of a gauge to go with treat-
ments claimed to be curative in consumption, by which
their relative merits may be determined. There is no
lack of "cures,'' so-called. "The woods are full of
them," but the limitation of the curative process
common to most of them has never been accurately
determined.
Thus far, climate, and the preferable climate is on
this eastern Rocky Mountain slope, has proved to be
first in the list of remedial means, however its curative
power is increased by other agencies.
The latest claimant to curative fame, aseptolin, is
by no means an e.xception to this estimate. The treat-
ment has some merit in it. However, the profession
will grant much of the credit to the Frenchman, Dc-
clat, who many years ago put forward the hypoder-
matic use of phenol, and to Dr. Louis Waldstein, of
New York, who in Berlin made prominent the similar
use of pilocarpine, as well as to Dr. Cyrus Edson,
who by combining them has lately brought the new-
remedy, aseptolin, into extended use. Yet the
' Read before the Colorado State Medical Society, June l6,
1S96.
effects have to be acknowledged as considerably
limited and not so different in kind as we would wish
from those produced by the Shurly and Gibbs method
with chloride of gold and sodium and with iodine, or
from the more recent effort to saturate the system w ith
creosote.
Tuberculin and antiphtliisin (Klebs'), which latter
is considered by some (Trudeau and Baldwin) onl) a
modification of the former, have not yet impressed
the medical profession with their great worth as a
means of treatment, for reasons the profession are
probably responsible for, though as a means for the
diagnosis of tuberculosis the position of tuberculin is
well recognized by veterinarians. It is, therefore,
very gratifying to have the hope revived that there
may be found a trustworthy means of comparing and
judging these curative methods tiirough the micro-
scopic examination of the blood.
It was to apply his method of staining and blood
examination in order to determine the cell changes
induced by the reaction to tuberculin, that I asktd
Dr. A. M. Holmes to study with me two of my cases
some ten weeks ago. The results are new and I am
gratified to present them to you in so clear a form,
considering the short time the study has been in prog-
ress. Much credit is due Dr. Holmes, for I am un-
aware that just this method of study and comparison
has been carried out by any one else. A short history
will enable us to comprehend Case I., which was
primarily a pulmonary and afterward a surgical tuber-
culous affection.
Case I. — Male, age thirty-eight, first seen July 26,
1895 ; a banker, married eight years, just arrived from
Vermont. His mother, whom the patient much resem-
bled, died of consumption. This patient had la grippe
followed by cough two years previously, and last winter
another attack, when he had night sweats. His weight,
about one hundred and fifty pounds, was not decreased,
because of good living and care. He experienced
only slight effect of elevation on coming here. Cough
was not severe; expectoration was whitish, about one
ounce in twenty-four hours, and contained tubercle
bacilli, three to five in a field, streptococci, and diplo-
cocci. There was some infiltration and dulness at the
left apex and very slight impairment of respiratory
sound on the right side. Diagnosis, fibro-tuberculosis,
first stage. Treatment, to use the inhaler because of
the bronchitis and mixed infection and to go into the
mountains.
September 6th he had returned from a stay at Idaho
Springs and was improved somewhat. The spirometer
record had increased from 205 to 225 cubic inches
and the manometer record from 95 to 1 10 millimetres.
September gtii I commmenced to give tuberculin
( Koch's), with ultimately increasing intervals between
the injections. The reactions were light and occurred
only after a few of the smaller doses. A maximum
dose of about sixty milligrams was reached. The
sputum cleared up (the germs disappearing) and finally
ceased altogether.
April 14, 1896.— Up to Febuary 7th the lung condi-
tion continued most favorable, but the tuberculosis had
not been wholly eliminated from his blood, for a small
abscess then came underneath the scalp above the
forehead, the pus from which was found to contain
tubercle bacilli; also, perhaps following a strain of
right arm and much pain, which kept him awake
nights, an abscess formed and infiltrated the tissues
below the right elbow-joint. Each of these conditions
improved under drainage, the renewal of tuberculin,
and the administration of hypophosphites with hydri-
odic acid. The scalp abscess has healed entirely,
but the trouble in the arm evidently comes from tuber-
culous necrosis and will necessitate an operation.
.April 15th Dr. C. A. Powers operated on the right
I
September 5, 1896]
MEDICAL RECORD.
elbow and we found, as we expected, necrosis of the
ulna. Both front and back sides near the end were
affected, the joint perhaps just escaping.
A conservative plan was decided upon — to expose
the diseased bone freely and scrape it, after which the
wounds were thoroughly packed with iodoform gauze.
June 13th. — The dressings were continued until the
wounds had healed by granulations from the bottom.
During the time of and preceding the ojDeration on the
elbow, for three or four weeks no tuberculin was given,
and it was during this f)eriod, when the necrosis of
the ulna was well under way, that the first blood ex-
amination, namely, that of April nth, was made by
Dr. Holmes, indicating, as he stated, a serious inflam-
matory state of the blood and some bone affection;
i.e., " an excess of bone marrow or spleen activity"
(see table). The tuberculin was continued and given
about every fourth day, from about the first of May to
date, in gradually increasing doses (from twenty to
seventy milligrams for a maximum dose) till there
was finally no reaction to speak of to the larger
doses. This was during the time the other four
blood examinations were made, the increase of the
young or new cells, the small lymphocytes, being
in exact hannony with a decided improvement in
the patient's condition in every way — in weight,
appetite, strength, feelings, mobility of the affected
joint, and ability to exercise.
Record of Blood Examinations.
«
i
M «
_«
T.
u >>
"a. 5-
'X.
Cases.
%l
Q.
i
s
Remarks.
II
1
About the normal
lb
8
65
I
0
Case I.
.April nth, necrosis forming.
6
21
72
i
I
Average of 500.
May 6th, two and one-half
9
17
72
2
0
do.
hours after a tuberculin
injection.
May Sth, just before an in-
II
20
66
3
0
do.
jection, 10:30 A.M.
May Sth, eight and one-half
18
16
64
2
0
do.
hours after injection.
7:30 P.M.
May igth, seven days after
32
13
53
If
0
Average of 500.
an injection.
Note increase
of small lym-
Case II.
phocytes.
April 13th, 5 P.M., before
7
19
72
I
I
treatment.
April 14th, five hours after
16
10
73
h
I
injection. 4:30 P.M.
April 15th, thirty hours after
16
16
66
I
I
injection, 5:30 p.m.
May 1 6th, seven hours after
21
7
72
0
0
E.xtreme re t ro-
injection, 5 A M.
grade m e t a -
morphosis.
June loth, third day after
9
13
77
0
I
Evidence of pus
injection, 10 a.m.
formation and
retrograde met-
amorphosis ex-
treme.
Case III.
About June Sth, before test
8
21
70
I
0
Evidencing t u -
with tuberculin.
bercuiosis.
June 17th, ne.vt day after
17
13
70
\
0
Increase of small
second reaction to tuber-
lymph 0 c y t e s
culin.
and tissue met-
amorphosis.
It is hoped the apparent though perhaps only ap-
proximate immunity reached in this case w'ill prove
to be of a permanent nature, as has been the case with
quite a number of patients treated from one to five
years ago. Of course these were selected with all the
care and precaution possible, as suitable for this
method, for none others in my judgment should ever
be given tuberculin except for diagnostic purposes. The
progress of the above case and of the one yet to be
described, together with the numerical changes in the
proportion of the various cells of tlie blood, are shown
in the accompanying table, which Ur. Holmes has
kindly prepared for me. To this are added the figures
of the normal proportion of the different cells accord-
ing to Neudorfer, of Vienna, for the purposes of com-
parison.
For the technique and the interpretation of the
staining-proclivities of the cells and of other evidences
of repair or degeneration, reference is made to Dr.
Holmes' paper.
Case II. — Miss , age twent)'-two, first examined
by me February 17, 1896. Both the patient's sisters are
possi'oly tuberculous, the mother is frail, and the
mother's two brothers and one sister died of consump-
tion. Previously to coming to ( 'olorado from Maine,
which was about seven years ago, she had neuralgia,
some cough and fever, was weak and sick, and had yel-
low expectoration. In Colorado she greatly improved
and the catamenia became regular. She ceased expec-
torating after one month. When eighteen years old
the glands in both axilla swelled. The swelling dis-
appeared in three years, but before that, namely, two
years ago, the hard lumps came on the right side
of the neck and one year ago on the left side.
There must have been as many as twenty on the
right side, reaching from the ear to the middle third
of the clavicle, and nearly as far down on the left side.
Those on the right were the largest, causing marked
deformity and two of them were commencing to sup-
purate. There was little or no expectoration and but
slight daily temperature rise. Spirometer record, 130
cubic inches; manometer record, 60 millimetres. Her
weight before coming was one-hundred and five pounds,
and now was one-hundred and twenty-three pounds.
Expansion, 29.5 and 31 inches, a little greater de-
ficiency on the right than on the left side. Remnants
of enlarged glands were noted in both axillje, with some
depression in the right infraclavicular space. Phy-
sical examination revealed no rales or breaking down
of lung tissue, but broncho- vesicular breath- sounds,
some dulness, and exaggerated voice at both apices front
and rear, with prolonged e.xpiration in the right infra-
clavicular space. The dii.gnosis was strumous phthi-
sis, so called, which was proved immediately after-
ward to be tuberculous by the tuberculin test. The
local reaction was shown positively by the high-
pitched broncho-vesicular exaggeration in the left
interscapular space; this was noted after the six-
milligram tuberculin dose, and afterward it was quite
general over the lungs. The glands in the neck ah^o
began to get harder and there was temperature reaction,
which seemed to become excessive, showing extrtrre
susceptibility. The test was stopped to prepare for the
enucleation of the glands, and thus get rid of so much
tuberculous tissue. This operation was perfoimed
by Dr. C. A. Powers, assisted by Drs. O'Connor,
Pedersen, and myself, April 29th, and some seventeen
to twenty glands were nicely enucleated. It was be-
fore and after this operation that the bleed examina-
tions shown in the table were made, in connectityn
with very small and infrequent doses of tuberculin.
The value of these examinations made bv Dr.
Holmes was manifest, showing the coincidence of an
abnormal susceptibility and the excessive tissue meta-
morphosis which wi.:, going on. Notwithstanding
other signs of improvement in this patient's condition,
this discovery contraindicated the pushing of such
treatment with so much tuberculous tissue to be gotten
rid of, and the moderate use of antiphthisin (Klebs)
was substituted, with mild inunctions ot the oleate of
mercury and the internal administration of syrup of
hypophosphites and uf hydriodic acid. This is pre-
332
MEDICAL RECORD.
[September 5, 1896
paratory to the extirpation in the near future of the
rest of the glands on the left side.' This obstinate
diseased condition is of the more interest because of
its persistence and the profound infection of the sys-
tem, as well as because it shows that the glandular en-
largements, which we have always thought to be
scrofulous, are profoundly tuberculous, though, as in
this case, no bacilli are found in the glands removed.
This verifies a statement I have previously made,
based upon our inability to find the bacilli tubercu-
losis in tissues evidently tuberculous, as in adenoid
growths in the region of tiie third tonsil in a patient
who afterward died of tuberculosis: namely, that
there is a pretuberculous state, of which some evi-
dence besides the bacillus of tubercle must be found.
Whether that evidence is to be found, as for a long
time I have hoped it would be, in the proper micro-
scopic examination of the blood, or as I believe it
does exist in the tuberculin test, there is no doubt in
my own mind that the two methods will go hand in
hand and verify or check each other, just as surely as
do the control tests of the assayers in our sampling-
works.
.\ beautiful illustration of the value of both these
tests is now given us in another of my cases (see
table. Case 3), whose blood has just lately been ex-
amined by Dr. Holmes. I refer to the case he de-
scribes, in which I could find no bacilli in the sputum
and had diagnosed bronchitis and hydronephrosis, and
possibly latent tuberculosis. But Or. Holmes was
sure from the morphological appearance of the blood
that the case was one of tuberculosis, he knowing noth-
ing of the kidney complication. I have since tested
this patient with tuijerculin and obtained a distinct
reaction, proving Dr. Holmes' diagnosis to be correct."
As to tuberculin: I was much impressed by Dr.
Hance's statement in his late paper on " The Treatment
of Pulmonary Tuberculosis," ' which verifies my own
experience and which I will quote in closing:
'' The writer recalls at least four patients who could
not continue the use of tuberculin, but subsequently
arrested their disease process under proper climatic
treatment, .\fter the continuous use of tuberculin, or
its modifications, extending over a period of nearly
five years, he is of the opinion that patients who are
' relatively cured ' by the use of tuberculin and
climatic treatment have stronger resisting powers
against subsequent infection than those who have
secured the same results by climatic treatment alone.
In other words, their cure (if one may use such a
term) is much more firm and lasting than in other
cases."
The Blastomycetes of Sarcoma. — Roncali, of Rome,
says ihat he has found a micro-organism in sarcoma
and adenoid carcinoma of the ovary. It is found both
within and without the cell. Before it acquires an en-
veloping membrane the protoplasm is chromatic, but
later it has a thick membrane and the protoplasm be-
comes colorless.
' July 26tli. — The course of the case to date has been so favorable
and the evidence of shrinkage of the glands so conclusive that the
patient is urging delay of any operation, with the hope that it
may not be necessary.
'' The morphological state of the blood indicates an enlarged
spleen and tuberculous kidney. .-Vt the same time a diagnosis of
tuberculous adenoma of the kidney, complicating hydro- or pyelo-
nephrosis and perhaps calculus, seems to be warranted by the
gross appearance of this tumor. It reaches from the spine
around to within three inches of the navel and from below the
si.xth rib in front to within two inches of the crest of the ilium,
and has oval borders. This conclusion is supported by the his-
tory of hemorrhages and discharge of pus in the urine, and the
fact that the patient has lived as a miner in high altitudes for thirty
years, CNcepting short sojourns in the East, during one of which,
at the World's Fair, in Chicago, his principal attack occurred.
' Medical Record, May 2, i8g6.
METHODS OF INSTRLX^TION IN FIRST
AID."
By JAMES E. PILCHER, M.D., Ph.D.,
CAPTAIN IN THE MEDICAL DEPARTMENT OF THE f.NITED STATES ARMY.
An ancient writer named Agatharachides, in describ-
ing the prehistoric race of Troglodytes, dwelt upon
their method of displaying fondness for the sick and
infirm by affectionately drawing a cord about their
necks until they suffered no more — the fact that the
sick might object to such drastic measures, or that the
patient's life was ended as well as his illness, ap-
peared to cut no figure with the Troglodytes They
were not unlike the gentle Scvthians, who were wont
to employ a sort of Fabian policy in therapeutics, re-
lieving their dear ones of the ills that beset them by
tenderly depriving them of food until Death should
arrive and complete their cure, which he invariably did
in the most effectual manner.
Human altruism has, however, usually manifested
itself in a different way. When, in the early history
of our race, the sick received any attention, it was di-
rected in the main toward the prolongation of life as
well as toward the alleviation of illness. Efforts look-
ing to the accomplishment of either were not a fea-
ture of early days. In case of war, no provisions were
made by leaders for the relief of the injured in the
field or on the march. The wounded soldier was de-
pendent for help either upon the kind offices of his
friends or the tender mercies of his enemies, and in
the great majority of cases he was neglected by both,
only to expire in lingering agony that was incompara-
bly greater in its suffering than sudden death amid the
fury of battle. Death being almost inevitable to the
injured man, it is hardly surprising that the wounded
warrior of old should have fought desperately until a
fatal stroke put an end at once to present pain and
future agony.
Wise in their day and generation were those com-
munal soldiers of the Middle Ages, who took their
wives with them into the field, in order that they
might be assured of suitable nursing in case of a
wound. Indeed, the vast companies of camp-follow-
ers that were found in the wake of every great army
of that and later periods, were composed to no small
e.xtent of women, from whose numbers nurses were
often secured for a favored invalid. But of organized
and .systematic assistance to the disabled there was
none. The first field hospital in history was not es-
tablished imtil the close of the fifteenth centur)-, when
Queen Isabella, of Columbian memory, established
one at Antiquera. And even this was but a sporadic
case, which was hardly duplicated for a couple of
centuries, until Larrey and Percy became the fathers
of the military sanitary system which has attained so
great a development at the present day. During that
period, however, surgeons progressed from the position
of personal attendants upon great commanders to a
recognized official station, with duties toward soldiers
as well as officers. Finally, the trained sanitary sol-
dier was conceived and created. The instruction of
a certain number of the soldiers of the line in the
treatment of emergencies and the preparation of
cases for the trained sanitarj' soldiers became a fixed
fact, and now the magnificent conception of instruct-
ing the entire enlisted force in the elements of first
aid has been evolved and put in operation.
The methods of rendering relief were even cruder
than the plan of organization. The few surgeons who
accompanied armies in the retinue of royalty and no-
bility were themselves in the majority of instances
mere ignorant pretenders, able to give only the most
' Read before the Association of Military Surgeons of the United
States at Philadelphia. May 14, 1896.
September 5, 1896]
MEDICAL RECORD.
333
unintelligent and blundering kind of assistance.
When the presence of surgeons in military commands
became more general and of better quality, their help
was still inefficient and incompetent, and this condi-
tion persisted almost up to the present da\-. The
brancardiers of Percy were litter bearers, not emer-
gency men. The care of the wounded even in hospi-
tals was of a most defective character as recently as in
our war of the rebellion, and the battlefield assis-
tance was confined to the medical officers aided by the
" horse sense" of the wounded man's comrades. The
thousands of deaths that occurred from a lack of an
acquaintance with the methods of applying temporary
aid, and the thousands more that ensued from sheer
neglect owing to the lack of sufficient attendants and
of proper organization among the few who were pres-
ent, can never be sufficiently regretted. In more re-
cent wars progress has been made ; but, as a matter of
fact, no military medical organization has yet been
able unassisted to grapple with the huge masses of
sick and wounded incidental to a great campaign.
Solferino, with its five leagues of battleground thickly
strewn with wounded in every stage of agony and lin-
gering despair, incited the different nations to estab-
lish Red Cross societies. Yet in the Franco-German
war, when these societies put forth all their strength
and struggled witli une.xampled energy, the wounded
remained at Sulz on the battlefield absolutely de-
serted and additionally tortured by cold and hunger
for three days; and at Gravelotte,' where the ambu-
lances could not arrive in time, the greatest suffering
resulted among the wounded. At the beginning of
the Russo-Turkish war, the Russian official medical
service compelled. the admiration of connoisseurs, who
asserted that nothing was left for others to do; yet,
during the progress of the campaign, the efforts of the
official medical service, the exertions of the Red Cross
societies, and the benevolence of private individuals
were all strained and taxed to the utmost in the en
deavor to succor the prodigious masses of sick and
wounded troops.'
The work of the SLUiiu. y corps of the Japanese
army in the recent Chino-Japanese war was effective
in the extreme. An observer remarked: " While the
storm of lead was still hurtling thickly through the
air, a company of Red Cross men, always well to the
front, appeared on the field, stolidly marching out
from the ravines, two and two, with stretchers and first-
aid appliances for their comrades, right under the
withering fire from the gunboats, with never a mo-
ment's hesitation. Unarmed but for a paltry dirk at
the side, helpless in any case against attack, with foes
heedless or ignorant of the sacred significance of the
Red Cross badge, they did not Hinch for a moment on
their errand of mercy. It would have been easy to
wait until the fire should cease, but they nobly went
on and did their duty as if on the parade ground at
home. One by one, Ihe dead and wounded were
sought out all over that wide field of blood and borne
away, until within twenty minutes the place was
cleared of every man, living or dead." It was a most
splendid example on a small scale of what first-aid or-
ganization and instruction can accomplish.
When a nation so new in Western civilization as
the Japanese can produce results which command the
admiration of the world to such an extent as in this
instance, who can deny the raison iPrtre of instruction
in first aid? The duty of rendering first aid to the
injured after an engagement is characterized by Long-
more as a " vast and serious concern, not merely im-
portant in respect to preventing aggravation of exist-
ing suffering, but upon it depends the question of life
itself in numerous instances, and in many others the
whole future condition of the wounded, whether it
• Roberts' " Ambulance Work."
shall be one of continuous pain and of comparative
uselessness, or the reverse of these conditions."
With so much dependent upon a proper knowledge of
the subject, the question of the best methods of popu-
lari?ing such knowledge is of the gravest importance.
By common consent, the meaning of the expression
■■ first aid" has been restricted to the temporary assis-
tance to be rendered by persons without medical train-
ing in the interval between the accident or emergency
and the arrival of a medical man. Emergency sur-
gery and emergency medicine are subjects excellently
taught in many medical colleges to embryo practition-
ers of medicine, but first aid is far from being taught
in the same proportion to the general public. During
the last score of years, however, much progress in this
direction has been made, largely through the influence
of the St. John Ambulance Association of England.
Thousands of civilian practitioners throughout the
L'nited Kingdom, Australia, Canada, China, Germany,
Gibraltar, the East and West Indies, Malta, New Zea-
land, Russia, South Africa, and our own country, in
addition to military surgeons, have undertaken the
instruction of classes in first aid. The extensive
amount of experience thus accumulated, supplementary
to the military observations of many countries, is now-
available for examination and sifting in order to
evolve the best method of teaching.
It was but natural that the oral method should have
been the first to be adopted in teaching first aid. It
was simply a recurrence to first principles. It was
the way Adam taught Cain the gentle avocation of
butchery and Abel the homely craft of horticulture.
It was a most effectual method where the instructor
was possessed of the art of putting things and the
audience endowed v.ith the faculty of rapid percep-
tion. But in these days we have not the phenomenal
memories of other da)s, when all teaching was oral.
Aids to the recollection are necessary not only on ac-
count of degeneracy of memory, but because the enor-
mously increased extent of the field of knowledge has
rendered it impossible for one mind to retain it all
in detail. Niccolo Bertruccio, the greatest anatomical
teacher of his epoch, taught the whole subject of anat-
omy in the eleventh century at Bologna in four lec-
tures. But who would be so preposterous as to attempt
to teach the subject as it is now known in a dozen
times that number.'
No description can take the place of a picture. The
earliest form of writing was picture writing. The pic-
ture writing of the American Indian to-day is graphic
and expressive in the extreme. Never was man such
a master of word painting that he could equal the sun
for accuracy and suggestiveness. The pencil, the
brush, and the camera are of the greatest value in
making clear instruction in first aid. The thirteen
cartoons of Henri de Mondeville, upon which the en-
tire instruction in anatomy at the Paris School of
Medicine in the thirteenth century was based, are fa-
mous in medical history. The anatomical drawings
of Bartolommeo Eustachio were so vivid and accurate,
that when they were discovered a century and a half
after his death and published for the first time, they
rescued his name from oblivion and emblazoned it
high on the tablets of immortality. The interest dis-
played by a class in anything like a picture is evi-
dence enough of the value of this element of instruc-
tion in first aid.
Early in the history of such instruction, the value
of practical demonstrations was recognized, but these
varied greatly according to the taste and wit of the
lecturer. It is difficult for many a man to place him-
self in the position of treating an actually injured
man in the absence of an actual patient: it is some-
times equally difficult to find a person who is willing
to assume the role of an injured man, while it is
334
MEDICAL RECORD.
[September 5, 1S96
rarer still that one can be found with the ability to
assume the role in a realistic manner. There can be
no question, however, as to the value of the practical
demonstration; for, if conscientiously carried out, it
will not only clarify the whole proceeding in the mind
of the learner, but many points will be brought out
unconsciously by the demonstrator. The training of
the surgeon makes many things second nature to him
which are absolutely beyond the ken of the non-medi-
cal man. These little essential features of treatment
come to light in the practical demonstration. The
demonstration also serves to correct in the mind of the
learner misapprehensions into which he may have
been led by ambiguities or technicalities in the words
of a speaker. However careful a medical man may
be in his effort to bring his language down to the
comprehension of the uninitiated, some technicality,
some scientific expression, precision itself to the phy-
sician but conveying no idea whatever to the layman,
is more than liable to creep in and obscure the sense
of his e.vplanation. This the demonstration will en-
tirely correct.
And then, as with the invention of printing the old
medical teachers put their prelections into tyjje in or-
der that their students might have copies constantly
at hand as aids to memory, so the earlier first-aid in-
structors came to put their lectures into book form for
the benefit of their classes. Tlie " Krste Hiilfe'' and
the " Samariterbriefe" of von Esmarch, the " Ambu-
lance Work'" of Roberts, the " Ambulance Lectures"
of Martin, the "" Emergency Notes'" of Butler, and
many others were of this class, and are very attrac-
tive reading because of the colloquial style in which
they were expressed. The little first-aid handbook of
the late Surgeon-Major Shepherd, of the British army,
was brought out by the St. John Ambulance .Associa-
tion, and a host of imitators sprang up all o\er the
world. There was a demand, liowever, for more
thorough systematically arranged text-books upon the
subject, which has been met by the publication of a
number of more extensive books, which are now the
recognized authorities upon the subject in this coun-
try. The crop of the smaller and more defective lit-
tle manuals continues to be active, every year produc-
ing one or two. There is no especial use for them;
they are rarely in any way an improvement upon the
original compend of .Shepherd. 'Their only ad\antage
seems to be that they excite an interest in first aid
among the author's friends and adiierents and certainly
in the author himself, thus proving to be valuable
agents in the propagandism of the subject. Whether
this is counterbalanced by the fact that many of their
readers are likely to look upon the compend as the
sum total of the subject and to look no further, is a
question. If, as is the case with the first-aid instruc-
tor in a metropolitan brancii of the Red Cross -Society,
the teacher calls attention to the incomplete character
of his own book and recommends the study of a more
extensive one in addition, the only objection is wiped
out. The pro])er use of the abbreviated manual is
as a pocket book for constant carriage in the pocket
as a remembrancer of the facts which have been
learned by the study of a larger one. The use of two
books in this way is certainly an excellent practice,
;is will be seen in detail farther on.
'The use of the text-book is best completed by the
addition of recitations. .\ cultivated and experienced
student may, perhaps, be able to absorlj the contents
of a book by simple peru.sal, but the ordinary reader
cannot. Few persons have gotten beyond the stage of
mental culture in which the verbal discussion of a
subject which has been read is of the greatest service
in fixing the facts in the mind. This is nothing more
nor less than a recitation. Cla.ss recitation is prefer-
able to solitary recitation, not only because of the ad-
vantages always to l)e derived from pergonal attrition
with individuals engaged in the same pursuit, but be-
cause of the new ideas brought out in the class-room
consideration of a subject. In numbers of instances
in the writer's observation, suggestions of the utmost
interest and advantage have been derived from the
least promising members of his class during such dis-
cussions. 'The recitation plan is far superior to the
lecture system because of the opportunity which it gives
to the learner to formulate and fix the facts which he
has been taught. For the same reason, it is even more
to the advantage of the members of a first-aid class if
they are given an opportunity to leach the subject to
others. If a man possesses much personal pride, the
position will put him on his mettle to learn more than
his class, and prove a genuine stimulant to study.
All of these methods of instruction have their ad-
vantages and all of them have their failings. A plan,
to be thoroughly successful, should combine all their
good featuies and exclude all their objectionable
|)oints. .\nd yet it is impracticable to devi.se a plan
tiiat shall be equally adapted to e\ery grade of intelli-
gence. There must l)e at least two grades of instruc-
tion, and perhaps three. In the army we have four
classes of persons to instruct: i. Hospital corps; 2,
officers of the line; 3, company bearers; 4, all other
enlisted men. The second and third classes iiiay be
considered in the same category in considering the
amount of instruction to be given them, about the
same extent of qualifications being desirable in both.
'The facilities for the instruction of the hospital
corps are greater than for either of tiie other classes,
their residence in the hospital and their more or less
constant contact with the sick and injured giving them
a certain degree of technique to be gained in no other
way, while their freedom from other duties makes it
possible for them to give much more time to first-aid
study than any other of the four classes.
'The company bearer, according to the e.xperiencc of
some medical officers, has been a most unsatisfactory
subject for instruction, for three reasons: (i) The fact
that through carelessness in selection a poor class of
men is apt to be detailed; (2) the frequent changes in
details; and (3) the interference of other duties with
the hours of instruction. The.se faults are all usually
easily remedied — the first by calling the attention of
the company commanders privately to the desirability
"f detailing good men ; I have yet to find the com-
pany comm.mder who is not amenable to reason under
these circumstances. The second difficulty is also very
readily overcome by calling the attention of the post
and company commanders to the disadvantage of
changes, and by declining to approve of new details.
.Vnd as to the third objection, po.st commanders will
almost invariably arrange for men on other duties to
Im,' jjresent at the hour of first-aid instruction. I be-
lieve the comjjanv bearer to be an important factor in
the first-aid work of the army, and it is hoped that
he will remain as a permanent feature. The recent
order requiring all enlisted men to be in.structed in
first aid has had a decidedly stimulating effect upon
the company bearers. Realizing that they have the
advantage of their comrades in their previous instruc-
tion, they are the more willing to push on and keej)
ahead.
The methods of instruction for the four classes may
with advantage be very much the same, differing only
in degree. 'The hospital corps, by daily instruction
until qualification is attained, should be pushed for-
ward to an entire acquaintance with the subject. The
officers and the company bearers are, as a rule, taught
better in weekly meetings, but at separate hours, and
at such a rate of progress as each may be capable of.
'The method of instruction giving the best residts is
a combination of the vivti ivft, the text-book, and the
September 5, 1896]
MEDICAL RECORD.
335
practical demonstration. The subject of each lesson
should be gone over orally by the teacher before any
recitation is held upon it. I'he talk upon the subject
should be illustrative and demonstrati\e, and points
should be clearly brought out. The lecture, if it may
be dignified with that title, should e.vactly cover the
ground of the lesson assigned in the te.xt-book for the
next session. To obtain the best results, it will not
be sufficient for the teacher simply to read the account
of the subject from the book, as is not infrequently
done ; he must speak in his own language and endeavor
to infuse the magnetism of his own personality into
his class. Many of the learners will prefer to read
the te.xt-book version before the lecture, thus placing
themselves in a position to more fully appreciate the
comments of the instructor. The next hour of instruc-
tion should then be opened with a recitation upon the
lesson previously given out. This recitation should
not be conducted in a pedagogical style, but with a
view not only to ascertain the familiaritj- of the stu-
dent with the lesson, but to fix it in the minds of the
learners by every available accessory. Charts, draw-
ings, photographs, specially constructed apparatus,
and practical demonstrations should all be used when-
ever they can be applied. The stereopticon is a valu-
able assistant, but there is a temptation in its use to
overdo the matter; it should not be used more than
once in four or five hours of instruction.
The great tendency of the instructor in first aid is
to fire over the heads of his audience. " There is a
fatal facility in the use of technical tenns," says But-
ler, which it is difficult to repress. To present his
facts in simple language and to avoid technicalities is
the earliest lesson the first-aid instructor has to learn.
It is astonishing what ignorance of matters pertaining
to the human body and the ills to which it is subject
may be found in the most intelligent laymen. It was
only the other day that I overheard a discussion upon
the reliability of the Scriptures, the ;irgument being
finally closed by a man of the highest intelligence, an
author and of commanding infiuence in the commu-
nity, who triumphantly cried: " How is it, then, that a
man has one rib less on one side than on the other?"
Xo technical e.xpression should ever be used until it
has been fully and distinctly explained: and, in gen-
eral, simple Anglo-Saxon nomenclature is better than
the Latinized verbosity of the scientific treatise.
■'Bleeding" is better than "hemorrhage;" a bone had
better be "broken" than "fractured;" '"breathing" is
as good as "respiration;" "bloodless" is clearer than
"exsanguinated." Simplicitv' of diction cannot be
sought for too assiduously.
It goes without saying that the elements of anatomv
and physiology are an indispensable preliminary to
first-aid work. The amount of instruction in this in-
troduction to the subject will vary with the four
classes to be instructed. The hospital corps, officers,
and company bearers should learn the skeleton to the
extent of becoming acquainted with the names, shapes,
and locations of all the principal bones and such con-
spicuous features of them as may be useful in first aid.
It will not be necessary for them to learn the structure
of the temporal or ethmoid bones, nor to know the
tarsus or carpus in detail. But the peculiar arrange-
ment of the bones at the elbow or shoulder or hip
should be learned — they should know what the olecra-
non, the trochanters, and the acromion are, because of
their relation to many accidents; and a similar ac-
quaintance with other parts of the osseous structure is
essential for a satisfactorj' comprehension of the emer-
gencies connected with them.
The study of muscles and joints in detail is not
needed in a student of first aid. The emergency man
will not attempt to reduce any but the simplest dislo-
cations, and individual muscles will play but a very
unimportant role in any assistance he may be called
upon to render. He should, however, know the gen-
eral characteristics, purposes, and functions of them
both. The nervous system is of comparatively little
importance to the first-aid man, and he need study only
the first principles of its structure and distribution.
He must, however, know the topography of the trunk
with reference to the principal viscera, because of the
important bearing these facts have on the application
of first-aid treatment.
The vascular system is, of course, by far the most
important division of the body with respect to first aid
study, since treatment of its lesions fonns the most im-
portant part of emergency work. The physiologv' of
the circulation explains the philosophy of haemostasis,
and the topography, particularly of the arteries, is an
essential for the application of proper treatment for
hemorrhage. The names of the principal arterial ves-
sels should be learned and their location and some
facts with regard to their size and relation to danger-
ous bleeding. I shall not attempt, however, to give a
complete synopsis here of the anatomical and physio-
logical facts essential as an introduction to first-aid
study. I have done this in full elsewhere.' It is de-
sired to suggest simply the merest outline preliminary
to a brief consideration of the best method of teaching
the facts.
The bony framework itself is the foundation of all
first-aid study, and nothing can be substituted for the
human skeleton for this purpose. The best results
are to be obtained from a combination of an articu-
lated and a disarticulated skeleton. In the former the
mutual relations of the component parts can be shown
and demonstrated, while by means of the latter the
peculiarities of the individual bones can be shown.
The course of the circulation and the location of its
component parts, other than the heart, can best be
shown by charts, as, except in the rarest cases, it will
be impracticable to demonstrate them upon the cada-
ver, which is the ideal method. Moreover, except with
the hospital corps, who become accustomed to death
through their ordinary duties, there are peremptory
though sentimental objections to the use of any part of
the cadaver, except the skeleton. But, while the to-
pography must be obtained from charts, many of the
most interesting general facts and much of the mor-
phology can be displayed in the anatomy of the lower
animals. The common domestic cat " is a treasure-
house of information for the first-aid class. A dog
may be even better, if he is larger. It is well to
anaesthetize the animal in the presence of the class and
to demonstrate the action of the heart and lungs in
active movement before life is extinct. If care has
been taken that the act of digestion shall be active at
the time of the demonstration, a display of the mesen-
teric lacteals is always received with great enthusiasm
by a class. A few remarks upon the similarity and
the differences in structure between the cat and the
human being are always interesting and clarifying in
their effect upon a class. The differences between the
various kinds of hemorrhage can be shown by practi-
cal illustration, and by opening a vein and an artery
at the same time the venous and the arterial bleeding
can be actually compared. A muscle or two can be
disssected out to show what muscle actually is, to-
gether with its general morpholog)', and the tendons
and aponeuroses can be displayed. If the long mus-
cles be taken for demonstration, an excellent showing
oi muscular action can be given. The biceps, for ex-
' " First .\id in Illness and Injury," by James K. Pilcher.
Svo. Second edition, 1S94, pp. 322. Charles Scribner's Sons,
New V'ork.
'-'The subject may be studied up with advantage in (lorham
and Tower's " Laboratory Guide for tlie Dissection of the Cat."
published by Scribner; or the excellent work on " The DissectioQ
of the Dog," published by Howell, Holt i Co.
336
MEDICAL RECORD.
[September 5, 1896
ample, may be isolated and the forearm moved by
traction upon it, so as to show both tiexion and supi-
nation. The sciatic nerve can be uncovered and used
as an illustration of the elements of the nervous sys-
tem. The skull can be opened and the undeveloped
brain of the cat can be used to demonstrate the mem-
branes and substance of the brain and its relation to
the spinal cord. The brain itself can be made to give
interest to the comparatively unintere-sting topics of
brain compression; for this purpose it is well to use
two beef brains, one hardened in alcohol to show the
form of the brain and its parts ; and the other fresh,
to show the te.vture and friability of its substance — an
important feature in the demonstration. A glance at
ophthalmic anatomy upon a beef's eye may always be
used with great advantage to lend interest to a lesson,
while the study of the circulation can never be consid-
ered complete without a demonstration of the heart's
action upon the cardiac organ of a bullock, using, to
show the valvular action, either air through the blow-
pipe or water through a rubber tube. The interested
student of first aid should i)e advised always to read
over in his manual on the subject the topic of the
demonstration, both before and afterward, in order to
prepare his mind to understand the demonstration and
to impress upon his mind what he has been shown.
The elements of bandaging and surgicaf dressing
should always be taught practically. For the ordinary
tirst-aid class the triangular bandage will be ample,
but tiie hospital corps must be taught the application
of the roller bandage as well. It is my plan in teach-
ing the triangular bandage, after carefully explaining
the theory and practice of the dressing and showing its
practical application upon all parts of the body, to di-
vide the class into equal parts, calling them the front
and rear ranks respectively. Each member of the
class, then, at the word of command, applies each
bandage upon the man with whom he is paired; first,
each front-rank man applies the head bandage upon
his rear-rank man, who then at the word of command
reciprocates the act; the rear-rank man then applies
the next bandage, and the front-rank man reciprocates
— and so on alternately until the entire subject has been
tjhoroughly gone over. This plan is an excellent one
to follow in studying the treatment of bleeding, of
broken bones, and of wounds. It not only gives each
member of the class actual experience in applying
treatment, but enables him to see its application in
his own person, fully as instructive an experience as
the other. What one of us has not learned far more
about some malady by observation in his own case
than he could have been taught by a thousand lectures
and a hundred cases in other individuals?
The treatment of drowning and the use of artificial
respiration for other purposes may with great advan-
tage be taught in the same practical manner.
Exercises in the extemporization of dressings are of
the greatest importance and contribute greatly to the
interest of a class. Each member should be given the
opportunity to exercise his own inventive faculty in
the origination of such appliances. The amount of
ingenuity developed by these practical e.xercises is
sometimes remarkable in the extreme. The sugges-
tions as to materials for dressings, splints, padding,
bandages, and the like are often original and valuable
enough to instruct the instructor.
Medical emergencies do not usually admit of prac-
tical demonstration. The " dummy chucker' does
not, as a rule, practise his arts for iht delectation of
first-aid students, although it might be possible for an
instructor whose work brought him in contact with the
criminal elements in a large city to find one for the
benefit of his class. I considered myself ver)- fortunate
when, upon one of my drill hours, a company bearer
had an epileptic convulsion in the presence of the de-
tachment. This has occurred but once in my experi-
ence, however, and I do not expect it again ; and this
class of emergencies, including the treatment of poi-
soning, particularly demands the use of a text-book.
It is impossible for a lecturer, however graphic and
impressive his delivery may be, to impress these sub-
jects clearly, definitely, and sufficiently by verbal
effort alone. They must be learned by careful study
and repeated re-reading.
One of the most efficient elements of success in
maintaining interest is yariety. A pursual of the
method already rehearsed would give variety to a les-
.son upon most of the emergencies considered. But a
plan that is of advantage in all cases is to divide the
time for instruction into three parts, devoting one part
to a brief lecture and demonstration, a second to a quiz
and recitation, and a third to litter drill. When either
one of the three seems to demand more than a third of
the time, any one or any two of them may be dispensed
with. Variety may also be obtained by detailing a
member of the class to conduct any part of the work,
giving him sufficient time previously to enable him to
prepare himself for the duty.
The foregoing remarks apply more particularly to
the instruction of the first three classes — the hospital
corps, the officers, and the company bearers — given by
medical officers. The instruction of the fourth class
— the enlisted men in general — must necessarily be
much less complete, both on account of the lack of
knowledge and experience upon the part of the line
orticers who are to conduct the instruction, and the
lack of capacity upon the part of the men who are to
receive it. The amount of instruction actually given
to the companies will necessarily vary according to the
personality of the instructing ofiicer. But enough for
the purpo.se may be presented in five lectures upon the
following subjects, each occupying a full hour:
1. The Human Body (the skeleton and the circula-
tion in particular).
2. Bandages and Dressings (the triangular bandage
in particular).
3. Wounds and Bleeding.
4. Broken Bones.
5. Insensibility (drowning in particular).
These subjects need not be presented in a consecu-
tive series, but the lecture hour for several occasions
succeeding each lecture could with much advantage be
devoted to going over the matter of the lecture with
the men and fixing the points in their minds. Wounds,
for instance, should not be ventured upon until the
bandages and dressings have been mastered.
The question of impressing the facts retentively
upon the remembrance of the men is a most difficult
problem. Demonstrations of practical anatomy are,
of course, out of the question, and it is usually im-
practicable for the skeleton to be used in teaching the
bones. Here pictures must come in. Charts may be
issued to the companies for general demonstration.
It is impracticable to expect them to study first aid
from a comprehensive text-book, for many of them
have not the intelligence to comprehend the subject
upon reading, and a still greater number have not the
patience to try it. In this case it seems to me that
we should go back to the method of the untutored sav-
age, which should be within the comprehension of the
least intelligent soldier, and teach by picture writing.
Something of this kind has been attemjited in the Ger-
man triangular bandage of Fsmarch, which has been
almost ruined in the peculiarly wretched American
imitation. The St. Andrew's Ambulance Association
of Scotland produces a triangular bandage which is a
great improvement upon all others, and in it has been
attained the climax of pictorially treated bandages.
But these are unsatisfactory as means of instruction,
both because of paucity of information and their de-
September 5, 1896]
MEDICAL RECORD.
357
ticiency in permanence. It is impossible upon a tri-
angular bandage to illustrate, even with very small
rei)resentations, a tithe of the points needed to impress
the mind of the soldier, and the crumpling and soiling
of the bandage in the hands of its possessor will eas-
ily render it too illegible for consultation — an objec-
tion which will grow with the entiiusiasm of tiie fre-
quently perusing soldier.
.Vdmitting the value of the handkerchief within its
limitations, /.f., the illustration of only a few of the
principal procedures in which it is applicable, we
should go much further. The need can be supplied
by a little book containing pictorial representations
of all the important facts of first aid, with as little
reading-matter as possible. After this idea had been
quite fully developed in the writer's mind, his atten-
tion was called to the ■" Album fur Krankentrager"
of Dr. Ruhlemann, a surgeon in the army of Sa,\ony,
which had been used with very great success in the
German army. Dr. Ruhlemann's book is directly in
the line suggested, but with the pages a trifle too large
and the illustrations very poorly executed. A little
book upon this plan is now in active preparation for
the .American press, and in it an effort has been made
to do away with the objectionable features of the Ger-
man work, and to present a little manual clearly Amer-
ican in its characteristics as well as in its language,
and arranged in the order suggested as the most de-
sirable one for the instruction of the enlisted force.
Officers of the line may with much advantage, in
transmitting first-aid instruction to their commands,
utilize as far as practicable the features for interest-
ing and stimulating the attention that have been pre-
sented by their own medical instructors, and add to
them such other features as their own ingenuity and
enthusiasm may suggest. Competition is always an
important stimulus to work among men. The enthu-
siasm which is awakened by competitions of any kind,
from baseball to rifle practice, may well give us pause
in our consideration of methods of instruction in first
aid. The writer saw a Canadian judge and an officer
of one of the Massachusetts courts, on the liigh seas
and near the coast of France, where it was impossible
for either to learn anything of the merits of the case,
warm up to the point of personal collision over the
respective merits of Valkyrie III. and the Defender.
The quality which will, at the close of the nineteenth
century, bring to the point of the duello two gentlemen
of the practical Anglo-Saxon race, because of the ri-
valry of a couple of racing sloops, would certainly
seem to be an advantageous addition to first-aid in-
struction. Competition may be introduced into first-
aid military work by the institution of inter-company,
inter-regimental, inter-department or brigade first-aid
competitions, and the establishment of a grand peri-
odical competition for the championship of the entire
army. Each company being divided into little squads
of four men, graded by a competitive examination, the
winning squad should be entitled to compete for the
championship of the post or regiment. The champions
in this competition should then be assembed at some
central point in the department, considering the army,
or the brigade, considering the national guard, to com-
pete for first place in the department or brigade.
And, finally, at such intervals as may be desirable —
annually, biennially, triennially, or even quadrenni-
ally— the department or brigade champions should be
given an opjiortunity to compete at some central point
for the championship of the army or State. A trophy,
consisting, perhaps, of a bronze figure in armor pro-
tecting a wounded comrade with a shield bearing the
red cross, might with advantage be the chief trophy, the
custody of which would he awarded to the company
furnishing the victorious squad. .Similar smaller de-
signs could be awarded to the companies furnishing
the department or brigade champion, and still smaller
ones for the champion squads of the regiment or post.
The writer has often observed the advantage of com-
petition in drilling his own detachment. When the
day is depressing and the men seem a little sluggish,
the dummy wounded are often instructed to seek their
own location, and then, after infomiing the detach-
ment that the design is to see which squad will bring
in its man the most expeditiously, carefully, and safe-
ly, the command is given, " Search for wounded.''
.\t the first suggestion of an approaching competition
an alert expression supplants the sluggish one, the
eyes brighten, and eagerness characterizes every atti-
tude. The response to command is instant and their
execution of the order characterized by a degree of
efficiency obtainable in no other way. It is believed
that the extension of the feature of competition to the
entire army in the manner suggested will be of incal-
culable benefit in promoting the efficiency of the ser-
vice.
First aid in illness and injury is an active, living
issue of a concrete kind, that can be appreciated by
every one, whether in the military service or in civil
life. It is, then, of the highest importance to deter-
mine the methods of instruction from which the great-
est efficiency of first-aid service can be derived. From
our study, we have determined that in militar)' prac-
tice there are two principal grades of instruction ;
1. Instruction of the officers of the line, the hospi-
tal corps, and the companv bearers, given by medical
officers.
2. Instruction of the enlisted soldiers in general,
given by officers of the line.
The best method of instruction is a combination of
the lecture, the demonstration, and recitation from a
text-book, neither of the three being sufficient without
the accompaniment of the other two.
The best instruction is characterized by extreme
simplicity of diction and the avoidance of all techni-
cality in language.
The best instruction is progressive in character, be-
ginning with anatomy and physiology, and advancing
to bandages and dressings, and then to emergencies
proper.
The class-room work of the first grade is advantage-
ously supplemented by home study of a first-aid text-
book, and, when desired, it may be complemented by
the use of a pictorial remembrancer.
The class-room work of the second grade may best
be confirmed and fixed by the use of a pictorial re-
membrancer, a copy of which should form a part of
the equipment of every soldier.
Interest in the work of both grades should be stim-
ulated in every possible way, especial attention being
devoted to the development of interest in the second
grade, a series of public competitions being suggested,
the champions to be rewarded by the custody of suit-
able trophies.
By the methods and with the stimulus thus provided,
it is believed that every member of the military forces
of the country, including the army, the militia, and
the national guard, may become qualified to cope tem-
porarily with any relievable injury that may occur on
the march, in camp, or on the field of battle. War can
never become benevolent, nor can bullets be trans-
formed into white-winged messengers of peace; but
the horrors of war can be enormously mitigated, the
sufferings of unnumbered victims assuaged, thousands
of useful lives saved. It has been stated that after
an engagement more deaths occur from delay in apply-
ing proper treatment and from exposure on the field
than from the fire of the enemy. It is the function of
first-aid instruction to avert all these, and by the mag-
nificent organization now established to diminish the
338
MEDICAL RECORD.
[September 5, 1896
mortality of future campaigns, to achieve victory at a
smaller cost, and to dull the teeth of the dogs of war.
.And in time of piping peace, no less than in days
of raging war, will the good effects of the system be
felt. The thousands of men that every year go out
from the army and the national guard into the daily
life of our country will carry with them the ability to
succor the suffering and rescue the perishing, and, by
the aid which they will afford here and there through-
out the entire nation, will accomplish an amount of
good, by the side of which even the splendid philan-
thropy of first aid upon the battlefield will seem to
be insignificant in comparison.
REPORT OF CAS?:S IX .\Hl)O.MI\-\L .\NI)
PELVIf SURCIKRY.
By .\. II. CORDIKk. \I.I).,
KANSAS CIT\. MO,
Gastro-Jejunostomy with the Murphy Button. .V
man, aged si.\ty-si.\, some eight years ago had an at-
tack of hepatic colic lasting several hours, followed a
few days later by a jaundice persisting three or four
weeks. He soon regained his former good health and
remained so up to two years ago, when he had another
colic attack not so severe and not followed by jaundice.
One year ago he began to have more or less pain in
the region of the stomach, or rather, as he termed it.
an uneasiness after eating. .Vftertwo or three months
of this uneasiness, he began losing Hesh and had oc-
casional vomiting spells. No blood was vomited at
any time. At the time I first saw him, March i, 1895,
the had not been able to digest or retain_jnuch solid
food for several months, and was greatly emaciated
from his former weight, two hundred and forty pounds.
He now weighs only one hundred and thirty pounds.
His appetite was fairly good, and liquid nourishment
was taken with relish and fairly assimilated. Solid
food caused pain and nausea until relieved by vomit-
ing. On examining him I found that he was greatly
emaciated, had a " swarthy'' look not e.xactly that of a
malignant cachexia. PuLse and temperature were nor-
mal. Examination of the abdomen revealed a greatly
dilated stomach, and its peristaltic action could be
plainly seen through the parietes. It was painful on
pressure only in the region of the pylorus; here an
unnatural sense of resistance could ije distinctly made
out, covering an area about as large as the palm of the
hand or smaller.
A test meal examined revealed an absence of hy-
drochloric acid. .\ diagnosis of a malignant stenosis
of the pylorus was the most acceptable theory to me,
yet a non-malignant stricture had been made out by a
good diagnostician before I saw the case.
A tonic of strychnine and iron was given, and nu-
trient enemas were ordered four times in twenty-four
hours, lender this regimen he gained eight pounds
in a month.
A median incision four inches long was made, ex-
tending downward from one inch below the xyphoid
cartilage. A loop of jejunum was pulled into the in-
cision. .\fter pushing the omentum to the left, a
'' puckering-string" stitch was put in the convex sur-
face, the gut was incised, and one-half of the Murphy
button — the larger piece (one inch in diameter) — in-
serted. The stomach was pulled into the incision and
a similar opening was made in its anterior wall about
four inches from the pylonis, and the other half of
the button placed in position and securely fastened by
pushing the two halves together. The approximation
was perfect. \ running Lembert stitch was put in on
one side to give additional security against any acci-
dent that might occur from vomiting; besides, the
walls of the stomach were thickened from long and
constant peristalsis. The patient left the table with
a pulse of 90. He vomited for the fir.st time ten hours
after the operation, a large quantity of bile being
thrown up. Two days later he had a similar attack of
vomiting. The bowels moved on the second dav.
There was no distentioi: at any time.
On the twelfth day I could feel the button distinctly,
near the tenth rib. It was freely movable and had
evidently completed its work and left its moorings at
that time. Eggs. milk, ice cream, soft toast, rare beef-
steak (chewed and the juice swallowed 1 formed his die-
tary at the end of two weeks.
On March i, 1896, the man had not found the but-
ton, but wrote me that he thought it had passed some
time during his three weeks' stay at the hospital. He
has continued to gain in weight and strength, is free
from pain, vomiting, or other .symptoms pointing to
malignancv, and I trust that my probable diagnosis
of malignancv may i)ro\e to be wrong.
Sterile Echinococcus Cyst. — A woman, aged forty-
six, the mother of .several children, was first seen by
me on September 10, 1895. Some seven years ago she
noticed an enlargement in the region of the gall blad-
der. She at that time had .several paroxysms of pain
in that locality. During the interval from that time
up to the present attack she had had no severe pains,
but more or less uneasiness in the enlargement.
Some three weeks ago, after a long, tiresome ride in
an uncomfortable vehicle over rough roads, she was
taken with pain in the right hyjwchondriac region.
.\ fever, continuous in character, of moderate intensity
(100'^ to 102° F.), began about this time; the pulse
was 90 to 100. The appetite was lost and in its stead
was a loathing of all nourishment.
Examination revealed a growth the size of a foetal
head, smooth, globular, painless, semi-fluctuating, oc-
cupying the right hypochondriac, renal, and umbilical
regions. The abdominal walls moved freely over the
growth. There was dulness all over the growth and
continuous with normal liver dulness. .At the lower
border of the growth and in the median line two inches
below the umbilicus, the globular or pear-shaped gall-
bladder enlargement could be made out, movable on
a stalk or stem, seeminglv about the arc of a circle six
inches in diameter.
On September 13. 1895. an incision was made in the
right .semilunaris, from a point an inch below the free
border of the ribs, extending downward three inches.
The liver was cut directly down upon. Evidences of
localized peritonitis existed over the surface of the
organ in a few places. The gland ■w'as smooth and
enlarged. Exploratory punctures were made, but no
pus or other fiuid save blood was found. The gall
bladder could be easily made out, as the enlarge-
ment in the median line spoken of above. This
incision was closed and another made directly over
the gall bladder, two inches below the umbilicus.
This o(x.'ning was only one inch in length, and in it
the gall bladder was stitched with one suture at its
fundus, the wound in the parietes was packed with
gauze, and the patient was put to bed.
There was absolutely no reaction following the ope-
ration. On the third day I incised the gall bladder.
,V large quantit)' (four ounces) of thick, clear, albu-
minous fluid escaped. Not wanting to remove the
stones (which had been diagnosed at the operation) at
that time, lest the adhesions be disturbed, I decided
to wait a day longer. At this time (four days after the
operation) I removed one hundred and twenty-five
stones, the large.st weighing thirty grains (a large
stone, as gall stones are very light in proportion to
their bulk). No bile escaped from the gall-bladder
fistulffi, showing that the cystic duct was yet occluded.
At this time J made another exploratory puncture in
September 5, 1896]
MEDICAL RECORD.
oo9
the enlargement, recognizing that there existed adhe-
sions over its surface and that no loop of intestine was
in front of the liver, thus making the punctures safe.
No fluid but blood was obtained by this tapping.
The patient died three weeks after the operation
from exhaustion, the stomach refusing to take or retain
any nourislimenl.
There are several features in this case worthy of
comment. The large number of gall stones, with an
entire absence of hepatic colic and absence of jaun-
dice, can be explained only by the supposition that
none of the stones ever passed into the common duct.
or, if thej' did, they passed without much constriction
or pain. The absence of bile in the gall bladder is
easily understood, with the cystic duct occluded as it
was by the stones in this case. The late attack, with
pain, tenderness, and fever, was due to infection in the
gall bladder. The large, smooth, liver mass was due
to the bulging of a cyst from its under surface or
deeper structure. The rapid development was decep-
tive, and the mass was made rapidly prominent at the
expense of the absorption of the adipose in the abdom-
inal parietes. The cyst, being in an old person
(ecchinococcus developing usuallv in the young), had
evidently developed earlier in life, and the ecchino-
cocci, dying, left the cyst sterile; its contents, in-
stead of having a specific gravity of 1.015 with no
albumin and abounding in sodium chloride, was so
changed bv this sterilitv that its specific gravity was
1.032 and albumin was present (possibly due to pres-
ence of blood). The absence of booklets can also be
readily understood as being due to the sterility of the
cyst's contents.
Pyonephrosis; Nephrotomy — A lady, aged forty-
six, the mother of three children, was taken down
some eight weeks ago, having had "bad health" for
several months before. She had been having what
was called cystitis — frequent desire to urinate and
much dysuria. Her bladder had been washed fre-
quently and treated locally by instilling various solu-
tions recommended for bladder inflammations, but all
to no avail, as she continued to get worse, passing
large quantities of pus (pyuria).
At the time I first saw her, with Dr. Porter, she was
thoroughly septic ; temperature varying from 100' to
105'' F. ; pulse, 120 to 140; anorexia, night sweats,
passing large amount of pus in urine that was ver}'
irritating and offensive. The urine was ammoniacal
or strongly alkaline. On the side to the right of the
umbilicus and extending from the last rib to the crest
of the ilium and into the loin was a well-marked en-
largement, globular in shape, smooth to the touch,
fixed, and verv painful on manipulation.
This tumor had been gradually increasing for sev-
eral weeks, and had not at any time diminished per-
ceptibly. The patient presented no evidence of jaun-
dice or other conditions pointing to gall-bladder or
liver involvement. This tumor was the size of a good-
sized cocoanut. Taking the histon,- of bladder trouble,
rebellious and protracted, and with pus constantly in
all urine, and the history of sepsis and a gradual en-
largement in the region of the right kidney, a diagno-
sis of pyonephrosis was made, and an early operation
was advised.
Operation was performed October 4, 1895. ^^ '^'^''"
ried nephrotomy was performed, making the opening
well posteriorly to promote drainage; the kidney was
inci.sed, a drainage tube was inserted, and gauze pack-
ing was introduced. A more extensive operation was
not advisable, owing to the extreme septic condition
of my patient. These cases stand operation and an-
a-sthetics badly. The kidney abscess drained fairly
well for a few days, the pulse, temperature, and appe-
tite improving very much. The discharge then began
to diminish, and with this the old symptoms of sepsis
returned. 1 then decided to do either a nephrectomy
or a more extensive nephrotomy. At the operation the
latter was decided upon, owing to the feeble condition
of the patient and the extreme difficulty likely to be
experienced in delivering the kidney and ligating the
pedicle. The old incision was carried downward
and forward to near the anterior spine of the ilium,
and the whole length of the enormously enlarged organ
was exposed on its convex aspect. The kidney was
incised its whole length and each compartment of pus
was broken into with the finger, during which process
.1 most terrific hemorrhage took place, filling the
wound faster than my assistant could sponge it out.
This part of the operation was quickly completed, and
the opening in the kidney was snugly packed with
gauze to control the bleeding. The wound was left
open in the overlying structures.
The patient suffered very much from shock and loss
of blood, and was put to bed in a very weak state.
One-tenth of a grain of strychnine was given during
the operation, which lasted only fifteen minutes; the
foot of the bed was raised, hot applications were made
about the body, and hot milk and whiskey enemas were
given. During the night she lost considerable blood,
and at my visit next day I found her calling for more
air and giving evidence of acute anaemia and profound
.shock. Pulse, 144; temperature, 96" F.
Twelve ounces of a sterilized normal saline solution
were injected into the cellular tissue of the posterior
surface of the thighs. Within an hour this resulted
in reducing the pulse to ii5 beats. The gauze pack-
ing was removed at the end of forty-eight hours, and
the cavity was irrigated with an iodine solution and
repacked. Nutrient enemas were continued each four
hours until her stomach was able to retain nourishment,
the wound being treated as above daily. Nourishing
food, iron, str^xhnine, were given right along day and
night.
January 15, 1896. — She improved for a few weeks
following the last nephrotomv, but again lapsed into
her old septic condition, with a pulse daily running
up to 120 to 140, temperature loi" to 103' F., the
drainage diminishing all the time. At this date I de-
cided to make an effort to remove the kidney. The
overlying tissues were infiltrated and indurated. The
kidney was as large as a cocoanut and extended below
.McBurney's point upward beneath the liver. An in-
cision was made along the line of the last operation,
but extended farther forward from the lower end of the
old scar. Another cut was made near the upper end
of the horizontal incision, the direction of which was
parallel with the last rib. This increased the work-
ing-limit considerably. The kidney was separated
from its firmly adherent surroundings, down to the
ureter and vessels. The pedicle was so deeply situ-
ated and the kidney so large that it was impossible to
get a ligature down to it. I thought I would have this
difficulty to encounter, and had my Koeberle serre-nceud
and wire ready. The wire was tightened about the
pedicle and the kidney cut away with scissors, leaving
a good pedicle button ; no loss of blood. The instru-
ment was permitted to remain for three days and was
then removed, without bleeding. Her convalescence
was uneventful.
Vaginal Hysterectomy for Cancer in the Preg-
nant Uterus. — The patient, aged thirty-two, eleven
months ago gave birth to a full-term child. Nothing
unusual occurred during her confinement or convales-
cence. Three months ago she had quite a profuse
hemorrhage, with a continuance of the flow from that
time up to the present. I saw her three months after
the first bleeding. She had been losing flesh and
strength very rapidly. .\n examination revealed a
bilateral cervical tear, and on both lips of the cervix
was a large cauliflower-appearing surface that oled
340
MEDICAL RECORD.
( vSeptember 5, 1896
easily 10 the. touch. 'I'he uterus was the size of a
small cocoanut and very much the shape of a preg-
nant uterus; but as the woman presented not one of
the subjective symptoms of pregnancy and had not
menstruated since her last confinement, eleven months
ago, the idea of pregnancy was quickly dismissed, as
the all-important point in the diagnosis related to the
question of malignancy. A piece was cut from the
growth and examined by myself and by two other
pathologists, all agreeing that it was malignant.
On October 29, 1895, I performed a vaginal hys-
terectomy, using, as I always use, the I'rice hysterec-
tomy forceps. It was somewhat difficult to pull the
uterus through the \aginal-vault opening, but, owing to
the elongation taking place from the traction on the
cervix at the expense of the width of the organ, it was
delivered and the operation was completed in twent\-
minutes. At the end of thirty-six hours the forceps
were unlocked and a few hours later removed. The
patient's temperature never reached the hundred point,
the pulse remaining under 80 during her entire con-
valesence. She left the iiospital on the nineteenth
day.
This is a very rare condition, occurring about once
in two thousand cases of pregnancy. In twenty-seven
cases tabulated by Vanderveer,' five women died dur-
ing labor undelivered and nine died during the puer-
peral period; in three cases the results are not men-
tioned; ten patients recovered — a mortal itv to mothers
of sixty per cent.
Another author reports three hundred cases of can-
cer of the uterus complicating pregnancy, with a mor-
tality of fifty-two per cent. Abortion occurs in thir-
ty-five per cent, of cancerous pregnant uteri. The
mortality to the mother in abortion is very high. In
twenty-five per cent, of cases dying undelivered the
fatal result was due to a retained putrid ftetus, shock,
or exhaustion. Post-partum sepsis comes in for a big
percentage in the mortality. Rupture of the uterus
occurs frequently. Rapid spread of the growth, owing
to increased circulation during pregnancy, takes place.
Most of the few mothers sur\iving delivery die within
three months. Only thirty-three per cent, of children
are born alive, and twenty per cent, of these die with-
in a few weeks. A large percentage of the few living
children is left motherless.
Tetanus. — Dr. K. F. Trevelyan reports a single
case of cephalic tetanus treated by injections of an-
tito.Tcic (antitetanic, Roux) serum. This was without
result, although two successful cases have been re-
ported by Caretti and by Einstein and Buonati. This
disease is also known as tetanus hydrophobicus, owing
to the pharyngeal spasm induced by attempts at swal-
lowing; tetanus paralyticus, as proposed by Klemm, to
emphasize the importance of the facial paral\sis; and
bulbar tetanus, to accentuate the fact that bull)ar sym])-
toms are so frequently present. There is, however,
no real difference between cephalic and ordinar)-
tetanus, as is shown by the fact that the mu.scular
spasm tends to become general in both ; in fact, it is
only a difference of mode of ingesta, the former resem-
bling more closely experimental tetanus. Failure in
this case may have been due to an insufficient quan-
tity used or to the use of the warm water in dissolving
the desiccated serum. This is the third instance in
which the author has observed the use of the remedy
— in one the Tizzoni-Caltani serum was employed —
and in all it did not appearto have the slightest effect
upon the disease. — Brilish Medical Journal, 1896, No.
1832, p. 321.
' See Journ.il .\mericai> Medical .Association, vol. .>oi. , pp. \\-
17. iSq2.
^trogrcss of |5aediail J>cicncc.
The Blood in Tuberculosis of the Bones.— Dr.
John Dane, of Boston, has studied the condition of
the blood in cases of articular and osseous tuberculo-
sis. The results of his observations are published in
the Boston Medical and Surgical Journal, and are sum-
marized as follows: (1) Most cases of tuberculosis of
the bones and joints do not decrease the number of
the red corpuscles in the blood. (2) They do, how-
ever, affect the percentage of hajmoglobin, giving rise,
in fact, to a mild degree of chlorosis. (3) The leu-
cocyte count seems to bear no direct relation to the
temperature. (4) High counts, especially in hip dis-
ease, point to the probability that there is or shortly
will be an abscess formation ; but low counts do not
preclude the presence of abscess, especially in cases
of long standing. (5) When, in connection with a
low leucocyte count an abscess is found to exist, the
pus from it is sterile, and the case is generally one of
long standing. (6) In the presence of an aixscess, a
low leucocyte count generally indicates the absence,
and a high count the presence, of a secondary infection
with pyogenic organisms. (7) Cases in which, at the
primary operation, the pus has proved sterile, show an
increase in the leucocyte count when the wound be-
comes infected with pyogenic organisms. (8) High
leucocyte counts do not always affect the differential
count. (9) Cases with a traumatic origin are gener-
ally accompanied by a high leucocyte count and run a
more severe course. This is especially shown in
cases of hip disease. That more of the cases which
entered with a developed abscess did not give a defi-
nite history of trauma is due no doubt to the fact that
the length of time the disease had been progressing
had caused a lack of ;iccurate detail at the beginning
being remembered.
Management of Pregnancy with Nephritis. Dr.
Mynlieff (/A/- /■>(7//(7/(7;;/, January i, 1896) says that
when a woman with chronic nephritis becomes preg-
nant the induction of ;ibortion is indicated on account
of the immediate jjeril of the patient, which increases
as pregnancy advances, the certain continuance of the
morbid |)rocess in the kidneys, the great tendency to
flooding and abortion, and the small prospect of the
development of the fcetus up to term. When the phy-
sician is called in when pregnancy is advanced, the
induction of premature labor may be undertaken at
the time which seems most favorable for saving the
life of tlie fiirtus. The history of jirevious pregnancies
must be duly considered, and if it is foinid that the
fcetus tends to oie at a certain date in pregnane)', tliat
date must be anticipated. In any ca.se the life of the
mother mu.st be considered first; hence immediate in-
terference is usually the safest course. The same
principle is often best for the foetus when viable, as it
may die suddenly earlier than in previous pregnancies.
Incompatibility of New Remedies. — Moerck points
out that trichloride of iodine is decompo.sed by alco-
hol and partially by water; the aqueous solution liber-
ates iodine from iodides; ammonia added to it forms
the explosive iodide of nitrogen; reducing agents lib-
erate the iodine; and many organic bodies, among
others the fatty oils and alcohol, decompose it. Hy-
droxylamin hydrochlorate is very unstable and read-
ily forms exjjlosive mixtures; it is a powerful reduc-
ing agent. Alkalies liljerate the base, which is unsta-
ble and explosive. — American Druggist and Pharma-
ceutieal Record.
The Doctors in France number 17,500. Four hun-
dred and fifty die each year and 650 new ones are
turned out by the universities.
September 5, 1896]
MEDICAL RECORD.
341
Medical Record:
A Weekly Journal of Mediciyie and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO.. 43, 45. & 47 East Tenth Street.
New York, September 5, 1896.
•■A PLEA FOR A SIMPLER LIFE."
Such is the title of a small volume by Dr. George S.
Keith, of Edinburgh, in which he seeks to point out
some of the evils which, he holds, have arisen from the
two opposite lines of medical practice during the past
century. A complete revolution has taken place in the
practice of medicine within the last si.\ty years. For-
merly all the common diseases were ascribed to over-
action, and the remedies were bleeding, vomiting,
purging, sweating— in fact, depletion in its most vio-
lent forms, h. fashionable London physician began
teaching that disease was due to a weakened action of
the functions and the body needed " setting up," i.e.,
stimulating and tonic medicines and plenty of good
food and drink. This system grew to maturity in a
short time and was carried to as great extremes as the
other.
Dr. Keith's observation of different methods of
treating disease in the various parts of Europe as well
as in the East caused him to lose faith in the " deple-
tory system " then practised in England. Dr. Keith
relates his personal experience with calomel and aperi-
ents, which influenced him further to doubt the efhcacy
of. drugs. Patients wish immediate relief, and some-
thing must be given, though one often gets more credit
for bread pills than for anything stronger. The apho-
rism of Hippocrates, "Melius remedium dubium quam
nullum" —'■^ Better a doubtful remedy than none" — has
done much harm. " Better no medicine than a doubt-
ful one." The doubtful medicine may obstruct na-
ture instead of aiding her, and the physician may never
know what the natural course of the disease might be.
For instance, it is the almost universal custom to ad-
minister an aperient when called to a case of scarlet
fever. The doctor is usually called in the second
stage of the disease, when the poison which has been
previously absorbed is being thrown off by the skin
and mucous surfaces of the throat and pharynx. It
seems natural that an aperient, by setting up intestinal
irritation, will interfere with the action of the skin and
throat and make the case much more severe than it
would be otherwise. Dr. Keith recommends the giv-
ing of nothing stronger than milk for three weeks
after the disease has made its appearance. When dis-
ease attacks the body, the appetite usually fails. Na-
ture usually indicates in this way the course to be
followed. There is a reserve fund of nourishment
laid up in the body in the shape of fat and tissue
which can be drawn upon during disease, when the di-
gestive organs require a rest. The propriety of giving
or withholding food depends entirely upon the condi-
tion of the digestive organs. " The physician should
always have a dread of giving too much as well as too
little." "The doubtful remedies which, according to
the new axiom, are to be avoided in states of disease
are medicines, alcoholic stimulants, and food ; and
nature's methods which we advise to be substituted
for them, or rather to be allowed full play without
them, are rest — not forgetting rest to the stomach —
warmth, or, in rare cases, cold; a free supply usually
of water and always of fresh air, and sufficient time
for the organs to recover their ordinary working-
powers, and especially for the nervous system to make
up its waste. In short, we must fall back on the old
and much forgotten vis medicatrix naturcc."
The author says that the means commonly employed
at the present time for the cure of many diseases are
precisely those which are, when used improperly, the
causes of the same diseases, i.e., food and stimulants.
'' If a healthy person takes too much carbonaceous
food the excess is for a time set aside in the form of
fat, or the secretion in the liver of bile is unduly in-
creased, the blood gets carbonized, languor and dis-
comfort come on, appetite fails, and a chill followed
by irritation of the stomach ends in a bilious attack.
This with enforced starvation clears off the super-
abundant carbon and leaves the sufferer in a healthy
condition. When the excess is animal food, this may
go on for years, and if the individual is of sound con-
stitution he may dispose of twice or thrice the quan-
tity of flesh food that is required by his system. The
kidneys usually give out first, or the blood becomes
loaded with animal matters and these are deposited in
various organs in the form of fibrin, which hardens
and destroys more or less of their substance and their
functions."
Dr. Haig has proved by recent investigation that
uric acid in the blood destroys its red globules and
induces ana;mia, for which good '"red meat" has been
considered the fittest cure. In experimenting on him-
self he took a certain quantity of beef tea as an equiv-
alent for a certain number of grains of uric acid. He
shows that iron is useless, so long as it is given with red
meat. The most white-faced family. Dr. Keith said,
that he ever saw was a family of six who had at least
two full meals a day of beef and mutton. The evils
of food e.xcess are much aggravated if at the same
time alcohol is taken.
The author writes: "In my younger days, in the
twenties and thirties, the food of the working man and
also of the upper classes was simple and good. It
consisted mostly of milk, eggs, fish, oatmeal, potatoes,
and a few other vegetables. There was no baker and
no butcher in the parish, and there was no doctor
within five miles. The sanitary state of the houses
was worse than now. But with the good food there
was not much general sickness. By and by times
changed; white bread and flesh came into the market,
and along with these luxuries came the doctor. The
improved sanitary condition should have led to a
342
MEDICAL RECORD.
[September 5. i8q6
healthier state." As to flesh the author says: "The
animal makes a perfect body from vegetable matter
pure and simple, but the phosphates go to form the
skeleton and in the muscle which we eat they are con-
spicuous by their absence.'" Simple and restricted
diet is more necessary in advanced life than earlier,
and stimulants do more harm then than formerly.
" If when in good health we took only the food nec-
essary for our comfort and work instead of working
the stomach to the utmost and helping it when it flags
with dainties, drugs, and stimulants, we would have
much more pleasure from our meals and a longer con-
tinuance of strength and health. If we could elimi-
nate from the old system of cure a large amount of
depletion, and from the new a larger amount of tlie
feeding and physicking, we would come nearer to na-
ture's mode of preventing and curing disease and wc
would find that prevention would be the larger ele-
ment; the need for the other would be well-nigh extin-
guished."
OUR SELF-PRF.SCRIHIiXG PATIENTS.
To such as have studied the causes of the present
decline in professional work it becomes a serious
question whether there are not other elements than
those attributable to stringent business relations that
explain the condition. While the science of medicine
has made great progress in the methods of diagnosis
and treatment, the physician finds that his vocation, al-
though more honorable and useful, is really less
remunerative, and his legitimate practice is propor-
tionately curtailed. There is no less sickness in the
world, but the number of patients has markedly
decreased. In fact, the sick oiies 'are inclined te-^et
the better of the doctor and to act more or less inde-
pendently of his direct ministrations. It is not diffi-
cult to understand why this is so, when we consider the
vast number of persons who willingly yield to the
growing habit of prescribing for themselves. This
tendency is fo.stered by the belief, in the majority of
cases, that such prescribing is tacitly sanctioned by
the profession itself by the use of many of the legiti-
mate remedies so frequently ordered for the relief of
the more common ailments. There is a very reason-
able foundation for this conviction, and its responsi-
bility rests more or less on the prescriber himself.
.■\l the bottom of tlie whole business is the prevailing
practice of delivering private clinical lectures to the
patient on the nature, extent, progress, and outlook of
his malady, and the indications for the use of special
drugs in the treatment of certain conditions. While
this may give evidence of remarkable learning on the
jiart of the medical adviser and may help for the time
being to establish his methods in the confidence of
his client, it too often educates the recipient into the
presumption of thinking and acting for himself. The
most superficial knowledge is all that is necessary to
this end, and, easily persuading himself that he has a
repetition of the malady of which he has had such an
authoritative opinion, he either repeats the prescrip-
tion at will or purchases his former remedy in op)en
market at the counter of the obliging pharmacist
Quinine, phenacetin, salol, morphine, pepsin, the
mineral laxatives, and a host of other much-used medi-
cines are given the currency of indispensable house-
hold articles. To such persons a diagnosis is a use-
less refinement, it being sufficient for their special
purpose that their physician has given explicit direc-
tions how to use the supposed harmless remedies
under what the patient believes to be similar circum-
stances. Not only this, but the remedy is freely pre-
scribed to all his friends who are willing to trust to
the blind chances of having a like ailment.
With shame be it said that ver)' many of the phar-
macists, far from discouraging such practices, not only
willingly abet them but ofter special inducements to
purchasers by peddling the favorite prescriptions of
well-known physicians. These drug sellers, for they
deserve no more dignified title, do not prescribe them-
selves, but are willing to recommend the prescrip-
tion of another, charging a round price for the trouble
of dispensing it. When it is understood that the phy-
sician knows of this, it is not difficult to explain why
.so few prescriptions are written and why so many pre-
scribers deal out their own medicines.
Aside from the purely business aspects of the ques-
tion, this inconsiderate self-prescribing is in the high-
est degree detrimental to the community at large in
.stimulating an unnecessary^ consumption of drugs, in
the formation of habits which eventually undermine
health, and in directly jeopardizing life by the loss of
valuable time in the prompt recognition and scientific
treatment of many of the dangerous and insidious
maladies of which the ordinarj- patient has no possible
knowledge. The profession should always be ready
with any information tending toward the prevention
of disciuse, but any attempt directly or indirectly to
teach therapeutics is fraught with untold evil to the
giver and the receiver. The more the patient is kept
in ignorance of the remedies prescribed, the better for
him, and certainly, under the circumstances already
named, the better for the prescriber. The physician
is never called in consultation with his patient, as the
very nature of the case precludes the necessity of more
than one opinion. The moment any argument is
allowed on this point all proper respect for purely
professional opinion is lost. This is one of the results
of selling the birthright for a mess of pottage. The
lesson is one which many of the too-obliging practi-
tioners can take to heart.
The Health Department of Greater New York.—
According to the proposed charter of Greater New
York, there will be but one health commissioner, who
may be appointed or removed at pleasure by the mayor.
The main office of the department will be on Manhat-
tan Island, but there will be a branch office with a
deputy commissioner, a register of records, and a san-
itary superintendent in Brooklyn and possibly in other
boroughs. The bureaus of the register of records and
of the sanitary superintendent will remain as at pres-
ent constituted.
September 5, 1896]
MEDICAL RECORD.
343
THE PATHOGENICITY OF THE DIPLOCOC-
CUS LANCEOLATUS.
That the presence of a micro-organism is not neces-
sarily an indication of the existence of disease can-
not be better illustrated than by the varying behavior
of the diplococcus lanceolatus, or the pneumococcus.
This organism, as is well known, is often to be found
in the mouths of apparently healthy individuals, pre-
sumably giving rise to diseased conditions when the
usual relation between its virulence and the bodily
resistance is changed — either the former increased or
the latter diminished, or both of these conditions are
operative. Other organisms, it is true, may also give
rise to pneumonia, but the capsulated diplococcus is
the most common exciting factor.
It is generally recognized that the pneumococcus
is responsible for many of the complications of pneu-
monia, as well as of a number of independent dis-
orders. This organism is possessed of pyogenic
properties, as some of the conditions referred to are
further attended with suppuration, the pus being
characterized by its viscidity, plasticity, and greenish
color.
Simple uncomplicated pneumonia must be viewed
as a purely local process in the majority of cases,
although a number of observers have succeeded in
finding pneumococci in the blood. That generalized
infection does not take place more commonly is to
be attributed to a relative immunity on the part of
human beings. In order for such infection to result —
that is, for the pneumococcus to undergo multiplica-
tion in the blood and to exercise pathogenic activity —
either the micro-organism must possess increased
virulence or the patient must manifest congenital or
acquired predisposition, or contra-immunitj'. Cases
in which the conditions just named prevail are so un-
common that an observation recently recorded by
Schabad {Cenfralb/att fitr Bakferiologic, No. 25, 1896)
seems for this and other reasons to be of unusual
interest.
A man, forty-five years old, w-as suddenly seized
with chill, fever, cough, and expectoration, .together
with pain in the right side of the chest. On the
second day he complained of pain in the right hip-
joint and on the fourth day also of pain in the left
knee-joint. Physical examination made on the sixth
day showed the area of cardiac percussion dulness to
be increased toward the left, while the heart sounds
were obscure, the pulse was frequent, and the vessels
were atheromatous. Dyspnoea was pronounced and the
percussion resonance over the upper lobe of the right
lung was impaired, while the breathing was bronchial
and subcrepitant rales could be heard. At the base
of the left half of the chest in the axillary region
pleural friction sounds were audible. The tempera-
ture was moderately elevated. Inoculation of agar
tubes with blood obtained under suitable precautions
resulted in the development of pneumococci, which in
turn yielded typical cultural and pathogenic reactions.
The case terminated fatally and post-mortem exam-
ination disclosed the following conditions: Acute
fibrino-purulent pericarditis; beginning parenchyma-
tous and fatty degeneration of the heart; atheroma of
the aorta; chronic pleurisy on the left and acute
pleurisy on the right; croupous pneumonia involving
the upper lobe of the right lung in the stage of gray
hepatization with suppuration ; acute purulent peri-
tonitis; cirrhosis of the liver; chronic hyperplasia of
the spleen; fatty degeneration of the kidneys; puru-
lent coxitis on the right and purulent gonitis on the
left. The pus from the joints from the abdominal
cavity and from the pericardial sac was thick and
yellowish, with a tinge of green. Smear preparations
and agar inoculations from the pneumonic lung, from
blood from the heart, from the splenic pulp, from the
pericardial and the peritoneal exudates, and from the
pus from the joints all disclosed the presence of
pneumococci. In some of the cultures the bacterium
coli commune also developed.
Drs. L. D. Bulkley and G. H. Fox, of New
York, were among the visitors registered at the Car-
lisle meeting of the British Medical Association.
The Medical Service at the Paris Exposition. —
Dr. Gilles de la Tourette has been appointed physi-
cian-in-chief for the world's fair of 1900 in Paris.
The Brewing of Ale is on the increase in Great
Britain, a tax having been paid on over one million
barrels more this year than last.
"Appendicitis as it Affects Life-Insurance Risks."
— The author of the paper with this title, which ap-
peared in a recent issue, was Dr. Albert Wood, not
Woods, as written.
The Fourth International Congress of Hydrology,
Climatology, and Geology will be held at Clermont-
Ferrand, Puy de Dome, France, September 28th to
October 4th. The general secretary of the congress
is Dr. E. Fredet.
Dr. Besnier will be the president of the next Inter-
national Congress of Dermatology, which will be held
in Paris in 1900 during the exhibition year.
Typhoid Fever in New Haven.^ — A small epidemic
of typhoid fever prevails at New Haven, sixty-nine
cases having been reported during the last few days
of August. Most of the cases have been traced in
their origin to milk supplied by one dealer.
The State Commission in Lunacy — According to
a telegram from Albany, Dr. Carlos F. MacDonald,
president of the State Commission in Lunacy, has re-
signed, the resignation to take effect the last of this
month. Dr. Peter M. Wise has been appointed by
Governor Morton to succeed him.
A Limited " Kur."— The park commissioners have
given permission to the members of the Kneipp-Ver-
ein to walk barefooted upon the grass of certain por-
tions of Central Park, between six and eight o'clock
in the morning. This privilege is granted for one
week only.
344
MEDICAL RECORD.
[September 5, 1896
The Semi-Centennial of Anaesthesia — It is pro-
posed in France to celebrate during the coming autumn
the fiftieth anniversary of the discovery of anesthetics.
The details of the celebration are not yet fixed, but it
will probably take place during the session of the
French Surgical Congress in October.
Closure of a Hospital. — The Mount Vernon Hos-
pital was closed the last day of August, owing to lack
of funds, and the managers have concluded not to open
again unless the city will appropriate an amount suffi-
cient for the needs of the institution.
Tuberculosis and Telephones. — It is said that Vi-
enna physicians have traced cases of tuberculosis and
other contagious diseases to the use of public tele-
phones, and the suggestion is made that a sponge with
a solution of carbolic acid be kept in every station for
a daily cleaning of the apparatus.
The Hospital Sunday Collection in London this
year has fallen far below expectations. It is said
that Guy's Hospital has taken most of the money
charitable persons had to give to hospitals.
Professor Gusserow has been appointed dean of the
medical faculty in the University of Berlin for the
year 1896-97.
Dr. Jacob Rosenthal died at Chicago, on August
24th, at the age of thirty-three years. He was gradu-
ated at the Jefferson Medical College in 1888, and after
a period of post-graduate study abroad engaged in the
practice of his profession at Chicago, devoting himself
especially to gynecology.
Vital Statistics of Philadelphia — For the week
ending August 22d there occurred in the city of Phila-
delphia 382 deaths, of which 187 were in children un-
der five years of age. The largest number of deaths
from a single cause — 66 — was due to cholera infan-
tum, and the next largest number — 39 — to sunstroke.
There were reported during the week 55 cases of ty-
phoid fever, 23 of diphtheria, and 14 of scarlet fever.
The Estimated Cost of a Medical Education in
Berlin is 2,300 marks, about $575. The fee for ma-
triculation is 18 marks; for examination for the medi-
cal faculty, 242 marks; diploma fee, 440 marks; fees
for all necessar}' lectures, etc., 800 to 1,200 marks;
cost of printing the dissertation, about 150 marks;
and the necessary books and instruments, 500 marks.
Then for board, lodging, and clothes, at least 7,600
to 8,000 marks must be added, and much more if one
would live in ordinar}- comfort.
The Ownership of the Prescription. — The Medical
Press, speaking of a proposal to prohibit the redispens-
ing of prescriptions, on the ground that it would check
the sale of poisons and other dangerous drugs, re-
marks : " We rather think that the purpose is to secure
for the general practitioner an additional fee whenever
a repetition of medicine is needed. Such a suggestion
may, perhaps, be grateful to a certain class of practi-
tioners, but in our opinion it is consistent rather with
the commercial morality of America, whence it ema-
nated, than with that of the ' Old Country,' and is en-
tirely beneath that which ought to govern our profes-
sion. A patient who pays his money for a prescrip-
tion seems to us to be quite as much entitled to the
unrestricted use of that document as he would be to
the use of any other purchased article."
Black Diphtheria in New Jersey. — An epidemic
of black diphtheria has been prevailing in Stockton,
N.J.
Unethical or Too Popular. — A strong opposition was
made this year to the re-election of Mr. Christopher
Heath to the presidency of the Royal College of Sur-
geons, the main objection urged against him being aj)-
parently that he had degraded his office by accepting an
invitation to give in America a course of lectures to
which an honorarium was attached. It surely cannot
be regarded as unethical or beneath the dignity of a
surgeon in England to receive a fee for strictly profes-
sional work, and he could hardly be expected to be so
generous as to pay his own travelling expenses besides
giving his time in order to deliver a course of lectures
to an American audience. Possibly Mr. Heath's op-
ponents thought he ought to confine his remarks to his
own countrymen, or possibly they were simply ani-
mated by vulgar jealousy.
The Moscow Congress. — The following are the titles
of the subjects set for discussion in the surgical sec-
tion of the International Medical Congress, August
19-26, 1897: I. "The Treatment of Infected Wounds."
2. "The Non-operative Treatment of Malignant
Growths and the Results of Serum-Therapy." 3.
" Results of the Operative Treatment of Cerebral
Tumors and of Jacksonian Epilepsy." 4. " Surgery
of the Lungs, with Special Reference to the Treatment
of Tuberculous Cavities and of Pulmonary Gangrene."
5. "Treatment of Cancerous Stricture of the CEsoph-
agus, Pylorus, and Rectum, with tlie Results Ob-
tained." 6. "Gonorrhoeal and Syphilitic Aflfections
of Joints." 7. "The Principles of Construction of
Different Forms of Prothetic Apparatus for Deformi-
ties following Diseases of Joints, Paralytic Affections,
Congenital Dislocations of the Hip, and after Ampu-
tations."
Yellow Fever in Cuba is increasing steadily and
is reported to be of a most virulent type. Its victims
are found almost exclusively in the Spanish army, the
ill-fed and ill-housed youths composing that army suc-
cumbing almost with the first touch of the disease.
The official report of the Spanish army sanitary corps
for the second ten days of July shows that there were
in the militar)- hospitals of Cuba at the end of that pe-
riod 8,838 cases, 5,538 of which were new, and that
346 deaths occurred, 250 being due to yellow fever.
Since that date the number of cases is said to have
largely increased, but the exact figures cannot be as-
certained, as the Spanish authorities are always tardy
in publishing their reports. The building of the Uni-
versity of Havana is to be converted into a hospital,
as it is now of little use, owing to the lack of stu-
dents. The epidemic of small-pox in the island is
gradually subsiding, through want of fresh material
for the disease to feed upon.
September 5, 1896]
MEDICAL RECORD.
345
jS>ociety Reports.
THK NFAV YORK PATHOLOGICAL SOCIETY.
Stated Mci'titif^, March ii. iHq6.
John Sl.mik F.i.y, M.I).. I'resideni.
Dr. Eugene Hodenpvl presented a series of speci-
mens illustrative of
The Association of Malignant Disease and Tu-
berculosis.— For the first specimen he was indebted to
Dr. Thacher. It had been removed from a man, fifty-
three years of age, who ten months ago had developed
a small tumor on the right side of the neck, opposite
the thyroid cartilage. One month later the growth
had been removed at the German Hospital. It had
.soon reappeared. When ne.xt seen it extended up
from behind the angle of the jaw to the median line,
was nodular, very hard, and adherent to the skin, jaw,
and deep structures. There was some superficial ul-
ceration. One week ago the breathing became very
difficult and painful. The urine was normal. The
temperature varied from 99.5" to 101.5° Y. At the
autopsy the upper lobes of the lungs were found to be
the seat of a recent tuberculosis, and the tongue con-
tained an epithelioma. On the right side, opposite
the thyroid cartilage, was an infiltrating growth, which
had ruptured into the oesophagus. Several sections
had been examined, but no evidence of tubercles found
in the epitheliomatous mass.
The second specimen showed not only the two le-
sions occurring in the same individual, but the com-
bination of the two diseases in the same lymph nodes.
The patient, a man of forty-four years, gave no tuber-
culous or syphilitic histor)'. He had had a small gland
in the neck since childhood, but it had not undergone
any appreciable change during all this time. Last
March a small ulcer was noticed on the right side of
the tongue, which soon healed. During the summer a
small painless lump appeared under the jaw. Last
November an ulcer appeared on the tongue and soon
began to increase rapidly. On admission, in Febru-
ary, he was moderately emaciated and was expectorat-
ing profu.sely. On the right side of the tongue and
floor of the mouth was a small growth, which was
somewhat ulcerated. There was a lymph node under-
neath the angle of the jaw. Dr. McBurney removed
the tongue by Kocher's operation, together with the
lymph node. In the lymph node (shown under the
microscope) was a combination of the lesions of tu-
berculosis and epithelioma. He had stained a num-
ber of sections for tubercle bacilli, but with negative
result. The miliary tubercles were slightly cheesy in
their centres, and contained a considerable number of
giant cells.
The speaker said that George Clement, in Vir-
chow's Archiv for 1895, had presented an excellent
resume of the literature of the subject. The combina-
tion of tuberculosis and epithelioma or carcinoma in
the same organ had been described by a number of
observers, but in all less than fifty typical cases of this
kind were on record. The combination of tuberculosis
and epithelioma in the same individual was much
more frequent. Lubosch's conclusions, from his
study of this subject, are : ( i ) That carcinoma may be
engrafted on an old tuberculosis, and that half of all
the cases reported belong to this class: (2) that an old
case of tuberculosis may become carcinomatous, and
the carcinomatous cachexia facilitate a fresh tubercu-
louseruption — a rare occurrence ; (3) that a carcinoma-
tous person may become tuberculous, although only
three instances of this kind were found on record; (4)
that a chronic, progressive tuberculosis may act as a
predisposing cause to carcinoma, in the same manner
that a local traumatism predisposes to malignant dis-
ease. Dr. Hodenpyl said that in the case reported it
seemed to him that the two lesions were probably
nearly simultaneous in their occurrence. There was
no tuberculosis found in the primary tumor.
Dr. George P. Biggs said that this specimen was
interesting to him in connection with the case of giant
cells which he had presented .some time ago. The two
conditions might easily be confounded. The rarity
of the association of malignant disease and tubercu-
losis seemed to him to be partly explained by the dif-
ferent periods of life in which these diseases usually
appeared. One susceptible to tuberculosis generally
succumbed to this disease before arriving at the age at
which carcinoma or epithelioma or dinarily developed.
Dr. J. S. Thacher recalled a case seen clinically
about one year ago, occurring in a nurse, about forty-
five years of age. This woman had presented only
certain vague abdominal symptoms, and several phy-
sicians had failed to make a positive diagnosis. At
the autopsy there was some diliference of opinion as to
whether the case was one of tuberculosis or carcinoma.
The peritoneum seemed to show typical miliary tuber-
cles, but in the pancreas were nodules looking more
like carcinoma. Dr. Coleman found, on making sec-
tions, that both conditions were present, the tubercu-
losis involving principally the peritoneum.
The President said he thought he had discovered
in the specimen under the microscope areas of cheesy
degeneration in the newly-formed epitheliomatous tis-
sue, suggesting that at least in those places the
tuberculosis was of more recent development than
the epithelioma. He could not see any reason why
tuberculosis and carcinoma should not be associated;
it was a pure assumption to suppose that they were in
any way antagonistic. He recalled a case of extensive
secondary carcinoma and diffuse pulmonary phthisis in
the same lung. He thought such cases were not so
very rare ; probably they had been overlooked or not
thought worth reporting.
Dr. HonENPYL then presented microscopical speci-
mens of
Multiple Miliary Aneurisms of the Left Anterior
Cerebral Artery. — These had been taken from a rather
elderly lady, who, while apparently in fair health, had
suddenly fallen forward from her chair and become
unconscious. She died soon after admission to the
hospital. At the autopsy the thoracic and abdominal
organs were found comparatively normal. There was
no atheroma of the larger vessels of the thorax and
abdomen. There was, however, a well-marked ather-
oma of all the vessels at the base of the brain, and the
left anterior cerebral arterj- presented what looked to
be multiple miliary aneurism. The vessel was stud-
ded with from ten to fifteen small nodules, varying in
size from that of a pin's head to three or four times
that size. There was a considerable extravasation of
blood at the base of the brain; evidently the hemor-
rhage had occurred from rupture of one of these small
nodules. Microscopical examination showed very ex-
tensive disease of the vessels. In at least one place
rupture had taken place into a blood-vessel, so that it
was really an aneurism; in the other places the more
accurate designation would be "atheromatous cysts."
Acute Exudative Meningitis. — Dr. Hodenpyl
showed some microscopical specimens from a case of
this kind, in which there had been scarcely any gross
lesions. He thought the diagnosis could not have been
made except by the aid of the microscope. The pa-
tient, a colored man, twenty-three years of age, was
admitted to the hospital on January 19, 1896. He
was very intemperate in his habits, and had had syph-
ilis two years before. About the middle of last No-
vember he had begun to suffer from dizzine.ss and
346
MEDICAL RECORD.
[September 5, 1896
headache, but thesse had temporarily improved under
antisyphilitic treatment. The headache had then re-
turned and become more severe. On admission he
was well nourished, the breath was foul, there was con-
siderable prostration, the urine was normal ; the tem-
perature was 100' F., pulse 66, and respirations
22. The physical examination was negative. On the
day after admission he was found to be stupid and he
passed no urine. Fourteen ounces of urine were
drawn by catheter. On January 22d, two days later,
there were convulsions and coma. The ne.xt day he
could hardly be aroused from his stupor. On January
25th there were convulsions again. On January 28tli
he died. While in the hospital the temperature had
been between 99' and 100.8' F., the pulse between 64
and 128, and the respirations between 16 and 24. At
the autopsy the pia mater was congested and some-
what dry, and although its lustre was slightly dimin-
ished its appearance was not at all characteristic. A
very small amount of clotted blood was found at the
base of the brain, and a little slightly blood-tinged
fluid in the lateral ventricles. All over the conve.vity
of the brain on either side the microscope showed a
moderate exudation in the meshes of the pia, and lit-
tle on the surface. The exudate consisted of serum,
fibrin, and leucocytes, with a few blood cells and cells
from the pia itself.
The speaker said that three kinds of meningitis nor-
mally showed no gross lesions, viz.: (i) Acute cellu-
lar meningitis, which was comparatively rare; (2) tu-
berculous meningitis, either with or without exudative
meningitis; and (3) acute exudative meningitis. It
seemed to him quite remarkable that such a small le-
sion should prove fatal, as it undoubtedly did.
Dr. George P. Bi<;r.s referred to a similar case,
that of a girl who had frequently been in the Hudson
Street Hospital for hysteria. One day, just as she
was about to be discharged from the hospital, she fell
dead. The autopsy showed no ver\- clear cause of
death, except that the pia mater seemed to be a little
dry and dull. Microscopical examination was made
of the medulla, cerebellum, and cerebrum, and in all
these parts an exudate was found. This consisted of
an extremely thin layer, but containing many cells.
The rapidity with which death might occur in these
cases was interesting. He remembered a case in
which a boy had died within twenty-four hours of the
onset of the first symptoms. Microscopical examina-
tion in this case disclosed the cause of death.
The next spiecimen, presented by Dr. HonE.vpvi., was
irom a case of
Primary Carcinoma of the Liver and Head of
the Pancreas. — It had been taken frojn a woman,
twenty-seven years of age, who had been comparatively
well up to one year before her death. At that time
she had begun to have some jaundice and offensive
diarrhrea, with abdominal pain. For three weeks prior
to admission she had had pretty constant pain to the
right of the epigastrium. On admission she was mod-
erately emaciated, intensely jaundiced, and suffering
considerable pain in the epigastrium. The abdomen
was moderately distended with fluid. The area of liv-
er dulness was ver)- decidedly increased, and also the
splenic dulness. There was an irregular fever, the
temperature sometimes rising as high as 103° F.
About two days before death an exploratory operation
was performed. An enormously di.stended gall blad-
der was found, and also a new growth in the region of
the pancreas. .\n anastomosis was made between the
gall bladder and the intestine by means of a Murphy
button. Death occurred from peritonitis and shock.
At the autopsy the abdomen was found to contain
about two quarts of bloody fluid, and the intestines
were distended with tarry blood. The intestinal suture
was tested and found to be complete. The gall blad-
der contained two ounces of dark bile. The stomach
was dilated and the mucous membrane bile-stained.
The left half of the pancreas was soft. The organ
was greatly enlarged, and behind and firmly adherent
to the duodenum and under surface of the liver was a
new growth. In the duodenum were two circular
openings with rounded edges, communicating directly
with the necrotic new growth. A probe passed only
a short distance into the common duct. The gall
bladder at the cystic duct opened by a solution of con-
tinuity directly into the cancerous mass. The liver
was enlarged and intensely bile-stained. The gall
ducts were greatly congested. The kidneys showed
acute degeneration.
The President remarked that some time ago he had
presented similar cases to the society. In two of them
the patient had died so early that all that was found
was a nodule restricted to the head of the pancreas.
The particular interest in the case was the demon-
stration of the fact that carcinoma did occasionally
begin in the head of the pancreas.
Carcinoma of the Liver and Stomach. — The next
specimen presented by ])k. HdHEMVi. was from a
man, fiftv-two vearsof age, admitted to the hospital in
November. Three months before, he had been success-
fully operated upon for hydrocele. .At the time of his
last admission the alidomen was distended, but no fluid
was withdrawn from it. Physical examination showed
the liver considerably enlarged. Emaciation and en-
largement of the liver were the only evidences of dis-
ease, and these were steadily progressive up to the
time of his death. At the autopsy there were three
quarts of bloody fluid in the abdominal cavity. The
liver weighed twelve pounds, and was almost com-
pletely replaced by carcinomatous new growth. At
the pylorus was a carcinomatous mass, just beginning
to ulcerate. There was also a small carcinomatous
mass at the head of the pancreas.
Primary Carcinoma of the Stomach with Perfo-
ration through the Duodenum into the Lung. — The
patient from whom Dr. Hodenpyl took these specimens
was a man, fiftv-one years of age, who gave a history
of vomiting after meals for a year before death.
Shortly before the last he developed some fever and
cough, with very fetid expectoration. In the lesser
curvature of the stomach the autopsy revealed a large
carcinomatous mass and an opening admitting two
fingers. This opening passed into the lower lobe of
the lung, in which was an abscess about the size of an
orange. The next specimen was one of
Carcinoma of the Pylorus, removed from a man,
fifty-six years of age, who had had vomiting and slight
pain in the .stomach for two years previously. He
had emaciated gradually, but there had been no vom-
iting of blood. Microscopical examination showed
the carcinoma to be of the colloid variety. The next
specimen was from a case of
Carcinoma of the Stomach without Symptoms.
— It was removed from an old man who had been
found in the street, bleeding from the mouth. He
died at the hospital before any history could be ob-
tained. -At the autopsy the man looked to be strong
and well nourished. The stomach and intestine were
filled with large blood clot, the stomach contained a
large coagulum, and at the cardiac orifice was an en-
circling and constricting carcinomatous mass with a
number of blood-vessels traversing this ulcerated
growth. The next specimen was one of
Carcinoma of the Stomach with Marked Con-
striction of the Pylorus. — This was not accompanied
by a clinical history. The last specimen by Dr. Ho-
denpyl was one of
Syphilitic Perforation of the Large Intestine, oc-
curring in a man, sixty-one years of age. He had had
a well-marked attack of syphilis, for which he had
Septt^mber 5, 1896]
MEDICAL RECORD.
347
been treated. There was a syphilitic necrosis of the
sternum. He came into the hospital complaining of
obstinate constipation. Enemata and powerful pur-
gatives were given, without causing a movement of the
bowel. .'\t the autopsy several syphilitic gummata
were found in the spleen, and in the abdominal cavity
was a beginning peritoniti.s. There was also a large
quantity of fa-cal matter in the abdominal cavity.
A Peyer's Patch in a Meckel's Diverticulum.
— Dr. Thomas S. Soitthworth presented the intestine
of a child of seven months, who had died of chronic
catarrhal entero-colitis. The solitary follicles were
enlarged and Peyer's patches swollen. About one
foot above the ileo-ca'cal valve was found a small
Meckel's diverticulum, in which was a Peyer's patch.
Ileo-Colic Intussusception.— The .second specimen
was from a child of two months, evidently syphilitic.
There had been high fever and some pulmonary con-
solidation just before death. At the autopsy the pos-
terior portions of the two lower lobes showed patches
of broncho-pneumonia. The spleen was enlarged, ap-
parently from syphilis, and the organ weighed thirty-
grams. In the lower portion of the ileum were si.x
intussusceptions, and one of them of the typical ileo-
colic variety. These intussusceptions, the speaker
said, occurring just prior to death, are usually in the
jejunum.
The societv then went into executive .session.
Stated Meeting, Marcli 25, iHg6.
Resume of the Oses of Formalin. — Dr. George
C. Freeborn read a paper with this title.
Dr. Henry Power said that in his experience for-
malin had appeared to be very irregular in its action.
He had noticed this especially in studying the minute
anatomy of the cells.
The President asked if it had been found that the
freshness of the tissues was an esseniial point in the
successful use of this agent.
Dr. Freeborn said that when formalin had been
first brought into use he had directed the spjecimens
to be placed in a two-per-cent. solution in the oper-
ating-room, and this plan had yielded excellent re-
sults. Subsequently he had found the specimens very
poorly preserved, and he had then increased the
strength of the solution to five per cent., with rather
better results for a while, but again there had been
trouble. Finally he had adopted the plan of substi-
tuting a two-per-cent. .solution of formalin for the
water ordinarily employed in Miiller's fluid. Since
then he had used this " formalin-Miiller's fluid'" and
there had been no trouble.
The President said that recently in preparing a
specimen for the museum his attention had been di-
rected to this matter. A heart had been mislaid, and
had become quite foul before he had seen it. It was
placed in a two-per-cent. solution of formalin, and
notwithstanding the very bad condition of the speci-
men when placed in this fluid it had been restored to
nearly as good condition as if it had been immersed
in alcohol or in formalin when quite fresh. He
would like to ask whether Dr. Freeborn had noticed
any effect on the diffuseness of the staining with the
haematoxylin as a result of delay in putting the tissues
in the formalin.
Dr. Freeborn replied that he had noticed this dif-
fuse staining in the amnion of some pigs when there
had been a delay of three or four hours before immer-
sion in the formalin solution. Kohn had experi-
mented on a putrefying solution of peas, using various
strengths of formalin, and he had found that anything
above a five-per-cent. solution would sterilize and deo-
dorize this " pea soup." Many other similar investi-
gations had been made with like results.
Dr. F. M. Jeffries referred to two mishaps with
formalin in preserving the intestine. After the speci-
mens had been placed in a two-per-cent. solution of
formalin for about three days they had turned black.
He had been at a loss to account for this. Possibly
it might have been due to some medication that had
been used, but it had ruined the specimens.
Dr. Thomas S. Southworth said that he had
placed a number of children's lungs in a two-per-cent.
formalin solution for a considerable time, and had ob-
tained a blackish-gray discoloration, which had not
been entirely removed by alcohol. It was probably
due to the length of time the specimen had been in
formalin before being transferred.
Dr. Freeborn said that a fcetal pig that had been
put in a ten-per-cent. solution of formalin about eigh-
teen months ago still retained its white color beauti-
fully. As formalin is an oxidizing agent, it was quite
possible that .something in the intestine had formed a
dark chemical compound with the formalin.
Dr. Power said that he had preserved fourteen
specimens of intestine in formalin without observing
this discoloration. They had not remained for any
length of time.
Dr. Edward Lea.minc; said that formalin was used
frequently in photography for the hardening of gela-
tin plates. The action of formic acid should be to
reduce the silver salts, and he had found that this had
occurred in unexposed plates. A similar reduction
might occur with salts of other metals.
Dr. Freeborn -said that .sometimes there was an
overoxidation of the methylic alcohol in the manu-
facture of formalin, by which formic acid \vas pro-
duced. He had also found that this oxidation would
sometimes continue in open vessels, resulting in the
formation of a considerable quantity of formic acid.
Improved Stage for Use in Photomicrography. —
Dr. Edward Leaming exhibited a new form of ap-
paratus intended for use with the microscope in photo-
micrography. It was found in certain cases that in
attempting to photograph a slightly uneven specimen,
or a nerve cell ^vith a long process, it was impos-
sible to get it all in the same plane with the slide held
in the usual way. To surmount this obstacle, the ap-
paratus exhibited had been devised by the assistant to
Mr. Kraft, of this city. It consisted of a light frame-
work and a light stage on which the specimen was
clamped. By means of an ingenious screw adjustment
the slide could be tipped in various directions and
across the axis of the lens.
Reproduction of Photomicrographs — Dr. Leam-
ing made some remarks on this subject, illustrating
them with some beautiful examples of such work in
colors. He said that he had attempted to utilize in
reproducing photomicrographs the three-color photo-
graphy by the gelatin process. The image was first fo-
cussed through a violet screen, and then negatives were
taken successively through red, violet, and green
screens. These are the complementary colors to the
three colors in which the photograph is finally
printed. The negative taken through the red screen
is printed in blue, that through the green screen is
printed in red, and that through the violet screen is
printed in yellow. The color screens are made of
glass and tough collodion properly colored. From
these negatives three bichromate gelatin printing-
plates are obtained and the printing is done by super-
position. Unfortunately, the manner of printing alters
the results somewhat, and, although this is of no im-
portance in ordinary artistic work, it is a serious
drawback to the use of this process for purely scien-
tific purposes.
Dr. Freeborn exhibited under the microscope the
original slides from which the colored photographs
had been made.
348
MEDICAL RECORD.
[September 5, 1896
Dr. Power said that he had taken a great deal of
interest in this subject in connection with general
photography. The lack of registration is a difficulty
with the printer, but probably there would be difficulty
in the registration even aside from the fault of the
printer, owing to the imperfections in our lenses and
the slight differences in the size of the images for the
different colors. He thought it possible that chang-
ing the camera length might obviate this. A moder-
ate amount of change in the length of the camera
would produce only a very small change in the image.
Dr. Le.amixg said that he thought Dr. Power was
in error on this point, for focussing, to be of service.
must be done chiefly through the objective and not by
changing the length of the camera. It was more diffi-
cult to focus through a violet screen, but if this were
done the images would he more nearly perfect.
Instrument for Cutting Off the Spinal Cord. —
Dr. Pe.arce Bailey said that in order to avoid the
mutilation of the spinal cord which occurred when it
was taken out in the usual way, he had devLsed an in-
strument, consisting of a small, slightly curved blade
at right angles to the stem. This knife should be in-
■serted some distance into the spinal canal and the
cord cut off at right angles. This also gave a much
better specimen for making sections.
Dr. J.\mes EwiNt; thought the instrument should
prove very useful. In removing the cord anteriorly it
was usually very difficult to e.\tract the last two or
three inches, but with this new instrument this could
be done from above.
Preservation of Specimens of the Intestines. —
Dr. He.nrv Power said that about one year ago he
had presented to this society a preliminary report on
the preservation of the intestine. He had continued
this line of experimentation since that time, using
children as the subjects. At first, the best method
had seemed to be the injection through a cannula of a
two-per-cent. solution of formalin very slowly into the
rectum. For the past year most of his experiments
had been done with only eight or ten inches of pres-
sure, and with a two-ix;r-cent. solution of formalin,
both peritoneum and bowel being injected in the ma-
jority of cases. He had learned that one of tiie most
important ])oints in the preservation of the intestine
was not to handle it. The formalin appeared to pene-
trate rapidly from the peritoneum to the mucous mem-
brane; hence it was better to inject into the peri-
toneum. He had selected formalin because of its
gaseous and penetrating nature. From three to five
specimens had been taken from the various parts of
the bowel, and they had been uniformly preserved,
much better than in the usual way. In tjie.se experi-
ments he had been assisted materially by Dr. South-
worth. In one case the injection had been made
shortly after death, and the autopsy performed forty-
three hours afterward. In another ca.se the injection
had been made twenty-four hours after death, and the
autopsy performed shortly after this, the intestine
being found in a state of excellent preservation. He
had found that the anatomical relations of the cells
were excellently pre.served, although the minute anat-
omy of the cells was not so good.
Dr. Ewi.m; said that in looking over these speci-
mens he had been impressed with the mar\ellous pres-
ervation of the endothelial cells. The nuclei, the
cell bodies, and the outlines between the cells could
be easily distinguished. He had never seen this with
any other method of preparation.
Dr. Si)i"rnw()RrH said that Holt, in his article in
Keating's Encyclopedia, stated that he rarely found
the epithelium present if the autopsy were made more
than six hours after death, and he expressed the belief
that the desquamative catarrh was the most frequent
form of acute intestinal disorder in children. This,
the speaker said, he was inclined to doubt, for even
when their autopsies had been made twenty-four hours
after death the epithelium had been preserved.
Photomicrographs by the Carbon Process. — Dr.
Power then presented several photomicrographs by
the carbon process. He said that the great advantage
of the carbon process was that the prints were entirely
permanent. As the pigment was either a finely ground
earth or finely pulverized carbon, and the background
apparently some form of lime suspended in gelatin,
even the yellowing of the paper was avoided. He
presented photographs of tissues done with an ampli-
fication of from ten to a thousand diameters, and of
bacteria with an amplification of from seven hundred
and fifty to one thousand diameters. He used mono-
chromatic light with '"critical illumination" from the
sun, and the plate was backed with some substance
which would not spread through the film, so that there
would be no spreading of the image from the whites
into the blacks.
A New Form of Degeneration of the Ovary. —
Dr. Mary A. I)i.\on-Jones presented four micro-
scopical specimens illustrating what she considered to
be a new form of degeneration of the ovary, by which
most of the organ was changed to myxomatous tissue.
Out of eighty diseased ovaries examined she had
found four specimens showing this degeneration.
This condition was associated clinically with marked
deterioration of the general health.
The societv then went into executive se.ssion.
Stated Meeting, April 22, i8q6.
Tumor of the Cerebellum. — Dr. Frederick Peter-
son presented a tumor of the middle lobe of the cere-
bellum, removed from a boy of twelve years, who had
been sent to him for examination in July, 1895.
.\bout Chri.stmas of 1894, up to which time the patient
had been perfectly well, he had an attack of grippe
with meningeal symptoms. .-Mter recovery from this
he suffered from periodical headaches, which grew
worse. These headaches were frontal, occurred once
a week, and lasted a few hours. Sometimes he was
delirious during these attacks. Six months previous
to coming under the observation of Dr. Peterson, he
was said to have had optic neuritis. The examination
revealed the following: Optic atrophy with feeble per-
ception of light, knee-jerks absent, no nystagmus, no
ocular palsies, no paralysis nor alteration of sensibil-
ity: pulse and respiration normal. He had attacks of
headache with vomiting weekly. A very peculiar
symptom was constant choreifonn movements of the
head, mouth and face muscles, and all four extremi-
ties, precisely like an ordinary chorea. There was a
.staggering gait. The diagnosis of a glioma or glio-
sarcoma of the middle lobe of the cerebellum was
made, the symptoms being typical. The boy, while
on a visit at Syracuse some time ago, fell down
stairs, fractured his skull, and died. Dr. Van Duyn,
who made the autopsy, had kindly sent him the brain.
On microscopic examination by Dr. Bailey the tumor
proved to be a glioma, and its situation in the ver-
mis was verified. The tumor was encapsulated, was
five centimetres broad and 2.5 centimetres deep, and
lay directly in the vermis, encroaching equally on
each side into the lateral lobe of the cerebellum.
The fourth ventricle was widely dilated, and the whole
bulk of the pons seemed to have been subjected to
considerable compression. Dr. Peterson said he had
seen many cases of tumor of the cerebellum, but never
before one with the choreiform movements which dis-
tinguished this case.
Primary Pernicious Anaemia. — Dr. James Ewing,
in discussing this subject, reported the following illus-
September 5, 1896]
MEDICAL RECORD.
349
trative case : The patient, a man of forty-live years,
of American parentage, had been admitted on April
9, 1896, to the Roosevelt Hospital. His family his-
tory was negative. There was a moderate alcoholic
habit, and some years before he had had symptoms of
secondary syphilis. For five weeks prior to his ad-
mission it was stated that he had been very pale, and
had suffered considerably from dyspnoea on e.\ertion.
'I'here had been no disturbance of vision, no headache
or dizziness, but for four weeks there had been cede-
ma of the extremities, and he had lost a good deal
of strength. The urine was of dark color and scanty.
On admission he was markedly pale, but not jaun-
diced; the pulse was regular and small, the arteries
were apparently normal, there was considerable cedema
of the feet and legs. The splenic area was slightly
increased. He was given arsenic and iron, but with-
out benefit. On April loth the ha'moglobin was
twenty-five per cent., and the blood count showed one
million one hundred and twenty-eight thousand red
blood cells. A dried preparation showed that the
condition was one of primary progressive pernicious
anaemia. The size and form of the blood cells were
very characteristic. There were very fine microcytes,
very large megalocytes, and gigantoblasts in abun-
dance, and great variations in the intensity of the
haemoglobin stain. There was a considerable increase
in the white blood cells, chiefly in the polynuclear
leucocytes, and some large myelocytes were found.
On April nth he was given five minims of Magen-
die's solution of morphine to produce sleep. After
this dose he went into profound collapse, and was with
difficulty resuscitated. On April 13th he suddenly
began to have difficulty in breathing, and he died four
hours later, with symptoms of asphy.\ia.
The autopsy was made two hours after death. The
lungs were emphysematous and e.Ktremely anaemic,
e.\cept for some small areas of consolidation. The
bronchial glands were slightly enlarged. The peri-
cardial sac contained a few ounces of reddish fluid.
The right heart was distended by a peculiar soft blood
clot. No other clots were found elsewhere, and it was
evident that the coagulability of the blood was greatlv
diminished. The total quantity of blood also ap-
peared to be diminished. The heart was nearly nor-
mal. The liver was enlarged and very firm. The
outlines of the lobules were very distinct, and the pe-
culiar rust color of the organ was very striking. The
spleen was markedly enlarged, weighing thirteen
ounces. The kidneys were somewhat smaller than
usual. The surface was granular, the cortex was thin.
the markings were indistinct, and the whole organ was
somewhat congested. In the intestine there was an
abnormal adhesion binding the transverse duodenum
down to the lumbar vertebrae, and producing a slight
narrowing of the lumen. There was evidence of ca-
tarrhal enteritis, but there were no parasites present.
The bowel contents consisted almost entirely of mu-
cus, giving a remarkably strong odor of hydrogen sul-
phide. The sternum, ribs, vertebra-, clavicle, hume-
rus, and hyoid bone had been examined, and in all
these situations there was very extensive increase in
the marrow cavities, and these cavities were filled w ith
red marrow.
Microscopical e.xamination showed in the spleen no
increase of connective tissue, a marked diminution of
cellular elements, both of the Malpighian bodies and
of the spleen pulp. In many of the Malpighian bod-
ies the small round cells were entirely wanting. A
slight reaction for iron, hemosiderin, was developed
by potassium ferrocyanide and acidified glycerin, but
it was much less marked than in the liver. There was
no granular pigment observed as a result of the exten-
sive destruction of the red blood cells in the spleen.
The thyroid showed a very marked general thickening
of the trabeculae, w'ith partial atrophy of many alveoli.
In the liver there was slight general increase of fibrous
tissue between the lobules and between the liver cells.
The liver cells showed marked fatty degeneration.
The nuclei and numbers of the liver cells were dis-
tinctly increased in number, and some of these new-
cells and nuclei were of very large size. Throughout
the liver there was an abundant deposit of yellowish
pigment granules, giving a very distinct reaction for
iron. In the stomach there was a moderate grade of
chronic catarrhal inflammation, with increase of con-
nective tissue and atrophy or dilatation of glands. In
the lowev dorsal and lumbar regions in the spinal
cord, the only parts examined, there was slight sclero-
sis of the columns of Goll, but without pronounced
atrophy of fibres in this region. Nissl's stain showed
ganglion cells to present in moderate degree an ab~
sence of chromophilic granules about the nuclei, in
many cells, while other cells showed extensive depos-
its of greenish pigment commonly seen after middle
life. The red marrow was found in all the bones ex-
amined— the ribs, sternum, vertebra;, clavicle, hu-
merus, and hyoid. In all of these bones the cancel-
lous spaces were very much widened and filled with
light red semifluid marrow. The shafts or outer plates
of these bones were distinctly thinner than normal.
The head of the humerus could be easily crushed in
by pressing on the cut surface of the cancellous tissue.
No fatty marrow was seen in any of these bones.
Cover-glass preparations were made from the various
organs concerned in blood formation and stained in
Khrlich's triacid mixture. So far as could be judged
by this method, while the red marrow in all the bones
contained a large number of megaloblasts, the total
number of nucleated red cells was considerably less
than is to be found in nonnal adult red marrow. In
the preparation from the ribs, the nucleated red cells
did not compose more than one-fiftieth part of the cells
present. All the red cells, both nucleated and non-
nucleated, seemed to number about one-eighth of all
the cells in the marrow of the ribs and other bones.
While, therefore, the locality of the formation was
very much w idened, it did not seem that the number
of the red cells in active proliferation was correspond-
ingly increased. The majorit\ of the new cells in the
red marrow consisted of small and large mononuclear
cells, myelocytes, polynuclear neutrophile leucocytes,
and eosinophile leucocytes. While the manufacture
of red cells was here very widelv distributed, it seemed
that the total productive capacity was probably di-
minished rather than increased.
Dr. Kwing here illustrated his remarks by exhibiting
charts and slides. The first showed the blood from a
case of pernicious ana;mia, with the characteristic
megalocytes and the small basophilic granules in the
megaloblasts. A chart of the blood from a case of
chlorosis was also exhibited. This showed that the
blood cells were moderatelv diminished in number,
and there was a general diminution in the ha;nioglo-
bin. In this case one did not see in any quantity the
large megalocytes of pernicious ana-mia. A common
form of degeneration, the speaker said, was the extru-
sion from the body of the red cell of a mass of proto-
plasm, which stains with methyl blue and which gives
all the characteristics of the blood plate. A chart
showing the characteristics of the blood of secondary
pernicious anasmia was also shown, and the relations
of this condition to primary pernicious anaemia were
discussed.
The examination of such a typical example of per-
nicious anaemia, in which all the essential features of
the disease were so strikingly developed, naturally
suggested, Dr. Kwing said, some considerations regard-
ing the etiology and pathogenesis of the disease. It
was now generally admitted that pernicious anaemia
350
MEDICAL RECORD.
[September 5, 1896
is primarily a condition of excessive hamatolysis
rather than one of defective ha-matogenesis. While
very acute cases of pernicious anamia had been re-
corded, in which the characteristic changes in the bone
marrow, leading to defective hamatogenesis, were ab-
sent, the disease seemed not to exist without excessive
hamatolysis. He had recently had an opportunity,
through the kindness of Dr. Northrup, of examining
an acute case, lasting only four weeks. In this patient
the red cells numbered less than five hundred thou-
sand per cubic centimetre. There was an almost entire
absence of nucleated red cells of all varieties and of
abnormally large red cells, although degenerative
changes in these red cells were extensive. While no
autopsy was made, the observations of Khrlich had
shown that such cases were unattended by the usual
changes in the bone marrow. As evidence of the ex-
cessive destruction of red blood cells in pernicious
anffimia, one might refer to: (i) the abundance of
degenerative changes in the red cells; (2) the colora-
tion of the plasma as seen in dry preparations: (3)
the deposit of large quantities of iron in the liver and
spleen ; (4) the appearance of excessive and patholog-
ical blood pigments and of an excessive amount of
iron in the urine; and (5) in the acute cases the very
rapid diminution in the number of red cells present in
the blood.
But these facts were not conclusive proofs that ex-
cessive hamatolysis was the sole factor in the produc-
tion of the disease. Degenerative changes in the red
cells are abundant in chlorosis and in secondary ana-
mia, when the number of red cells is not markedly re-
duced and when iron is not always present in exces-
sive amount in the liver or in the urine. Neither is
the presence of an excess of iron in the liver a positive
indication that pernicious anaemia has existed. In a
series of examinations of forty-four livers, taken as
the cases came to autopsy, Russell found in seven
quite as much iron as Hunter found in the liver of
pernicious ana;mia. These were cases of marked
secondary anamia from cancer, tuberculosis, and other
diseases, and the patients had not suffered from perni-
cious anamia. In those cases of pernicious anarmia
which follow pregnancy, it was difficult to see what
could be the toxic agent which could alone initiate
and continue a fatal destruction of red cells. Even
more difficult was it to explain those cases which fol-
low large hemorrhages by the assumpion that there is
present in the blood a toxic agent which continues the
destruction of red cells. .\n examination of the clin-
ical aspect of the disease seemed to show that, accord-
ing to their etiology, there were cases of pernicious
anemia which were very probably caused by a toxic
agent circulating in the blood and destroying red cells,
and that there were other ca.ses which could be most
reasonably referred principally to defective ha;matoge-
nesis. In the first class might be placed those exam-
ples of the di.sease which were associated with the
presence of intestinal parasites or blood parasites,
such as the cercomonas globus or the malarial organ-
ism; also the cases following infectious diseases. Of
the idiopathic forms, while the very acute cases, unat-
tended by marked changes in the bone marrow, were
most naturally referred to excessive hamatolysis, it
•was difficult to see how a toxic agent destroying red
blood cells could, in a few weeks, have produced
■changes in the bone marrow of such enormous extent
as were found in the case just reported. It was much
more probable that an abnormal process of cellular
proliferation, leading to defective ha;matogenesis, was
the chief factor in the production of the blood changes
in this case. It would appear, therefore, that both ex-
cessive hamatolysis and defective haematogenesis were
essential features of the disease process in pernicious
.anaemia, and that sometimes one and sometimes the
other was the more prominent. The speaker said that
a large number of studies had been undertaken with a
view of determining the nature of the toxic material
which destroys the red cells in pernicious ansemia.
The studies of Hunter in this direction were impor-
tant. In an article in the British Mciiu-al Journal,
February 8, 1896, he reported some recent experiments,
and supported his previous conclusions that pernicious
ana-mia is a specific form of blood destruction, occur-
ring chietiy in the portal circulation and caused by
the absorption of the products of intestinal bacteria.
Cadaverin and putrescin he regarded as the probable
agents concerned. Jurgenson had reported a case of
pernicious anamia cured by the removal from the in-
testine of enormous numbers of the bacterium termo,
and Liebman had produced a condition of chronic
blood poisoning resembling pernicious anamia by
the intravenous injection of haemoglobin, of glycerin,
and of pyrogallic acid. He believed the disease to
be due to hamoglobinamia. The followers of the
Dorpat school believe that the poisonous agent in the
blood of pernicious anamia comes from the destruc-
tion of both red and white blood cells. The nervous
origin of pernicious anamia had received some little
support. Some of the cases reported, like the present
one, showed changes in the central nervous system,
but in no instance did these changes appear to be of
more than secondary importance. The theory most
widely accepted was that the disease represented a
rapid form of blood destruction, associated with a re-
version of the blood-forming function to the embry-
onal type : in other words, it represented a tumor
formation in a fluid tissue. This analogy to a tumor
formation, however, appeared to be more applicable to
leukamia than to pernicious anamia. A comparison
of the blood of fa'tal vertebrates with that seen in
cases of pernicious anamia certainly did show many
points of resemblance, but the likeness did not seem
to him to be especially striking.
Dr. Thom.as S. .Southworth said that in examin-
ing cases of pernicious anamia he had met with diffi-
culty in diagnosis owing to the intermediary class of
cases. Many cases were diagnosticated clinically as
acute primary pernicious anamias. He had come
to rely upon two things, viz. : the existence of megalo-
cytes — the large non-nucleated red cells — and the
presence of the megaloblasts — the oval, large, nucle-
ated red cells. Unless these were present in consid-
erable numbers, however, the diagnosis could not be
positively made.
Dr. .Southworth then exhibited microscojx; slides
illustrating these points, and presented microscopical
specimens from a case of
Rachitic Ansemia. — He said that in January of the
present year a baby of eighteen months, with marked
evidence of rachitis, had been admitted to the Babies'
Hospital. The spleen had extended to the left ante-
rior superior spine, and measured three by two inches
below the ribs. The liver had been enlarged, coming
down one and one-half inches below the ribs. There
had been al.so some enlargement of the superficial
glands. The number of red cells had been five mil-
lion one hundred and forty-four thousand to the cubic
millimetre, the ratio of the white to the red cells being
I to 168. The most interesting point in this case was
the extremely large number of megaloblasts.
Dr. Ewixc; a.sked Dr. Southworth as to the relative
frequency of the severe forms of pernicious anamia
in connection with rachitis. He said that while he
had found a great variety of severe forms of anamia
in connection with rickets, he had not observed pro-
gressive pernicious anamia.
Dr. Southworth said that he had seen many cases
of profound anamia, and the condition had yielded to
the usual antirachitic remedies and tonics. In the
September 5, 1896]
MEDICAL RECORD.
351
case just repwrted the anxmia was not particularly
marked, as there were over five million red cells.
Pernicious Anaemia — Dr. Charles Fischer also
presented a microscopical specimen from a case of
pernicious antemia. There was no clinical history.
The patient had been in the hospital only three weeks.
At the autopsy no other lesions had been found.
The specimen showed all the varieties of degeneration
that had been described by Dr. Ewing.
The society then went into executive session.
GTlinical i)epavtmcut.
A CASE OF SUPPLEiMENTARY AMNIOTIC
SAC WITH FIBROID TUMOR OF THE
UTERUS.
Bv DANIEL S. ROBINSON, M.D..
>P,\V HAVES, COSN.
In the early evening of December 7, 1895, I was
hurriedly called to attend Mrs. L , aged forty-four
years, in labor with her third child. On arriving at her
home I found her suffering from strong, regular pains,
having been in labor since 1 1 I'.M. of the previous
day. On examination I found the tense membranes
protruding nearly two inches beyond the vulvar orifice,
and, as during the inter\al a normal vertex presenta-
tion was made out, at the next pain I ruptured them.
The rupture was followed by a profuse discharge of
the liquor amnii, but on making an examination at
the next pain I was surprised to find that, while the
head was low and apparently completely filled the
parturient canal, the "bag of waters'" still seemed
intact.
As all the circumstances of the case seemed to
point strongly to some anomaly of the placenta or
membranes, I ruptured this second sac and a verv
few pains sufficed to deliver the patient of a seven-
p>ound girl. More difficulty was encountered, how-
ever, in the delivery of the afterbirth. Attempting
to deliver by Credo's method, only to fail, I inserted
two fingers into the vagina, and found that while the
placenta and a portion of the membranes were lying
free in the vaginal canal, another portion of the
membranes was still in utcro.
Following this up, I found that it seemed to lead
to the left and to be attached in some way to the
uterine wall. Gentle manipulation after some few-
minutes caused detachment and gradually the entire
mass was drawn into the vagina and delivered. The
uterus did not retract as it should, there being a dis-
tinct tumor of the left side about as large as an
orange. The patient denied the existence of anv
tumor, but said "that lump'' was always there and
gave a history of menorrhagia, which made the prob-
able diagnosis very simple. An examination of the
afterbirth showed, about three inches from the pla-
cental insertion of the funis, a large sac formed by
development of the outer (amniotic) sheath of the
cord, and this, having prolapsed in front of the de-
scending head, had given the impression of the mem-
branes being still intact after rupture of the first sac.
The capacity of this supplemental sac was about
two litres. Whether or not there was any connection
between this sac and the fibroid probably existent I
don't know, but it is my belief that in some way it
was an attempt of nature to save the fcetus from in-
jury during development.
A point in the case of interest to the maternal im-
pressionist is the fact that the second and third digits
on each hand are united, caused, the mother believes,
by frequent visits during her pregnancy to a friend
whose infant child has the same deformity.
DYSTOCIA, DUE TO DISPARITY BETWEEN
THE SIZE OF THE HEAD OF THE FCE-
TUS AND THE CIRCUMFERENCE OF ITS
SHOULDERS.'
Bv .\. KKNEST GALLANT, M.D.,
FORMERLY I.NTEK.VE, SLOAN M.\TERMTY HOSPITAL, ETC.
I'he failure of recent te.Kt-books or works on the com-
plications of the above-named condition to mention it
as a cause of difficult labor, has determined the writer
to place this case on record.
The dystocia and the death of the child can be ac-
counted for as follows : Circumference of the shoul-
ders, 44 centimetres (17 "4 inches); occipito-frontal
circumference, 33.5 centimetres (13!^ inches — or a
difference of 10.5 centimetres (4^^ inches) ; and sec-
ondly, the unusually fat condition of the mother, who
weighed two hundred and twenty pounds, the pelvis
being so filled with adipose tissue as to seriously
interfere with the distention of the vagina. This,
with the disproportion between the head and shoulders,
compressed the body to such a degree as to stop the
umbilical circulation and resulted in the death of the
child while in the vagina.
The mother first came under the writer's care at the
Roosevelt Hospital, Out - Patient Department, in
March, 1894. Native of Ireland, twenty-eight years
of age, housewife, married two and a half years. She
had borne one child one and a half years ago, and
had had a miscarriage in July, 1893. She menstruated
regularly every four weeks, for two days. There was
pain one day before and during the first day, with
some leucorrhcea. She complained of a dragging
pain in the lumbar region. The perineum was lace-
rated nearly to the sphincter ani and the cervix was
lacerated bilaterally. The uterus was forward, three
and a half inches deep, roomy, and tender on pressure.
Diagnosis: Fungous endometritis.
April 14th, dilatation of the cervix, curettage, irri-
gation with tincture-of-iodine solution (sherry color),
resulting in a firm contraction of the uterus. Inter-
nal hemorrhoids removed by scissors and the edges
brought together with catgut sutures, after the meth-
od described in Mathew's Medical Quarterly, vol. i.,
page 518, 1894.
May 2d the patient had an attack of appendi-
citis and the next day the writer removed the ap-
pendix, six inches long, through a five-inch skin in-
cision, made necessary by the fact that the abdomen
was covered by fat four inches deep. The appendix
was bound down by strong fibrous bands to the colon
and lateral abdominal wall. In spite of the thickness
of the abdominal wall, the wound was closed by a
single line of silkworm-gut sutures passed through all
the layers.
November 5th the vulva, cervix, and vagina were
of a bluish hue and congested. The last menstrua-
tion, July 5th and 6th, was scanty. Pregnancy was
normal. The abdominal cicatrix did not stretch.
Labor pains began in the early morning of April
16, 1895, and by 9 p.m. the cer\ix was drawn up and
was very soft; the membranes were bulging, and, ow-
ing to their density, were punctured. A small quan-
tity of liquor amnii escaped. The head was in R. O.
P., movable above the brim. Pains recurred at inter-
vals of from five to fifteen minutes, but at no time
were they strong. The forehead showing a tendency
to come down first, counterpressure on the forehead
through the vagina was kept up in order to produce
Hexion and cause rotation of the occiput on the pel-
vic floor. The advance was very slow; the patient be-
came exhausted and the pains weak, and after two hours
the forceps were applied and traction was made during
' Read before the section on obstetrics and gynecology. New
York Academy of .Medicine, March 26. 1896.
352
MEDICAL RECORD.
[September 5, 1896
the pains. No anesthetic was used. The head was
brought down so as to bulge the vulva and stretch the
perineum, and the forceps were removed, but the head
retreated well into the pelvis after the subsidence of
each pain. The cord was not around the neck. .\s
no advance was made the forceps were reapplied, and
strong traction delivered the occiput over the perineum
and the face from behind the symphysis pubis. The
mouth and nose w-ere cleared of mucus. The child
was cyanotic and made no effort at inspiration.
Traction on the neck and efforts to produce rotation
were of no avail. The cyanosis was increasing. Two
fingers were introduced and the left arm was brought
down, then the right arm, and by pulling and twisting
the body was w ith difficulty delivered. Pulsation in the
cord had ceased, and the heart could not be felt nor
heard. Various means at resuscitation were resorted
to, but not the slightest sign of life could be elicited.
Dr. E. A. Tucker informs me that the largest child
out of four thousand delivered at the Sloane Ma-
ternity Hospital measured forty - three centimetres
around the shoulders, or one centimetre less than the
subject of this report.
The writer presents the mother for examination of
the scar of the appendiceal wound, which has with-
stood so severe a strain as the weight of a child fifty
centimetres long, in so stout a woman, and now at the
end of two years shows no sign of hernia. This result
speaks well for the single line of sutures in closing
abdominal wounds.
10 West Thiktv-Sixth Stkeki'.
ACUTE UTERINE INVERSION.'
Hv WALTER LINDLEY, M.D.,
LOS A.SGELES, CAL. ,
PHOFE66UK OK (.V.NECOLOGV l.v; THE MEDICAL COLLEGE OK THE ITNIV'EKSITV
OF SOUTHERN CALIFOR.NIA ■ PRESIDENT OF THE CALIFORNIA STATE MEDI-
CAL SOCIET\', l8go, ETC.
This accident occurs only in about one case of con-
finement out of two hundred thousand, but as it is
liable nevertheless to occur in the work of any general
practitioner, I have felt justified in calling attention
to ray own recent experiences:
Case: Mrs. C ; aged twenty-eight ; primipara.
The labor was normal but somewhat tedious. Posi-
tion: L. O. A. Child, vigorous boy. I waited until
pulsation ceased before tying the cord. The patient
was in good condition and I waited ten minutes before
taking any steps toward encouraging the progress of
the third stage.
I then grasped the fundus through the abdominal
wall and began using very moderate friction. The
womb contracted for three or four minutes and sud-
denly, to my astonishment, disappeared. .Vt the same
moment the placenta popped out and there was alarm-
ing hemorrhage. Calling for a hypodermic of ergot
and for hot-water douche I attempted to thrust my
left hand into the vagina, but was met by a large tumor
at the introitus. Like an electric shock the realiza-
tion came to me that I had here to deal witli an in-
verted uterus.
The hemorrhage being profuse, without loss of time
I coned my left hand and dimpled the centre of tlie
fundus with the coapted thumb and tips of the fingers,
while making counterpressure through the abdominal
wall with my right hand. By the steady pushing of
the left hand, dropping the thumb out of the cone
after a slight advance toward the cervix, the uterus
was quickly returned to its normal relations.
While my ideas in regard to the length of time
taken in this little operation are somewhat hazy, yet
' Read before the California State Medical Society, April 24,
1896.
il was probably from three to five minutes. The
bleeding continued alarming and there was complete
inertia of the uterine walls. The patient had already
taken ergot hypodermically and by the mouth, and as
quickly as the uterus assumed its normal position the
hot water was turned into the cavity from a fountain
syringe through a uterine irrigator; meanwhile I used
friction through the abdominal wall with my right
hand. It was all without avail. The patient's con-
dition was critical. I then had six ounces of acetic
acid added to three quarts of hot water, and almost
synchronously with the first contact of the acetic acid
I felt the uterine walls begin to contract. The con-
test was soon over, the uterine fibres again performed
their functions, and the hemorrhage ceased. There
was no laceration of the cervix. In a few minutes I
repaired the lacerated perineum with silver wire.
The patient's recovery was rapid and uneventful,
the only untoward symptoms being that on the third
afternoon her temperature rose to 100 F. for two hours,
and that her milk was so scanty she could not supply
nourishment for the child. I'lie restoration of the
perineinn was perfect.
If there had been any difficulty what\ever in
dimpling the fundus and pushing il quiikly back.
it would have been better to adopt tlie plan usually
advised, of grasping the fundus in the hand and
pressing upward on the sides with the fingers and
thumb, thus, as the '"American Text-i5ook of Obstet-
rics" says, '■ endeavoring to restore first that portion
of the uterus which came out last." There are modi-
fications of these two methods and the physician can
doubtless readily see which ]jlan is the best for the
case in hand. When there is complete uterine inertia
immediately following labor, the method adopted by
me is simple, rapid, and easily executed.
In the Medical Record, of October 26, 1895,
is an interesting account of an operation by Drs.
Davis and Packard for inversion of the uterus, which
had existed for five days. The method adopted was
this: The first step consisted of pressing the index
and middle fingers firmly and steadily against the
presenting fundus, at the same time making gentle
counterpressure through the abdominal wall. " Grad-
ually the uterine wall yielded, .so that at the end of
fifteen minutes the two fingers were buried in the
tumor as far as the distal joint. The whole hand
was now passed into the vagina and four fingers were
pressed firmlv aganist the mass, thus pushing it toward
the cervix bv continuous pressure, the elbow mean-
while resting on the bed as a point of support. With
the help of the thumb, some degree of massage to
the uterine walls was accomplished, with a view to
rendering them more pliable and thus more tractable
to further manipulations. Very soon the uterine walls
began to soften, whether from the relaxing effect of
the ana^sthetic. or from the manipulations, or from
both combined, and the cervix as felt behind the
pubis grew appreciably softer. .\t the end of half
an hour it was possible to carry the fundus before the
four fingers fairly into the mouth of the constricting
cervix, where they were steadily held as a wedge."
This case differs from mine on account of the length
of time after labor and the contraction of the uterus.
Gould's y'car Book for 1895, quoting Jewett, says:
"In a recent study of 100 cases of inversion Eeckman
found 54 occurred spontaneously, 21 after interference,
and in 25 the cause was unknown. He believed the
accident to be most frequent in primipara; and- in
young women. In this series of cases there were 14
deaths. In two of the cases the uterus was irreduci-
ble, in 4 the reduction was spontaneous, in 61 there
was artificial reduction, and in 119 hysterectomy was
performed."
315 West Sixth Sirebt.
September 5, 1896]
MEDICAL RECORD.
353
SPIRIT OF TURPENTINE IN THE TREAT-
MENT OF BURNS.
Dr. H. L. McInnis, of Edmonton, Canada, writes:
"Spirits of turpentine applied to a burn of either the
first, seond, or third degree will almost at once relieve
the pain. The burn will heal very rapidly, much more
so than by any other treatment that has come under
my notice. I apply the turpentine as follows : After
wrapping a thin layer of absorbent cotton over the burn,
I saturate it with the turpentine and then bandage.
The common commercial article is the one I use, as
it is generally found in every house. Being volatile,
it evaporates, and it is therefore necessary to keep the
cotton moistened with it. When there are large blebs
I open them on the second or third day. It is best to
keep the spirit off of the healthy skin if possible, as
sometimes pain is produced by its action. As I can
find no mention of this treatment in the books I have,
I take the liberty of sending this note, so that others
who have greater opportunities may test the value of
this treatment."
ACUTE MULTIPLE NEURITIS (BILATERAL)
RESULTING FROM AN .A.TTACK OF DIPH-
THERIA.
By M.\J0R L. .M. M.WS,
siRr.EON, V. s. ARM^■,
r.'KT SAM HOISTOV, TEX,
Priv.^te B. N , Battery " F," Third Artillery,
American, aged twenty, was admitted to hospital
February 24, 1896, suffering from sensory and motor
disturbances of both upper and lower extremities.
He had been under treatment in the post hospital from
the 3d to the 28th December, previous year, for a
serious attack of diphtheria, contracted in San An-
tonio, the disease being quite prevalent there at that
time. His condition on admittance was as follows;
Numbness and delayed sensation of both feet and legs
as high as the knees, and both hands and arms as
high as the elbows; the paraesthesia almost amounted
to complete anssthesia. With the eyes diverted, he
was uncertain as to whether a pin was introduced into
his skin or not. Complete loss of tactile sensation.
There was also paresthesia of the chest surfaces,
paresis of the flexors and extensors of both upper and
lower extremities, with complete loss of the cutaneous
and tendinous reflexes. The gait was shuffling and
very uncertain; he could move slowly, dragging his
feet along, exhibiting marked paresis of the extensors.
The skin was cold and moist over the affected areas.
The line of demarcation between the parts affected
and the non-invaded areas was well marked by the
sensory symptoms and the surface coldness just re-
ferred to. He was suffering from no special pain or
increase of temperature. The thermometer recorded
99° F. under the tongue and the heart beat was slightly
under loo, the latter probably resulting from exercise
in reaching the hospital. Diminished electro-con-
tractility was also noted, with marked pain upon the
application of the faradic current. The patient's
statement was as follows: That he first experienced a
sense of weight and heaviness of feet and hands, which
was quickly followed by numbness and tingling of
the same parts about three weeks before entrance into
hospital. The numbness began in the toes, extending
to tlie ankles and finally to the knees within a few days.
About one week after the numbness started in the
toes, it began in the fingers and rapidly extended to
the elbows. There was more or less pain, though not
severe, from which he concluded that he was suflfering
from rheumatism. It appears that the attack was not
preceded by fever. Motor disturbance began when
the numbness ascended as high as the ankles, and he
was hardly able to walk when it had reached the knees.
He states that during drill he could scarcely grasp
the corporal's hand (he being No. 3) when the order,
" Prepare to mount," was given, and was unable to
grasp the trail of the piece at the order, '"Prepare to
limber or unlimber." Private N is quite young,
had during the past year been in the hospital several
times, and, being sensitive for that reason, failed to
present him.self for treatment until he could go no
io.iger. The similarity of symptoms bewteen multiple
neuritis (polyneuritis) and ascending paralysis (Lan-
dry's disease) frequently render a diagnosis bet\^een
these two diseases difficult, and indeed it is said by cer-
tain authorities to be quite impossible at times. I would
infer from the literature on the subject that there are
those who regard these diseases as identical. Both
diseases are certainly quite uncommon in general
practice, and extremely so among soldiers. I do not
recall a single case of either before in my army experi-
ence. Upon the patient's admittance into the hospital,
therefore, the question as to the true nature of the
disease naturally presented itself, whether we had a
Landry paralysis or a case of multiple neuritis to deal
with. It will be observed from a comparison of the
following two paragraphs that a marked similarity in
the symptoms of the two diseases exists, sufficiently
distinct, however, when the two diseases are typical
cases, for a diagnosis.
Acute Multiple Neuritis — The disease usually
begins suddenly with fever and symptoms of an acute
infectious disease, is accompanied by sharp burning
or tearing pains. This is soon followed by sensory
symptoms, such as formication, tingling of the toes
and fingers, and numbness which advances into
paraesthesia or complete anaesthesia of the affected
parts. Paresis of the flexors and extensors of the arms
and legs soon merges into complete paralysis. There
is loss of or diminished faradic contractility. The
paralysis as a rule extends from legs to arms before
the trunk is invaded. Coldness of the surfaces of the
affected parts is a prominent symptom in multiple
neuritis. The later symptoms are trophic changes in
muscles affected, skin, nails, and hair; oedema of the
hands and feet; albuminuria and enlarged spleen.
The patient may die in a week from paralysis of the
respiratory muscles, or the disease may terminate in
recovery after weeks or months.
Acute Ascending Paralysis (Landry). — Slight
fever the first few days; pain in toes, fingers, and back
first few days, accompanied by weariness and genera!
discomfort. Sensory symptoms are usually absent,
though slight tingling, numbness, and hyperaesthesia
have been observed in toes and fingers. .Actual paraly-
sis soon supervenes, involving feet, legs, thighs, arms,
and trunk. The muscles of articulation, deglutition,
and respiration are generally affected. The paralysis
may begin in upper extremities. The patellar refie.\es
are sometimes obliterated. Electrical reaction remains
normal. No trophic changes occur in muscles, skin,
nails, or hair. Death may occur within a few days, or
the disease may continue for months and the patient
finally recover.
As a rule there is a marked difference in the sensory
symptoms; numbness, tingling, formication, pares-
thesia and anaesthesia are always present in multiple
neuritis and rarely so in ascending paralysis. The
disease usually begins with fever and simulates the
attack of an acute infectious disease in the former,
which is not the case with the latter. This was not the
case with Private N . The electrical reactions are
different in the two diseases and trophic changes do
not occur in ascending paralysis. The paralysis in
multiple neuritis usually begins in the feet and legs,
then advances to hands and arms. In ascending
paralysis the paralysis extends from the legs to the
354
MEDICAL RECORD.
[September 5, i8g6
trunk before the arms are involved; this symptom is
variable. However, there are many exceptions to be
noted, both in the march of the paralysis and as well
in the sensory symptoms. Both diseases may termin-
ate fatally within a few days from paralysis of the
respiratory muscles, or both may go on to a tedious re-
covery.
When sensory symptoms are present in ascending
paralysis, the diagnosis between that disease and
multiple neuritis then becomes very difficult.
Pathology. — In acute multiple neuritis we find
degeneration of the medullary sheath and a.xis cylin-
ders of the nerve fibres. At first we find them swol-
len, divided into segments of a semifluid consistency.
In more severe cases, the medullary sheath is broken
up into fine granules of fat or molecular de'bris, which
are absorbed. The axis cylinders may be not only
swollen but also changed into a granular mass, which
may be completely absorbed, so that an empty sheath
of Schwann alone remains as a trace of a former nene
fibre. As recovery occurs, regeneration of the nerve
fibres takes place. Dr. Starr is authority for the
above pathological statements.
In acute ascending paralysis we find myelitis of the
motor tracts of the cord of the anterior gray matter
and of part of the medulla oblongata. The myelitis may
be chiefly of the antero-lateral columns in the cervical
and dorsal regions (Zennerj. Hun states that Lan-
dry's disease without sensory or bulbar symptoms
must be regarded as a clinical entity for which no
corresponding lesion has yet been discovered.
The following history of this very interesting case
has been taken from the hospital records :
The general condition of the patient remained ex-
cellent. His mind was clear, he was free free from
pain when undisturbed, his appetite was excellent, and
he slept well. The paralysis of arms and legs became
complete within several days after admittance. Numb-
ness and ana-sthesia of the aft'ected parts remained
unchanged until March 3d, when slight symptoms of
returning sensations were observed. About this time
he suffered considerable pain in the knee-joints. The
temperature, taken morning and evening, was normal,
and the pulse rate ranged from 60 to 84. March 4th,
hyperaisthesia over arms and legs was complained of;
the patient stated that he experienced a sensation simi-
lar to that of striking the ulnar nerve over the elbow-
joint whenever anything touched his skin. He suffered
from extremely cold hands and feet during the first
three weeks after admittance into the hospital, so much
so that the application of hot-water bottles became
necessary for weeks. He was allowed to sit up March
23d, and was rolled about in an invalid chair. There
were no marked changes in motor or senTsory disturb-
ances until March 27th when the sensation of numb-
ness and hyperesthesia suddenly disappeared.
.\pril 5th the patient began to walk with a shuffling
gait and at this time had slight control over the ex-
tensors and flexors; there was still complete loss of
the skin and patellar reflexes and more or less dimin-
ished loss of faradic contractility. His anal and
vesical sphincters remained unimpaired throughout
the entire sickness. The treatment consisted of good
nutritious diet, applications of heat, and iodine painted
over aftected parts. Later iodide of potassium and
electricity were used.
April 1 6th walking w'as improved; he still experi-
enced delayed sensation over both feet, legs, hands,
and arms. More or less paresis of the flexors and ex-
tensors existed. He stated that his sense of touch was
keener in the right arm and left leg than in the left
arm and right leg at this date.
.\pril 24th improvement in walking continued; he
had better control over flexion and extension of both
upper and lower extremities. He stated that there
was less delayed sensation in the left arm and right
leg than in opposite arm and leg.
April 28th the patient was able to walk naturally,
but still experienced slight delay in sensation over the
affected parts. He said he was able to perform his
duty. I regard him as virtually recovered, and but
for the removal of a congenitally elongated prepuce,
which was done .April 25th, would return him to duty.
CONGENITAL OCCLUSION
THRA.
OF THE URE-
By THEO. G. DAVIS, M.n.,
BRIDGETON. N. J.
The report of a case by Dr. Allen in the Medical
Record of June 6, i8g6, recalls the case of a female
child born in September, 1885, who did not pass urine
for three days, when my attention was called to it.
On examination no urethral orifice or urethra could
be found, but by inserting my little finger into the
vagina, about an inch and a quarter, there could be
found a fluctuating body, evidently the distended pos-
terior urethra. With a finger in the vagina as a guide,
a small trocar was thrust through the tissues where the
urethra should have been and a small catheter was
passed through the cannula into the bladder, where it
was retained for four days, the urine being passed
through it until it was removed and then through the
wound made. The girl is now eleven years old and
has always had perfect control over urination.
ARREST OF SMALL-POX IN ITS VESICULAR
STAGE.
Bv F. S. FURMAN, M.D.,
SHRE\EPORT, LA.
In the Medic.\l Record of July i8th there was an
article by Dr. Alonzo Bryan, of Detroit, Mich., en-
titled " Arrest of Small-pox in its Vesicular Stage.'"
In this article the doctor alludes to a paper read
by him at a meeting of the Detroit Medical and
Library .Association, in which he maintained that the
eruption of true small-pox extends to and includes only
the vesicular stage, and that the vesicles are simply
infection atria through which pus germs and sapro-
phytes are intromitted to the structure of the true skin
and to the general system.
The paper claimed that the germs of suppuration
and of putrefaction are lying in wait, embedded in the
epidermis, ready to commence their ravages upon the
true skin and system at large as soon as their liberation
is effected through the instrumentality of the maceration
of the epidermal layers by the fluid of the vesicles.
Furthermore, he declared it as his opinion that the
aforesaid pathological germs might be forestalled in
their pernicious action by means of germicidal fluids
applied to the general surface of the body, whereby a
complete maceration of the epidermis could he
effected.
To accomplish this object, he proposed baths of
long duration in antiseptic fluids. In a word, he sug-
gested the cautious and gradual evolution of a system
of disinfection to be applied to the entire epidermal
covering; and when the epidermis was disinfected it
was to be kept aseptic by means of suitable antiseptic
dressings applied to the cutaneous surface until the
complete desiccation of the vesicles.
By means of such a course he proposed to arrest
the small- pox in its vesicular stage, and completely
prevent suppuration of the skin and suppurative fever
with its various dangerous complications.
This paper was never published, and the first refer-
ence I saw to it was in Dr. Bryan's article in the
Medtcal Rfxord of July iSth. The doctor goes on
September 5, 1S96]
MEDICAL RECORD.
355
to report a case of discrete small-pox treated by him
in the small-pox hospital at Detroit, in which the treat-
ment was entirely local and was successful in arrest-
ing the small-pox in its vesicular stage.
I shall report two cases of small-pox treated by me
last spring, in which the treatment, though differing
slightly in some particulars from that adopted by Dr.
liryan, was yet the same in essentials, in that it was
directed to the local treatment of the vesicles and had
for its object the prevention of the transformation of
the vesicles into pustules.
The first case was one of varioloid. The patient
liad been recently vaccinated, and though the temper-
ature reached 104° F., not over one hundred papules
appeared over the entire surface of the body.
As soon as the papules developed into vesicles I
scrubbed the surface first with soap and water, fol-
lowed by peroxide of hydrogen ; I then opened the
vesicles, allowing the contained fluid to escape, and
taking a soft-wood splinter sharpened to a point,
I first dipped it into liquid carbolic acid and then in-
troduced it into the cavity of the vesicle. The surface
of the skin was again washed with peroxide of hydro-
gen and oiled, to relieve the smarting caused by the ap-
plication of the carbolic acid; after this the surface
was covered, wherever practicable, with cloths wrung
out in carbolized water.
The patient's temperature was taken frequently, and
was never found to be above normal after the stage of
invasion.
In this case only two pustules were developed — one
in the hair before the treatment was begun, and one on
the tip of the nose, which owing to its location was not
properly protected.
My second case was one of discrete small-pox.
which came under my treatment during the vesicular
stage. In this case too much surface was involved for
me to use the carbolic acid as freely as I did in the
first case, so I treated it on a plan more in accordance
with that adopted by Dr. Bryan.
-After thoroughly washing with soap and water and
peroxide of hydrogen, I opened the vesicles, and then
washed the surface with a ten-per-cent. solution of
carbolic acid. I should say, however, that there were
about ten or twelve pustules which I opened and after
removing the pus treated with carbolic acid, as I did
the vesicles in my first case. When I began my treat-
ment the temperature was 102" F., and six hours later
it was normal and continued so until the patient was
discharged. The disease immediately went to the
stage of desiccation.
In neither of these cases was there any pitting, ex-
cept from the pustule on the tip of the nose in the first
case.
My first case was such a mild one that there is a
question whether or not there would have been any
secondary fever had the patient received no treatment
at all; but in the second case there is no doubt in mv
mind that the secondary fe\'er was prevented by the
treatment.
I have reported these two cases, as I believe they are
further proof of the truth of Dr. Bryan's theory quoted
in the paper mentioned above. I am sorry it was
impossible for me to use this treatment in a case of
more virulent type of small-pox, but in view of its
success in my second case and in the case treated by
Dr. Bryan, both of wliich were discrete, I should not
hesitate to use it where more surface was involved;
modifying the strength of the antiseptic fluid used
according to the extent of surface involved.
.As to the kind of antiseptic used, that would, of
course, be merely a matter of preference on the part of
the physician, as we would not hope for specific action
of mercuric bichloride, carbolic acid, or other anti-
septic beyond their germicidal action.
PNEUMONLA COMPLICATED WITH FATTY
TUMOR IN THE RIGHT AURICLE.
By JOS. L. SPKUILl,, M.D.,
BALTIMORE, MD ,
ASSISTANT RESIDENT PHYSICIAN, ST. AGNES HOSPITAL.
C. G , German, aged twenty-three, came to St.
Agnes Hospital Dispensary (i5altimore), suffering
from well-marked acute lobar pneumonia in its first
stage, having had the initial chill about twenty-four
hours previously. He was at once taken into the
hospital.
The patient was a strong, robust man, giving a
history of good health all his life, but said he was an
habitual drinker. The temperature was loi ' F., pulse
120, general condition good. The patient seemed to
do well for three days, the case not being one of
unusual severity, with the exception of high fever,
which at one time reached 105° F., falling about three
■degrees, however, when cool sponging was resorted to.
His pulse, respiration, and general condition remained
good, and he took quite an amount of liquid food.
At the beginning of the second stage of the disease,
the patient was put on stimulating treatment, his case
seeming favorable until the fourth night after admis-
sion. At 9 P.M. he expressed himself as feeling very
well and soon dropped into a quiet sleep. Three hours
later his condition was still good, temperature being
102.5'' F. and pulse fair. At 2 .jv.m. he began to show
marked signs of heart failure. The extremities be-
came cold, the face and lips pale, the pulse rapid and
feeble, failing to respond to repeated hypodermic in-
jections of brandy, strychnine, and digitalis. Patient
died one hour later.
Post-mortem examination showed the lung exten-
sively involved, and upon opening the heart a peculiar
fatty growth about the size of a large walnut was
found in the right auricle, firmly attached to its
walls and requiring dissection to remove it. Micro~
scopical examination showed the growth to be of fatty
structure.
SNAKE BILE FOR SNAKE BITE.
By L. S. .\LEXANDER, M.D.,
ST. AUGUSTINE, FLA.
Some months ago I saw an article in one of the New
York journals concerning the treatment of snake bite
with the bile and flesh of the reptile. Having seen
the failure of other remedies, I determined to make
use of this suggestion at the earliest opportunity.
Consequently I directed a taxidermist of this city
who had on hand a number of rattlesnakes to prepare
a gall bladder for use in an emergency. On or
about the 12th of June the same taxidermist, an aged
man, was struck on the inside of the left knee by
one of his large rattlers. Immediately disposing of
the snake, he proceded to examine the wound, which
was bleeding freely. Suction by the mouth, a milk-
ing or strapping process with the fingers, with a hunt
for and application of some household ammonia, must
have taken several minutes before the bottle of bile
was thought of. This was applied freely to the
wound, and an incision was al.so made into which
the bile was poured. It was probably half an hour
before he reached my office, apparently all right but a
little anxious. I continued the application of the bile
and covered the wound with a piece of the wall of the
gall bladder. No other treatment was pursued beyond
a few doses of carbonate of ammonium. There was not
one particle of swelling, nor did the man suffer from
inconvenience of anv kind.
556
MEDICAL RECORD.
[September 3, 1896
therapeutic glints.
Rheumatic or Muscular Pains. —
1| Llilorofi)rmis pur.L- I v.
Tr. opii,
Acidi salicylici aa S iv.
Spts. vini rect ; iv.
Olei dulcis q.s. ad | xij.
This should be rubbed into the parts thoroughly or
applied by means of flannel cloths. — M.'^nley.
Follicular Tonsillitis. —
I{ Olei creosoti gtt. viij.
Tinct. myrrha-,
Glycerini aa 3 ij.
Aq ad 5 viij.
S. Use as a gargle every two hours.
— Dr. Levy, Medical and Surgical Reporter.
Pain of Gastric Ulceration. —
R Exalgin gr. xlv.
Extract of belladonna,
Codeine phosphate aa gr. v.
.Sugar of milk gr. Ixxv.
Mix and divide into ten cachets. Dose, one to be taken
with the onset of pain.
— Dr. Bo.\s, Semaine MHicale.
Cough Mixture. — This prescription, given in the
pharmacopctia of the Edinburgh Royal Infirmary, con-
tains no opiate :
I^ .\cid. hydrocyan. dil 3 ss.
.\cid. nitric, dil 3 iij.
Glycerini 3 i.
Inf. quassi;e ad | vi.
Ft. mist. S. .\ tablespoonful in a wineglass of water three
times a day.
It is both a sedative and tonic in cases of phthisis.
^Dr. Warburton Begeie.
Whooping-Cough —
V, Infusion of belladonna leaves (gr. viij.) in
distilled water 3 v.
.\ntipyrin gr. xv.
Syrup of gooseberry %\.
M. .S. A teaspoonful every two hours for a child of five
years.
As a rule there may be given, for each year of the
child's age, gr. viij. of belladonna leaves in infusion
and the double dose of antipyrin. — Dr. Eschler, La
Medecine Moderne.
Gonorrhoea. —
1^ I'erchloride of mercury I
.■\ntipyrin r . . . . 100
Distilled water 10,000
The injection should be used four times a day and
retained as long as possible. The addition of anti-
pyrin prevents smarting. — Dr. V.mikr.
To Prevent lodism It is claimed that the follow-
ing may be given indefinitely without causing iodism :
K I'otr.ssii iodidi 3 iss.
Ferri et ammonii citratis 3 ij
■finer, nucis vomicoe 3 ij.
.■\qu:e § iss.
Tinct. cinchon.ie comp | ij.
S. Teaspoonful three times daily, in water, after meals.
— Sanderson, Medical Weekly.
Pulmonary Tuberculosis Dr. Otis {Boston Medi-
cal and Surgical Journal, May 29th, p. 527) says: " In
every well-arranged plan of treatment of pulmonary
tuberculosis, when any exercise at all is allowable,
pulmonary gymnastics, carefully arranged and adapted
to the strength and condition of the individual, should,
I believe, be embraced. In the famous sanitariums
abroad, where such excellent results are obtained, they
play an important part in the treatment. We may in
the future obtain a serum product which will accom-
plish all that was hoped for from tuberculin; but one
must not forget that large numbers of consumptives
are now being cured and restored to usefulness by
means of the persistent application of nature's rem-
edies, sunlight, abundant alimentation, continuous
outdoor life, hydrotherapy, and good breathing. The
vis medicatri.\ natura; may not always give brilliant
and rapid results, but when intelligently employed it
is a method which rarely disappoints either the con-
fiding physician or trusting patient."
Malarial Haematuria — Keep the bowels open with
calomel followed by salts, use hot mustard baths, and
administer the following combinations in alternation
every three hours:
V, Spirit, turpent 3 ij-
.'\cidi carbol gr. x.
Pot. chlorat 3 'ij .
Spirit lav. comp 3 ij.
Acacia gum 3 iij .
.•\qua. menth. pip q.s. ad 3 iv.
— Dr. J. E. LoNi;, Louisville Medical Monthly.
Diarrhoea. — A serviceable prescription in cases of
watery diarrhcea due to exposure, or exhaustion, or an
irritant food, etc., is as follows:
R .\cid. sulph. aromat 3 ss.
Olei cajuputi gtt. xl.
Fl. ext. hematoxylin 3 ij.
Spt. chloroformi 3 i.
Syr. zingiberis q.s. ad J iij.
M. .S. Tea-spoonful in water every two or three hours.
— College and Clinical Record.
Adherent Pericardium. — Dr. Broadbent (Boston
Aledical and Surgical Journal) publishes the notes ot
four cases, in each of which there was visible retrac-
tion, synchronous with the cardiac systole, of the left
back in the region of the eleventh and twelfth ribs,
and in three of which there was also systolic retraction
of less degree in the same region of the right back.
In all the cases there was a definite history of pericar-
ditis, and in three of them there were other conditions
strongly suggesting an adherent pericardium. The
only means of causing this retraction on both sides
seems to be the diaphragm, which, if pulled upon,
would have more effect upon the floating eleventh an<l
twelfth ribs than upon the more fixed ones. In cases
of large heart with adherent pericardium there is a
considerable area of the ventricle closely adherent to
the central tendon of the diaphragm, and the powerful
contraction of an hypertrophied heart must give a de-
cided tug to this structure. That it should aflect the
ribs more often on the left side ought to be expected,
since the adhesions are mainly to the left of the me-
dian line, while the liver, which is often large in
these cases, may restrain the movement on the right.
Apart from the adherent pericardium one was a case
of aortic disease of rheumatic origin, the others of
mitral disease.
Cold Bathing during Menstruation.— Cold bath-
ing during menstruation is a beneficial measure, pro-
vided women become accustomed to it by bathing
every day for eight days before. Henzel holds that
cold salt-water baths facilitate the menstrual flow, in-
crease the duration of genital life, and increase fe-
cimdity. — Dr. I)epa.SSE, L.ancet- Clinic.
Japanese Physicians do not look with favor on the
bicycle, and regard its use as injurious to both men
and women.
September 5, 1896]
MEDICAL RECORD.
357
Qlorrcsponclcncc.
OUR LONDON LETTER.
(From our Special Correspondent.)
ELECTIONS TO THE MEDICAL COUNCIL — THE REPORT OF
THE ROYAL VACCINATION COMMISSION — THE REPORT
OF THE ADULTERATION COM.MITTEE — WATER FAMINE
— GLOUCESTER GRANT BEV's DE.\TH.
Lo.NooN, August 21, 1896.
The plot thickens as to the elections to the medical
council. For the three vacancies there are more than
double that number of candidates, all of whom may be
said to have some points in their favor. Dr. Glover
seems to have completely amalgamated with Drs.
Woodcock and Drage, who are supported by the Brit-
ish Medical Association. Thus we have once more
The Lancet and the British Medical Journal rowing in
the same boat. Perhaps this partly accounts for the
compliments these journals have recently exchanged,
which not so long ago would have been deemed im-
possible. At the last meeting of the Association of
Fellows of the Royal College of Surgeons it* was re-
solved that Mr. Walter Rivington be in\ited to be-
come a candidate and that the society of members
should be asked to join in this invitation. Mr. Riv-
ington is one of the liberal councillors of the college
and has a long record as an able medical reformer.
He is also on the senate of the London University, of
which he is a graduate in arts as well as in medicine.
He has taken an active part in the movement to re-
dress the wrongs of Dr. .\nderson, of whose case I
have written more than once. This and the question
of representing members in the council of the college
are the chief reasons for the Association of Fellows
proposing him, but his other qualifications are of the
highest. Those who feel unwilling for the British
Medical .Association to permanently "nobble" the di-
rect representatives and so to resent Dr. Glover's con-
duct in facilitating such a result, will be able to
plump for Mr. Rivington and thus express their senti-
ments while voting for a sound and sincere reformer.
Distant as the election still is, the signs of a com-
ing contest increase. Candidates have rivalled each
other in condemning the council for its shortcomings,
and of course implying that their election would tend
to inaugurate a new era. At last one of the council-
lors has entered a defence. Mr. Brudenel Carter, who
represents the .\pothecaries' Society and whose jour-
nalistic position gives him great influence and unusual
scope for his literary ability, has written a letter in
which he examines somewhat cynicallv the claims of
the candidates, and puts questions as to how they
could improve matters as naively as if he really
thought the council quite a model body. But he is
not content with this method of defence, and, perhaps
with a view to draw his opponents, casts scorn on agi-
tators and dangerous persons, sneers at the literary
quality of some addresses, and pronounces others
"balderdash.'" Candidates and their champions have
no hesitation in picking up the gauntlet thus thrown
down. Mr. Victor Horsley is to the front, and e.x-
poses without mercy some errors of Mr. Carter's, and
assures him he "cannot be credited with a ten-years'
useful service, on which he is inclined to plume him-
self." Mr. Horsley had a paper at Carlisle, in which
he impugned the regulations of the council and the
acts of its president. This he intimates will shortly
be published in full, and he challenges Dr. Carter to
refute any of his statements. -So further developments
may be anticipated.
Dr. R. Rentoul, who is one of the candidates, has
found out that the registered practitioners in the Isle
of Man are not considered entitled to vote at the
election. He wants to know if the Isle of Wight is
also disfranchised. The act provides for the election
of three representatives by practitioners resident in
England, one by those in Ireland, and one by those in
Scotland. It is strange if the adjacent islands of the
three kingdoms are not to be included. Perhaps the
Isle of Man, having a certain local government of its
own, is considered by the council as a separate State.
The matter will probably be submitted to the privy
council, and we shall then learn whether islands are
not in legal phraseology embraced in the name of the
country to which they belong. Assuredly the island-
ers are required to obey the laws of the kingdom.
At last the report of the commission on vaccination
has appeared. Whether it is worth the seven years'
incubation is a question with many. Perhaps the an-
swer must be left until we see what legislation may be
carried. The recommendations are in effect to make
vaccination more attractive to the people and to ren-
der compulsion less stringent. The report recom-
mends that the age during which the operation is obliga-
tory should be extended from three to six months,
which is the Scotch limit. The commissioners do not
advise the substitution of other forms of punishment
for pecuniary penalty. They do not consider it feasi-
ble to hand over the duty of enforcing the law to
county councils, nor to vest in the local-government
board the duty of proceeding against defaulters.
They consider it would be advisable to devise a
scheme permitting parents who are honestly opposed
to vaccination to escape, but not those who are merely
indifferent or negligent. They suggest that the parent
might be required to attend before the local authority
and satisfy them of his honest objection, or a statutory
declaration to that effect might be demanded. Any
plan of the kind, it is admitted, should be such as
would not be adopted merely to save trouble connected
with the operation. It seems to me that such propo-
sals to give the parent a little trouble can operate no
more effectually than the fine at present imposed. If
adopted only after the first fine had been paid, the plan
would be an e.xcuse for not inflicting more than one
fine in one case. The commissioners think it would
promote the practice of vaccination if the fee payable
to the public vaccinator were to be paid to every qual-
ified practitioner who performed the operation, and
they advise a system of inspection to secure that the
prescribed rules should be observed in such cases.
They think persons committed to prison for non-com-
pliance with the vaccination laws should not be
treated as criminals.
Sir Guyer Hunter and Mr. Hutchinson, while agree-
ing in the main with their fellow-commissioners, ap-
pend the following memorandum to the report: "We
are not able to recommend such a large relaxation of
the compulsory law as is implied in the paragraphs
dealing w ith compulsion. We think that no further
change should be made than to allow a magistrate, be-
fore whom anyone refusing vaccination has been sum-
moned, to abstain from inflicting fine if satisfied on
the evidence given on oath that the objection was one
of conscience. We also think that notwithstanding
the difficulties set forth -in the paragraph dealing with
revaccination, that operation at the age of twelve
should be made compulsory."
From the foregoing it will be seen that the commis-
sioners admit the protection afforded by vaccination,
and the agitators will obtain little comfort from the
report. The commissioners state that it not only di-
minishes the liability to attacks of small-pox, but that
it renders the disease less fatal and less severe. They
also state that the protection diminishes with lime, and
therefore revaccination is desirable. Thev admit
some dangers, although in relation to the extent of the
358
MEDICAL RECORD.
[September 5, 1896
work they pronounce them insignificant. As a secur-
ity against dangers they would give parents the right
to demand calf lymph.
From these brief notes culled from its pages it will
be seen that this heavy blue book, which has taken
seven years to produce, confirms most of the opinions
of the profession, putting them only in as mild a way
as possible. Lukewarm advocates will be satisfied
and agitators discouraged, while the few honest fad-
dists are to be allowed to hold their foolish prejudice
and keep in a protected community a family which,
being unprotected, is by so much a public danger.
The report of the committee on the adulteration
acts is rather encouraging, but will not quite satisfy
sanitarians. Still, if all the recommendations could
at once become law, adulteration of food and physic
would be more risky and therefore less profitable.
The report acknowledges that the undue leniency of
magistrates has made it worth while for the dishonest
to go on adulterating and paying the fines when caught.
Heavier penalties are recommended and the offenders
are to be made to publish their convictions in the lo-
cal newspapers. It is also recommended to define the
word food so as to include flavoring or other ingredi-
ents. This would prevent adulterated baking-powder
longer escaping on the plea that it is not a food.
On the other hand, it is not proposed to enforce a
statement on labels of mixtures as to the proportion of
ingredients, so that a " mi.xture of chicory and coffee"
may contain ninety or more per cent, of the "cheap
and nasty." The most important recommendation of
the committee is that a court of reference should be
formed which shall settle the limits and standards
of the quality and purity of articles of food. It is
further advised that the local authorities should take
for e.xamination a larger number of samples yearly,
and that these samples should not be taken by officers
well known to the tradesmen.
The water famine in the east of London is still a
public danger. The breakdown of the East London
Water Company will proliably greatly increase the de-
mand to terminate the monopolies of the companies.
The Gloucester epidemic of small-pox is considered
at an end, after a record of more than two thousand
cases.
The death of Dr. Grant, better known as Grant Bey,
who did distinguished service in Egypt, is regretted by
all who take an interest in that country and especially
in its sanitary progress. He was a scholar of wide
learning and had received many distinctions.
DISCRIMINATING TREATMENT OF APPEN-
DICITIS.
'I'o THE Editor of the Medical RtcoRo.
Sir: The appendicitis question will not down so
long as the extremist, in a presumably laudable effort
to show the general practitioner the error of his ways
and to save him from the wrath to come, continues to
insist that every case of appendicitis must be operated
upon immediately, and the general practitioner ob-
durately refuses to accept this dogma. When the
specialist impugns his statistics, denies his diagnostic
ability, and in his delightfully modest way suggests
other sources of pain in the right side of the abdomen,
the general practitioner bears it with becoming meek-
ness, knowing that in the eternal fitness of things the
account will soon be balanced, in that he will not be
able to advise the removal of the appendix if inca-
pable of recognizing the disease which demands its
ablation.
The extremist makes the assertion, regardless of its
absurdity, that but from nine to fifteen per cent, of ap-
pendicitis cases recover under medical treatment.
Since he operates on all of his patients, his information
apparently does not come from personal experience
and may be taken with the customary modicum of
sodium chloride. In this connection Dr. Woods' article
in the Medical Record of August 22, 1896, furnishes
valuable information and, written from the standpoint
of the insurance company, is undoubtedly free from
bias.
The operative surgeon informs us that after medical
treatment relapse will occur in the vast majority of
cases. We maintain that, under the opium treatment
favoring localized plastic peritonitis, relapses are in-
frequent. Dr. Morris says that some of my twenty-
four cases " are not very well since their recovery,"
which leads me to wonder if Dr. Morris has informa-
tion, other than purely theoretical, in regard to my
cases which I myself do not possess, or whether he
states this on the principle that if the facts do not ac-
cord w'ith the theory so much the worse for the facts.
The apostle of operative procedure claims that med-
ical treatment does not cure in these cases and holds
up before our rapt vision the prospect of a safe, sure,
and permanent cure. But in a liberal proportion of
cases the appendix is not removed at the time of the
operatioiT. Can he then consistently claim that his
patient is cured, ay, sugar-cured, plus tlie liability
to a troublesome ventral hernia?
The operative expert comnuinicates to us in due and
ancient form the assertion that cases in country prac-
tice in which the person cannot pay a surgeon or
cannot be removed to the hospital need but seldom
occur. We who are familiar with the sordid poverty
of many of these patients, the niggardly policy of our
poor officials, the wretched roads, the snow blockades,
the prejudices of such people who are apt to consider
the hospital a sort of terrestrial gehenna, and the abso-
lute refusal of many of these patients to be cut open —
we would like the expert to explain how the necessary
funds are to be obtained, the objections set at naught,
and the desired end accomplished. If an operative
surgeon is summoned he will expect to be recom-
pensed. Jjut the ■' fee does not enter into the contro-
versy and is unworthy of being mentioned by an hon-
orable practitioner." The said honorable practitioner
should quietly dip his hand down into his pocket to
pay it and perhaps forego a post-graduate course in
operative surgery in New York or other uttermost
parts of the earth in consequence. On the other hand
the local surgeon, if he works with an eye to his
patients' interests rather than his own, having only a
moderate experience in abdominal surgery, will
operate on appendicitis cases only when stern neces-
sity compels.
The operative propagandist has an alluring way of
contrasting the brilliant records of our most expert
operators in well-equipped hospitals with some very
doubtful statistics of results under medical treatment.
Of what value is this in the question at issue? That
surgical treatment for ity and suburban cases is emi-
nently successful was established long before this con-
troversy arose. A contrast of the average results from
surgical and from medical treatment would be to the
point, and when the results of operations performed by
the average surgeon throughout the country are sup-
plemented by the results of cases in which patients
have been ripped open by the tyro with more zeal for
surgical fame than regard for human life the mortal-
ity will be found very high.
The real questions at issue are:
I St. What is the best treatment for outlying cases?
2d. What proportion would recover if treated medi-
cally?
3d. What proportion would relapse?
4th. What proportion of these cases if operated on
under existing conditions would recover?
September 5, 1896]
MEDICAL RECORD.
359
5th. \\'h;it proportion would relapse?
6th. How shall we select the operative from the
non-operative cases?
In deciding these points neither dogmatic assertions
nor brilliancy of satire will count. What we need are
facts — facts, which at best are stubborn things. My
own contribution to this subject is that I have
furnished twenty-four facts in the twenty-four consec-
utive cases which recovered under the opium treat-
ment— facts which seem to have aroused the ire of
some of my brethren.
In order to decide these points many statistics from
private practice must be furnished. I still hold to mj
conviction that had I, since the beginning of my prac-
tice, adopted in all of my cases either an exclusively
medical or an exclusively surgical treatment, I should
have lost some of them, while as it is I have yet to
record a death from appendicitis. I do not pretend to
lay down any rule as to when operation is or is not
indicated. These questions are largely questions of
judgment, of most excellent judgment in the individual
case, and I would suggest to some of our specialists
that the exercise of this faculty should not be held in
suspension or abeyance, should not be limited in its
application by any inelastic and arbitrary rule, to
merely a choice of operators or the most favorable
time for slitting the abdominal parietes."
.A. writer in the Medical Record of June 13th says
that euthanasia will be 2^ fait aaompli "as soon as
the opium treatment shall be regularly adopted" in
gangrenous, perforative, or acutely suppurative ap-
pendicitis. ■■ Gently and with Christian resignation,"
to use his own words, I would " point out to him'' that
having neither a '" very pretty talent for mathematics"
nor for " the gentle art of embroidery," as he so freely
acknowledges, he should not heedlessly attempt to
show that " two and two make six," by implying that
I have ever advocated that the opium treatment should
be "regularly adopted" in all cases, a position which
I should attack were it necessary as earnestly as I do
the other extreme. It is the extremist who exposes
himself to attack, it is the extremist whom I attack,
and it is the extremist who, aside from his proneness
to err, e.xhibits at least one other human trait — he
squeals when he is hurt.
What manner of man is the surgical enthusiast ?
Will he never be content? We do not deny the
necessity for operative procedures in many cases.
When he shows us a brilliant record of successful
operations we applaud his success, we acknowledge
his merit, we admire his skill, we marvel at his beau-
tiful, not to say pulchritudinous dexterity, we even
buy his books — and read them: but when this same
enthusiast, unmindful of the history of the clitoridec-
tomy fad, the oophorectomy fad, the multitudinous
other fads in fashion for lo, these many years, un-
blushingly demands that the general practitioner
yield up every case of appendicitis to the goddess of
the knife, we, the general practitioners, not entirely
oblivious to nature's reparative power, backed up bv a
host of eminent surgeons, with a vivid memory of fads
which have come and of fads which have gone, rise up
and answer emphatically, NO.
W. X. M.\cArtney.
P'oRT Covi.sGTO.N, N. v., .\ugusc IS, l8^6.
A Sign of Death. — Dr. G. H. Brandt, writing to
the Britisli Medical Journal with reference to the ap-
plication of heat in cases of suspected death, sends
the following mode of application: Light a wax vesta,
apply the rtame close to the skin until a blister is
formed; if it contains serum the person is still living;
if, on the contrary, it contains only gas, it will burst
with a small explosion and life is extinct.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending August 29, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
.Small-pox
Deaths.
100
6
2
2
5
i8
o
Isn't it a Wart ? — Dr. X begins a communi-
cation to a contemporary : " I have on hand an en-
larged prostate."
"Keep thy heart above all that thou guardest, for
out of it are the issues of life,'" is an injunction nearly
thirty centuries old, yet it is still a maxim as pregnant
with wisdom for us in the treatment of the sick man
as many a more modern dictum. — Emerson.
A Human Crazy Quilt is what a girl in San Rafael,
Cal., calls herself. She has been covered with skin
grafts taken from numerous friends, to cover the re-
sults of a severe burning accident. It is said that she
makes careful note of the location of each friend's con-
tribution for future reference.
Slobbering. — Dr. Sanchez de Slivera {Lo Spcri-
mentale) concludes that healthy infants never dribble.
Infants that dribble only in the daytime, though ap-
parently in good health, have their digestive functions
impaired. Infants that dribble at night are suffering
from obstruction of nasal respiration. These phe-
nomena are altogether unconnected with dentition.
High-Altitude Treatment.— Dr. Mays {New York
Aledical Journal, June 27, 1896) writes as follows:
The ever-recurring question is: Should patients with a
disposition to blood spitting be sent to high altitudes?
From a theoretical standpoint I think many objections
may be raised against such a change, but practically
I believe that high altitudes have no detrimental effect
on this condition ; on the contrary, it seems that nearly
all such cases derive benefit from this kind of treat-
ment.
Prevention of Conception. — I dare any political
economist to show me one expedient whereby concep-
tion may be avoided. I challenge him to name a
single preventive which will not do damage either to
good health or good morals. Even natural sterility
is a curse. Show me a home without children, and
ten to one you show me an abode dreary in its loneli-
ness, disturbed by jealousy and estrangement, distaste-
ful from wayward caprice or from unlovable eccen-
tricity.— Dr. Willi.am Goodell.
Gastric Ulcer. — Dr. Williamson {Fhysician and
Surgeon, ]\x\\\ \?>()i,) recommends: i. Absolute rest in
bed. 2. Laxative saline mineral waters and rectal
alimentation. Later on liquid nourishment and after
three weeks a more generous diet: tonics, preferably
the hypophosphites at first, owing to the liver's inactiv-
ity usually, and iron preparations subsequently, along
with arsenic, which is one of the best. For gastralgia
— anodynes, especially morphine. For hemorrhage —
absolute rest, ice, morphine, and ergotin hypodermi-
cally.
36o
MEDICAL RECORD.
[September 5, 1896
A New Complaint. — '' Is there any particular ner-
vous complaint connected vvitli your profession ?b
asked the cheerful idiot of the rifleman. " There is
the tennis arm, the bicycle face, and the baseball arm,
and I thought there might be something of the sort
among you gunners."
" No," said the rifleman; " nothing of the sort."
'' It is very queer,'' said the cheerful idiot thought-
fully. '■ I didn't suppose you could hit the target
without taking sharpshooting pains." — Iiulianapolis
Journal.
Menstruation in Eskimos. — Dr. Cook, who was
with the Peary e-xpedition, says the Eskimo girls do not
begin menstruating until they are eighteen or twenty
years of age.
Odor a Symptom of Disease. — Dr. McCassy {Lan-
cet-Clinic) writes as follows: Diseases have their char-
acteristic odors. Insane asylums have a familiar odor.
Favus has a mousey odor; rheumatism has a copious,
sour-smelling, acid sweat. A person suffering with
pysmia has a sweet, nauseating breath. The rank,
unbearable odor of pus from the middle ear tells the
tale of the decay of osseous tissue. In scurvy the
odor is putrid, in chronic peritonitis musky, in syph-
ilis sweet, in scrofula like stale beer, in intermittent
fever like fresh-baked brown bread, in fevers ammo-
niacal, in hysteria like violets or pineapple. Measles,
diphtheria, typhoid fever, epilepsy, phthisis, etc., have
characteristic odors.
An Old Medical Work. — Dr. Dodson [North Caro-
lina Medical Journal, July 20, 1896) writes as follows:
In ancient Egypt the god Thoth was the guide of
physicians and left his MSS. in the oldest known book
in the world, the Prissi Papyrus. This book, written
in the sixteenth century before Christ, contains on
one hundred and ten pages the hermetic book upon
the medicines of the ancient Egyptians, known also to
the Alexandrine Greeks. These pages are supposed
to be the revelations from the god Thoth, and with the
drugs, prescriptions, weights, and measures are also
the pious axioms to be repeated by the physician.
He uses these in compounding his drugs. These va-
rious incantations somoth his way to the minds of his
patients.
Labor. — Dr. Hirst says: " In the earlier stages of
excess of expulsive power of the uterus, if the pains be
so frequent as to threaten exhaustion, nerve action and
muscular power may be lessened by the administration
of ciiloral in fifteen-grain doses every fifteen minutes
until three doses have been given. Opium and bro-
mide may also be used. If the patient is irritable,
establish mental control. If there is uterine inertia,
the majority of cases must be treated in the first stage by
inunction, in the second by the forceps. If the inertia
is due to weakness or fatigue, quinine, fifteen grains,
or stimulants may be given. If there is apathy of the
uterine muscle, lukewarm injections of water should
be made against the anterior wall of the cer\ix. Ergot
should not be given, as it causes tetanic spasm and
contracts the cervix." — Medical World, June, 1896.
Consanguineous Marriages. — The results of these
marriages have been differently regarded by various
authors. Esquirol attributed to them a predisposition
to insanity among the descendants. Meniere affirms
that in the majority of cases deaf-mutes owe their in-
firmity to the ties of relationship between their pa-
rents. Lucas thinks that these marriages are a cause
of degeneration in the human race; that they produce
mental dulness, brutality, insanity, impotence, etc.
Liebreich states that consanguinity is frequently the
cause of pigmentary retinitis among the descendants.
Raynaud ranks consanguinity among the conditions
which may produce albinism. Luys .seemed to have
proved also, says the writer, the injurious influence of
consanguineous marriages. On the other hand, says
the writer, others have boldly declared themselves in
favor of these marriages, and state that they are not
at all injurious, that generally they give good results.
It is not astonishing then, he says, that in the face of
such extreme opinions other authors, such as Levy,
Bouchardat, Voisin, Darwin, Lacassagne, Ballet, and
others, should view the question from both sides and
affirm that these marriages are productive of both
good and evil results, according to whether the con-
tracting parties are exempt from or affected by con-
stitutional diseases. With such a diversity of opin-
ions, continues the writer, it is difficult for physicians
to decide when they are consulted by patients in re-
gard to the subject. M. Perrin recently made a study
of the question under consideration, and gives his con-
clusions as follows: First of all, among the numerous
affections attributed to marriages of consanguinity,
idiocy, insanity, and epilepsy are due generally to he-
redity, but in a few cases consanguinity of the parents
may certainly be the cause. As to convulsions in the
young, the cases are so numerous that it is impossible
to attribute this aflection to the influence of consan-
guinity. It may have a share in the production of
deaf-mutes, but it is not an invariable factor. With
regard to affections of the sight, the influence exer-
cised by consanguinity has been ascertained, and in
albinism it has been distinctly proved. Concerning
sterility, M. Perrin thinks this cannot be attributed to
consanguinity alone. He has further shown that cer-
tain congenital deformities have been so frequently
observed in children whose parents were perfectlj'
healthy that, in these cases, we are forced to admit
the theory of consanguinity alone. On the whole,
says the writer, we may conclude that if under certain
circumstances consanguinity and heredity are two etio-
logical factors which combine in the same family to
bring about the same morbid results, it is none the
less true that in some cases consanguineous marriages
among healtliy persons may exercise an unfavorable
influence on the children. M. Perrin, says the writer,
advises physicians not to dissuade their patients from
marriage if there is no diathesis, no hereditary dis-
ease, and if they are in good health and ha\e strong
constitutions; on the other hand, it is not well to en-
courage them, he says, because even in the best condi-
tions the children of such marriages have presented
irremediable defects. But if the physician discovers
the least trace of physical or mental affection, he
should exert all his influence to prevent such mar-
riages, for they could only be productive of deplorable
results. — Neiii York Aledical Journal.
The Emergency Ration. — .\ board of officers has
recommended to the secretarv- of war the following as
a suitable emergency ration for the United States
army: Hard bread, 16 ounces; bacon, 10 ounces; pea
meal, 4 ounces; coffee, roasted and ground, with 4
grains saccharin, 2 ounces, or a half-ounce of tea w ilh
4 grains saccharin; salt, .64 ounces; pepper, .04
ounces; tobacco, half-ounce: making a total weight,
with coffee, of 33.18 ounces; or, without tea, 31.68
ounces.
A Living Serre-Fine. — Greek barber surgeons in
the Lexant use large ants to keep together the edges
of cuts. The ant, held with a forceps, opens its man-
dibles wide, and as soon as it seizes the edges of the
wound has its head severed from the body, but retains
its grip. People have been seen with wounds healing
held together by seven or eight ants' heads. The kind
used is a species of big-headed camponotus.
Medical Record
A Weekly yoiimal of Medicine and Surgery
Vol. 50, No. II.
Whole No. 1349.
New York, September 12, 1896.
$5.00 Per Annum.
Single Copies, loc.
THE TREATMENT OF CONGENITAL DISLO-
CATION OF THE HIP, WITH ESPECIAL
REFERENCE TO THE HOFFA-LORENZ
OPERATION, WITH AN ILLUSTRATIVE
CASE.'
By royal whitman, M.D., .M.R.C.S.,
NEW YORK CITY,
CLINICAL INSTRLXTOR IN ORTHOPEDIC SURGERY IN THE COLLEGE OF
KHVSICIANS AND SCRGEONS AND CHIEF OF THE ORTHOPAEDIC DIVISION OF
THE VANDERniLT CLINIC ; ASSISTANT SURGEON TO THE HOSPITAL FOR
RUPTURED AND CRIPPLED ; ADJUNCT PROFESSOR OF ORTHOPAEDIC SURGERY
IN 7HE NEW YORK POLYCLINIC.
Congenital dislocation of the hip, although not a
common disability, is certainly not a rare one, if one
may judge from the report of the Hospital for Rup-
tured and Crippled, in which are recorded fifty-one
new cases for the year 1895, although undoubtedly the
histories of many of these patients may also be found
in the records of other institutions, as may always be
assumed of cases of a peculiar or incurable nature.
Although a satisfactory explanation of the exact
causes of the displacement is still wanting, the knowl-
edge of the anatomical conditions, until recently in
great degree speculative, is now firmly supported by
hundreds of observations recorded by Hoffa, Lorenz,
and others. An indication at least of an acetabulum
is practically always to be found in its proper position,
and it is often of nearly normal size and shape. The
upper extremity of the dislocated femur is somewhat
smaller than normal, the head of the bone is usually
flattened from side to side or otherwise distorted; the
neck is short, almost invariably depressed to a right-
angled relation with the shaft, and may be bent some-
what forward; the ligamentum teres is usually absent
after the age of five years; the capsule is hypertro-
phied and often drawn upward into a somewhat purse-
like form.
These changes, which at an early age are in great
degree the result of altered function, are progressive
in character under the influences of weight, pressure,
and attrition on the parts immediately involved, and
are accompanied by corresponding effects on the use
and ability of the limb and on the posture of the body.
It is evident, then, that whatever is to be done for
the relief or cure of the disability must be undertaken
at as early a time as is practicable. The only ques-
tions, can be whether or not the disability is suffi-
ciently serious to warrant the attempt to remove it,
and, if so, what means are to be employed toward this
end. These questions are by no means settled, if one
may judge from the advice that patients accumulate in
their journeys from physician to physician and from
clinic to clinic.
.\s the disability is not attended by notable pain,
the mothers may be assured that it will be outgrown
and that it is of no consequence. Or, if the true na-
ture of the deformity is recognized, it is instinctively
compared in the mind of the surgeon with the trau-
matic dislocation of the adolescent or adult, not only
' Read before the orthopredic section of the New York
.\cadcmy of .Medicine, February 21, iSq6.
to the belittling of the importance of a disability that
is not accompanied by limitation of motion or pain,
but to the exaggerating of the difficulty of effective
treatment. It must be understood, then, that the ques-
tion of treatment is to be considered and decided, not
by the present condition of the patient alone, but by
the knowledge of what the final eft'ect of the deformity
is likely to be; and there is both theoretical and prac-
tical proof of the statement that as the anatomical de-
formity tends to increase, so with age its clinical
symptoms will become more evident.
The congenital dislocation of the hip is practically
always a dislocation on the dorsum, upward and back-
ward. If the displacement is of both sides the pel-
vis is suspended by the elongated capsules«on femora
whose heads are above and behind their normal posi-
tion.
The effect of the deformity on the gait and appear-
ance of the patient is in brief as follows: As the sup-
port of the body is displaced backward the pelvis is
tilted forward, and the necessary compensation in the
erect posture causes an increased lumbar lordosis and
prominent abdomen.
Because of the absence of a firm support for the
femoral heads, they are alternately forced upward in
walking. This insecurity, increased by the functional
weakness of the muscles attached about the neck of
the bones and their abnormal separation and displace-
ment, causes the peculiar rolling, waddling gait, so lu-
dicrous, ungraceful, and characteristic that the diag-
nosis of the affection may often be made at a glance.
When the dislocation is of one side only the waddle
is replaced by a limp which is, however, peculiar in
its characteristi.s. As the head of one bone only is
displaced upward and backward, the lumbar lordosis
is less marked, but the pelvis is twisted; the anterior
superior spine of the dislocated side is always in ad-
vance of the opposite side and at a lower level (Fig.
i). There is a peculiar telescopic limp, a sudden
and exaggerated lunge of the trunk toward the short
leg, that has been likened to the motion of descending
steps (Fig. 2). The abnormal mobility may cause at-
trition, and sudden strain upon the weakened joints
may set up attacks of traumatic synovitis.
The extent of the secondary changes, the amount of
pain, and the increase of restriction of motion will de-
pend in great degree upon the strain to which the
weakened part is subjected. It may, I think, be
stated that a double congenital dislocation of the hip
would make a laborious occupation impossible; fortu-
nately, the great majority of cases occur in females, so
that the question is of less importance than it would
otherwise be.
It may, then, be confidently predicted of the indi-
vidual suffering from this disability that the awkward
and noticeable waddling gait will continue; that
weakness and disability, compared with the normal
condition, will be marked; that pain or discomfort in
the lumbar region, which is almost always the accom-
paniment of abnormal lordosis from any cause, will
be experienced at times; and that discomfort or pain
at the weakened joints may be expected after over-
exertion.
There is a probability that the disability will in-
j62
MEDICAL RECORD.
[September 12, 1896
crease, and there is a verj' decided possibility that the
restriction of motion and repeated inflammations may
to a great extent disable the patient in later life.
The same prediction as to slowly increasing limp,
weakness and disability, may be made of the one-
sided dislocation; not only is the actual shortening
increased by the dislocation, but to this may be added
the apparent shortening due to the increasing limita-
tion of abduction and tendency toward permanent ad-
duction of the limb.
If these statements can be supported by clinical ex-
FiG. I. — Congenital Disloca-
tion of the Left Hip, illus-
trating the tivisting of the
pelvis and the abnormal
lordosis.
Fig. 2. — Front View of the Same Pa-
tient, illustrating the inclination of
the body, the prominence in the tro-
chanteric region, the comparative
atrophy and shortening of the leg.
perience, I think it will be acknowledged that, even
did not the weakness, awkwardness, and deformity of
the immediate condition warrant interference, the
knowledge of the more important disability of later
years, not to mention the moral elTect of a noticeable
deformity, makes the only question one of the proba-
bility of the attainment of a cure or relief, and not of
the possible difficulties in reaching this end.
In times past such arguments have been sufficiently
conclusive to stimulate treatment lasting through
years, by the use of braces and even by confinement to
bed, and it was only the hopelessness of cure by such
efforts that led to the practical abandonment of this
method of treatment. Here and there one finds re-
corded a case successfully treated by apparatus, but
even the most favorable report makes no claim that
the head of the bone had actually been replaced in a
sufficient acetabulum, supposing such to exist.
The object of the splint treatment has been simply,
by drawing the head of the bone into the- neighbor-
hood of the acetabulum and by removing the strain of
functional use, to check for a time the progression of
the deformity. This can undoubtedly be done; the
more efficient the support and the longer it is used, the
greater the palliation, but when the support is removed
one may again expect the slow- increase of the disabil-
ity : so that except in selected cases and except for the
purpose above stated, this treatment no longer de-
serves serious comment.
There now seems to be, if not an open acknowledg-
ment, certainly a tacit acceptance of the fact that there
can be but one effective treatment of this condition,
and that is to replace the head of the bone in its nor-
mal position, either in the acetabulum or an enlarge-
ment of its rudimentary indication. The credit of
this great advance undoubtedly belongs to HofTa, but
the details of the operation in the direction of sim-
plicity and effectiveness have been so essentially mod-
ified by Lorenz that it seems necessary to couple his
name with that of its originator, and especially since
Hoffa has long since abandoned the method of opera-
ting that formerly went by his name.
The conception of the treatment is Hoffa's; the
operation is that of Lorenz. It seems proper, there-
fore, in order to avoid confusion, to speak of the treat-
ment as the Hoffa-Lorenz operation.
The delay in accepting and practising the method
may be ascribed to the unfortunate functional results
that have followed the few reported operations in this
country — results that were unsuccessful or only par-
tially successful either because of the inexperience of
the operator and the failure to replace the bone in a
sufficient acetabulum, or because of the faulty tech-
nique and succeeding suppuration and contraction by
which the limb was drawn into a distorted position.
On the other hand, the most fortunate operation by
this method may be disappointing, if too much is ex-
pected as an immediate result. It cannot be hoped,
for example, that a perfect joint can be made by plac-
ing the deformed femoral head in a more or less arti-
ficial acetabulum, nor that muscles whose relations
and functions are suddenly changed can balance the
body or move the limb through its normal arc.
The operation is distinctly for the future of the pa-
tient; it is simply claimed that if the head of the
femur may support the body by the secure resistance
of an acetabulum in its normal position, compensatory
deformity of the body will disappear because the bal-
ance has been restored; the shortening will be re-
duced, insecurity will be replaced by security, and
the disability will become gradually less rather than
greater, because distortion of the limb and attrition
of the bone will be prevented, and the accommo-
dative changes of the future will be toward the normal
rather than the abnormal.
Again, as these operations are performed in child-
hood, when the regenerative and accommodative power
is so great as to ensure useful joints even after de-
structive disease, we can well imagine how much more
effective may be the accommodation to a condition free
from morbid influences.
So far, then, as the immediate result of an opera-
tion is concerned, it may be considered a success if
the head of the bone is securely held in the new posi-
tion, if there be no contractions that distort the limb
and a range of motion from complete extension to
forty-five degrees of flexion, sufficient to allow the pa-
tient to sit with comfort. If these essentials are at-
tained, the patient has made the most important step
toward complete recovery.
The following illustrative case is of interest, as this
appears to be the first occasion on which a patient has
been presented to a medical society in this country
as a successful immediate result of this operation.
The child, a girl, four years of age, was admitted to
the Hospital for Ruptured and Crippled on August 25,
1895, during my service as substitute. The peculiar
limp and projecting abdomen and a lump in the but-
tock had attracted the mother' s attention when the
child began to walk. She was taken immediately to
a public institution, where the parents were assured
that nothing was the matter. Later at another hospital
the mother was told that the child was "spoiled at
birth." The deformity had become such an eyesore
September 12, 1896]
MEDICAL RECORD.
3^3
to the parents that they readily consented to the pro-
posed operation.
The case was one of typical congenital dislocation
of the left hip. The great trochanter occupied the
usual position behind and above the normal acetabu-
lum, on a level with the anterior superior spine; the
lordosis was well marked; there was the usual twisting
of the pelvis and atrophy of the leg, which was one
inch shorter than its fellow when no weight was borne,
and the usual peculiar limp.
On the following morning the Lorenz operation was
performed, and, as this has been recently modified
somewhat by the author, its main points will be de-
scribed.
An incision was made just to the outer side of the
anterior superior spine, and e.xtended downward and
slightly outward for two and one-half inches. The
fascia was freely divided and the joint exposed in the
interval between the tensor vagina; femoris and gluteus
niedius muscles. The capsule was freed and opened.
December 15, 1895. As the parents live far from
the hospital, she has been seen at infrequent intervals
only, and has had none of the massage, the manipula-
tion, and the special training that have been insisted on
by Lorenz as an indispensable part of the treatment,
other than that which a busy mother has been able to
apply. For this reason the case is of interest as show-
ing a result attained under the ordinary unfavorable
conditions.
The head of the bone is securely held in the new
acetabulum. The abnormal lordosis has disappeared;
the shortening is reduced to about one-fourth of an
inch, representing the change in the angle of the neck
of the bone; there is no prominence in the region of
the trochanter. The child runs about all day without
fatigue. There is still a well-marked limp, though of
an entirely different character from that observed be-
fore the operation, and when the child is under direct
instruction it can be much reduced. Contraction has
disappeared and there is voluntary motion from full
Fig. 3. — To Illustrate Voluntary Flexion Five
Months after Operation.
Fig. 4. — The Weight Supported on the Re-
placed Femur, illustrating, when contrasted
with Fig. I, the absence of abnormal lordosis.
Fig. s. — Front View of the Same Patient.
exposing the head of the bone; this was of fairly nor-
mal appearance, somewhat like an acorn in shape, with
a deep depression on its anterior surface. The neck
was as is usual, short and depressed to a right angle
with the shaft. The ligamentum teres was absent.
The situation of the old acetabulum was found, and it
was, rapidly enlarged to a sufficient size. When the
upper part of the capsule had been thoroughly divided
the head of the bone could be easily replaced.
The capsule was not sutured, the wound was closed
except for a small drain, and the limb in a slightly
abducted position w-as placed in a long spica plaster
bandage.
The after-history is not eventful. The original band-
age remained in position for a month ; it was then
replaced by a short leather support, which was in turn
removed three weeks later, since which time no support
has been used. The child began to walk about on
the leg at the end of six weeks, .\lthough the impor-
tance of after-treatment was recognized, it was not
considered best to retain a young child exposed to the
dangers of a large hospital, and she was discharged
extension to one hundred degrees of fle.xion ; abduc-
tion, adduction, and rotation are about three-fourths of
normal, which means that for all practical purposes
motion is perfect (Figs. 3, 4, 5).
According to Lorenz's experience this case may be
classed as one of the best results, since he considers a
very much more limited range of motion, from fifteen
to forty-five degrees, a good result. As to the limp,
which depends on insecurity, it may be expected to
grow less with functional use, because it is the inse-
curity of muscular weakness, not the insecurity of non-
support. For the immediate result, the better the
motion the greater the limp; in fact, according to
Lorenz, the firm ankylosis that might follow suppura-
tion gives a better immediate result, provided there is
no distortion of the leg. In from one to two years the
limp may become imperceptible, much naturally de-
pending on the training and after-treatment.
So far as the operation is concerned, from my own e.x-
perience and from my observation of those performed
Ijy others, the following points deser\-e attention :
The operation is somewhat difficult, since its field is
364
MEDICAL RECORD.
[September 12, 1896
deep and cannot be easily exposed to view. The neck
of the femur is short and held tightly against the pel-
vis by the hypertrophied capsule. The operation
should be as rapid as possible, and this rapidity may
be aided by an accurate knowledge of the normal
position of the acetabulum and a clear conception of
the size and shape to which the rudimentary depres-
sion is to be enlarged, and it must be remembered
that this is to be large and deep. The capsule should
be freed, incised, and cut through, particularly at its
upper attachment, as it is at this point that the re-
sistance to reposition is most marked. In young chil-
dren the obstacles to reposition will be found to be
almost entirely in the capsule. In older subjects the
preliminary e.xtension by heavy weights or the exten-
sion by the screw machine at the time of operation
may be necessary. In exceptional cases the head of
the bone may be distorted so that shaping may be
necessary.
It is evident that although the dislocation may be
successfully reduced, the necessity for long-continued
and careful after-treatment is not thereby removed ;
but it is care applied to a useful, growing limb, se-
curely in place, rather than the same amount of treat-
ment devoted to holding the limb approximately in
normal position, as when mechanical means only are
applied.
It is probable that the only other method of treat-
ment likely to be extensively used in the future is the
attempt to replace the dislocation by manipulation
without open operation, as advocated by Paci ; but
this method must have a much more limited scope
than is claimed by its author, for if its object is to
actually replace the dislocation, it is not likely to be
successful except in young children, because the ace-
tabulum is not of sufficient size to contain the bone,
and because the opening through the elongated capsule
is impossible, not to mention the other difficulties in
the resistance of muscles and ligaments, which are
sufficiently familiar to those who have attempted the
open operation.
Lorenz's argument is particularly conclusive on this
point, as he has performed the manipulation of Paci,
and then by the open method examined the relation of
the parts and again laid bare the capsule and at-
tempted reposition by this method — but never with
success. He insists that the ■" fourth movement " of
Paci will inevitably dislocate the head of the bone
forward if it comes into the neighborhood of the ace-
tabulum, and that it is because of this forward dislo-
cation that the favorable results are obtained by this
method.
Lorenz also asserts that the only effective method
for the actual and immediate reduction, of a disloca-
tion by such means must be by traction, flexion, and
erctreme abduction; direct pressure downward on the
trochanter and then toward the median line, while the
leg is rotated slightly inward. He has further per-
fected the method and it will be described by him at
the May meeting of the Orthopjedic Association. As
neither Lorenz nor Hoffa advise open operation before
the age of two years, it would seem that the attempted
reposition would be indicated in those rare instances
in which one has the opportunity to apply treatment
at this early period; and if, as is no doubt the case, the
anterior dislocation is so much less disabling than the
posterior, it would seem that the method of Paci might
be carried out simply with this aim in view, if it were
impossible to replace the head of the bone in its ace-
tabulum, or when the open method had been refused
or was considered to be impracticable.
Were it not for the continual evidence of mistakes
in diagnosis that cases afford, one would suppose
that the presence of the dislocation must be self-evi-
dent. The diagnosis can offer no difficulty in any
but very exceptional cases. It is characterized by an
habitual limp or waddle not accompanied by the pain
of joint disease or the helplessness of paralysis (the
affection which I find most often made to explain the
symptoms) ; a shortening of the leg, explained by the
elevation of the trochanter on the affected side or on
both sides when compared with Nelaton's line; finally,
when the limb is flexed and adducted to its extreme
limit, the neck and rounded head of the bone can be
plainly felt, beyond and above the trochanter. Thus it
may be distinguished from the rare cases of depression
of the neck of the femur, which in j'oung children may
be due to rachitis, and from the dislocation the result
of destruction of the head of the bone, as in acute
epiphysitis of infancy, of which no history can be
obtained.
Fortunately at the present time, thanks to the
work of our Euroisean colleagues, Hoffa and Lorenz
and Paci, the congenital dislocation of the hip is no
longer a hopeless disability. The simplicity and the
reasonableness of the operative method have always
been self-evident, and now that its feasibility has been
so decisively proved it would seem that the time had
come for more decided effort to relieve the sufferers
from this deformity.
RUDIMENTARY ORGANS.'
By CORA H. FLAGG, M.D.,
tOSTON, MASS.
I\' all of the higher animals we find a large number
of structures which are either absolutely useless or of
such slight service as to bear little or no relation to
the existing life or wants of the animal.
Those parts which are absolutely functionless are,
strictly speaking, rudiments — though it is hard, in
many cases, to make a distinction between them and
those that have so far degenerated as to be of slight or
doubtful value.
A very liberal interpretation of the subject would
make it include those structures which were formerly
of greater physiological importance than at present, or
parts that may be in a state of transition, and even
those that are merely pathological in their signifi-
cance.
All rudiments are characterized by their great va-
riability, either in size, form, sex, time of occurrence,
or their entire suppression. They are often a source
of decided disadvantage and even of danger to life, as
in the case of the vermiform appendix.
To comparative anatomy and embryology we owe
much for the elucidation of this subject. Comparative
anatomy shows us that all vertebrates are constructed
on the same plan ; so, finding the same parts which are
rudimentary in higher animals well developed and
highly functional in the lower animals justifies the
conclusion that these parts in the higher animals are
now in a degenerate and functionless condition, but
that they once had an important function in ancestral
forms.
The human embryo shows successively and progres-
sively during the course of its development the ances-
tral forms through which man has passed in the ascent
from the simple to the complex organization. To
briefly illustrate: The embryo of man has at an early
period gills much like a fish, with ramification of
blood-vessels in true fish t}-pe. These are found in
the embr)OS of all existing vertebrates, together with
other structural peculiarities which would result in the
transformation of an aquatic into a terrestrial animal.
The heart is at first a simple chamber, like that in the
' -\ prize essay, College Physicians and Surgeons, Boston,
Mass., session 1S95-96.
September 12, 1896]
MEDICAL RECORD.
365
worms; the backbone is prolonged into a tail, which
extends beyond the extremities; the great toe is op-
posable like the thumbs. Three months before birth
the whole body, except soles and palms, is covered
with a thick coat of soft woolly hair. In short, the
human embryo, during its development, recapitulates
the history of the evolution of all its ancestral forms.
In consequence of this, we have found in the embryo
more than three hundred rudimentary parts or charac-
ters, most of which disappear in the economy of growth,
but many are retained in the adult form. Of these I
shall consider only those of general interest, and
that necessarily in a superficial manner.
As to the part played by a gradual evolution of the
environment, the laws of natural selection, disuse,
economy of growth, or the combined effects of enlarge-
ment from increased use, suppression, and change of
function, I cannot touch upon at all. This phase of
the subject has been most extensi\'ely and satisfacto-
rily worked out. Suffice it to say that rudimentary or-
gans have furnished a most perplexing problem to those
whose interest or condition of mind lead them to seek
a teleological explanation of man's origin. Viewed
only in the light of e\olution has their meaning been
made clear.
Let us begin with that most obnoxious of all rudi-
ments, the human tail. Has man a rudimentary tail?
In answering this question we must bear in mind that
the definition of a tail in human anatomy must be in
strict accord with that of comparative anatomy, which
is, '■ that so much of the vertebral column as is posterior
to that which attaches to the pelvic girdle is caudal."
At an early stage in the development of the human
embryo there is, as we have already said, in direct
continuity with the axial skeleton, a free, pointed ap-
pendage, projecting beyond the extremities, and having
an unmistakable resemblance to the tail of a lower ani-
mal. During the course of development this becomes
shorter and shorter, is slowly taken into the trunk, and
persists in the adult form of both man and apes as the
OS coccyx. As is the case with all vestiges, it is ex-
tremely variable; being made up usually of four ver-
tebra;, it is found sometimes in the male composed of
five, while in the female the number varies from three
to six. That it is a true rudiment is shown by this
variability in number, its incomplete development at
birth, together with the fact that there is a whole se-
ries of degenerate caudal muscles attached to it. This
is also a direct proof that it was at one time an exter-
nal and functional tail. Although functionless now
as a tail, the coccyx has some use in supporting inter-
nal parts.
The skeletal system furnishes many points of inter-
est, on account of the assumption of the upright posi-
tion by man. In consequence of this, the sternal por-
tion of the thorax has shortened and the sternal ribs
have diminished in number and size, because the chief
support of the viscera is no longer in the ventral but
in the caudal direction. We find, consequently, a
compensatory widening of the pelvis, especially pro-
nounced in woman, furnishing additional support in
child bearing.
We must consider the eleventh and twelfth ribs —
and a thirteenth rib is not a very rare occurrence — as
rudiiuentary in nature. They have lost their sternal
attachment. It is found that their chief use is in giv-
ing support to the serratus posticus inferior and a por-
tion of the latissimus dorsi muscles; but it must be
noted that the former muscle is unmistakably rudimen-
tary, while that part of the latissimus dorsi attached to
the ribs is very insignificant compared with the rest of
the muscle.
The large transverse processes of the lumbar verte-
bra must be considered as vestiges of ribs. In fact,
they are ribs at one period in the embryo. The first
pair of ribs also shows signs of beginning degenera-
tion.
From these facts we see that the vertebral column
was evidently furnished with a greater number of ribs
than at present.
The slender and variable styloid process of the tem-
poral bone is clearly a rudiment, a left-over or made-
over structure from the gill stage.
Probably the most harmless rudiment we possess is
the pisiform bone of the wrist. As all mammals are
constructed on the common plan of five digits, and as
careful research shows this vestige to be the carpal
bone of a long-vanished si.xth finger, we shall have to
go back at least to the amphibia to account for its
origin.
Numerous foramina are found in certain bones, oc-
casionally in those of civilized man, more commonly
in ancient remains and the lowest races. We need
mention but one that always occurs, the canal in the
posterior aspect of the petrous portion of the temporal
bone, the aquaiductus vestibuli. It has been fully in-
vestigated and proves to be one of the most ancient
and interesting of relics. It is the rudiment of a struc-
ture which primitively connected the inner ear directly
with the external world, and opened on the dorsal as-
pect of the head. This is evidenced by the following
facts: In the embryos of all vertebrates the develop-
ment of the auditory vesicle begins by the formation
of a patch of exoderm cells. This patch soon becomes
invaginated and forms a pit, to the inner side of which
the auditory nerve becomes closely applied. As this
pit sinks deeper and deeper into the connective tissue,
its mouth narrows and soon becomes closed in all
higher vertebrates. The ear vesicle gradually moves
still farther from the surface, yet remains connected
with it by an elongated duct, either opening on
the dorsal aspect of the head, as in elasmobranchs,
or ending in a blind pocket. In the higher verte-
brates the ear vesicle undergoes most complicated
changes, which have been confined, however, wholly
to its lower end, leaving this primitive dorsal exter-
nal auditory canal unused. It still persists in man
as a canal leading from the vestibule of the complex
inner ear and opening on the top of the petrous bone.
.Some anatomists tell us that it still contains a tubu-
lar prolongation of the lining membrane of the vesti-
bule, which ends in a cul-de-sac between tlie layers of
the dura mater. To sum up: The aquaeductus vesti-
buli is all that is left of the primitive ear tube through
which the remote ancestors of man, the early sharks,
heard.
It is said that hardly a human subject has been ex-
amined which has not shown some variation in the
muscular system. In fact, in no other system do we
find so many variations. On account of the degenera-
tion of the tail, we have a whole series of muscles,
which in tailed animals are strongly developed, for
moving it. On the ventral side of the coccyx are the
vestiges of the coccygeus muscle, being in the lower
animals the adductor coccygeus or tail-wagging mus-
cle. The curvator coccygeus corresponds with the de-
pressor Cauda; of the tailed animals. The rudimentary
character of the extensor and levator coccygei is in-
dicated by their extremely small size and by the fact
that they may be wholly or partially replaced by fibrous
tissue, or may be entirely wanting. Their vestigial
character is even more pronounced in the anthropoids
than in man.
An interesting series of muscles is the panniculi or
skin muscles — so called because they have their points
of origin and insertion in the skin. They are weU
developed in many of the lower animals, in which they
spread like a mantle over the back, head, neck, and
flanks. They plaj- an important part in raising the
scales and feathers of reptiles and birds. In some
366
MEDICAL RECORD.
[September 12, 1896
mammals they act as a protection against injury to the
skin, as is seen in the strong twitching by which a
horse or ox shakes oiif an insect. In man and apes
only a feeble trace of this class of muscles is found,
such as the platysma myoides in the cervical region,
the muscles of the external ear, and those of the scalp.
The whole of the external shell of the ear in man is
merely a rudiment, having no function whatever in its
present condition. Its various folds and prominences
in man are represented in the lower animals by mus-
cles which are used for opening and closing or widen-
ing and narrowing the external auditory passage.
While those three rudimentary extrinsic muscles — the
attollens, attrahens, and retrahens — are large and func-
tional in moving the ears of most of the lower mam-
mals upward, forward, and backward, they are outside
the control of the will in us, making the ear practically
immovable. It has been said that the resting position
has had much to do with crumpling the pinna, but to
this must be added the effects of disuse through greater
freedom of motion of the head and greater brain devel-
opment. Excepting the primates, mammals determine
direction of sound by exclusion — they move the ear
until a position is found where the sound is loudest.
In our complex brain the terminals of the auditory-
nerve have so specialized as to be capable of perceiv-
ing quality of sound in different relations to the indi-
vidual. This, plus the capacity for correlating past
experiences of sound, enables us to detect immediately
its direction, and we have no further need of an exter-
nal ear with a set of muscles to move it. Elaborate
experiments have been made to prove that the crumpled
condition of our ear deflects rather than concentrates
sound vibrations. In the little blunt point projecting
from the infolding margin of the helix we see the last
relic of the pointed ears of our ancestors, which fact is
emphasized by our finding it in the human embryo
(before that stage when the helix rolls in) projecting
upward, as is normal in the ears of lower mammals.
The subclavius in man is very small and insignifi-
cant, often only a band of fibrous tissue and as often
absent. It may have a little use to aid in steadying
the clavicle during movements of the arm, for we find
an analogous muscle in birds, which is large and
strong, raising the wing in flying.
The pyramidalis has the rudimentary character of
variability. " It is very insignificant, often wanting on
one or both sides. It is the remnant of a powerful
muscle, which in the marsupial ia greatly strengthens
the abdominal walls and supports the pouch.
The levator clavicula;, ischio- pubic, musculus ster-
nalis, gluteus quartus are interesting rudiments, which
we need not treat in detail.
The palmaris in the forearm and the plantaris in
the leg are good examples of degenerates. The former
is still slightly functional in aiding to ''make a fist."
Formerly it extended through the palmar fascia to the
phalanges, acting as a strong flexor of the fingers.
Now it reaches only to the palmar fascia. The plan-
taris is a true rudiment. While it formerly extended
through the palmar fascia of the foot to flex the toes,
it now does not even reach the fascia, but has shifted
back to the os calcis, and is frequently absent. This
muscle is largely developed in tree-climbing animals.
The assumption of the upright position has had
much to do with this great variation in the muscular
system. It caused that massive development of the
gluteus maximus and gastrocnemius which must neces-
sarily have thrown out of balance the nicety of rela-
tions of other sets of muscles. The changing of the
foot from a prehensile to a supporting and walking
organ brings into existence rudimental conditions of
muscles. Professor Wood, of London, from examina-
tion of a large number of cases, finds that anomalies
in muscles of the limbs are more numerous than else-
where. And in the arm he finds that there are two
hundred and ninety-two variations as against one hun-
dred and nineteen in the leg, owing, no doubt, to com-
plexity of movement in serving a highly developed
brain. Osborn says that " in the muscular system we
find organs so far on the downward grade that they are
mere pensioners qp the body, drawing pay — that is,
nutrition — for past honorable services without per-
forming any corresponding work.''
Although man is the least hairy of all the primates,
a careful examination of the skin shows that hair folli-
cles are to be found over its whole surface, in some
regions, as the head, axilla, pubes, being strongly de-
veloped, while in other parts it is a fine, soft down.
In males these downy hairs are often well developed
on the breast, neck, abdomen, and limbs. These facts
lead to the conclusion that primitive man was far
more hairy than at present. To go back further, we
can e\en see in the rudimentar}* condition of the hair
of man traces of his descent from the lower animals.
Hair appears on the embryo of homo at about the thir-
teenth week of intra-uterine life. The very first is
seen about the eyebrows and mouth, the same parts
where the " whiskers" or tactile hairs of lower animals
are found. .At about the sixth month the whole body,
except the palms and soles, is covered with a soft,
thick hair, called the '"lanugo." This soon disap-
pears and gives place to the developing buds of the
permanent hair follicles.
In the mamma we have an organ, functional in one
sex, rudimentary in the other. It is clearly indicated
that some remote ancestor of the vertebrates must have
been hermaphrodite, which indication in strongly ac-
centuated by this embr)'ological fact: at a very early
period in fcetal life both male and female glands occur
in the same individual. In a short time one gland dis-
appears. Which gland shall disappear and which
shall persist, is determined by conditions which are
not as yet fully understood.
It is significant in this connection that every human
being at one period of its existence is double-sexed or
hermaphrodite.
During the past few years an immense number of
cases have been recorded of the occurrence of more
than one pair of mamma;. These instances of poly-
masty occur equally in both sexes, and may be regard-
ed as a return to a primitive condition, where many
glands were developed and many young were brought
forth at one birth. There has been a large amount of
research on this subject and numerous facts have been
collected, which go to show that the male mammK are
not merely inherited from the female but are true ves-
tiges derived from hermaphrodite ancestors. Occa-
sionally they are functional in the male. There are
data which point toward degeneracy of the female
mamm£e, one cause of which may be found in present
modes of dress. A physician of large professional ex-
perience and observation says that degenerate malfor-
mation of the nipple is quite common, and it may be
well to investigate how far the pressure of the corset
is a cause of this.
The lowest races of men, as well as the apes, still
retain the wisdom tooth as the largest in the series,
while in civilized man it is clearly a rudiment, having
many variable characteristics. It is late in its devel-
opment, sometimes not appearing at all. Instead of a
molar with four cusps, it is often but a stump with co-
alesced roots. It is the earliest to decay. The habit-
ual eating of soft food, which the use of fire permits,
does away with the necessity for heavy jaws for the at-
tachment of powerful masticating muscles, and is the
initial factor which tended to weaken and shorten the
jaws, crowding out the wisdom tooth.
In certain glands of the axillary and anal regions
the secretions have a penetrating odor, of which we are
September 12, 1896]
MEDICAL RECORD.
367
not able to discover any use in man. But it is well
known what an important part they play in mammals
on account of their odorous secretions.
The nervous system is conservative in preser\-ing
antiquated structures. Still persisting in this system
we have the last traces of the invertebrate descent of
man in the mysterious pineal gland, the rudiment
whose history has most recently been cleared up.
Speculations concerning its nature began as far back
as the time of the Greek philosophers, by whom it was
thought to be the seat of the soul. It is a small, red-
dish, cone-shaped body, about the size of a cherry
stone, which in man and the other mammals is pushed
away from the surface of tlie brain by the growth of
the cerebrum, until it has come to occupy a depression
between the corpora quadrigemina. Its base is divided
into two stalks, which are intimately blended with the
optic thalami. In vertebrates, lower than mammals,
this organ lies just under the top of the skull, at the
parietal foramen. The pineal gland is now known to
arise during the development of all vertebrates, and to
have undergone degeneration in proportion as the
skull became more and more solid. In the lower ver-
tebrates— the amphibia and reptilia — the pineal body
is found to be divided into two parts, one part still
connected with the brain, while the other, made into
a bladder-shaped structure, is closely connected with
the first part. An English and a German scientist,
both working independently on the brains of certain
reptiles, discovered that the pineal gland in these ani-
mals was a true optic lobe, and that the bladder-shaped
appendage was the rudiment of an unpaired, highly-
developed median eye. While in all vertebrates we
find this pineal optic lobe, in only the lowest verte-
brates do we find the rudimentary pineal eye con-
nected with it. Yet we do find the eye in the embryos
of animals still a little higher up the scale. All that
persists in man and the higher vertebrates is this pin-
eal optic lobe, all trace of its associated eye having
long disappeared. In the hatteria punctata, the sole
survivor of an e.xtinct species of beak-mouthed lizard,
found in Australia, we find a well-developed pineal eye
on the top of the head, covered with a transparent
scale, which acts as a cornea. In this animal there
is a nerve connection between the eye and the pineal
gland. But in even this low form its degeneration is
begun, as is shown by the deposition of a mass of pig-
ment cells under the transparent scale, which renders
the eye functionless. In varanus, a more modern t}'pe
of lizard in which the pineal eye is found, there are no
pigment cells to obstruct sight, but degeneration is
shown here by the absence of the nerve connecting the
pineal eye and the pineal optic lobe. It is interesting
to note that in many animals the skin, connective tis-
sue, and dural tissues over the parietal foramen re-
main uncolored; sometimes they are so clear and
transparent that they might be considered a kind of
cornea. In considering the intimate relationship be-
tween birds and reptiles, a Russian zoologist has dis-
covered in the embryos of certain birds a brow spot,
also a transparent scale like that of the now living liz-
ards above mentioned, which in their structure point
to the last trace of a pineal eye. Careful e.xamination
shows this eye, whether found in the embrj'o or in the
adult form of still lower vertebrates, to be of the type
of an invertebrate eye. To sum up briefly: The pin-
eal eye is never functional in vertebrates when found.
The only vestige left of it in higher vertebrates is the
optic lobe or pineal gland, which must be considered
as an heritage from the seeing apparatus of an inver-
tebrate ancestor.
We find another rudimentary organ in the pituitary
body of the brain, which, although not yet ontologi-
cally solved, bids fair to throw more light on our re-
mote ancestry. The lobus olfactorius, although func-
tional, is in a degenerate condition. There can be no
doubt that we inherit the sense of smell in an enfee-
bled condition from our early ancestors, in whom it
was of very great service in guiding them to food and
warning them of danger.
The calamus scriptorius is as yet an unreadable ru-
diment.
The eye presents an interesting rudiment in the lit-
tle fold of the conjunctiva which lies at its inner an-
gle, and is known as the plica semilunaris. This mem-
brane corresponds to the third eyelid or nictitating
membrane of the lower animals. In birds, reptiles,
and some amphibians, in whom the upper and lower
lids are nearly immovable, it is highly developed and
can be drawn wholly across the eye by means of a spe-
cial muscular apparatus. The use of the nictitating
membrane in the lower animals is to maintain the
healthy condition of the eye by removing foreign mat-
ter which has escaped the eyelids. What clearly de-
monstrates this function is the inverse relation which
always exists between the development of this body
and the facility with which the animal can rub the eye
with the anterior limb. Thus, in the horse and o.\ it
is well developed, while in the dog, which may use its
paw to some extent when it is required to brush its
eye, it is smaller. In the cat it is still less, while in
man and the monkeys, whose hands are perfect, it is
reduced to a very small rudiment. It sen-es also to
cover the eye in the lower animals, as well as to keep
it clean; but in man that function is wholly per-
formed by the lids. Although in man and the higher
apes this membrane has undergone extreme degenera-
tion, yet in some of the more primitive races it fre-
quently encloses a cartilaginous support.
The function of the suprarenal capsules is still un-
known. We are justified in classing them among re-
trogressive organs, from the fact of their larger size in
the embryo than in the adult.
In many places where canals open on a free sur-
face the orifices are usually surrounded with glands
and a collection of tissue of the adenoid variety. The
tonsils are an example of this, occurring in the throat,
marking the inner border of the gill-slit orifices. They
are among the dangerous rudiments in man. There is
a third tonsil in the vault of the pharynx; although
not associated with the gill slits, yet it is a curious
fact that it is situated at the pharyngeal orifice of a
duct which in the embryo traverses the floor of the
pituitary fossa and opens into the roof of the pharynx.
This tonsil is identical in structure with the tonsils of
the fauces. As is well known, adenoid tissue has an
inherent tendency at slight irritation to increased ac-
tivity of its cellular elements, thus enlarging the mass.
This enlargement, especially of the pharyngeal tonsil,
is the source of much trouble in childhood.
Between the true and false vocal cords there is on each
side of the larynx a diverticulum, known as the sinus
of Morgagni. This invagination is directed outward,
sometimes upward. In man these Morgagnian pouches
are variable and, so far as we know, functionless.
But we have no difficulty in recognizing in them the
homologues of the vocal sacs of the monkeys. In
them they can be filled with air from the lungs, and
when so filled are of immense size. Their only con-
ceivable function is to act as resonators when the ani-
mal howls. From these facts we might be led to in-
vestigate the probability of these sinuses playing a
part in influencing the quality of the singing voice in
man.
Nothing is definitely known of the function of the
thyroid gland. The manner in which it originates
justifies us in classing it as a vestigial organ. There
are strong evidences of its having undergone a change
in function, which, so far as we can say, appears to
have an important relation to the central nervous sys-
368
MEDICAL RECORD.
[September 12, 1896
tern, since its removal is apt to give rise to idiocy,
muscular twitchings, epileptoid movements, disturb-
ances of deglutition and respiration. Its probable
function is to form a secretion or remove some waste
from the blood that would injure the nervous system.
The thymus gland is still more difificult to under-
stand. It is large in the embryo. At the end of the
second year it begins to degenerate. In old people
there are still epithelial, lymphoidal, and fatty vestiges
of it always present. The fact that it has its greatest
development in the lower fishes may enable us to de-
termine its function in them, thus giving us a clew to
its use in homo.
The vermiform appendi.x is probably the most dan-
gerous rudiment that we possess. Let us consider a
few facts that have been collected concerning it. It
is a feebly developed organ, which is attached to tlie
short caecum. Its average length in man is four inches.
It is strongly developed in the embrj'o — its length, in
proportion to the large intestine, being one to ten,
while in the adult this proportion is one to twenty.
Ribbert's investigations prove that in a large number
of cases it is occluded. His tables show further that
this occlusion increases with the age of the subject ex-
amined. He has made another table, which proves
that occlusion increases as the length decreases. The
presence of this rudiment points to the conclusion
that the total length of the great intestine, as w-ell as
of the body cavity, was formerly greater than now.
The great variation in form and size of the ca;cum
supports this view. The ca;cum has a great length in
the lower, vegetable-feeding animals. In the marsu-
pial koala it is more than three times as long as the
whole body. It is now thought that, on account of
changes in diet and habits, the cascum in man has be-
come much shortened, the vermiform appendix being
left as a rudiment of this shrunken part. As is true
of all rudiments, it is occasionally absent in man. In
looking over the great amount of research that has
been made on this rudiment alone, one realizes that
in a short paper like this no attention adequate to its
importance can be given to it.
Although I stoj) here in the enumeration of man's
rudimentary organs, I have by no means exhausted the
list. We might begin to think that man is a sort of
Nature's patchwork, were we not certain that every
modification of structure is the direct result of that
grand, immutable law of the universe, whose working
raises the simple into the more complex, develops force
difl'used into force more concentrated, and that this
law is as well shown in the evolution of complex
worlds from simple nebulous matter as in the evolu-
tion of psychic man from simple forms of life.
374 Newbury Street.
Indications for Curettage. — i. All tho.se cases of
persistent leucorrhcta with tender and subinvoluted
uterus. 2. For dysmenorrhcta in young girls and
maiden ladies who, in spite of internal remedies, must
spend two or three days out of each month in bed,
and in whom an undeveloped and oftentimes flexed
uterus is found. 3. for barrenness, when the fault
is plainly with the woman, and no tangible cause
other than poorly developed uterus exists for failure
to conceive. 4. In all cases of menorrhagia, whether
from fibroids, polypi, or other neoplasms, especially
in the menorrhagia occurring at "the change of
life," and which is not amenable to other treatment.
5. In all septic diseases of the uterus or its appen-
dages, whether following accouchement, abortion,
operations, or gonorrhcea, whether the inflammation be
acute or chronic, curettage is indicated, and the earlier
the better. — Dr. L.-^ncaster, Virginia Medical Scmi-
Monthfy, May 22, 1896, p. 97.
SYMPHYSEOTOMY.'
By EDWARD A. AVERS, M.D.,
PROFESSSOR OF OBSTETRICS, NEW YORK rOLYCLINlC.
Gentlemen: Until September 30, 1892, when your
distinguished townsman. Prof. Charles Jewett, did
a symphyseotomy, but three such operations had been
performed in this country, none of which had been
reported. To-day our records show some eighty-
five and more cases recorded. Over four hundred
cases have been reported by Zinke, including all coun-
tries. Outside of Italy and France, the operation was
as little used in other European countries previous to
1892 as in America. And as in America, so it has
been taken up by most of the nations of Europe since
that time. Every obstetrician is therefore deeply in-
terested in having its proper place clearly defined.
Scope of the Operation The scope of the opera-
tion must depend upon the skill required to perform
it, the essential mortality that belongs to it, the mor-
tality depending upon the enforced though undesirable
conditions under which it must be performed, and their
comparison with those of its alternatives — version,
induced labor, craniotomy, and Cesarean section; and
upon the after-disabilities to the mother and the mor-
tality of infants delivered by it. It further depends
upon the degrees of pelvic contractions, the dimen-
sions of the foetal heads, and the increase of pelvic
space obtaining after pubic separation.
Comparative Mortality. — Internal podalic version
in cases of contracted pelves will sometimes secure de-
livery of a living child when, if it were not employed,
an operation with the knife would be necessitated.
The tendency of physicians not thoroughly trained in
abdominal and pelvic mensuration is to exaggerate
the difficulties at times and leap to an operative deliv-
ery that is not necessary. In such cases version is
conservative. But the most skilled examiner finds it
much more difficult to foretell that version will de-
liver than that symphyseotomy will do so.
It were far better not to undertake a version and
fail to deliver, as it only adds to the difficulties by
getting the child in the most awkward position for
either craniotomy or symphyseotomy.
In the last two years I have done two basiotrypsies,
and, through my hospital staff, delivered a foetal head
that had been left in the uterus with the body torn
away. All three were cases of impossible delivery by
version. Basiotrypsy is an easy operation if one has
a trephine, but this instrument is in very few offices.
Maternal mortality through version, from exhaus-
tion, rupture of the uterus, or infection, averages from
one-half to two per cent. The mortality to the foetus
is from ten to twenty-five per cent.
Induced Labor. — The mortality from induced labor
is for the mother from one to three per cent. The
mortality for the infant in the first six months is from
seventy-five to ninety per cent. These figures for
infant mortality in prematurity seem large, but the
more I have in\estigated die subject the larger have
the figures grown. We must bear in mind that not
all this mortality belongs to prematurity. Walcott
gives in a recent paper the infant mortality from
all causes as thirty per cent, in Bavaria, 20.3 per
cent, in Holland, 16.6 per cent, in France, 16.3 per
cent, in Massachusetts, and twenty-six per cent, in
Boston. The incubator and improved infant feed-
ing have not yet brought premature infant raising
to a satisfactory accomplishment. As an alternative
to symphyseotomy induced labor loses probably one-
half its utility through that percentage of cases not
being recognized in time for its performance.
Craniotomy. — There is a very wide variation in the
' Read before the Brooklyn Medical Society, April 17, iSq6.
September 12, 1896]
MEDICAL RECORD.
369
mortality of craniotomy. Done early and without
damaging effort with the forceps, it is quite a safe
operation, unless there is great contraction of the
pelvis. Its total mortality is in the neighborhood of
fifteen per cent. Done early and with skill, its mor-
tality is from one to two per cent. For the child of
course it is one-hundred per cent.
Caesarean Section. — The best per cent, obtained
for Cesarean section is eight.
The average general mortality is between twenty-
five and thirty per cent. For the Porro operation
it is nearly thirty-eight per cent. For the infants
it is 22.4 per cent. There is little need of so great
a mortality for infants, the per cent, being due
to some extent to operations after the infant was
dead. In others it has been due to the present
method of first constricting the uterus before opening
it and removing the child. The essential mortality
for infants should not be more than in normal labor,
if the operation is begun early. The mortality for the
mothers will always be high, no matter how great fu-
ture efforts will be to lessen its dangers. It will al-
ways be the operaation last selected. I state with
positive assurance that the newer operation, symphy-
seotomy, is sure to have first consideration from this
time on.
Symphyseotomy. — The general mortality for sym-
physeotomy in this country, where all but three cases
were done during the antiseptic period, is about nine
per cent. Following the admirable tabulated records
of over four hundred symphyseotomies, covering all
countries, published by Zinke and Harris, I have
made a table of only those cases occurring since 1886,
when antiseptic surgery was well established and in
which the patients had not been in labor longer than
twenty-four hours.
This leaves out a number of cases which were suc-
cessfully operated upon after being longer in labor,
but impartiality demands some such definite limit for
classification.
Summary of Tarul.-\ted Cases.
Total number of cases, . . . . . iii
Total number of maternal deaths, ... 6
Total number of children born, . . . .112
Total number of children died, . . . .16
Average number of hours in labor, . . .16
Of the si.x maternal deaths. Case 78 in Zinke's
Table had " septicaemia when admitted to the hos-
pital."
Case 176, Zinke's table, died from septic peritoni-
tis, a condition that was believed to have originated
before the operation.
Case 174, Zinke's table, had a periosteal pelvic
fibroma, rupture of the vaginal wall, phlegmasia in the
left leg, and died from an embolus in the pulmonary
artery.
Case 19, Harris' table, died from pneumonia and
intestinal paresis from impacted faeces.
Case 74, Harris' table, died from septic peritonitis.
Case 6, not yet reported, my own, died over a
month after operation from sloughing of large cicatri.x
in the vagina and from pneumonia.
This table therefore gives a mortality of five per cent.
Of these si.x deaths the first was septic before entering
the hospital, the second was believed to be infected
before being operated upon, the third, with a perios-
teal pelvic fibroma, should be counted as a symphyse-
otomy death, although it was a mistake to select this
operation. The fourth case, operated upon by Dr.
Davis, of Philadelphia, did not die from symphy-
seotomy at all. The fifth case, done in a moribund
condition, cannot be fairly said to touch the question
of the ■■ essential " mortality. The sixth case, my own,
did not have any joint trouble, as will be seen in my
report, about to be given.
It is therefore no exaggeration to say that the es-
sential mortality of symphyseotomy is not much over
one per cent. I believe the operation is slightly more
dangerous than induced labor. I should say it is one
per cent, greater risk. On the other hand, the risk
for the child by induced labor is fully three hundred
per cent, greater; that is to say, a mortality of
from seventy-fi\e to eighty per cent, as against twenty
to twenty-eight per cent, by symphyseotomy.
As regards the rate of mortality, symphyseotomy
takes precedence over Cesarean section and craniot-
omy, and is practically on a par with induced labor,
but with much superior results in infant-life saving.
Mensural Limitations. — In a separation of two and
one-half inches, which is, or should be the limit of dias-
tasis, a gain of half an inch is secured in the diameter
of the conjugata vera. The average biparietal diameter
of infants at birth is three and four-fifth inches. That
of the occipito-bregmatic diameter is the same, so that
we have a circle of this size representing the smallest
cylinder the foetal head can offer for passage through
the pelvis. There is a reduction of about a quarter of
an inch in this cylinder by moulding. Three-quarters
of an inch to an inch then is gained in space by mould-
ing, pubic separation of two and a half inches, and
forceps compression. On the single basis of inches
we would say that symphyseotomy should not be un-
dertaken with a conjugata vera of less than three
inches. But the elements of variation here are nu-
merous. The pubic bones have been separated by
Caruso three and two-fifth and three and three-fifth
inches without evil.
The fcttal head may be so small that delivery could
be accomplished by operation in a conjugata vera of two
and one-half inches. Again, the biparietal diameter
may be too great for delivery in an almost average con-
jugate diameter. My third case, of twin renown, had
a conjugata vera of four inches, but with a narrowed
internal transverse diameter, and both infants measured
at birth four and one-half inches in the biparietal
diameters.
Practically the most important and difficult factor
in leading to a proper selection of cases is the indi-
vidual doctor's skill in physical diagnosis. I beg
leave to call your attention to a new obstetrical his-
tory chart which will shortly be published, the aim of
which is the development of skill in diagnosis and
prognosis in all matters pertaining to an approaching
labor.
Methods of Operating. — Three ways of performing
symphyseotomy are now recognized: Morisani's,
Pinard's, and the one which I recently brought forward
at the Academy of Medicine in New York.
Morisani's method of cutting down to the upper
border of the pubis, then passing a curbed Gal-
biati knife down behind the joint and cutting frcm
the base up and out, is not popular in this coun-
try, as it should not be, being both anatomically and
surgically objectionable. Pinard's operation, which
consists of cutting down upon the face of the sym-
physis through the soft tissues and exposing the joint,
is a great improvement over Morisani's. The chief
objection to it lies in the cutting through the vessels
of the clitoris, causing much hemorrhage, and in un-
necessarily exposing the joint.
I have operated five times in the last eighteen
months by a new method which I described in a
paper before the obstetrical section of the Academy
of Medicine in January. This paper appeared in the
May number of The Po/yc/iiiic Medical and Surgical
Rc-iic7u.
Following are the brief essential points in the oper-
ation :
370
MEDICAL RECORD.
[September 12, 1896
1. Secure full dilatation of the cervix, if possible
wfthout risk- to the child, before cutting the symphysis.
2. Make the initial incision a little above the sub-
pubic arch and under the elevated clitoris.
3. Have the urethra and bladder held to one side
with a small male sound.
4. Introduce the left inde.x finger within the vagina
against the posterior ridge of the joint up to the top.
5. Pass a narrow tenotomy knife with the point
close to the joint up to within a half inch of the top,
and under the overlying soft tissues, cutting the mid-
dle portion of the joint.
6. Substitute a probe-pointed bistoury and meet the
left index finger with the probe over the top of the
joint, and work the blade through the joint downward
until separation is felt by the posterior finger.
7. Have an assistant press the mouth of the wound
and the tissues lying over the joint with a small piece
of gauze.
8. Deliver with the forceps, if possible, and refrain
from suprapubic pressure, aiming to deliver the head
through the cervix without drawing it down below the
symphysis.
9. Hold the bladder well to one side while pressing
the pubic bones together.
10. Pass a small strip of gauze into the prepubic
wound and another against the cervix after irrigating,
leaving both pieces expo.sed for easy removal, having
refrained from stitching cervix or perineum.
11. Dress the vulva with gauze and strap the joint
with adhesive strips.
12. Remove all the gauze in thirty-six hours and
irrigate the vulva and vagina twice a day, keeping the
vulva carefully dressed between times.
13. Attend to catheterization in person.
Following is a report of my fifth case, not hitherto
published.
Mrs. K. L , aged 29, Irish: one previous preg-
nancy, four years ago: she was in labor one week, and
was attended by a physician who made several visits,
then by a midwife, and was finally delivered by the
latter of a full-term, stillborn child.
Examination. — She was admitted to the Mothers'
and Babies' Hospital February 14, 1896; weight, 110
pounds; last menstruation. May, 1895. Abdominal
wall flaccid, prominent in right upper quadrant: iliac
crests, I o| inches; anterior superior spines, 10 J inches;
external conjugate, 7 inches; trochanters, 11 inches;
fundus 2 inches from the ensiform : uterus flaccid,
thin; amniotic fluid moderate; foetus movable; head
at inlet; fcetus highest in right upper quadrant; back
in middle, left side; extremities felt in right upper
quadrant; foetal heart heard in left lower quadrant;
fcetal pulse, 112; foetal movements felt most by the
mother in the middle upper portion, head resting in
the inlet and movable; head medium.
Vagina remarkably misshapen; a longitudinal cica-
trix extended from the posterior part of the cervix to
within two inches of the posterior commissure, form-
ing a small, wire-like strip.
Labor commencing, the cervix was found to be fully
dilated, bag of waters presenting, retraction of the an-
terior lip going on, and the cicatricial band was felt
to be severely stretched during uterine pains. An
enormous cicatricial ring an inch and a half thick em-
braced the entire ostium vaginae, absolutely inelastic,
limiting the diameter of the os to two inches, with no
possible increase save by cutting or tearing. The
entire pelvic floor was cicatricial, hard, inelastic, re-
sisting, unpliable. This ring extended up around and
behind the symphysis; it was impossible to introduce
the hand beyond the ring, much less to hope to deliver
a foetal head through it.
The urethra was found divided in the middle, so
that a sound introduced in the meatus passed into the
vagina. The posterior urethral opening could not be
seen, but was felt under and behind the pubis, close
to the anterior lip of the cer\-ix; the bladder could be
seen distended above the pubis, covering irregularly
a space one inch below the umbilicus and two and a
half inches to the right and left. A soft catheter was
introduced with difticulty and the urine drawn off: the
foetal condition was excellent, the cervix quite fully
dilated.
Labor began at i :3o .a.m., February 14th: presenta-
tion, L. O. A.: bladder full and high: head engaged;
moulding complete: transverse diameter of pelvis
much reduced; the vaginal cicatrix prevented direct
measurement; subpubic arch was 2 inches wide; dis-
tance between the ischia, 4 inches: distance of coccyx
from subpubis, 3 inches; conjugata vera 3^ inches.
The vagina w.is irrigated with bichloride solution
at II A.M.; bowels moved freely during the morning.
The longitudinal cicatricial band running down
from the posterior cervix was cut; numerous incisions
were made in the vagina to right and left of the rec-
tum. This enlarged the vaginal opening one inch,
although leaving everything very^ rigid- The amnion
was ruptured and forceps applied. The justifiable
limit in traction with safety to the child was em-
ployed, the head being in proper position, but no ad-
vance was .secured. The foetus was still in excellent
condition; version being impossible on account of the
rigidity of the vagina, which rendered introduction of
the hand or arm out of the question, symphyseotomy
was accomplished in a few moments. The head de-
scended one-half inch following section and separa-
tion of one and one-half inches ensued. After consid-
erable difficulty and severe forceps traction, the head
was delivered, the child being in a most vigoroi s con-
dition. Not more than three or four ounces of blood
were lost in the entire delivery. My subcutaneous
method, as employed in four previous cases, was used
in this case with entirely satisfactory results.
The wound and vagina were packed with iodoform
gauze, and then patient placed in a stretcher sus-
pended in bed, the canvas being cut under the but-
tocks, with adhesive straps bound about the pubes and
trochanters. Great difficulty was experienced in bring-
ing the symphysis together, owing, probably, to the
rigidity of the soft structures.
This woman must have been frightfully handled
in her first labor, with granulation healing of the
vagina.
The child, a male, weighed eight pounds and six
ounces: its pulse was 120 after birth.
The measurements of the foetal head were as fol-
lows :
Biparietal, with head fully moulded 3^ inches.
Uitemporal 3 J "
Fronto-mental 4 "
Occipito-frontal 5 "
Cervico-bregmatic 3j "
Suboccipito bregmatic 4 "
Occipilo-niental 5* "
Thirty-six hours after delivery the gauze was re-
moved from the pubic wound, and the parts were
gently washed with bichloride solution.
The catheter was not needed, the urine not being
retained bv the bladder. Temperature elexation of
from one to three degrees kept up, the cause being a
double slough of the vaginal cicatricial tissue. A
fistula formed just within the internal anal sphincter,
and a slough from the base of the bladder was thrown
off.
The pubic wound was in no way infected, but
healed up promptly, being entirely closed in eight
days from delivery. The patient was slowly improv-
ing four weeks from delivery, when pneumonia super-
vened and she died March i8th, thirty-three days after
September 12, 1896]
MEDICAL RECORD.
2,7^
delivery. The child is living and well, now two
months old. Without desiring to strain conclusions
in the slightest degree, I can fairly say that the one
error in the case was in not doing a Cesarean section in-
stead of a symphyseotomy. I can fairly say that death
in no way can be charged to the pubic section, but to
the tremendous cicatrix in the vagina. I did not real-
ize when I made pubic section how great the resist-
ance of the soft parts would be.
The behavior of this case is the strongest argument
yet shown in favor of my method of operating. Here
was a vaginal condition that in either Morisani's or
Pinard's method would almost certainly have infected
the pubic joint. My method has now been witnessed
by four or five of our most prominent obstetricians, and
has been highly approved without e.xception. It has
greatly reduced the chances of hemorrhage, not more
than from three to four ounces of blood being lost in any
case of the six now on record ; it has very much lessened
the liability of infection of the joint and renders sec-
tion of the joint much simpler than before. The real
dangers in symphyseotomy are not in the pubic sec-
tion, but in the delivery of the child after separation
of the joint. Laceration of the vagina appears from
a study of the records to be the most prominent dan-
ger. I must emphasize the importance of securing
the fullest dilatation of the cer\ix before making
pubic section : otherwise, in pulling with the forceps
the undilated uterus is dragged down into the pelvis,
filling its space and pressing the depressed bladder
into the diastasis, also causing the tissues in the re-
gion of the bulbi vestibuli to swell with blood and pre-
venting their stretching, thus causing them to burst and
give a starting tear to the anterior wall of the vagina.
The operator must also be on his guard to secure by
the forceps, if necessary, anterior rotation of the occi-
put, the alteration in the form of the pelvic cavity re-
sulting from pubic separation preventing the customary
act of the sacro-sciatic ligaments in throwing the pari-
etal eminence forward. There is a distinct tendency
at times for the head to remain in the transverse oc-
cipital position. I must speak emphatically in favor
of forceps delivery as against version following sym-
physeotomy, if the head is presenting normally. In
the table previously referred to there were 1 1 2 cases,
of which 82 were delivered by forceps, and 14 by
version; 4 being by both and 12 not reported. Foetal
deaths when forceps were used were 7 out of 82 and
by version 5 out of 14 cases.
My paper upon the after-effects of successful sym-
physeotomies in America, in the Folydmic Journal,
gives a remarkably favorable report. Not a single
patient has been permanently disabled, and but one
has a persisting fistula, which is rapidly closing. No
disablement of pennanent character- has resulted.
Further comment seems useless. -Symphyseotomy has
established itself on the unshakable rock of demon-
strated fact, and comes to us a welcome choice in
preference to craniotomy or Cesarean section, and in
most cases of induced labor also.
The Poison of Tetanin. — A writer in the Journal
oj the American Aledical Association writes that Brieger
has found and isolated a ptomain from the tissues in
a fatal case of tetanus which he named tetanin. This
was obtained also from cultures of the bacillus by
Kitasato and Weyl. This sub.stance kills animals
with the characteristic symptoms of tetanus, but is not
the substance to which is due the intense intoxication
of tetanus, and Brieger himself obtained a toxalbumin
of much greater toxicity. This toxalbumin, the cheniic
relations of which we do not know, is probably only
an impure form of the specific toxin — a mixture of the
precipitated albumins and the toxin.
THE VALUE OF CARBOLIC ACID IN SOME
CATARRHAL DISEASES OF CHILDREN."
By S. henry DESS-A-U, M.D.,
PROFESSOR OF P/EDIATRICS, NEW VORK SCHOOL OF CLINICAL MEDICINK.
During the past autumn and winter I have treated
with carbolic acid nearly three hundred infants and
children complaining of a group of catarrhal symp-
toms, which I have classed as being of infectious
origin — in other words, a mild, irregular type of influ-
enza. Altogether the results in these cases have been
so nearly uniform and satisfactory that I regard them
as well worth reporting.
In the beginning of the past season many children
affected similarly to these now reported were treated
with a mild sudorific and expectorant mixture, a com-
bination of liquor animonii acetatis, ipecac, ether, and
syrup of senega, but it was soon observed that the
prompt success which had always been previously ex-
perienced in like cases did not follow. This led me
to become suspicious of the nature of the compaint
until later on its infectious character was fully recog-
nized. About that time my attention was directed to
the adoption of carbolic acid as a remedy, largely
through a most instructive article on its use published
in the Medical Titnes for November, 1895, t>y '">'
friend. Dr. James Robie Wood.
Perhaps it is familiar to all physicians who have
been many years in practice that after using a certain
remedy for a period of time we discard it for some
new remedy grown more popular, until after a lapse
of time we return to the use of our old friend with re-
newed confidence. I, like many other older members
of the profession, had years before used carbolic acid
largely in the treatment of various infantile com-
plaints depending upon a low order of germ infection,
such as summer diarrhoeas, erysipelas, pertussis, and
slight congestions of mucous membranes. When in-
fluenza made its appearance in this country eight
years ago, however, the newer coal-tar derivatives were
then in vogue, and, as the type of the disease was
much severer than now, we easily found ourselves
using an apparently well-indicated remedy, like anti-
pyrin, phenacetin, or salicylate of sodium, as they were
analgesic as well as antipyretic. A wide experience
with these coal-tar products in the presence of fever
soon taught us to be careful of their depressing effects
upon the heart, which is brought about through their
influence upon the haemoglobin of the blood, convert-
ing it into a methaemoglobin, as well as by interfer-
ence with complete conversion of increased waste
products incidental to the fever process, the latter
being now regarded as a conser\'ative manifestation
to get rid of the disease poison. A reaction in our
therapeutics of influenza had thus begun to occur, and
I was one of those who preferred to adopt an elimina-
tive method of treatment, as outlined in my remarks
on the discussion of this disease before the New York
County Medical Society in November, 1891.
At the present time, however, the mild type of the
affection, as manifested in children by a dr)- cough,
worse at night, with very few coarse ronchi heard on
auscultation, either alone or together with few dry
subcrepitant rales in localized areas, scattered over
one or both lungs, alternating on slight exposure to
changes of atmospheric temperature, with a coryza or
possibly a diarrhoea, did not seem to call for so active
a line of treatment as severe cases, or those attended
with prostration and pneumonia.
The good results obtained with carbolic acid in the
cases of dry bronchitis led me later on to extend its
use with like good results to other cases, those in which,
for instance, a post-nasal catarrh with rise of rectal
' Read before the Society for Medical I'rogress of the West
Side German Dispensary, May 9, l3y6.
372
MEDICAL RECORD.
[September 12, 1896
temperature two or three degrees, or an oedematous con-
dition of the mucous membrane of the soft palate and
post-pharyngeal space was present, the latter extend-
ing in some instances to the lar}'nx, and producing
aphonia and even stenotic respiration.
It is, however, for the dry irritant cough or bron-
chitis of influenza that I especially wish to recom-
mend carbolic acid as an almost specific remedy.
Thompson describes the cough of a bronchitis as
either irritant or expectorant. Clinically the irritant
cough is not a succession of sounds linked together as
in the expectorant cough, but is dry and barking, or
like the cough of a sheep, " schathusten "' of the
Germans. This feature of the cough alone would
tend to indicate the germ origin of the bronchitis.
Moreover, this condition with scant secretion of mu-
cus lasts longer than in the first stage of an ordinary
bronchitis, in which the nonnal secretion is first dimin-
ished in quantity and afterward increased with alter-
ation in quality. In fact it may continue until the
cough entirely disappears, without any subsequent in-
crease of secretion. In the mean while the physical
signs are out of all proportion to the amount and effort
of the cough.
The elevation of rectal temperature before men-
tioned was observed in these cases to continue for
four or five days. Another characteristic feature in
these cases under consideration is the appearance of
the tongue. It is slightly covered with a white, moist
or glazed- like fur, less at the tip and sides than at the
base and centre. Through this gum-like coating, as
if delicately laid on with a brush, the fungiform
papillfB project, reddened and often enlarged, giving
the tongue the appearance, as some English writers
have described it, of a white strawberry. This condi-
tion of the tongue I regard as entirely characteristic
of this form of germ infection of mucous epithelium,
and a diagnosis of influenza is possible from its pres-
ence alone, by any one thoroughly familiar with its
appearance.
It will be recognized at once that this description
is not that of an ordinary subacute bronchitis, in which
the lungs on auscultation may show different varieties
of rales, either dry or moist, but without any rise of
temperature after the second day, unless complicated
■with a pneumonic process, or an exacerbation of the
disease depending upon further extension into other
bronchi.
Granting, however, that mv cases were only those
of an ordinary subacute bronchitis, and that the con-
dition of the tongue, loss of appetite, and general
malaise went for naught, the fact remains that the
cough persisted in spite of the usual expectorant treat-
ment that was previously entirely successful in ordi-
nary bronchitis. Hence I was forced to seek some
other mode of treatment, and, as I said before, my
thoughts most naturally turned to carbolic acid. And
why not? Have not the tar preparations been used
in pulmonary catarrhs from traditional times.' .And
was it not known in the early days of the use of car-
bolic acid that it was partly eliminated from the lungs
in the same manner as tar and the terebinthinates.'
Was not carbolic acid used by many of us in the treat-
ment of pulmonary tuberculosis with fairly good re-
sults, long before the introduction of creosote for this
disease, upon the assumption of its antiseptic action
on the pulmonary mucous membrane? Finallv, is it
not the basis of all the other coal-tar derivatives and
the simplest form for medicinal u.se?
"The end crowns the work." My choice, so far in
my experience, has happily proved most satisfactory
and my theory apparently correct. Many of these
cases of annoying cough in infants and children have
been relieved in two or tfyee days, all of them cer-
tainly within a week, whereas in the beginning of the
season cases of this class were not relieved sometimes
in three weeks or even longer.
The preparation I have used is a one-per-cent. so-
lution of the chemically pure acid, to which is added
a small quantity of glycerin or simple syrup. The
dose for children under five years of age is a tea-
spoonful, equal to between one-half and two-thirds
of a drop of carbolic acid. This is given every two
hours until improvement is aecided, when the inter-
vals maybe increased until the cessation of all symp-
toms is complete. The taste is not unpleasant,
though now and then some objection may be made to
its administration at first, but with a little firmness
this soon gi\es way. Perhaps it may be well to threw
out the hint that a word of assurance on the part of
the physician to the parent as to the nature of the
remedy will serve to secure their confidence, as in the
commencement of my present experience several pa-
rents, detecting the drug from the odor of the solution
and knowing that carbolic acid was a powerful poi-
son, hastened back to the druggist to learn if some
mistake had not been made in dispensing the pre-
scription. One woman even accused me of wishing
to kill her child. A friend has suggested to use the
word "phenic acid," as being not so familiar. I can
certainly recommend this simple treatment for influ-
enza bronchitis, or even influenza of a mild type, with
perfect confidence. So far I have observed no bad
effects from the remedy when used in the dose and
manner I have stated. I am well aware that Jacobi
and other writers on paediatrics, while recommending
carbolic acid as an internal antiseptic remedy, urge
so much caution as to its irritant eftect upon the kid-
neys as to debar the cautious physician from employ-
ing it.' All of us who have seen cases of poisoning
from carbolic acid are familiar with the smoky color
of the urine, which is said to be due to the presence of
hydroquinone, a product of oxidation of the acid from
its combustion in the body. This in itself, to my mind,
is no proof of any lesion of the kidney, for there is
every reason to believe that it occurs in the blood cir-
culation. .\s to any other evidence of renal lesion,
such as albumin and casts, I know of none. Thus
far, out of nearly three hundred cases treated with car-
bolic acid in the manner I have mentioned, I have
seen only one case of nephritis occurring during its
use, and that one I do not attribute to the acid, but to
a complication of influenza, which we now know may
cause nephritis, the same as .scarlatina, diphtheria,
or measles. Medical friends have informed me of
cases of influenza nephritis occurring in their practice
this season in which no carbolic acid had been given.
In regard to the rationale of its therapeutical action,
I can only say that I believe carbolic acid to be a
typical antiseptic. By this I do not mean that it de-
stroys any germ or antidotes any toxin as a germicide
is supposed to do, but that it renders the blood and
tissues of the body, the soil upon which the germ
thrives, sterile, thus checking any further production
of the toxin. That carbolic acid can and does perme-
ate the blood and tissues of the body can be conxinc-
ingly demonstrated to any one who has ever been pres-
ent at an autopsy where death was caused by a toxic
dose of the same. The blood- is dark and uncoagu-
lated, and gives a decided odor of the acid. As to
the daily amount of carbolic acid employed being
sufficient to affect the blood and tissues so as to pre-
vent the further growth of the influenza germ, I cannot
furnish any positive proof or demonstration to corrob-
orate my explanation of its antiseptic action. But,
besides the happv therapeutical results that follow its
use, it may be stated that there is more than a mere
possibility that this assumption is tme, for M. Raulin,
' Chemically carbolic acid is regarded as a phenyl alcohol, and,
like the other alcohols, is largely e.xcreted by the kidneys.
September 12, 1896]
MEDICAL RECORD.
373
a French scientist, quoted by Bacigalupi, has very
prettily shown that some of the lower order of germs
are most sensitive to the action of certain elements
that are either necessary or prejudicial to their growth.
Thus, for e.\ample, the aspergillus niger, order of mu-
cedinte, is increased in growth by the presence of zinc
in a culture medium seven hundred times its weight
of the metal contained therein, while one-sixteen-hun-
dred-thousandth of a grain of nitrate of silver arrests
its growth abruptly, and it will not even begin to grow-
in a silver vessel, so sensitive is its prejudice toward
this metal. Who shall say after learning such facts
that analogous conditions may not exist in weak path-
ogenic germs, such as those causing influenza, ery-
sipelas, summer diarrhoea, etc., toward carbolic acid,
even in the small quantity I have recommended, since
the blood becomes impregnated to that extent.'
I have observed that after a few days' use of car-
bolic acid the transpiratory function of the skin be-
comes most active. In addition to the slight physio-
logical action of carbolic acid upon the sweat glands,
I think this can be explained by regarding the normal
restoration of eliminative function to have occurred as
soon as the further generation of the materies jtiorhi
has been checked. This is nature's own method of
re-establishing the healthy state.
Since the foregoing was written, I find that Erunton.
in his work on "■ Pharmacology and Therapeutics,"
1885 edition, p. 690, recommends carbolic acid as a
most ser\'iceable remedy in precisely the class of cases
that I have here reported. Consequently I cannot lay
any claim to originality in the treatment of influenza
catarrhs with carbolic acid other than in the manner
of administration of the remedy. Brunton recom-
mends the use of a weak solution of carbolic acid to
be inhaled in the form of a vapor or spray, while I
give it internally, a decided advantage in my estima-
tion, especially in the treatment of children in a dis-
pensary practice.
In conclusion it may be truthfully said that in car-
bolic acid we have a most valuable remedy when
properly used. This statement does not apply merely
to children nor to influenza affecting them, but to
adults and diseases affecting them as well. History
in medicine, as in politics, repeats itself, and I be-
lieve the day is not far distant when we will be found
using carbolic acid as frequently as in years past, but
with a better knowledge of its true value than we
formerly possessed.
144 West Eightv-Fifth Street.
Colles' Fracture. — Dr. Morgan, before the Medical
Association of Georgia, April 15, 1896, says that every
case of Colles' fracture can be readily reduced by
strong, forced dorsal flexion, effected during anaesthesia.
He considers Wyeth's modification of Pilcher's dress-
ing the best. The plaster-of-paris dressing is preferable
in old people in whom there is a firm impaction which
the surgeon does not care to break up, or in cases in
which the fragments are more or less comminuted. It
should be applied from the lower border of the meta-
carpus to the middle third of the forearm, with the
patient's hand in the straight position. A straight
dorsal splint may be employed but is not very desir-
able, while in no case should the angular or pistol-
shaped splint be used; no splint should be allowed to
extend beyond the metacarpus. The fingers should
remain freely movable, and limited motion should be
encouraged at first, followed later by more active
motion. In aged patients in whom there is more or less
impaction of the broken ends reduction should not be
attempted, as impaction favors the consolidation of
fractured bones, and a crooked wrist is better than
a failure at bony union.
ETHER AND OXYGEN AS ANESTHETICS.
Bv JOHN L. CORISH, M.D.,
BROOKLYN.
Mv attention was called to the use of oxygen in con-
nection with ether as an anaesthetic by an article
which appeared in a Brooklyn daily paper in Decem-
ber last, describing the results of experiments made in
a Brooklyn hospital.
On January 5, 1896, I was called upon to attend
a child three days old, who was suffering from a severe
capillary bronchitis with marked cyanosis, dyspnoea,
and atelectasis of the lungs. A further description of
this remarkable case will be reserved for a separate
article, but I wish to embody in the present one the
result of the administration of oxygen with nitrogen
monoxid as an anaesthetic. This nux-ture was not
given for the purpose of producing ana-sthesia, but for
an entirely different object, namely, the dilatation of
the lungs and removal of obstructions of mucus from
the pulmonary lobules. On January 8th, the last day of
the administration of the oxygen mixture, I gave forced
inhalations at four different times, the last being at
3:15 p. iM. The child had recovered from the cyanosis,
atelectasis, etc., but I gave one additional application,
thinking that I would make the treatment doubly sure.
The mixture was administered by passing the gases
through a globe wash bottle and then into an ice bag,
altered and applied in such a manner as to encircle
the chin and vault of the skull. The child took the
mixture while crying. The pressure used was half an
atmosphere, as shown by the gauge on the bottle.
The natural color of the skin changed to a rosy hue,
distributed evenly over the whole body. The child
cried for perhaps half a minute, and the respirations
decreased in frequency and depth (they had been
thirty-five previous to the administration). As the
administration of the oxygen progressed, their char-
acter became similar to those of a person suffering
from morphine poisoning, as were the symptoms of
decubitus, etc., with' the difference of the rosy hue of
the skin as previously mentioned. Suddenly the
breathing stop]3ed entirely. I e.xamined the heart and
found the pulse 140, full hucI regular. The mother
became alarmed; she thought the child was dead. I
resorted to Sylvester's method for restoration and kept
it up for a period of fi\e minutes with no results.
While preparing my hypodermic for an injection of
brandy, the child gave a deep gasp, a convulsive one,
and then let out a hearty yell. From that point on
the child's respiration became normal.
As the child lay there with no respiratory move-
ment, with excessive redness of the skin, and natural
heart beat, it recalled to my mind the case of a line-
man who was shocked with a 700-volt current, am-
perage unknown, whom I attended last August. The
positions in this state of anaesthesia of both man and
child were the same; the character of the heart beat
was the same. There were no respiratory movements
in the case of the lineman for twenty minutes; he re-
covered under the D'Arsonval treatment. The ques-
tion to be answered is : What was the condition of the
child during the period when respiration was absent?
Had it been depri\ed of any of its natural resources?
No. Then, what rendered it oblivious to the rough
usage and treatment which we adopted to restore it to
consciousness? I had simply introduced into its sys-
tem a superabundance of oxygen ; in fact, to such an
extent that the system was saturated, and the respira-
tory centre satiated. The system was supplied with
an excess of oxygen stored up in the circulating fluid,
as is done by the mother for the foetus in utero. The
child did not have to use its respiratory apparatus to
sustain life until the superabundance of oxygen had
been used up in the bodily requirements; and when it
374
MEDICAL RECORD.
[September 12, 1896
had been used up what happened? Any medical
man, who has watched the newly born infant knows
how with a gasp of deepest proportions the new arrival
begins the struggle of life — with a yell. That is what
occurred in this case. When the child found it could
take care of itself, it ceased crying. I am positive
from the tests I made that the child was totally un-
conscious during those seven minutes, and that an
amputation could have been performed without the
child's returning to consciousness until the extra sup-
ply of oxygen stored in the system had been used up.
This explains how it is possible for an intra-uterine
amputation of the arm or leg to take place with the
foetus in utero, without giving rise to reflex symptoms
on the part of the mother. It may be claimed that the
nitrous oxide used to dilute the oxygen was the cause
of the anesthesia, but Wood in his " Therapeutics"
positively states that nitrous oxide does not produce
anaesthesia of itself, that the effect is caused by a want
of oxygen. As a result of their experiments M. Jolyet
and Blanche reached the same conclusion. Paul Bert
asserts that nitrous oxide as an ana;sthetic is des-
titute of positive qualities. I think these arguments
will be sufficient to exclude nitrous oxide as the
cause of the anaesthesia in this case.
I have spoken all along of the physiological result
obtained in this case as an ana-sthesia. Was it anas-
thesia which was produced.' What is anaesthesia?
Dunglison says: "Anaesthesia is the deprivation of
sensation and especially that of touch; according to
some, paralysis of sensibility; it may be general or
partial." .All the characteristics of anaesthesia were
present in this case without the toxicological symp-
toms accompanying etherization, which are similar to
those present in apoplexy, viz., stertor, dilatation of the
pupils, etc. The pupils in this case were normal;
there was no sensibility in the eye. Slapping and
pinching did not excite reflex movements. From the
above I conclude that oxygen is an anaesthetic, and an
anaesthetic par excellence, if given in sufficient quanti-
ties. This brings me to the administration of ether
and oxygen in combination for ana-sthetic purposes.
The following case will bear out my conclusions:
Edward H , seventeen years old, weight 135
pounds, residing at Fort Hamilton, was severely in-
jured on February 9, 1896, by a falling chimney.
Chloroform was used in the preliminary examination.
The patient was suffering from severe shock at the
time; still he had vitality sufficient to make a deter-
mined resistance to the administration of the chloro-
form, which was given by Dr. , ambulance sur-
geon of Seney Hospital. The excitement was very
marked; the anaesthetic was administered for forty
minutes, and recovery did not take pl;K:e for three
hours. On February 17, 1896, in company with Dr.
Blackmar, of Bay Ridge, I put the right lower extrem-
ity in a Buck's extension (for fracture of the femur)
and attended to other injuries at the same time. I
used a compound of oxygen and nitrous oxide, the gas
being pas.sed directly through the ether in the wash
bottle without the intervention of a water wash bottle.
The apparatus used was the identical one employed
in the case of the child above noted. The patient was
told to elevate the hand; he did so, and kept it up for
eight minutes, when it dropped, .\nasthesia was in-
complete until three minutes after the dropping of the
hand, the mixture still being applied. The anaesthesia
was sustained for one hour and twenty minutes under
the following conditions: Inhaler applied at 11:30
A.M.; complete anesthesia at 1 1 :4i, inhaler removed;
reapplied at 12:15 ''•^'- f°'' three minutes; interval of
twelve minutes; reapplied for four minutes and then
discontinued altogether. Patient opened his eyes at
12 :48 P.M. and fully recovered at i p.m. .\t this point
I would like to call attention to the relatively small
amount of ether employed, namely, two ounces and
six drachms, the patient being in a condition of
etherization for one hour and twenty minutes. This
amount includes loss from handling, and necessary
waste by volatilization, etc. All articles published
previously on this subject have shown a far greater
proportion of ether used for the length of time
the patient was in a condition of etherization. This
may be accounted for in several ways: ist, owing
to the imperfect construction of the apparatus; 2d,
the continued application of the mixture when un-
necessary; 3d, the o.xygen, having first passed through
water, is not capable of absorbing as much ether
as it would if passed directly through ether with-
out the intervention of an intermediate wash bottle;
4th, instead (jf the ether vapor and oxygen being thor-
oughly mixed before reaching the cone, the ether had
been placed in the cone itself and the oxygen passed
through it, i.e., an attempt had been made to unite the
oxygen and ether in the cone itself, a quantity of the
ether thereby not being uniformly mi.\ed with the
oxygen and rendering a certain amount of the ether
unnecessary.
I would call special attention to this important
point: that there was an entire absence of excess
of mucous secretions in the nares and pharynx.
At no time was there any cyanosis, neither were the
extremities cold. There was an entire absence of
vomiting and nausea. Patient had partaken of two
eggs, two slices of toast, and a cup of coffee at 8:30
A.M., three hours previous to etherization. Fifteen
minutes after recovery from the eiTects of the ether he
was given a cup of coffee, which did not in the slight-
est degree disturb his stomach; half an hour after the
recovery he fell into a doze and slept for four hours.
Dr. Blackmar tells me that he gave the patient mor-
phine, one-eighth grain, and atropine sulphate, one-two-
hundredth grain. I do not tiiink that this alone would
have caused such refreshing sleep. When the patient
awoke he immediately sat up in bed. There were no
symptoms of exhaustion following the operation.
Care should be taken to use an oxygen prepared
otherwise than the ordinary commercial oxygen which
is largely advertised and sold as pure oxygen, as much
of this gas is unfit for human consumption, being sat-
urated with chlorine and other deleterious gases.
Pure oxygen itself is unsuited for the purpose of an-
aesthesia because of its dense specific gravity, it not
passing through the capillary blood-vessels when un-
diluted. It has been repeatedly demonstrated that
animals cannot live in an atmosphere of pure oxygen.
Nature kindly points the way by directing us to the
use of nitrogen, which forms such a large percentage
of the air we breathe; it therefore follows that we
should imitate nature by using nitrogen monoxid as
a vehicle for carrying the oxygen, it being lighter in
its specific gravity and being exquisitely applicable
for this purpose. The mixture that has given me the
most satisfactory results is one composed of two
parts oxygen and one part nitrogen monoxid. A point
I wish to make here is that if one is sure of the
quality of the oxygen, it is advisable to pass it
directly through the ether, instead of first passing it
through water, and do away with the pouring of the
ether into the inhaler, generally constructed of paper
and. towels. Tiie advantages are that the mixture is
more thor(jugh, the gas is not loaded with watery
vapor in addition to the ether, the lungs can more
readily absorb the mixture, and there is very little
loss, especially when given through a suitable in-
haler. At the time that these experiments were con-
ducted I sought in vain for an inhaler with which to
carry out the administration of the oxygen. Within
a short time an inhaler has been brought to my atten-
tion, which is infinitely better than the one I im-
September 12, 1896]
MEDICAL RECORD
375
provised. I believe this inhaler is on the market and
can be obtained from any drug store where oxygen is
for sale.
Oxygen as an Anaesthetic. — An extended series
of experiments in the employment of ether, chloro-
form, nitrous oxide, and oxygen leads me to the follow-
ing conclusions:
(a) The excitement stage due to the cuting off of the
oxygen from the circulation, thereby causing nervous
reflex muscular movements and irritation of the air
passages, is abolished when the oxygen is added, on
account of the blood receiving sufficient oxygen.
(/») The cyanosis which is caused by the reflex pa-
ralysis of the vasomotors, thereby allowing dilatation
of the venous and contraction of the arterial blood
vessels, due to a lack of oxygen at the nerve centres,
is little marked or entirely absent.
(f) That there is no increase of the mucous secre-
tion is due to the removal of the cause of irr'tation
and congestion of the mucous membranes. This nui-
sance, which in many instances is intolerable, partic-
ularly in the surger)- of the nose and mouth, has in
some cases in which the secretion entered the larynx
caused dangerous symptoms of asphyxiation or subse-
quent pneumonia.
((/) The vomiting and nausea, owing to the conges-
tion of the stomach and irritation of the palate, are alle-
viated and this of necessity does away with the danger
of food becoming lodged in the air passages.
(e) The ana;sthesia may be continued without stertor.
This symptom, due to muscular paralysis of the palate,
is not a necessary accompaniment of ana-sthesia. It
shows that excess of the anjesthetic is being used.
The palate is controlled by both voluntary and invol-
untary "'forces.'' This symptom is a ver\' good guide
for the operator to go by.
(y") The recovery from ana;sthesia is quicker and
more complete, owing to a minimum of ether being
used. The recovery cannot be hastened by the em-
ployment of oxygen separately after the operation.
(g) The amount of ether used is just sufficient to
keep the patient under its effects, and when thor-
oughly mixed with the oxygen (compound) no serious
symptoms can result. The patient will not breathe at
all if oxygen be given to the point of saturation, and
therefore no more ether will be taken in than is re-
quired until the respiratory centre calls for more o.xy-
gen.
(//) Owing to the amount of oxygen stored up in the
system by this method, the etherization may be dis-
continued at times for from fifteen to thirty minutes
and complete anaesthesia may be readily and quickly
reinduced in thirty seconds, if occasion requires, by
application of the previous method. This advantage
to the specialist in pharyngeal operations must be
apparent.
(/') Owing to the character of the heart beat not being
much altered, the combined anaesthetic can be given
with comparatively less danger in cases of stenosis
and insufficiency of the cardiac valves.
Finally, I wish to state that I believe and think it
■will be borne out by subsequent experiments that
■when the oxygen is given in superabundance in con-
nection with ether, a double etfect will be produced,
/.(■., an anaesthesia from ether primarily and from oxygen
secondarily. Ether is eliminated from the system by
means of the lungs through respirator)' efforts. If we
can supply sufficient oxygen to the system, so that the
respiratory centre is not irritated or rendered dormant,
we prolong our anasthesia until such time as the ether
is split up chemically and passed off through the skin.
Another point to be observed in the use of oxygen
■with ether is this: in extensive operations in which
great loss of blood is to be expected and it is usual
to constrict the limbs, it would be advisable to ad-
minister oxygen before the tourniquet is applied, so
that when the blood is allowed to reenter the circu-
lation it will be in a condition more in conformity
with that of the rest of the body.
With regard to the anasthetic power of oxygen when
properly induced, in its application to surgery, I am
positive that it will be of very great value in opera-
tions on young children who may require surgical in-
terference of short duration. Operations about the
mouth and nose could be performed to the entire sat-
isfaction of the of)erator, as the apparatus could be
dispensed with immediately on the cessation of respi-
ration. Under the condition of o.xygen anesthesia,
so to speak, the system is saturated with oxygen, the
blood in the veins assumes an arterial hue, and the
surgeon would have difficult}' in recognizing venous
from arterial hemorrhage, but this would be insig-
nificant in comparison to the benefits obtained.
It is to be hoped that further research into this very
important subject will prove that as we perfect our
apparatus we will approach the point where we will
use the minimum amount of ether and the maximum
amount of oxygen.
I have no doubt that this article will be se-
verely criticised, and in fact would be surprised if it
were not. I would ask my critics, however, before
subjecting the article to adverse criticism, to make
their experiments in accordance with the plan I have
adopted.
Ni.netv-Second Street, .near Third .Avenue.
^ronircsB 0t IJXcdical J>cience.
Fistulae in Ano. — Dr. Metcalf [Fhysicians and Sur-
geons) says : '' Fistula in ano may be caused by pene-
trating wounds, by suppuration arising from injur}- to
the mucous membrane from foreign bodies in the
faces, or from catarrhal dysenteric or gonorrhoeal in-
flammation extending into the submucous tissue. The
suppuration may start in hemorrhoids, occasionally
caused by improper methods of treatment."
Sciatica. — Dr. C. Xegro {Semaine Medicah) treats
sciatic neuralgia by digital compression of the painful
points along the course of the nerve, and has almost
unvarying success. Out of one hundred and thirteen
cases he had good results with one hundred. The pa-
tient reclines in bed with the lower limbs in a state of
complete muscular relaxation. Compression is first
made at the point of exit of the ner\'e, w hich is usuallj'
the most sensitive point. The right thumb is placed
in contact with the painful point, and over the right
thumb the left is placed : the pressure must be ener-
getic and last about twenty seconds. Lateral pressure
is made at the same time, the thumbs remaining in a
fixed position. Other painful points are successively
treated. The seances of compression are repeated
every other day. Ordinarily six seances suffice for a
cure.
Pental and its Administration. — At a recent meet-
ing of the Society of Anesthetists Dr. Prince Stallard
read a paper on this subject (Neiu York Medical Jour-
nal \. Pental, he said, was a clear, mobile, colorless
liquid, having no marked taste, but producing a slight
burning sensation when it was placed on the tongue,
and a slight irritation at the back of the throat, which,
however, soon disappeared. It was exceedingly vola-
tile and highly inflammable: it had no escharotic ac-
tion when dropped on the skin, and its smell was
somewhat pungent, but not disagreeable, as patients
never complained of its odor. Xx. the ordinary tem-
perature of the room it was so volatile that it was nee-
376
MEDICAL RECORD.
[September 12, 1896
essary to administer it by the closed method, with the
admission of as little air as possible. If exhibited
on a piece of lint, as was usual with chloroform, a
large quantity of the drug was required. In one hun-
dred and forty-eight cases Clover's portable ether in-
haler had been used. Two drachms of pental were
poured into the reservoir, the indicator placed at o,
and the patient encouraged to fill the small bag with
his expirations; the indicator was then turned rapidly
but evenly to 3 ; rarely was it necessary to turn to F.
Pental was thus given more rapidly than was advisa-
ble with ether, and attention had been directed to the
absence of coughing, struggling, and fighting for
breath, so characteristic when the latter drug is given
alone without the previous exhibition of nitrous oxide
gas. No restriction had been placed on the patients
with regard to diet, and in only one case had there
been after-vomiting. The clothing should be quite
loose around the throat and abdomen so that the tiio-
racic and abdominal movements could be quite free.
All the administrations had taken place at about 10
A.M. In all the cases the patients had been seated in
a dental chair, the head having been placed in an easy
position midway between flexion and hyperextension.
The horizontal position, said Dr. Stallard, would be
much safer, as signs of cardiac failure had not infre-
quently occurred in the cases quoted, pental, in this
respect, resembling chloroform. V^'hen tiiis drug was
inhaled the pulse was at first quickened, and likewise
the breathing, and then the pulse became fuller and
bounding, with dilatation of the capillaries of the
face, which was evinced by extreme flushing, similar
to that observed when nitrite of amyl was inhaled;
swallowing movements were observed, but never any
coughing or struggling; screaming might occur, and
dreams of. a pleasant nature were frequently experi-
enced. Spasms, tonic and clonic, were occasionally
present in the arms or in the legs. The lid reflex was
usually present unless the ana;sthesia was deep; when
the patient was deeply under the influence of the drug
the pupils were dilated and the eyeballs turned up-
ward under the upper lids, and, in some cases, the
conjunctival vessels were prominent and congested;
the arm when raised dropped helplessly to the side.
At the height of anx-sthesia the pulse became small,
and might be running. There was no cyanosis or
d iskiness of the features, and stertor was very rare.
Micturition and defecation had never been observed.
Opisthotonos and twitchings of muscles had been
noted in a few cases, the patients having generally
been tranquil. The breathing could hardlv be heard,
and this, said the author, constituted one of the dan-
gers, and, in this respect, pental again resembled
chloroform. Recovery w-as extremely rapid, and was
not followed by any stupor or drowsiness. As a rule,
there were no after-effects, and the patients felt quite
well three minutes after the remcnal of tlie face piece,
and were able to walk out of the house. One case
only of vomiting liad occurred and three or four of
nausea; slight headache had been noted in a few
cases, but tiiis had rapidly passed off. The average
time required to produce anxsthesia had been fifty-six
seconds, and the average anesthesia obtained had
lasted for seventy-six seconds. The pre-anasthetic
stage had varied from thirty to one hundred and
twenty seconds and the ana;sthetic period from twenty-
five to two hundred and ten seconds. The advantages
maintained for pental, said Dr. Stallard. were: i.
Longer anaesthesia than nitrous oxide gas yielded.
2. Simple apparatus. 3. No struggling, coughing, or
dislike to the drug. 4. The small amount required,
which averaged two drachms. 5. Rapid recovery.
6. The absence of after-efl'ects. The disadvantages
were: i. The insidiousness of its action — an over-
dose could easily be administered. 2. Noiseless and
shallow breathing. 3. Screaming. 4. The sudden
cessation of respiration. 5. Sudden cardiac failure.
Dr. Dudley Buxton, speaking of the mortality fol-
lowing the administration of pental, said that Dr.
Stallard had given one case out of one hundred and
forty-nine, but he doubted whether it had really been
due to pental. Gurlt had given three deaths in six
hundred administrations, and Snow had given two in
two hundred and thirty-eight cases. One of the diffi-
culties in working with amylene and pental, he said,
was the presence of impurities. Before we could ac-
cuse pental of causing deaths we must be sure it was
pure pental and not some mixture of drugs simulat-
ing it. In all probability much of the pental at pres-
ent supplied was impure. One German observer had
found albuminuria and hemoglobinuria occurring in
many cases within three or four days after the admin-
istration. Pental, so far as we knew at present, was a
most useful drug, but it possibly and probably pos-
sessed grave disadvantages from its tendency to affect
respiration, perhaps through s])asm of the glottis and
of the diaphragm. In the cases of death it was to be
noted that these had arisen from failure of respira-
tion, while the heart had continued to beat for some
minutes afterward. A marked injustice might easily
be done to any new aneesthetic if, because cases of
death had occurred in the early days of its adminis-
tration, its use was therefore discarded.
Mr. Joseph \Miite said that forty years ago he had
used amylene extensively, principally for the extrac-
tion of teeth, and had found it a charming ana-sthetic,
quick in its action, with no after-effects, and liked by
the patients. When it had been used for longer ope-
rations he soon found that alarming symptoms had
been very apt to arise, and feeble respiration and cir-
culation had occurred very suddenly, so that he had
discarded the drug, as he did not consider it as safe
as chloroform.
Dr. Silk was struck with the siniiiarit)- of the re-
marks of Dr. Sallard's cases with those he had him-
self published as occurring wiien bromide of ethyl was
administered, and, given the change of name in the two
records of cases observed, it would be difficult to dis-
tinguish the one from the other. He had noticed that
witii bromide of ethyl decomposition always occurred
sooner or later when the bottle had once been opened,
and as the clinical symptoms appear so similar he
would ask Dr. Stallard whether he had found any evi-
dence of decomposition occurring with pental. He
was of opinion that patients should not be in the den-
tal chair, but recumbent during the inhalation of pen-
tal, as vascular depression so frequently occurred.
Dr. Augustus Cook said he had been administering
pental during the last four or five years; all his cases
had been fairly long ones, some of half an hour's ex-
tent, but his patients were invariably in the recum-
bent position. The main advantage of pental was
the absence of after-effects; it might even be adminis-
tered on a full stomach without fear of causing vomit-
ing. The open method was emploj-ed in all the cases.
Dr. Dudley Buxton asked if Dr. .Stallard could ex-
plain why in these recorded cases one would give ar»
anesthesia of ninety seconds, another of twent)'-five
seconds, and another of as much as two hundred and
ten seconds.
Dr. Stallard said that he had frequently noticed
decomposition of the drug. With regard to albumi-
nuria, he had examined twenty-five cases after ad-
ministration and found no albumin, but it must be
remembered that all his cases had been short ones
and its effect would not be long enough to injure the
kidney. The fall of blood-pressure was marked.
With regard to the length of anesthesia obtained, he
was of opinion that there was a marked personal fac-
tor in manv cases.
September 12, 1896]
MEDICAL RECORD.
377
Medical Record:
A Weekly Jouriial of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, & 47 East Tenth Street.
New York, September 12, 1896.
RABBITS AND REFORM.
The course of reform never did run smooth, any more
than that of true love. Its troubles with the perversi-
ties of human nature have been chronicled and sung
in all the ages. Its purest projects have ever been
thwarted by the selfishness of designing men ; its con-
verts, like Voltaire's woman, never can be trusted till
they're dead; its noblest precepts have ever been flatly
defied by sinful humanity. We can therefore imagine
that it must have been with almost a sigh of relief
that the great and good men known as "The Com-
mittee of Fifty" upon alcoholism turned from this
stiff-necked and ungrateful species to pursue their
studies upon and among the docile and amiable rabbit
and the timid hare. But fate still pursues them. The
question sought to be decided was the apparently
simple one, whether the daily ingestion of alcohol
sufficient to produce acute intoxication in hitherto re-
spectable and well-behaved bunnies affected in any
way their resistance to inoculation with various patho-
genic germs. The investigation was accordingly in-
augurated in that native haunt of purity and propriety,
the University of Pennsylvania, in its Institute of Hy-
giene, and under a competent bacteriologist. But no
sooner had it begun than difficulties began to spring
up on every side. Rabbit nature suddenly developed
striking similarities to the human ditto, in point of per-
verseness. In the first place, under no circumstances
and in no combination, neither with the fragrant mint,
the cooling lemon, nor the ardent but too constant
onion, could bunny be induced to absorb the beverage
of his own free will. This, of course, simply confirms
our previous impressions as to the very low grade of
intelligence possessed by these animals, but it was a
very real and serious obstacle to the experiments, for
all the alcohol given had to be injected through a
stomach tube, which, owing to the resistance offered by
the animal, was very apt sooner or later to produce
lesions of the gullet or stomach which gave rise to
serious and often fatal secondaiy septic infections.
Secondly, it was found extremely diflicult to deter-
mine a " standard '' dose which could be relied upon
to produce acute intoxication in any case, partly from
the wide range of individual susceptibility to the drug,
but mainly on account of the difficulty of deciding
when the animal was actually drunk. The " truly
rural '" articulation test was, of course, out of the ques-
tion in a species of such reticent habit; their expres-
sion is mild but singularly fixed, and couldn't be
sillier, and the only sign which the experimenters
could find to be depended upon was a staggering gait.
Even this, of course, was naturally hard to elicit in a
creature of such consen'ative and earth-loving tenden-
cies, and which keeps nearly as much of its surface
constantly applied to the ground as a penny bun does.
Thirdly, in order to overcome his positively adhesive
equilibrium, it was found necessary to give enormous
doses of alcohol, such as would be the equivalent of
nearly a quart of whiskey/f/- diem for a human being,
and these caused such a rapid loss of weight that the
experimenter himself declared that the lowering of
the resisting power produced was probably analogous
to that effected by simple starvation.
The result of the experiments showed that under
this vigorous treatment the resisting power of the ani-
mals was distinctly lowered for the various strepto- and
staphylo-groups (pyogenic), but scarcely affected at
all for the typhoid, diphtheria, and other bacilli.
As a contribution to the study of the effects of al-
cohol upon the human subject these experiments are,
of course, to the physician's eye little less than a farce,
but we fear that such little discrepancies as those
most frankly and fully pointed out by the bacteriolo-
gist in charge, in his recent report, will in no way dis-
courage our temperance friends from using the results
in their next onslaught upon the drink demon.
A similar investigation is just being carried out
upon monkeys, which present the advantages of having
no conscientious or other scruples against taking the
liquor in almost any form and of being gifted with both
a loquacity and an activity- of movement which enable
them to exhibit the characteristic symptoms of the
drug with an almost Hibernian promptness and un-
mistakableness. However, we fear that long ere the
research is concluded the thumbs of the experimenter
will look back with keen regret to the days of the
blameless and non-belligerent bunny, and that the
ideal subject for these experiments has not yet been
found.
THE LAW AND ACCIDENT INSURANCE
POLICIES.
The liability of companies insuring against accidents
is so often tested in courts of law that it becomes of
the utmost importance that the relative positions of
plaintiff and defendant should be accurately defined.
In the practice of this new branch of jurisprudence
numerous decisions have been rendered which aid
very materially in the formulation of leading princi-
ples of action in given cases, and in the main they
may be considered just and reasonable to all parties
concerned. That more, however, is to be learned is
.shown by a case recently before the appellate division
of the Supreme Court in the third department of this
State. A physician in Essex County sued the Inter-
State Casualty Company for $487.50, in consequence
of cellulitis resulting from a self-administration of a
hypodermatic injection of morphine. In order to
base the action upon an accident and bring the occur-
378
MEDICAL RECORD.
[September 12, 1896
rence under the intent and meaning of the policy held
by the plaintiff, a novel and ingenious claim was
made. While the physician was driving on his rounds,
away from immediate help, he was seized with exhaus-
tion arising from an injury previously received. He
accordingly stopped his horse, and while he was admin-
istering a hypodermatic injection to himself the horse
started suddenly and the needle was driven to an un-
necessary depth into the leg. Cellulitis ensued, which
disabled him for a period of many weeks. The com-
pany refused to pay the doctor, and the Circuit Court
in Essex County, before which the case was tried, dis-
missed the suit on the grounds that the administration
of the morphine was voluntary, that the drug had noth-
ing to do with the cause of the inflammation, and,
lastly, that the whole difficulty was caused by an un-
clean needle. From a scientific point of view, the de-
cision was an eminently just one, and the only surprise
is that the judgment of the first court was reversed by
the appellate court, mainly on the ground that the
mere depth to which the needle penetrated might
have been an important and leading causative ele-
ment. It will be interesting to note what will be
the result of the recommendation of a trial by jury
on the points involved. It will be extremely diffi-
cult, in the light of our present knowledge of wound
treatment, to prove any relation of cause and effect
with the mere depth of the wound, provided a per-
fectly aseptic instrument was used. The mere start-
ing of the horse was the only element of accident in
the case, and had evidently no more to do directly
with the after-results than if the animal had been
miles away. The slightest prick of a septic needle
would have settled the question of infection, no matter
how carefully otherwise the instrument might have
been used.
The case in point, although only directly important
to the litigating parties, is likely to involve questions
which may affect the relations of practitioners to pa-
tients in defining what may or may not be preventable
disasters. An unclean needle deliberately used in
administering a hypodermatic injection is by no
means an accident.
THE CASTRATION OF CRIMINALS.
In a paper entitled " The Crimes of Medical Men,"
in the Medical Herald io\ June, 1896, Dr. W. O. Hen-
ry mentions as one of the crimes of which some, no
doubt many, of us are guilty is a failure to urge legis-
lation to prevent the marriage of criminals, or to have
them castrated. Whether we are to regard such a fail-
ure as wrong or not must depend entirely upon wheth-
er or not we think the " proposed remedy is one that
will the most surely prevent crime."
As to forbidding marriage, most persons of the class
referred to are married before they become confirmed
drunkards or are known as habitual criminals; more-
over, it is by no means certain that they would pro-
create less if they were not married and had their lib-
erty.
Castration of the " rapist" might fit in with the
sense of justice as well as with that of retaliation of
most people, but if the community should reach the con-
clusion that drunkards and criminals should not leave
descendants, it would seem that an effectual means to
that end could be found aside from depriving them of
organs which are %o important as to be characteristic
of sex, and which, it is more than likely, are essential
in some respects to normal mind and physical health.
And then, who shall say that the drunkard and the
criminal have fallen so low that they ought as a result
of mutilation to be deprived forever of the possibility
of redemption through woman's purifying influence?
The reason for making a general law condemning
these unfortunates to castration is suggested solely by
judgment based presumably upon facts, but the facts
are not all in or are too uncertain in their application
to assure a whole profession that the judgment is
final. But if it were proven that procreation by these
persons is so baneful to society as to justify steps ef-
fectually to stop it, the end could be reached simply by
such restraint as would prevent the sexual relation,
while incidentally the criminal would be made to
forego his crimes and the drunkard his debaucheries.
Then, in the event of a mistake having been made by
the community, it would not be impossible to undo the
injury.
TAPEWORMS OF POULTRY.
The bureau of animal industry of the United States
department of agriculture has recently published a
bulletin in which our present knowledge of tapeworm
in poultry is presented in a concentrated form, richly
illustrated with two hundred and seventy-six care-
fully drawn figures, while the ample facts are well
arranged for reference, offering an excellent founda-
tion for those who desire to take up such investiga-
tions. The medical profession and the public can
be assured that there are no attending horrors of
infection involved in the investigations of Dr. C. W.
Stiles, who has compiled this work, and that chicken
roasted, boiled, or fried may be prescribed by physi-
cians or enjoyed by ladies without fear or suspicion
of danger lurking in this favorite and appetizing
dish, for although we must now admit that the pres-
ence of tapeworms is very prevalent in turkeys, geese,
ducks, fowls, and other birds eaten as food, both
wild and domesticated, we have the comforting assur-
ance that none of the tapeworms of birds is transmis-
sible to man, in any stage of its development, and
that the presence of tapeworms in the intestines of
fowls does not in itself warrant the condemnation of
their bodies as an article of food. The life history of
the poultry tapewomi agrees with that of other tape-
worms : the eggs are contained in the droppings of the
diseased animal — the ova are then swallowed by the
necessary intermediate host. Within the ova are the
six hooked embryos, known as oncosphere ; these bore
their way into the body of the intermediate host, and
are developed into the larval form, known in this case
as cysticercoid. This lar\'a, snugly hid in the body of
a tempting-looking worm or snail, is innocently swal-
lowed by a turkey, duck, or chicken, and is then de-
veloped into the adult tapeworm. One of the most
September 12, 1896]
MEDICAL RECORD.
379
common of intermediate liosts is the minute little
crustacean abounding in pond and lake waters, popu-
larly known as the water flea.
These water fleas are so commonly bearers of the
parasites that geese and ducks are found to be in-
fested with no less than five different kinds of tape-
worms which have obtained entrance to their bodies
by means of the ingested fleas. It is, therefore, a
merciful provision of providence that the human fam-
ily is proof against contagion of this character, which
is fatal to so many birds, but the fact nevertheless
offers a strong argument for freeing by perfect filtra-
tion all drinking-water from contaminations. The
treatment for poultry tapeworm is much the same as
for those found in man, the chief drugs employed
being extract of male fern, turpentine, powdered ka-
mala, areca nut, pomegranate-root bark, pumpkin seed,
and sulphate of copper. Dr. Salmon offers a word of
warning advising that the above drugs should be as
fresh as possible, as failure in treatment is often due
to the fact that old drugs have been used which had
lost their anthelmintic value. The suggestion is a
good one, and causes us to wonder how often the good
work of the physician is rendered abortive by his pre-
scriptions being prepared with drugs which are the
remnants of an old stock and impotent for good.
Dr. Francis Richard Cruise, of Dublin, has recently
had knighthood conferred upon him by the lord lieu-
tenant of Ireland.
Camden County (N. J.) Medical Society — At the
regular monthly meeting of the Camden County Medi-
cal Society, at Camden, N. J., Dr. J. Chalmers Da
Costa read a paper on " Malignant Tumors."
Reducing the Death Rate. — The death rate in
Chicago is going to be materially reduced, not by
the introduction of needed sanitary measures but by
estimating the population of the city at a much higher
figure than hitherto.
Individual Cups for School Children Dr. Frank
P. Connelly, superintendent of the bureau of conta-
gious diseases of Newark, has recommended to the
board of health of that city that no drinking-cups or
dippers for general use shall be provided in the public
schools, and that each scholar shall be required to
provide an individual cup or glass.
An Austrian Code of Ethics is now in process of
formation. The compilers have just finished with the
knotty problem of consultations, and have decided
that, in case of two or more consultants being called
in, the last one summoned takes precedence over the
others. Each consultant in turn must be told what
fee the previous one received, and may then value his
own services accordingly.
Medical Women in Scotland The Marquis of
Bute, who is lord rector of St. Andrew's University,
has given notice of his intention to move at the next
meeting of the University Court that a woman shall
be appointed to the post of assistant professor of med-
icine and lecturer in physiology at St. Andrew's. It
remains to be seen whether the Scotch students will be
as unmannerly as their Irish confreres, who threat-
ened to leave the university rather than come up be-
fore a woman examiner.
Generous Gift to the Philadelphia Polyclinic
The trustees of the Philadelphia Polyclinic Hospital
have just received $5,000 from Mr. Barclay Lippincott,
to establish a free bed as a tribute to the memorj- of
his wife, Mar\' Lippincott.
The New Mexico Medical Society, at its annual
meeting at Socorro, N. M., on August 12th and 13th,
elected officers as follows: President, Dr. C. G. Dun-
can, of Socorro, N. M. ; Secretary, Dr. H. J. Aber-
nathy of Socorro, N. M. The next meeting will be
held in Albuquerque on the second Wednesday in
May, 1897.
Norristown (Pa.) Hospital for the Insane. — Dr.
Susan J. Taber, who has been for twelve years first as-
sistant physician, has been selected as the successor
of Dr. Alice Bennett, recently resigned, as chief resi-
dent physician in the women's department of the Nor-
ristown Hospital for the Insane.
Would It Were So !— The editor of the St. Louis
Clinique has made a discovery that will astonish most
of our New York readers. He says that " there is
one thing in which our Eastern brethren get ahead of
us smartly, and that is in collecting their fees. They
certainly get the wealth, whether they earn it or not.
If you get a prescription you have got to pay for it.
It is easy to keep books in New York. Everything is
cash and on the gold standard."
The Ninth Annual Meeting of the American Asso-
ciation of Obstetricians and Gynecologists will be
held at the Hotel Jefferson, Richmond, ^'a., Tuesday,
Wednesday, and Thursday, September 22, 23, and 24,
1896. Railway rates from all points to and from
Richmond for this meeting will be one full fare going
and one-third fare returning, on the certificate plan.
Members on purchasing their tickets must secure from
the agent a certificate that they have paid a full fare
to Richmond. On reaching Richmond they can ob-
tain a return ticket for one-third of the usual fare.
An Unusual Suit for Damages — A suit for Sio,-
000 has been entered by Dr. D. C. T. Watkins, of
Pottsville, Pa., against a female patient, who, after re-
fusing to make payment of a bill for the treatment of
a compound fracture of the tibia, claiming imperfect
setting and shortening, had a skiagraph made of the
fractured bone and sent a communication to a local
newspaper, stating that the picture showed shortening
and deformity due to overlapping of the fragments.
Foreign Dentists in Hungary. — It has for a long
time been a disputed question whether dentists who
have obtained dental diplomas abroad should be per-
mitted to practise in Hungary. Considering that only
qualified medical men are allowed to practise dentistry
38o
MEDICAL RECORD.
[September 12, 1896
in Hungarj-, and that there is no special examining
board for dentistry in this countrj', the government has
declared that for the future a license granted in an-
other country will be valid only if its possessor is a
qualified medical man who acquired his diploma of
M.D. in one of those universities which are recognized
in Hungary. — The Lancet.
" Masked Appendicitis." — In the article with this
title in the issue of August 29th, it was stated that the
evening temperature of the patient ran from 100° to
1 10° F. ; and in the last line the author stated that the
temperature never went above tio° F. In each in-
stance it should have been 101° F., instead of 1 10° F.
New York State Association of Railway Sur-
geons.— The annual meeting of this association will
be held under the presidency of Dr. C. S. Parkhill, of
Homellsville, on November 17, 1896, at the Academy
of Medicine, New York City. The secretary of the
association is Dr. C. B. Herrick, of Troy.
The Water Supply of Brooklyn. — Many com-
plaints have been made during the past summer of the
foul condition of Brooklyn's water supply. An exam-
ination of the ponds whence the water is drawn has
shown that they are full of decaying vegetable matter
and of insects and their larvae. The water is discol-
ored and has a bad odor and taste. It has been rec-
ommended by the health board that the ponds and res-
ervoirs be cleaned and the pipes flushed, without wait-
ing for the natural purification which will result from
the cooler weather and the heavy autumn rains.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical corps
of the United States navy for the two weeks ending
September 5, 1896: August 24th. — Medical Director
David Kindleberger placed on the retired list, Sep-
tember 2d; Assistant .Surgeon H. La Motte ordered
to the naval hospital at Norfolk ; Surgeon C. Biddle
detached from the Monongahela and placed on waiting
orders. August 26th. — Medical Inspector J. C. Wise
and Surgeons J. C. Byrnes and C. Biddle ordered as a
board to convene at Annapolis, September 3d, to ex-
amine candidates for admission to the naval acad-
emy. August 29th. — Passed Assistant Surgeon E.
R. Stitt ordered to duty in the bureau of medi-
cine and surgery. August 31st. — Passed Assistant
Surgeon C. H. T. Lowndes detached from the naval
hospital, Philadelphia, and ordered to the Wash-
ington navy yard; Assistant Surgeon L. Morris or-
dered to the naval hospital, Philadelphia. September
3d. — Assistant Surgeon G. D. Costigan ordered to the
naval laboratory for instruction.
Dr. Thomas Gallagher, the alleged dynamiter who
was sentenced to a life imprisonment in England thir-
teen years ago, on purely circumstantial evidence, has
just been released and arrived in this country last
week. He has been found to be incurably insane, and
was removed to a private asylum a few days after his
arrival. He was graduated from Bellevue Medical
College in 1880, and had a large practice in Brooklyn
before he went to London. He became insane dur-
ing his life in prison, and is said to bear marks on his
body of ill-treatment. It does not follow, however,
that he was badly treated, for the tissues of the insane
are exceedingly vulnerable, and Dr. Gallagher's inju-
ries may have resultea from the use of only such force
as was necessary to restrain him.
Typhoid Fever from Ice Cream. — An outbreak of
typhoid fever occurred during the latter part of July in
the town of East Barrington, N. H. The cases were
all traced to a single source. The first case was an
unrecognized one, the patient being unwell but help-
ing about the house and doing part of the milking.
It is supposed that he must have in some way contam-
inated the milk, as by going to stool and not washing
his hands before returning to his milking. The water
supply was carefully examined and found to be all
right. On a Friday evening a party was given at the
house and the guests ate of ice cream made at home
from tlie milk supply above referred to. Within the
next ten or fourteen days fourteen of the guests came
down with typhoid fever — eight in the town of Bar-
rington, of whom one died; two in Lee; one each in
Dover, Rochester, and Woodbury, N. H., and one in
Haverhill, Mass. All of these out-of-tow^n cases were
guests at the party. No other cases occurred in the
town, and all were partakers of the cream. — Boston
Medical and Surgical Journal.
Obituary Notes. — Dr. Elswortk F. Smith, one of
the oldest physicians of St. Louis, died at Fort Mis-
soula in the early part of August. He was born in
St. Louis and was graduated from the St. Louis Medi-
cal College in 1848. After studying four years in
Paris he returned to his native city, where he practised
until a few years ago. He was seventy-three years
old. His death resulted from injuries received while
trying to extinguish some burning curtains. — Dr. Al-
EXA.N'DLR BucHAXA.N', of this citv, died on September
2d, of pulmonary tuberculosis. He was born in Glas-
gow, but while still young came to this country.
He was graduated in medicine in Glasgow in i860, and
also from the New York Medical College in 1862. He
had lived and practised in New York since that date.
He left a widow and three children. — Dr. Hull
Allen, of Milford, Conn., died a short time ago at his
home in that town. Dr. Allen was in his ninety-sev-
enth year, and until recently was in the active enjoy-
ment of good health. — Dr. Abraham Livezev, the
oldest physician in Bucks County, Pa., died at Yard-
ley on August 31st, at the age of seventy-five years.
He was graduated from Princeton College in 1842
and from Jefferson Medical College in 1844. He was
at one time professor of obstetrics in the Woman's
Medical College of Philadelphia. — Dr. Sylvanus
S. Mulford, of New York, died suddenly of heart
disease on September 9th. He was born in 1830, and
was graduated in medicine from the College of Physi-
cians and Surgeons in this city in 1856. — Dr. Wil-
liam M. McLaury died suddenly at his home in
this city on September 8th. He was born in 1830,
and received his medical degree from the medical de-
partment of the University of the City of New York in
i860.
September 12, 1896]
MEDICAL RECORD.
381
An Editor's Vacation. — The editor of a French
contemporary announces to his readers that he is go-
ing to take a two months' leave of absence, in order to
relieve them of his writings and himself of a stone in
the bladder.
A Law that Should be Observed. — It is stated
in the Sun that there is in New York a city ordinance
which provides that no person shall place or post or
cause to be placed or posted in any street of the city
"any handbill or advertisement giving notice of any
person having, or professing to have, skill in the
treatment or curing of any illness, or offering for sale
any medicine, under a penalty of $25." It is a pity
that this ordinance is not enforced.
The Rays Did Not Depilate. — A man in Paris
heard of a case in which the hair of the head fell out
from a patch exposed to the .v-rays, and thought he
had discovered a way to make his fortune. He ac-
cordingly advertised that he would guarantee to re-
move the mustaches and whiskers with which some
French women are adorned. He took his fees and e.\-
l"osed the patients to the apparatus, but, as the hair
showed no sign of disappearing, he was straightway
arrested for fraud.
Tenement Houses in Greater New York. — In the
proposed charter for Greater New York it is required
that all tenement houses must have light, ventilation,
and ample means of exit in their construction. They
are to be inspected twice each year, and the infected
and uninhabitable buildings must be condemned.
Two buildings cannot be placed on the same lot, un-
less there is a clear open space between them, not less
than ten feet wide. No building shall occupy more
than sixty-five per cent, of the area of its lot. In tene-
ment houses erected after June 16, 1897, every sleep-
ing-room must have a window, at least twelve square
feet in size, admitting light and air directly from the
street or yard.
Pennsylvania and Maryland Union Medical As-
sociation.— The nineteenth annual session of the
Pennsylvania and Maryland Union Medical Associa-
tion was held at York, Pa., on August 27th. An ad-
dress of welcome was delivered by Dr. T. M. Living-
ston, of Columbia, president of the association, and
was responded to by Dr. Charles G. Hill, of Baltimore.
Addresses were delivered also by Drs. Joseph Price,
of Philadelphia, and E. \V. Meisenhelder, of York.
The following officers were elected for the ensuing
year: President, Dr. Joseph Price, of Philadelphia;
Vice-Presidents, Drs. C. A. Rahter, of Harrisburg;
Charles G. Hill, of Baltimore; Secretary and Treas-
urer, Dr. Roland Jessop, of York; Executi'ce Committee,
Drs. Alexander R. Craig, of Columbia; A. A. Long, of
York; G. H. Bare, of Cecil County, Md. ; G. H. Rohe,
of Baltimore; \V. M. Weidman, of Reading; S. D. Ris-
ley, of Philadelphia: George R. Welchans, of Lancas-
ter; C. G. Treichler, of Honeybrook; and H. L. Orth,
of Harrisburg.
A Physician's Right to Withhold Alcohol. — It is
stated in the British Medical Journal \.\\-1lX. the highest
criminal court in Magdeburg, on May 28th last, gave
judgment in a trial, at the instance of the State attor-
ney, of Dr. Hirschfeld, who was accused of having
caused or accelerated the death of a man who had
been thirty-six hours under his care whom he had sent
to hospital, where, after treatment for eight days with
large doses of alcohol and quinine, the patient died.
The accused had administered no alcohol. The dis-
ease was stated to have been serous inllammation of
the cellular tissue of the left arm, ushered in by py-
rexia (blood poisoning). The district medical officer
and one of the hospital staff" attributed the death to
the withholding of alcohol. In justification. Dr.
Hirschfeld pleaded that he believed alcohol to be mis-
chievous in all diseases, taking away the patient's
strength. Smith, of Marbach, quoted Harnack, of
Halle, and Drysdale, of London, and there were two
adjournments to procure an authoritative opinion from
the General Aledical Council of Saxony, which opinion
called attention to the great change of medical opinion
as to the therapeutic value of alcohol, and upheld the
principle that it is inadmissible to put any limit to the
e.xercise of the individual judgment of the physician.
There was a verdict of acquittal, and the State was
made liable for the costs of the prosecution.
" Janus " is the name of a new international bi-
monthly periodical to be devoted to the history of medi-
cine and to medical geography. The new journal
is published in Amsterdam under the editorial charge
of Dr. H. F. A. Peypers. Among the list of asso-
ciate editors appear the names of the following Amer-
icans: Surgeon-General Dr. George M. Sternberg, of
the United States army; Dr. William Osier, of Bal-
timore: and Dr .William Pepper, of Philadelphia.
In the list of collaborators are Dr. L. C. Gray, of
New York; Dr. J. Guiteras, of Philadelphia; Dr. A.
Jacobi, of New York ; Dr. Charles Jewett, of Brooklyn ;
Dr. L. C. Lane, of San Francisco: Dr. A. E. Regens-
burger, of San Francisco; Dr. N. Senn, of Chicago;
Dr. F. A. Shattuck, of Boston; Dr J. T. \Vhittaker, of
Cincinnati ; and Dr. Charles Denison, of E)enver.
The first number, that of July-August, 1896, opens
with an introduction in French, entitled "Janus Redi-
vivus," by Prof. B. J. Stokvis, of Amsterdam. This is
followed by articles on " Yariolation and Vaccination,"
by Dr. J. Petersen, of Copenhagen ; " Study of Lep-
rosy in Iceland," by Dr. E. Ehlers, of Copenhagen;
'■ History of the Functions of the Cerebral Cortex," by
Professor Adamkiewicz, of Vienna: "Vaccination
against Snake-Poison," by Dr. Calmette, of Lille;
"The Early History of Lanolin," by Professor Huse-
mann, of Gottingen; "History of Diphtheria in Den-
mark," by Dr J. Carlsen, of Copenhagen ; " A Pseudo-
Precursor of Pasteur," by the editor, Dr. Peypers; and
the " Medical Jurist of Three Centuries Ago," by Dr.
R. Landau, of Frankenberg. These articles are writ-
ten in English, French, or German, according to the
nationality or inclination of the authors. The num-
ber closes with a number of abstracts on subjects rela-
ting to medical geography and the history of medicine.
If the promise of the first number is fulfilled, y<7////J
will be a very valuable addition to medical periodical
literature.
382
MEDICAL RECORD.
[September 12, 1896
ilctitnt)s and JXottccs.
Twentieth Century Practice. An Encyclopedia of
Modern Medical Science. By Leadinjj .•\uthorities of Eu-
rope and .America. Edited by Th(j.m.^s L. Sted.m.an',
M.D., New York City. In Twenty \'olumes. Volume
\'II1. •• Diseases of the Digestive Organs." New York :
William Wood and Company. 1896.
The publishers announce that they have again been obliged
to issue a volume of this series out of the regular order, and
that the seventh volume will be the ne.xt to appear. The sur-
prising thing is, not that a volume must occasionally be pub-
lished ahead of its turn, but that one appears with such regu-
larity every three months. \\'hen it is remembered that the
contributors to this work are scattered far and wide over the
world, and that each doubtless writes in his own language
and must be translated, we can only mar\-el at the success of
the editor and publishers in keeping their promise of four
volumes a year.
The present volume deals with the " Diseases of the Diges-
tive Organs. " The first article, that on "Diseases of the
Mouth," by Professor Mickulicz and Dr. Kiimmel, of Bres-
lau, treats of the general diseases of this cavity, and is an ex-
cellent presentation of the .subject. We find little said of the
local affections of the tongue, lips, and other parts, and we pre-
sume that the.se are to be treated of in a subsequent volume.
Following this is a short but sufficiently comprehensive
article by Dr. R. H. Fitz. on •' Diseases of the Oesopha-
gus," and this is succeeded by one of considerable length on
the " Diseases of the Stomach," written by Dr. Ma.\ Ein-
hom. The author devotes a number of pages to a consid-
eration of the various manipulations employed in the exami-
nation of the stomach and in the treatment of its disorders,
the e.xplanation being accompanied by numerous well-made
illustrations, which are apparently original. Professor Leo,
of Bonn, has an article of about thirty pages on the " Dis-
eases of the Pancreas." If the aim of study is to learn that
we know nothing, this article admirably accomplishes the
object, for one rises from its perusal with the conxiction that
most pancreatic affections can be diagnosed only in the dead-
house, or if, perchance, diagnosed earlier, nothing can keep
the sufferers from this place. This is followed by a well-
written and verj- original article on the • ' Diseases of the Peri-
toneum;" that is to say, on peritonitis from various causes.
The .section on " Appendicitis " is interesting and instructive.
The author. Dr. B. F. Curtis, of New York, being a sur-
geon, is naturally inclined to the operative side of the present
controversy, yet he is by no means intemperate in his advo-
cacy of surgical measures. Not only this section but the
whole article may be read with profit by physician and sur-
geon, alike. The concluding articles in the volume are on
'• .Animal Parasites " and '• Treatment of the Diseases caused
by .Animal Parasites " the first by Dr. J. Ch. Huber, of Mem-
mingen, in Bavaria, and the second by Dr. James M. French,
of Cincinnati. The first article is ver)' rich in bibliographi-
cal references and a little too academic for the average phy-
sician, we imagine, yet it appears to be exhaustive in its
treatment of the subject. The second article, that on treat-
ment, is thoroughly practical. The volume, regarded as a
whole, appears to be fully up to the high standard set by the
earlier numbers of the series, and it becomes more and more
evident that the promise of an authoritative work on latter-
day medicine will be kept.
The FfN'DUS Oculi, with .\.\ Ophi h.^lmoscopic
Atlas Illustrating its Physiological and
Pathological Conditions. By W. Ada.vis Frost,
F. R.C.S. , Ophthalmic Surgeon, St. George's Hospital;
Surgeon to the Royal Westminster Ophthalmic Hospital.
New York: Macmiilan & Co. Price, Si 8.
This publication, which forms a book nine and a half by
twelve inches and is one and a half inches thick, is printed in
large (Columbian ) type on heavy white paper. The text of
the work is preceded by a preface, table of contents, list of
illustrations, and an introduction. There are fortv-six figures
in the body of the text and forty-seven plates of chromo-
lithographs with one hundred and seven figures, which repre-
sent all of the more common appearances of the fundus oculi
in health and in disease. -All of the colored plates were pro-
duced from drawings from actual cases, made by an artist
under the direct supervision of the author. The upright
image and artificial light were employed, except in a few in-
stances, in which the indirect method was used. In the intro-
duction an argument is advanced for the purpose of impress-
ing the general practitioner with the importance of a knowl-
edge of ophthalmoscopy, and the work is avowedly produced
for his use. Ophthalmoscopy cannot be practised satisfac-
torily by those who employ it only occasionally; for this
reason such publications as the one under review will be
consulted most frequently by the student in ophthalmology.
The text of the work, which occupies two hundred and eight
pages, is divided into thirteen chapters, which are devoted
to the discussion of the anatomy of the parts involved in the
production of the fundus picture, explanations of the different
appearances obser\-ed, etiolog\', and normal and jjathological
histology. The discussion of the different conditions ob-
ser\ed in the fundus bears evidence of very careful observa-
tion and research. It is fully up to date, except in some
parts relating to the anatomy of the retina, where the most
recent views have not been adopted, and in some minor
details of morbid anatomy, particularly in regard to albumi-
nuric retinitis. The direct, concise, and lucid manner in
which the descriptions of the various conditions are given is
truly admirable. Exhaustive without being verbose, com-
plete in facts without being confusing, the conception and
completion of the argument leaves little 10 be desired. Too
much cannot be said in praise of the colored plates. They
faithfully represent the conditions that they are intended to
depict, producing the best impression when viewed by arti-
ficial light. Seven plates — twenty-one figures^are devoted
to the representation of physiological variations in the ap-
pearance of the fundus. This is an excellent departure,
since it serves to acquaint the student with the great vari-
ations in physiological conditions — a point often insufficiently
emphasized. Plates representing the appearances of the
fundus when intra-ocular growths, tubercle, or cntozoa are
present have been omitted, but, on account of their relatively
rare presence, this omission does not detract greatly from the
value of the work.
A .Manual of Anatomy. By Irving S. Haynes, Ph.B.,
.M.D., .Adjunct Professor and Demonstrator of Anat-
omy in the Medical Department of the New York Univer-
sity ; \'isiting Surgeon to the Harlem Hospital. [Philadel-
phia: W. B. Saunders. 1896.
This is the work of a practical instructor, one who knows
by experience the requirements of the average student and is
able to meet these requirements m a ver)' satisfactory- way.
It is a book on regional and topographical anatomy chiefly, a
large part of it being devoted to a description of the abdom-
inal and thoracic viscera and their relations to the surface of
the body. The illustrations are largely reproductive of pho-
tographs of dissections, and many of them are excellent.
The author has endeavored to depict the relation of the vis-
cera to the surface landmarks by means of composite photo-
graphs, but not with great success, for. like all composite
photographs, they are quite indistinct. The author calls
special attention in his preface to the index, and. a careful
testing of it convinces us that he has cause to feel satisfied
with it. The book is one that can be commended.
Diagnosis and Treatment of the Rectum. Anus,
AND Contiguous Textures. Designed for Practi-
tioners and Students. By S. G. Gant, M.D., I'rofessor
of Diseases of the Rectum and Anus, I'niversity and
Woman's .Medical Colleges; Lecturer on Intestinal Dis-
eases in the Scarlett Training-School for Nurses, etc.,
Kansas City. With two chapters on " Cancer " and
"Coloiomy" by Herhert William Allixgham,
F. R.C.S. Eng. , Surgeon to the Great Northern Hos-
pital, etc. Illustratetl with 16 full-page chromo-litho-
graphic plates and 1 1 5 wood engravings in the text.
Philadelphia: The F. A. Davis Company. 1896.
If It is true, as has many times been stated, that doctors
want picture books, then the volume just issued will meet a
good sale. We are inclined to believe, however, that Ameri-
can physicians are being educated up to a standard of illus-
tration which the present work has failed to reach. In the
abundance of woodcuts and colored drawings, mediocrity
rather than finished elegance and accuracy of detail has pre-
vailed. The author has aimed to give to the physician
seeking knowledge of these ailments and the methods advo-
September 12, 1896]
MEDICAL RECORD.
38;
cated for their relief a practical working book, and with this
aim has scattered his object lessons with a profuse bounty.
It is unfortunate that the printer did not insert tissue slips
to face the lithographs, and thus prevent sticking of the text
page, as happened in several instances in the volume be-
fore us. The te.xt shows a wide familiarity with these dis-
eases, and methods of cure and authorities are frequently
quoted. " Railroading as an Etiological Factor in Rectal
Diseases " is a chapter not to be found in other similar
works. The author's railroad-hospital work and society con-
nections have evidently made his subject familiar to him.
The work is eminently practical, and gives the impression
of honesty of opinion as the result of honest search for
truth.
The Non- Heredity of Inebriety. By Leslie E.
Keeley, M.D., LL.D. Chicago: .S. C. Griggs & Co.
1896.
Thirty-nine chapters, comprised within three hundred and
forty-two pages, and covering all forms of questions bearing
upon the general subject of inebriety, have the ultimate aim
of demonstration that it is a disease, not of hereditary origin,
but one readily curable. The author states that in the
discovery of his method of cure he investigated the ques-
tion on the lines of natural selections relating to pathology.
"I learned," he says, "that cells acquire an immunity
from poisons by being poisoned. I finally learned that cer-
tam well-known drugs will obliterate the vestiges of variation.
or whatever changes there may be in nerve cells after long
use of alcohol."
Just what these drugs are is not mentioned.
Hahnemann's Defense of the Organon of Ra-
tional Medicine, and of his Previous Homoeopathic
Works against the Attack of Professor Hecker. An E.\-
planatory commentary on the Homoepathic System. Trans-
lated by R. E. Dudgeon, M.D. Philadelphia: Boencke
& Tafel. 1 896.
This work has not hitherto been translated. It was sup-
posed to have been written by Friedrich Hahnemann, son of
the father of this system of medicine, but the translator be-
lieves it to be in reality the work of the paternal master hand.
The reply was made at a time when homoeopathy was threat-
ened with overthrow from the attacks of Hecker. of Dresden,
who at that time was a leading authority. This is said to be
the only writing e.xtant in which Hahnemann defends his
teachings, and will consequently be read with interest by all
interested in them. It is not a purely defensive work, as oc-
casional thrusts at the scientific medicine of the day are found
here and there, and the translator has left all of the asperities
of diction for which the writer was occasionally noted.
A letter from Hahnemann himself to his publisher will be
found interesting. As to whether it was worth while to
translate the "refutation," we must leave the reader to de-
cide.
Blind Leaders of the Blind: The Romance of a
Blind Lawyer. By J AMES R. CoCKE, M.D., author of
" Hypnotism," etc. Boston. Lee & Shepard. 1896.
There are no less than fifty-two chapters in this novel.
Most of them are devoid of interest or of sufficient literary
noteworthiness to explain their existence.
An Inquiry into the Difficulties Encountered
IN Reduction of Dislocations of the Hip. By
Oscar H. Allis, M.D., Surgeon to the Presbyterian
Hospital, Philadelphia, etc. The Samuel D. Gross Prize
Essay. Philadelphia. 1 896.
After some twelve pages of interesting reminiscences, the
essay takes the form of a discussion of the following proposi-
tions :
1. The capsule is the most important agent against trau-
matic dislocations of the femur.
2. For the laceration of the capsule and dislodgement of
the head of the femur, the femur is employed as a lever.
3. Every lever has a fulcrum; the fulcra required in dis-
locations of the femur are bony and ligamentous.
4. Dislocation by thrust, if possible, is infrequent.
5. Reduction by circumduction is the simplest, the most
brilliant, and the most hazardous of all modes of replace-
ment.
6. Methods suggested for reduction of dislocation of the
head of the femur when associated with fracture of the shaft.
An introductory study treats of the anatomy of the parts ;
then the lesions produced in experimental work are taken up,
and this is followed by pathological considerations. In Part
II. reduction of dislocations by manipulation is fully entered
into and the methods and obstacles are critically examined.
The illustrations are numerous and instructive, and the whole
essay is deserving of much praise.
Elementary Anatomy and Surgery for Nurses.
A Series of Lectures Delivered to the Nursing Staff of the
West London Hospital. By W. McAdam Eccles, ^LS.
Lond., F.R.C.S. Eng. , Assistant Surgeon to the West
London Hospital, Assistant Surgeon to the City of London
Truss .Society, etc. London : The Scientific Press, Lim-
ited. 1896.
The more important points in anatomy requisite for a nurse
to know are particularly brought out. An abstract of
surgery is given in much the same manner. These are im-
portant matters, especially for surgical nurses, to acquire, and
have not always been dwelt upon in works upon nursing.
There are nearly one hundred illustrations.
Perhaps most of the information could be obtained from
other works usually found in the library of the trained nurse,
but here the essential points are given in compact form.
Encyklopadie der Therapie. Herausgegeben von Os-
car LlEliRElcH, Dr. Med., Geheimer Medicinalrath, 0.0.
Professor der Heilmittellehre an der Friedrich-Wilhelms-
L'niversitat. unter Mitwirkung von M.\RTIN MENDEL-
SOHN. Dr. Med.. Privatdocent der inneren Medicin an
der Friedrich-Wilhelms-L'niversitat, und Arthur Wurz-
BURG, Dr. Med., Kgl. Sanitatsrath, Bibliothekar im Kai-
serlichen Gesundheitsamte. Erster Band, III. Abthei-
lung. Berlin: August Hirschwald. 1896.
This part of Liebreich's " Cyclopedia of Therapeutics "
completes \'ol. I. It includes titles from Ceradia to Dia-
mine, and contains such important subjects as cinchona,
and its alkaloids, chloral, chloroform, chlorosis, cholera, co-
caine, cystitis, intestinal affections (under Darm), and dia-
betes. The articles are concise but comprehensive, and con-
tain all the information needed for the average reader,
expressed in the fewest possible words. A feature of the
work is a brief notice of all the health resorts in the world.
Among them we find: "Coney Island, Ort im Staate Xew
York, Seebad." As a work of reference for the busy prac-
titioner, this one leaves nothing to be desired.
Transactions of the First Pan-American Medical
Congress, Held in Washington, D.C, September
5, 6, 7, and 8, 1893. In two parts. Washington: Gov-
ernment Printing Office. 1895.
That it required two volumes of over eleven hundred pages
each of small-type print to contain the papers and discus-
sions indicates what a vast amount of work was represented
in this first congress of the Americas.
That such a meeting and exchange of views can only be
enhanced in its benefits by a distribution of the published
transactions goes without saying. Much can be learned by
physicians of North America concerning the diseases pecu-
liar to the southern climes by the study of these papers ; the
the converse is probably of equal truth. The papers are not
uniformly of the highest scientific order, and it would be un-
just to medical America to have the impression go abroad
that these two volumes represent the best effort of scientific
medical thought on this side the Atlantic.
Traitement des Maladies des Femmes par l'Elec-
tricite. Par le Dr. L. R. Regnier. With preface
by Dr. Labadie. Paris: Lagrave. 1896.
For all those whose interests lead them toward the study
and employment of the powerful therapeutic agent, elec-
tricity, in gynecology. Dr. Regnier's work will prove instruc-
tive. The literature has been carefully worked over, and the
author's personal experience has been brought to bear upon
the selection of data and commentation. This is one of the
Progres Medical series of publications.
Anleitende Vorlesungen fur den Operations-
CURSUS AN DER LEICHE. \ 0V\ PrOF. E. V(iN BERG-
MANN und Dr. H. RoCHS. Third enlarged edition, with
63 illustrations. Berlin: August Hirschwald. 1896.
This is a very useful little work, well illustrated, and adapted
for the use of students of operative surgery, and might be of
384
MEDICAL RECORD.
[September 12, 1896
aid likewise tp teachers of this branch as well as that of re-
gional anatomy.
It is arranged in the form of fifteen lectures upon opera-
tions on the cadaver.
Fear. By Angelo Mosso. Translated from the Fifth
Edition of the Italian, by E. Lough and F. KlESOW.
London. New York, and Bombay : Longmans. Green &
Co. 1896.
This is a work in which physicians will find much of Inter-
est. There are chapters on the circulation of the blood in
the brain during emotion, trembling, the physiognomy of
pain, fear in children, maladies producing fear, hereditary
transmission, etc. The author believes that fear is a disease
to be cured.
A H.\NDBOOK ON Leprosy, By S. P. Lmpev, M.D.,
M.C. Late Chief and Medical Superintendent. Robben
Island Leper and Lunatic Asylum, Cape Colony, South
Africa. Philadelphia : P. Blakiston, Son & Co. 1 896.
Coming from one e.xperienced at one of the largest leper set-
tlements in the world, the little work of Dr. Impey should
carry some weight with it. It is profusely illustrated and
well calculated to meet the want for which it was especially
written, i.e., to supply information to medical men as well
as to interested laymen upon the subject of what leprosy is
and what it is not. The author's experience at the Robben
Island Inhrmar)- taught him that many cases were sent in as
leprosy which were in reality something entirely different.
Die Heilung der S^•PHlIJs. \'on Dk. C. Wester-
field. Wiesbaden.
A LITTLE brochure intended for the patient, giving him use-
ful instruction, not alone about the care necessar\- in bring-
ing about his own cure, but also concerning the precautions
necessary to prevent danger to others. There has been too
little effo't on the part of physicians to instruct the public in
those things which should be known about syphilis.
It may be that such literature is not put forth with wholly
unselfish motives, but if accidental transmission is prevented
in a few instances the end may justify the intention.
Formulaire. Aide-Memoire de la Faculte de Medecine
et des Medecins des Hopitaux de Paris. Par le Dr. Fer-
dinand Roux, Mention Honorable de I'lnstitut, etc.
Fourth Edition. G. Steinhcil, Editor. Paris. 1896.
Alphabetically arranged as eight subjects, with the first
four letters at the top of the page, in dictionary fashion, to
make reference easy, and giving the various plans of treat-
ment under the names of the different authorities. Dr.
Rou.x's little work comprises in its four hundred and twenty-
three pages much therapeutic information in a compact and
accessible form. The paper and print are good, but the
binding is of rather thin cardboard.
Die Pathologie der Schutzpocken Impfung. Von
S.-R. Dr. L. FiJRST, Special-.Arzt fiir Kinderheilkunde.
Berlin : V'erlag von Oscar Coblentz. 1 896.
Coming, as this work does, just as we are celebrating Jenner's
centennial, it seems ver>- timely. The author has consid-
ered preventive vaccination from its many sides, and has de-
voted much space to the abnormal and pathological appear-
ances which follow now and then, and has pointed out the
proper therapeutic measures to pursue in these conditions.
These are grouped under the different headings: "Auto-
inoculation," "Abnormal Local Course," and "Generalized
Anomalies." L'nder the head of infections are given first at
some length the various dermatoses, and secondly, the other
infectious processes. Ten pages of literary references close
a volume which will prove of interest to a large class of read-
ers, including the dermatologists.
Affections Chirurgicales du Tronc (Rachis,
Thorax, Abdomen, Bassin), Statistique et Obser-
vations. Par le Dr. Polaillon, Chirurgien de 1' Ho-
tel Dieu, etc. Paris: Librairie Octave Doin. 1896.
The audior, already known by his hospital statistics of sur-
gical affections of the extremities, presents in this vol-
ume the statistics of his hospital experience, extracting the
principal facts of importance, and giving the results of treat-
ment with and without operation. The fatal cases have not
been omitted and often teach useful lessons. Such a work,
based upon personal observ'ations extending over a period of
seventeen years, carries with it an element often lacking in
compilations giving the experience and opinions of a number
of different obserxers.
Part First treats of the various diseases of the thorax, ab-
domen, peh'is. and spinal column ; Part Second will comprise
those of the ano-rectal and genital regions.
Most of the histories of cases are given with great detail,
with temperatures and changes from day to day.
Text-Book of Comparative Anatomy. By Arnold
Lang. Professor of Zoologj- in the University of Zurich,
formerly Ritter Professor of Phylogeny in the L'niversity
of Jena. Translated into English by Henry M. Ber-
nard, M..A. Cantab., and Maiilda Bernard. Part II.
London and New York: Macmillan & Co. 1896.
This volume corresponds to the third and fourth parts of
the original, which were late in appearing, and the difficulties
of translation have combined to cause a delay in llic appear-
ance of this second \'olume of Professor Lang's comparative
anatomy of the invertebrata. In spite of this delay, zool-
ogists will be repaid in the knowledge that the material has
been well worked over before being submitted to the printer.
The drawings, which are numerous. ha\'e been almost wholly
the work of the author's pen. The translation is commenda-
ble, when the dilliculties of such an undertaking are consid-
ered.
The volume is in reality more in the nature of a compre-
hensive treatise u|)<)n the groups with which it deals, " Mol-
lusca," " Echinodermata, " and " Enteropneusta, " than an
unbroken continuation of the first volume.
How TO Feed Children. A Manual for Mothers. Nurses,
and Physicians. By LoflSE E. Hogan. Philadelphia:
J. I'.. Lippincott Company. 1896.
This is a work based upon various papers which have ap-
peared of late in periodical literature. It offers in a practical
form suggestions as to diet in infancy and childhood, such
as are approved by the best authorities. There are two
hundred and thirty-six pages, inclusive of index, and all
worth reading. Much valuable information is given upon
this important topic.
Braithwaite's Retrospect of Medicine. ^■olume
CXIII. January 7th to June. 1896. London: Simpkin.
Marshall, Hamilton, Kent & Co. 1896.
This half-yearly journal contains its usual retrospective view
of discoveries, practical improvements, and advances in all
departments of medical science.
A general index covering the volumes issued since 1893 is
contained in this number, providing easy reference to any
subject one may be investigating.
Des Angines Couenneuses Non-Diphtheriques.
Considerations sur la Pathogenic, le Diagnostic, et le Traite-
ment. Par M. le DociElR Dufaud, Medecin-Major
de 2d Classe. Paris: A. Maloine, Editeur. 1896.
A BROCHURE of a hundred and odd pages covering the
various forms of membranous affections of the throat which
are not due to diphtheritic infections. Twenty-eight obser-
vations are given and a bibliographic index is appended.
The question is an important and interesting one. and
ever>- light that can be thrown upon it is welcome.
VEROFFENTLICHUNGEN AUS DEM GEBIETE DES MLII AR-
Saxitatswesens. Herausgegeben von der Medicinal-
Abtheilung des Kbniglich Preussischen Kriegsministe-
riums. Heft 10. Berlin: Veriag von August Hirschwald.
1896.
This volume is taken up chiefly with a consideration of the
a-rays, and contains numerous excellent examples of shadow-
picture patholog)'.
On Germinal Selection. By August Weis.mann.
Chicago: The Open Court Publishing Company. 1896.
This is a translation by J. T. McCormack from an address
delivered before the International Congress of Zoologists at
Leyden, September 16, 1895.
The author, while assuming that primar)- variations are ac-
cidental, endeavors to demonstrate that an interior mechanism
exists which compels them to go on increasing in definite
direction the moment selection interx-enes.
September 12, 1896]
MEDICAL RECORD.
385
«ocictvj Reports,
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, May ij, i8g6.
John Slade Elv, M.D., PREsinENX.
A New Method of Preparing the Blood for Clinical
Purposes. — Dr. Louis \\ali>steix said that since the
work of Ehrlich and his followers, attention had been
drawn again to the granules that are found in leuco-
cytes, of which Max Schultz gave a description long
before the studies of Ehrlich on this subject. Since
that time the e.xamination of blood with a view of de-
termining the nature and the number of these granules
had entered the clinical field and had become more
important as a diagnostic method.
The method of Ehrlich and his followers was more
especially one that could be applied in the laboratorj-
only, as it required certain special apparatus and con-
siderable time was needed to perfect the coloring. A
number of other investigators had, however, given
their attention to this clinical method, among others,
Hardv and Kanthack in England, several investiga-
tors in Germany, and Dr. Ewing in this country. Dr.
Ewing had originated a method which came very near
to the ideal one. During last year, the speaker said,
he had devoted considerable attention to this subject,
and in the Berliner kliiiisclte U'oehensihrift of .\pril of
last vear he had published the description of a method
which, with some modifications, he desired to describe
and demonstrate this evening. .\11 the various meth-
ods had for their principal object the rapid and per-
fect fi.xation of the blood. The more perfectly and
the more quickly this was done, the better. Heat,
when applied in various ways, did this in more or less
complete manner: but often the flame and the incuba-
tor were not at hand at the bedside, and hence he had
resorted to the fumes of osmic acid. He had used this
agent previously in some studies that he had made
under Hanvier, in Paris, in 1881. But there was a
disadvantage connected with this plan, i.e., the longer
the blood was subjected to the fumes of a four-per-
cent, solution of osmic acid, the less it would take up of
the coloring agent. Last summer, in England, he had
made some unsuccessful experiments with formalin,
but since that time he had iiad more encouraging re-
sults with this agent. He was now able to prepare a
satisfactory slide in si.x or seven minutes, and this prep-
aration could be kept and e.xamined at leisure. The
method was so simple that even the nurse could spread
the cover glass for the physician. He believed the
time would come when the blood would be e.xamined
just as commonly and systematically as the pulse and
temperature are at the present time. There was a cer-
tain school of pathologists which thought that we had
reached the limits of cellular patholog)', but he felt
confident that the time was coming when cytology'
would be e.xtended into the profounder study of the
blood corpuscle during life, and that here we would
find as important information as in the chemical and
biological investigations of the serum.
It is most essential that the slides upon which the
blood smears are made should be perfectly clean, and
it is well to this end to wash them with alcohol and
ether, equal parts. The puncture for obtaining the
blood is best made with a spear such as is used by the
dermatologists for the treatment of acne, for it will
then not be necessary to squeeze the finger or ear too
much. .•V fraction of a drop of blood is caught up by
the end of a smearing-slip, which is placed at an acute
angle on the slide and drawn over its surface with a
gentle pressure as soon as the drop has run along the
entire edge of the slip. These slips are made of crown
glass, measuring three by two and one-half by one-
eighth inches, with edges ground perfectly smooth
and rounded. The slide is then immediately placed,
blood downward, over the mouth of a bottle containing
a ten-per-cent. solution of formalin (twenty-five per
cent, of the commercial formalin, which is a forty-per-
cent, solution), and allowed to remain there from three
to five minutes, which is long enough to fi.x the blood
elements. These specimens can be colored at once or
kept any length of time for further treatment. It is
advisable to use only Griibler's alcoholic eosin, as the
ordinary eosin differs greatly in staining quality as
well as in solubility when coming from different facto-
ries. For the close study of the two varieties of gran-
ules stained with eosin, the best fluid is one contain-
ing eosin to saturation in eighty-per-cent. alcohol, to
which is added twice the quantity of alcohol of the
same strength. The smears are treated with this solu-
tion during two minutes, and then washed with water
and allowed to dry in the air, and enclosed with Can-
ada balsam, which should not, however, be dissolved
in xvlol or benzol; that dissolved in cedar oil gave,
the iaest results. Besides the large " eosinophile''
granules the smaller ones are also distinctly colored;
they, as well as the former, are, therefore, '• acido-
phile" — a fact upon which attention had already been
called in the above-mentioned article, and which had
also been found by Hardy and Kanthack (" o.xyphile'').
Ehrlich designates them as " neutrophile" granules,
because he found that they take up both acid and ba-
sic aniline dves. Although it was not the purpose of
this communication to enter upon a discussion of the
granules themselves, it might be mentioned that when
basic dyes are applied to such specimens previously
stained with eosin, these smaller granules take up the
basic dye in proportion to the time of exposure to their
action; methylin-blue, for instance, will show them
violet at first, blue at a later stage, and lastly it will
have neutralized the red completely, so that the gran-
ules will be entirely discolored. The eosin acts evi-
dently, in respect to the basic dye, as a mordant, much
as in the case of cotton in the dyeing industry. Cot-
ton is dyed by an acid color, but not by a basic dye.
But if the acid dye be used first, it is found to act as a
mordant: the cotton thread is thus provided with what
the dyer calls an " acid back." The small acidophile
granules also take up what the dyer calls " substantive
dyes," just as does cotton. It is possible, therefore,
that these so-called neutrophile granules are bodies
resembling carbohydrates, and may thus be chemically
different from those bodies which take up the basic
dyes, e.g., the nucleus and other forms of granules.
The large acidophile or eosinophile granules are read-
ily saturated with acid dyes, and will not, therefore,
take up anv basic dye when once colored w ith an acid
dve, provided that the basic-dye solution employed
does not contain above a certain proportion of alcohol
when other conditions prevail.
As a basic dve, the speaker said, he used for its
distinctive qualities, both with regard to the staining
of the nucleus and certain differentiations of the baso-'
phile granules, thionin — not the thionin of commerce,
but what is also known as the "violet of Lauth." It
is also called the thionin of Hoyer, because Hoyer
used it in 1890 in his investigations of mucin. The
speaker recommends the following staining fluid; a
saturated solution of thionin in thirty-three-per-cent.
alcohol, to which is added twice the quantity of alco-
hol of the same strength. The specimens are exposed
to this solution for two minutes, thoroughly washed
wnth water, allowed to dry in the air, and enclosed in
Canada balsam. • Thionin is an excellent nuclear
stain, and produces peculiar coloring in certain blood
specimens, which are to be treated of on a future occa-
386
MEDICAL RECORD.
[September 12, 1S96
sion; it imparts, for instance, a brownish color to the
large granules (basophilic [?]) found in leucocxtha-
mia. Under certain conditions the serum would be
of a bluish tinge, and the red discs would be colored
from blue to light green, depending upon certain de-
grees of anamia. For these reasons this dye was a
very valuable one. The best plan was to stain one
slide with the eosin and the other with the thionin.
That the formalin instantaneously fi.xed the blood was
demonstrated by the fact that in certain cases the
"budding" of the leucocytes was well shown.
This solution of thionin is also a capital one-color
stain for malaria-blood specimens, the plasmodia ap-
pearing with admirable distinctness against the light
greenish tinge imparted to the red blood corpuscles.
From a number of indications the speaker ventured
to conclude that continuous and systematic examina-
tions of the blood during the entire course of the dis-
ease would lead to most interesting results, from which
might be ascertained important information not only
concerning the action of the toxins in infectious and
other acute diseases, but also symptomatic changes in
reference to their treatment. He would, therefore, rec-
ommend that such blood slides should be made by the
attendants quite as regularly as the records are taken
of the temperature, pulse, and respiration. At all
events, he would continue his work along these lines,
and hoped to be able to report upon it at some future
time.
Dr. J.'V.mes Ewing said he had examined a number
of specimens stained by this method, and considered
it a most excellent one. The method of spreading the
blood was in itself a distinct advantage over the ordi-
nary technique, in that the specially ground slide was
more easily handled than the cover glass and the blood
was spread more uniformly. It seemed to him even
superior to the method of dropping the blood on one
cover glass and spreading it On another cover glass,
for Dr. Waldstein's plan gave a good opportunity for
the formation of rouleaux. The fixation he had found
to be very simple and in every way satisfactory. He
had tried Ehrlich's triacid mixture in addition to Dr.
Waldstein's coloring agents, and he had come to the
conclusion that the triacid mixture was the best of all.
He had found that in the method of fixing by formalin
the corpuscles were rather more yellow than w hen fixed
by heat. Ehrlich's dye itself was not a very good nu-
clear stain, and in specimens fixed by formalin the tri-
aoid mixture did not stain so well as when the fixation
was secured by heat. The blood plates were, however,
rather better .stained after the formalin fixation than
after heat. The theolin stain was certainly a most
valuable one. The whole method called for a very
careful and extended trial by every one interested in the
study of the blood.
Dr. J. S. Th.-vcher asked if the length of time the
blood was Exposed to the formalin was of importance.
Dr. Waldstein replied that he had not found any
bad effect from prolonged exposure to formalin, but
one or two minutes sufliced iin the purpose of fixation.
An Experimental Study of Some of the Nutri-
tional Changes Resulting from Fat Starvation.
— Dk. ('. .\. Hkrikr presented a paper with tiiis title.
He said that this experimental study had been origi-
nally undertaken to determine if the lesions of rickets
could be produced in growing animals by withholding
fats, so far as possible, from their dietary. This was
suggested by the fact that the clinical indications of
rickets were often made promptly to disapjjear by the
addition of fat to the food. The pig was selected for
these experiments.
Pig 1 was experimented upon for a period of
fifty-one weeks, beginning December 16, 1893. It
was given a limited quantity of milk from the Walker-
Gordon laboratory. The average proportion of fat in
this milk was one-fortieth per cent., whereas the milk
of the SC5W usually contains from eight to ten per cent,
and that of the cow one per cent, of fat. At the end
of the first week, notwithstanding the fact that the ani-
mal was receiving about one-three-hundredth part of
the nonnal proportion of fat for a pig, its weight in-
creased, so that at the end of the fifty-one weeks the
total increase in weight was sixteen pounds. The ani-
mal became markedly constipated, and after a few-
weeks showed great muscular weakness and the skin
and hair became dr)-. Toward the end of the term of
experimentation the animal became very weak and
drowsy ; then the temperature rose, and it was evident
that it was moribund. It was therefore killed. It
was found that the ha;moglohin had been reduced to
sixty-five per cent., and that there was a slight reduc-
tion in the number of red cells. Pig 8 was fed on
the same milk, but was allowed to take as much as it
desired instead of a limited quantity. At the end of
twenty weeks the animal showed some muscular weak-
ness and a tendency to drowsiness. Pig 2 was ex-
perimented upon for fifty-six weeks. It was given a
supplementary diet of carbohydrates. Toward the
end of the experiment the urine was at times saccha-
rine. The faces were dark and sometimes diarrhceal.
The skin remained soft and well nourished. Toward
the end slight muscular weakness was noted.
An inquiry into the pathological anatomy of the
changes in the skin, principally, showed that there was
no subcutaneous fat, but, instead, a layer of gelatinous
material. In all the parts of the body where fat was
normally located this gelatinous material was found.
In Pig 2 some shrinkage was found in the fat cells af-
ter eight weeks, and after fourteen weeks they were
shrunken to half their normal size. At the end of
twenty weeks the fat layer was very pale and the fat
cells were reduced in size, but there was no gelatinous
material such as was found in Pig i and Pig 8. The
heart was large, pale, and flabby; there were several
hemorriiages on either side of the coronary arteries;
instead of the usual fat layer was one of gelatinous
material. Many of the muscular fibres of the left ven-
tricle were the seat of slight granular degeneration.
The histological appearance of the liver was normal.
Tiie kidneys were surrounded by the same gelatinous
material, and these organs were enlarged and con-
tained hemorrhagic spots. The epithelium of the tu-
bules everywhere showed granular degeneration, and
the cells of the secreting tubes were swollen and de-
generating— in short, the kidneys presented the appear-
ance of parenchymatous degeneration. The supra-
renals appeared normal, except for being unduly large.
Tiie knee-joints were filled with bloody synovial Huid.
The cranial bones were thinner and more brittle than
normal. The bone marrow was replaced by materia)
having the consistence and appearance of blood clot.
Sections from the femur showed normal bone struc-
ture. In Pig 2 the femur showed a development of
bone almost exactly the same in degree as in Pig i, the
marrow adjacent to the compact bone being very red,
while the rest was of the normal pink color. A chem-
ical examination of the gelatinous material showed it
to be evidently a phosphorus containing proteid,
known as a nucleo-albumin : hence, the process al-
ready described might be properly described as a
'• mucoid degeneration." An inquiry into the quantity
of urea and phosphoric acid and the ratio between the
two resulted in showing that there was a very consid-
erable increase in tiie amount of urea excreted in the
course of the experiment: but there was not a corre-
sponding increa.se in the excretion of phosphoric acid
— indeed, there was a slight decrease. The striking
feature was the high ratios throughout, or, in other
words, the small quantity of phosphoric acid excreted
in proportion to the urea. In Pig 9 there was an ir-
September 12, 1896]
MEDICAL RECORD.
387
regular but slight increase in the phosphoric acid.
These animals were fed on fatless milk, and in all the
proportion of phosphoric acid was distinct!}' lower than
in the animals fed-on normal milk. On feeding Pig 9
with an additional allowance of suet, there was an im-
mediate return to the ratio lormally observed in pigs
fed on normal diet. This would seem to prove that
the low phosphoric-acid secretion was the result of the
defective absorption of phosphorus from the intestine.
Notwithstanding the great diminution of fat, the quan-
titv of phosphorized fat — the lecithins of the brain —
was not diminished. In endeavoring to study mi-
nutely this process of mucoid degeneration, it was
found that the cells broke up into larger and smaller
fat globules; then the cells diminished in size, the
cell membrane grew irregular in outline, and in time
the cell contents were free from fat. The findings in
Pig 2 show that this withdrawal of fat from the milk
did not necessarily cause this mucoid degeneration.
The chronic degeneration of the kidney in Pig i prob-
ably resulted from the prolonged activity in e.xcreting
nitrogenized material, owing to the highly nitrogenized
diet. This view was confirmed by the findings in Pig
2, in which there was much less nitrogenized food, and
no such changes were found in the kidney.
The following were the author's conclusions: (i)
That the lesions resulting from fat starvation in pigs
do not resemble rickets: (2) that prolonged fat starva-
tion leads to the disappearance of fat from the adipose
of the body and its replacement by a gelatinous homo-
geneous-looking substance; (3) that this substance
contains a nucleo-albumin but not mucin, but the
pathological change may be spoken of for the present
as mucoid degeneration; (4) that the lecithins of the
brain and liver are not materially reduced by fat star-
vation; (5) that fat starvation does not lead to mucoid
degeneration if the animal be given a large excess of
carbohydrate food; and (6) that fat starvation causes
a very imperfect absorption of phosphoric acid from
the intestine.
Dr. Alexander Lamhert asked if the paralysis ap-
peared to be due to a general weakness or to a nerve
lesion.
Dr. Herter replied that he thought it was due to
the local atrophy of the muscle fibres. The nerves,
however, were not examined.
Dr. Reginald H. Sayre asked if the hind legs
alone were paralyzed in these animals.
Dr. Herter replied that all four legs were affected,
but the hind legs suffered more severely in Pig i.
They were about equally affected in Pig 8. As to the
question of fat star\'ation and its bearing on rickets,
he would say that the appearances were more like
those of scurvy than of rickets. He had examined the
breast milk from women nursing rickety children ex-
clusively, and had been surprised to find that in some
of these the milk was exceedingly rich in fat, and in
none was the fat below the average.
Dr. Waldstein said that in a rather large clinical
experience he had seen many rickety children, and he
had never been impressed with the idea that there was
a causal connection between the proportion of fat in
the milk and rickets, but he had been impressed with
the fact that many children were rachitic whose moth-
ers had been chlorotic or markedly anaemic during the
period of pregnancy. He could recall several in-
stances in which the same mother had had both healthy
and rachitic children, and in every instance the mother
had been anaemic during the time in which she had
carried the child which had subsequently developed
rickets. He had made many inquiries on this point.
with results of a similar tenor. Moreover, he had not
found that the use of cod-liver oil was of benefit in
rickety children. The only valuable treatment, in his
experience, for rachitis, had been the administration
of phosphorus in olive-oil emulsion, according to the
method of Kassowitz. He had not obtained such re-
sults from the use of Thomson's solution of phospho-
rus. He recalled having seen in lipomata of old peo-
ple a gelatinous condition answering the description
of mucoid degeneration as given in the paper.
Dr. James Ewing said he had repeatedly seen the
fat about the heart and kidney in cases of acute phthi-
sis replaced by a gelatinous material.
The society then went into executive session.
C!>TiiticaT tlcpai'tmcnt.
INFLAMMATION OF THE SUBLINGUAL
GLANDS.
liv A. H. HEXDERSON, M.I)..
MON^, SOUTH SHAN STATES.
.\s primary inflammation of the sublingual glands is
of rare occurrence, I send the following: On June
2d a Shan came asking me to go and see a wo-
man who was growing a second tongue. I was in-
formed that when this happened they grew very fast
and were very sore. I found it to be not a bad de-
scription of the general appearance for one who knew
nothing of anatomy. The symptoms were those of
parotitis — pain, swelling under the jaw, temperature of
100° F., pulse of 120, with a copious flow of saliva,
according to the report of the patient, although the
amount seemed normal when I saw it. The treatment
and subsequent history were those of parotitis. As it
seemed to be known by the people, I presume it is not
uncommon here, though this is the first case I have
seen.
DOES APPENDICITIS FOLLO\r FAMILY
LINES?
By WILLIAM T. SMITil, M.D.,
HANOVER, N. H,
Three cases coming under my notice within a few
months past have suggested the above question. The
following is a brief account of these cases:
Case I. — A man, forty-five years of age. Acute
catarrhal appendicitis. During a year he had had
three attacks. The appendix was removed. One year
before this operation a daughter of the patient died
of peritonitis resulting from appendicitis. She had
had three previous attacks.
Case II. — A child, eleven years of age. I removed
a perforated appendix from an abscess cavity. Two
weeks before, a first cousin of the patient, twelve years
of age, had been operated on in another State for
appendicitis.
Case III. — A boy, aged thirteen. Appendicitis of
three days' standing. When he was first seen by me,
perforation had taken place and he had general peri-
tonitis. I removed a gangrenous appendix. Just
eleven months previously I had made an autopsy on an
elder brother of this boy who had died of general peri-
tonitis. I found in his case also a gangrenous appen-
dix.
These are three cases out of about a dozen which I
have seen during the year, in most of which no spe-
cial inquiry was made in the line of the question sug-
gested. Probably the underlying cause of appendi-
citis is commonly obstruction of the lumen of the
organ or of its artery, or of both. Its length, the char-
acter of its attachment to the gut, its mobility, its
position are important factors in determining obstruc-
tion, and such structural characters are doubtless
transmitted in families.
388
MEDICAL RECORD.
[September 12, 1896
PYROZONE AND DILUTE HYDROCHLORIC
ACID IN SUPPURATING INFLAMMATIONS
OF THE MIDDLE EAR.
Bv WILLI.VM CHEATII.VM, .\.B., M.I).,
PROFESSOR OF DISEASES Of THE EVE, EAR. THROAT, AND NOSE IN THE LOUIS-
VILLE .MEDICAL COLLEGE, ETC., LOL'ISVILLE, KV.
I SUPPOSE that in giving the history and the result in
these cases nothing new is being written. It is my
purpose to attract the attention of the physician to the
line of treatment that has rendered me the best service
in this sometimes most obstinate affection.
Case I. — A. C , male, aged twenty-three years;
had had suppuration of the right ear for many years;
there was some cedema and tenderness over the mastoid.
The discharge from the ear had a ver\- disagreeable
odor ; there was some discharge through the Eustachian
tube into the throat; the auditory canal was much
swollen and very tender. Hot applications and hot
douches of carbolized water soon reduced the cedema,
and gave freer drainage. After partially relieving
the stenosis of the auditory canal, with curette and
pick I removed large cholesteatomatous masses and
found the middle ear and contents swept away, and in
its place a large funnel-shaped cavity, base in and
ape.x at about half-way of auditory canal, which at this
point w^as still much contracted. The curette, chromic
acid, pyrozone, and many other remedies were used,
but the epithelial masses still collected. Formalin,
boric acid, and alcohol were tried with the same re-
sult.
I finally directed that ten drops of a mi.\ture of di-
lute hydrochloric acid, gtts. .\., and pyrozone, 3 i., be
put into the ear morning, noon, and night, after cleans-
ing. A wonderful change was noticed in a few days,
and in a short time there was no secretion from the
cavity. There has been no return in several months.
C/\SE II. — Mr. G had had suppuration of his
right middle ear for twenty years. On cleansing away
some inspissated pus I found his case was one of attic
disease with bone necrosis, .\bove the middle-ear
cavity proper and not communicating with it was a
large cavity, which was filled with inspissated pus and
necrosed epithelium. Rough bone was felt with the
probe; small pieces were detached with the curette.
The ear was directed to be kept thoroughly cleansed
by means of carbolized warm water; it was curetted
once or twice; iodoform, iodol, boric acid, loretin,
formalin, and alcohol were used at different times,
with applications of chromic acid and lactic acid; the
ear was treated by the dry method also and drained
with bits of iodoform gauze, with no permanent relief.
This case was on hand about the same time as the
one first reported. The same mi.xture of dilute hydro-
chloric acid, gtts. X., in pyrozone, 3 i., was given, with
the direction that ten drops be put in the ear one, two,
or three times a day, to be left in five minutes after
having been forced in deep by firm pressure upon the
tragus, and then the ear wiped dry with absorbent cot-
ton. This case in a few weeks began to improve rap-
idly, going on to recovery with no relapse.
I have treated several similar cases with but one
failure, that in a tuberculous subject. Of cases of
less severity I have treated many, with only an occa-
sional failure. I have yet to see this treatment fail in
acute cases. Of course in the primary stage of acute
cases such medication is contraindicaled, but after
pain, throbbing, and swelling have subsided, and sup-
puration continues notwithstanding ordinary treatment,
the acid and pyrozone check it very promptly.
.\s to drainage in these cases, the iodoform or
some other of the gauzes cut into narrow strips, lately
advised by several, has given me by far the best re-
sults.
The treatment mentioned is not a cure-all by any
means, but I hope this brief report will lead to others
trying the acid-and-pyrozone combination. Of course,
when the deeper sinuses are involved surgery is first
indicated, then the pyrozone and acid. Under its use
I find mastoid-cell involvement much less frequent;
I do not believe these effervescing preparations in-
crease such dangers.
T\YO CASES OF OBSCURE INTRA-ABDOMI-
NAL LESIONS.
Bv F. li. TIBB.\LS, M.D.,
DETROIT, MICH.
The diagnostic difficulties presented by intra-abdomi-
nal lesions are many and varied, and fortunate indeed
is the surgeon of experience who escapes error. .Many
an abdomen has been opened and nothing found to
account for existing symptoms ; many a Cttliotomy has
disclosed conditions far different from those previ-
ously diagnosed.
When we consider the number of important viscera
liable to injury or disease and the obscurity of symp-
toms pointing thereto, the wonder is that we are not
more frequently led astray. From the region of the
pancreas, gall bladder, and pylorus to the appendi.x
and viscera of the female pelvis inclusive, lies a sur-
gical field rich in possibilities, teeming with uncer-
tainties and perplexing doubts.
I do not propose in this a clinical paper to cover
the diagnostic difficulties of this great surgical field,
but by reporting two unusual acute cases to illu.strate
some of the knotty problems with which any one of us
may at any moment be confronted.
Case I.^ — Miss Ida S , aged twenty, took cold
during menses and suffered from dysmenorrlKJta, with
mild ovarian pain for several weeks following. A
bimanual examination disclosed a retroverted uterus,
which was considered the cause of the continuance of
pain. Ovaries and tubes seemed normal ; they were
not sensitive on pressure, and I found at no time dur-
ing this period the slightest rise of temperature. The
treatment consisted of the usual uterine sedatives,
douches, and rest. I had not seen her for a week,
when at lo a.m., on September 20, 1895, 1 was called to
find her with temperature of 102.5" I'- '^^^ pulse of 90.
She had had a sharp chill the previous evening, and
there were great pain and tenderness over McBurney's
point. Vaginal examination again disclosed nothing
e.xcept a retroverted uterus, firm pressure with the
vaginal finger eliciting no sensitiveness of right ovary
or tube. Dr. Donald Maclean saw her in consultation
with me at 4:30 p.m. Temperature then was 104" F. ;
pulse, iio; pain easier; there was no tympanites and no
vomiting. We advised immediate operation, but vari-
ous delays incident to securing family consent and re-
moval to hospital occurred, and the patient presented a
temperature of 105^ F. and pulse of 130 when ready for
operation at midnight.
The abdominal incision was made adjacent to the
appendix, but the appendix was found to be nornial.
Further examination disclosed a broken-down right
ovary, tiie abscess cavity capable of holding perhaps
one-half drachm. This unexpected abscess had un-
doubtedly ruptured at the inception of the attack and
already had induced localized septic peritonitis.
Both tubes were found swollen (catarrhal, without
pus) and were removed with some difficulty through
the original incision.
The abdomen was thoroughly flushed and drained,
but the peritonitis extended and the patient died
twenty-eight hours later.
Case II. — Mr. J. C. W , aged thirty-five, was
riding his wheel between 5 and 6 p..m., Saturday,
September 12, 1896]
MEDICAL RECORD.
589
April 25, 1896. He threw himself off in order to escape
an approaching electric car and struck the asphalt
pavement with some force, the gluteal region being
the impinging part. He thought himself uninjured
and remounting his wheel rode five miles, then went
home, ate a hearty supper, and took a young lady out
to an evening entertainment. After escorting her
home, while riding down town on the wheel, he for the
first time felt abodminal pains, which soon so in-
creased in intensity that he sought relief in a conven-
ient drug store, where I was called to see him at
12 130 A.M., seven hours after his fall. He attached
no importance to his fall, and, as the only objective
symptom was pain, I gave him anodynes, took him
home in a coupe, and left him resting easily.
Sunday, 10 a.m. — Had a restless night. Little pain,
but great soreness. A full breath was p.iinful. There
was no vomiting. The patient had urinated; tempera-
ture, 99° F. ; pulse, 90.
5 P.M. — Bowels had not moved nor had gas passed
since the morning visit, though he had taken calomel,
gr. iij., and phosphate of sodium, 3 i. Temperature
was now 100" F. ; pulse, 120. Tympanites beginning.
I secured Dr. Maclean in consultation two hours
later. Temperature was now 101.5° ^-'i pulse, 130;
tvmpanites more marked. Four ounces of clear urine
were drawn by catheter, being the entire quantity se-
creted since 9 .\.m. The rapidly developing tympa-
nites, rising temperature and pulse, and paresis of the
intestinal tract were considered indicative of some un-
usual intra-abdominal lesion and immediate operation
was proposed and accepted.
Operation was performed at 9 130 p.m. with Dr. B. P.
Brodie as anaesthetist. A three-inch incision was made
below the umbilicus and the accessible viscera were
carefully examined, but neither hernia, volvulus, intus-
susception, nor hemorrhage was found. The intestines
were congested and much distended with gas, and there
Avas much free fluid in the abdominal cavity. The in-
cision was now extended upward, the bowels were
turned out, and careful search was made for a point of
rupture. .\t last on the posterior wall of the stomach
close to the pylorus was found a raw surface, the result
of ruptured adhesions, and a small hole extending
completely through the stomach wall, through which
the contents of the stomach were oozing. The point of
rupture was the site of an old ulcer, of which neither
the patient nor his family could give any history, and
the concomitant adhesions to the duodenal mesentery
when torn loose by the jolt of his fall made a rupture
of the weakened stomach wall possible.
The wound was carefully repaired, the cavity thor-
oughly douched, and the long incision rapidly closed.
The patient rallied well and apparently would have re-
covered but for an unsuspected abnormality of the kid-
ney, to which I attribute his complete suppression of
urine, for no urine whatever was secreted from the
catheterization two and a half hours before operation
until his death at 5 p.m. the next day.
The post-mortem revealed a congested right kidney
normal in size, while the left kidney was only one-
fourth its usual size and was firmly embedded in
the median line against the head of the sacrum.
This abnormality is of interest both as such and
as a factor in the final outcome of the case. Evi-
dently the one kidney capable of secreting became in-
active from shock and thus deprived the patient of
otherwise good prospects of recovery. The condition
of the stomach and intestines post-mortem was excel-
lent, the congestion and distention of intestines and
all evidences of peritonitis having disappeared, while
tlie hole in the stomach was completely healed.
These two cases met with in my practice during the
year past seem to me worthy of record as illustrati\e
of the diagnostic difficulties of intra-abdominal lesions.
Primary abscess of the ovary is a condition of ex-
treme rarity and one which we can seldom recognize
during life. In my case diagnosis was not possible
until the rupture of the abscess, when exact diagnosis
became of little moment, as the rapidly developing
symptoms made clear the need of prompt operative
interference.
The other case is remarkable in that a deep ulcer
of the stomach had existed and extensive adhesions
had formed without the knowledge of the patient, and
because so slight an injury as the jolt of a fall upon
the buttocks cost him his life.
My thanks are due to Dr. Maclean for the skill,
unfortunately unavailing, with which he wielded the
knife, as well as for his valuable diagnostic assist-
ance.
TWO CASES OF HYDROPHOBIA.
Bv \V. MOSER, M.D..
BROOKLVN, N. V.
Case I. — The boy was bitten on the left lower eye-
lid by a dog. The wound was treated at St. Catha-
rine's Dispensary until completely healed. The Pas-
teur treatment was not instituted, as the dog, which
was a stray cur, was not supposed to be afflicted with
rabies. Seven weeks after the date of the bite the
boy was admitted into St. Catharine's Hospital, ser-
vice of Dr. Moitrier, with the following symptoms:
Great muscular prostration, great excitability, diffi-
culty in swallowing, especially water. There was no
fear of water (hydrophobia) /tv- sc', as the boy could
look at a glass of water without showing fear, but as
soon as the glass of water was taken from the table
and brought to him with the request that he drink it,
he would become terror-stricken, falling, if the re-
quest for him to drink be urged, into general convul-
sions. Rectal enemata of water produced no convul-
sions. Hallucinations occurred at times, the most
frequent being that he was being bitten by dogs.
Hemiplegia on the injured side was noted. CEdema
of the lungs set in on the second day and was the im-
mediate cause of the boy's death. The autopsy, per-
formed by me, showed cedema of the lungs and an
acute inflammation of the meninges of the brain and
cord. All the other organs were normal, excepting a
few punctate hemorrhages on the pons Varolii.
Case II. — A boy, four years old, was bitten on the
left hand by a dog. The wound was cauterized and
treated at the boy's home. Five weeks from the date
of bite the boy was carried by his father to St. Catha-
rine's Hospital, in the service of Dr. Moitrier. He-
then presented the following symptoms; great mus-
cular prostration ; the difficulty in swallowing water was
so great as to cause a peculiar choking sensation at
each attempt: hallucinations occurred, the most fre-
quent being that dogs were biting him. The boy had
only a few general clonic convulsions. Hemiplegia
occurred on the left, the injured side. CEdema of
the lungs set in on the second day, to which the boy
succumbed.
Remarks. — We note, in reviewing these two cases,
the diagnosis of which was confirmed by Drs. Gibier
and Labadie, the following peculiarities in their
symptomatology :
1. Both boys were under the impression that dogs
were biting them.
2. The singular fact that both should have had
hemiplegia on the bitten side. Dr. Fuhs concurred
in the opinion that the hemiplegia was on the left side.
3. That both boys died in two days from oedema of
the lungs.
4. We note the period of incubation — seven weeks
in the one case, five in the other.
158 Ross Street.
390
MEDICAL RECORD.
[September 12, 1896
A POSSIBLE EFFECT OF ANTITOXIN.
By E. CROSBY CHAMBERLIN, M.D.,
NEW YORK.
Without discussing the value of diphtheria antitoxin,
when early administered, I wish to relate a case which
is of some interest. A young woman, aged twenty-two,
has been afflicted with a chronic diarrhoea for the past
four years. In December I attended her for a gas-
tritis, which after a few washings of the stomach
passed away. Two months later diphtheria developed ;
being pharyngeal at first, it extended in all directions
until two days later, when an otitis media with a
copious discharge was developed. This day the
report from the board of health was received confirm-
ing the diagnosis. She had been using for two days
corrosive sublimate, both internally and as a gargle.
The discharge from her ears by this time was so
abundant she could not sleep, it Hooding out of the
external meatus over the face through absorbent
coiton and everything. I at once gave her two grains
of antitoxin. The next day the discharge was re-
duced at least one-half. Later she received another
injection of antitoxin, and the following day not only
had the discharge entirely disappeared but the
diarrhoea was reduced from five or ten stools daily
to one or two stools of a normal solid consistency.
That was two months ago and at present she has not
had a return of the distressing diarrhoea.
FRACTURE OF THE BASE OF THE SKULL,
OF BOTH SUPERIOR MAXILL.i:, OF THE
NASAL BONES, OF THE INFERIOR MAX-
ILLA, AND OF THE HYOID BONE — RE-
COVERY.
Bv I,. I!. SMITH, M.U..
AND
GEORGE HASL.\.M, M.U.,
FREMONT, NEB.
O.N' the evening of December 26, 1895, Mr. T. N ,
aged sixty-seven, after taking an accustomed dose of
a hypnotic, retired to rest and slept until about 2
A.M. of December 27th, in a room upstairs with
which he was somewhat unfamiliar, as his habit had
been to sleep downstairs. Arising in a semi-conscious
condition, as was his wont, to relieve his bladder, he
turned as he would have done in his own room below,
and in consequence fell down a flight of stairs, a verti-
cal distance of twelve feet, and then rolled or crawled
a farther distance of about four feet, where he was
found by members of the family, who had been awak-
ened by the noise of his involuntary descent.
Arriving at about 2 130 a.m., I found the patient rest-
ing on a lounge, to which he had been carried. He
was partially conscious, being able to give an intelli-
gent answer to a direct question and able to complain
of pain in the back of the neck whenever his position
was changed or when he made an effort to turn. He
also complained of pain in the throat, .\fterward he
had no recollection whatever of this period.
Blood flowed from the mouth and nose: respiration
was difficult and could be effected only through the
mouth, as the nose was completely closed. The posterior
wall of the pharynx was also swollen and tended to in-
crease the difficulty. The left eye was closed, theej'e-
lid blue and much swollen; the right eyelid was swol-
len and slightly discolored. Pulse was slow and weak.
Further examination demonstrated both superior
maxillas to be separated from the cranium and mova-
ble on each other. The nose, which formerly was de-
flected to the right, was now strongly bent to the left,
and the bones were movable. A compound fracture
■of the lower jaw was discovered on the left side at the
posterior border of the canine tooth.
Fractured base of the skull was diagnosed from the
condition of the eyes, etc., and was confirmed by fur-
ther and independent examination made by Dr. Has-
lani some eight hours later. At this time and later no
cause for the pain in the hyoid region could be de-
tected, in spite of repeated examinations made both
from within and from without.
On Monday (December 30th) the patient recov-
ered consciousness and at once redoubled his com-
plaints of pain in the throat, especially on making an
effort to swallow, no reasonable cause for which could
be detected until the tenth day, when he forced a
mouthful of fluid down at one gulp. There was an
extreme though momentary pain, followed by instant
relief. Distinct crepitation in the body of the hyoid
was now easy to detect, either on making lateral pres-
sure or when the patient swallowed. Evidently the
parts had been firmly held in an unnatural position
until now suddenly released.
For two weeks after the accident his gait was un-
steady and it was possible to walk only by looking
directly in front, a single side glance being sufficient
to disturb his equilibrium; to turn a corner was a
matter of considerable difficulty. During a period of
six weeks he suffered from severe neuralgic pains,
which he said shot toward the cranial vertex, and dur-
ing this whole period it was always necessary for him
to support his head with his hands when in any posi-
tion other than the recumbent. The chest and abdo-
men were ecchymosed as low as the navel, and were
for a long time perfectly black.
Mr. T. N made a good recover)-, except that in
consequence of his refusal to submit to surgical treat-
ment the portions of the lower maxilla are ununited.
The roof of the mouth presents a bulging ridge along
the intermaxillary suture, where the bones have re-
united.
STRANGULATED HERNIA IN AN AGED
SUBJECT— OPERATION— RECOVERY.
Bv S. S. CARTWRKIHT, .M.D.,
KOXBl'KV, N. V.
I WAS called, June 23d, to see M. S , aged seventy-
eight, suffering from left inguinal hernia. He had
been troubled with it for five or six years. In April
last I had reduced it for him and advised him to wear
a truss; but he did not follow the advice. On June
24th, after considerable difficulty, I reduced it: but on
June 25th it came down again. I then called Dr. A.
R. Ellis, of this village, to assist me. We adminis-
tered ether and kept him under the influence of it for
two hours, reducing the hernia, so far as the bowel was
concerned; but a portion of the omentum could not be
reduced. I saw him again June 2sth, and found the
hernia strangulated. No further attempt was made at
reduction, and we sent for a surgeon, who came but
refused to operate on account of the hopelessness of
the case. He decided that the omentum and bowel
were both gangrenous, which was evidently a mistake.
The following day his pulse was between 60 and 70,
his temperature about 99 F. I decided that an oper-
ation should be performed, and sent for Dr. William
Kemble, of Rondout, N. Y. He came on Sunday,
June 28th, and after a careful examination it was de-
cided to operate.
The operation was performed by Dr. Kemble, as-
sisted by myself and Dr. Ellis, in the usual manner.
On account of hydrocele of the tunica vaginalis tes-
tis, it was deemed proper to remove the left testicle.
A portion of the omentum was removed, all bleeding
vessels were secured by catgut ligatures, the bowel and
remainder of the omentum were returned to the cavity
of the abdomen, and the wound was closed by contin-
September 12, 1896]
MEDICAL RECORD.
391
nous suture. The antiseptic used was carbolic acid,
I to 20.
June 29th. — The patient had rested well. I admin-
istered a dose of Epsom salts, which operated in the
course of the day.
June 30th. — Temperature, 100.5" P- ' pulse, 80.
July 1st. — Temperature, 99.5° F. ; pulse, 72. There
was no particular pain nor inconvenience. From this
time the temperature gradually fell to the normal.
The sutures were allowed to remain until July loth,
when they were removed, the wound being nearly
healed. The rubber drainage tube was removed at
the same time On July 12th he was up and dressed.
The surroundings were of the most unpromising
kind, and the age of the patient would have led one
to expect an untoward result; still the termination was
all that could be asked for.
The lesson of this is that we should not despair
of such a case if one comes under observation, and
instead of waiting for death we should give the pa-
tient a chance of life.
SUBPHRENIC ABSCESS.
By L. B. smith, M.D.,
AND
GEORGE HASLAM, M.D.,
FREMONT, NEB.
Mr. C. R , aged forty-five, a man of medium build,
of fairly good habits, but who some ten or more years
ago would occasionally imbibe too freely, had always
enjoyed good health except that some six years ago he
suffered from lumbago.
On January ig, 1896, he complained of a sudden
severe pain in the right side in the region of the lower
ribs. He was compelled to remain two or three days
in bed, and then got up fairly well. During the week
following he complained of nothing but weakness and
some indefinite stomach symptoms. He was unable
to work, but walked around and seemed to be conva-
lescing. He then complained of a neuralgic pain in
the left leg, which was diagnosticated and treated as
sciatica. The pain disappeared, to reappear on the
right side two weeks after its origin in the left side.
In each case the limb was somewhat swollen but did
not pit on pressure; the veins were slightly engorged
but not varicosed. After about another week there
was pain in the left groin, followed by general abdom-
inal pain. The patient was constipated from the be-
ginning.
On April 21st the pain reappeared in the right side,
as at the beginning of the illness, and on the 23d he
commenced to vomit and retch, with the eructation of
much gas. About the beginning of May the pain be-
came worse and the gastric symptoms more severe.
Somewhat later the lower chest began to swell, and
subphrenic abscess was now diagnosticated. As soon
as this condition was recognized the abscess was
opened by Drs. George Haslam and by H. N. Brown,
who excised portions of the ninth and tenth ribs and
opened the pleural cavity, which was lined with a layer
of stratified lymph about five-sixteenths of an inch thick.
More than a pint of grumous fluid escaped. The dia-
phragm was then opened, when a much larger quantity
of similar fluid escaped.
On May 19th the patient died. Only a limited
post-mortem examination was allowed. It was found
that the cavity reached half-way down behind the right
kidney. No exciting cause for the condition could be
traced.
The Roentgen Rays kill tubercle bacilli, according
to a report made to the Academie des Sciences by
MM. Lortet and Genoud.
Pneumonia. — Calcium chloride in four-grain dose.
Asthma. —Ice pack over pneumogastric in region
of neck. — Sanger.
Hiccough. — Sugar. When purely nervous, hydro-
chlorate of pilocarpine, one-tenth grain, three or four
times a day.
Rickets. —
R Phosphorus gr. '^.
Cod-liver oil gr. mccccc.
Saccharin gr. l.x.w.
Essence of lemon gtt. ij.
M. A small teaspoonful may be taken daily.
— Marfan, Revue des Maladies de V £nfance, Julv,
1S96.
Gout.—
R Magnesii sulph 3 ij.
Potass, bicarb gr. xv.
Tr. colchici sem TU, x.
Infus. buchu | i.
Ft. haustus. S. To be taken every four or six hours, fol-
lowed by a large draught of water, not too cold.
FOTHERGILL.
Granular Conjunctivitis. —
I^ Mercuric o.xide gr. iij.
Zinci,
Thymol,
Muriate of cocaine aa gr. ss.
Camphor gr. ss.
Vaseline ; ij.
M. ft. ung.
■ — North American Fractitio)ier.
Hypodermatic Treatment of Tuberculosis. —
R Pjeechwood creosote 25 gm.
Camphor 15 gm.
Aristol 10 gm.
Eucalyptol 30 gm.
Sterilized neat-foot oil ad 250 sc.
For hypodermatic injection.
One cubic centimetre (sixteen minims) of this solu-
tion contains one-tenth gram (one and one-half grain)
of creosote. — V. Gilbert, Medical Week.
Creamy Emulsion of Cod-Liver Oil
V, Cod-liver oil 500 parts.
Finely sifted sugar igo
Pulv. gum arable,
Pulv. gum tragacanth .^a 5 "
Infusion of coffee 200
Rum 100
Mix" the sugar and gums in a mortar, and in the
bottle which is to contain the emulsion shake together
the oil and cold infusion of coffee. Pour a sufficient
quantity of this liquid into the mortar to make a paste.
While stirring, add to the portion remaining in the
bottle the rum, and then gradually incorporate it with
the emulsion. — Therapeutic Gazette.
Night Sweats of Phthisis —
I( I.iq. potass, arsenit HI xv.
Tinct. belladon Til xv.
Aqu;i; amygdal . amar X v.
M. S. Take from fifteen to twenty drops of the mixture
about five o'clock in the evening.
— Pharmaceutist he Zeitung.
Irritability of the Bladder after Delivery.—
1{ Salol.
Tincture of hyoscyamus aa 3 ij-
Infusion of buchu q.s. ad J vi.
M. S. Teaspoonful three times a day.
— FoTHERGiLL, Manual 0/ Midwifery.
392
MEDICAL
Migraine. —
I? I'ure chloroform,
Alcohol aa I ij.
Morphine gr- i\-
Syrup I i-
Water 3 " ■
M. S. Teaspoonful every half hour till pain is relieved.
— Journal des Pratifkns.
^ Caffeine citrate gr. xx.
Phenacetin gr. xxx.
White sugar gr. xv.
Sufficient for ten capsules. One ever)- three or four hours
during the period of the attack.
— Indian Lancet.
Diminish the hyperesthesia of the painful area by a
spray of some local anaesthetic, and immediately after-
ward practise compression of both temporal arteries
by means of rings of cork held in place by a gauze
bandage. Administer the following in four doses at
intervals of two hours :
I? Antipyrin gr. viiss.
Sparteine sulphate %''• Vi-
Caffeine citrate gr. iss.
If there is gastric derangement, the above may be ad-
ministered by enema. — Aritzman, Presse Medkak.
Hay Fever Discard the use of sprays, and apply
to the nostrils, on a cotton pledget, an unguent com-
posed of six parts of cocaine muriate, ten of carbolic
acid, twenty of menthol, one hundred and twenty of oil
of sweet almonds, two hundred and forty of zinc oint-
ment.— Amerkan Medknl Journal.
Diabetes —
Vf Arsenate of sodium gr. A-
Carbonate of lithium gr. ij.
Codeine gr. ^.
Dr)- extract of cinchona gr. viij.
Make into one cachet. Prepare thirty such. One after
breakfast and one after dinner.
— Robin, Journal des Pratifkns.
Flatulent Colic—
I^ Spirit, chloroformi.
Tr. cardamomi comp aa 3 ij.
M. S. A teaspoonful ever)- half-hour, in water.
— Bartholow.
Quinine Mixture. — The following is advantageous
in irritable stomach when quinine is to be given:
I^ Sulphate of quinine gr. ij.
Citric acid gr. vi.
Simple syrup.
Syrup of orange flowers Jia 3 ss.
This is to be placed in a w-ineglass containing bi-
carbonate of sodium (from three to five grains) in sat-
urated solution, and drunk during effervescence. —
/ournal de Aledecme de Paris.
Intestinal Worms. —
V, Oil of chenopodium I ij.
S. To be given on sugar three times daily, in doses of five
drops, to a child of three years, and ten drops to one of ten years.
A carthartic should be given every second or third day.
— C. \V. Towx.sExn.
I^ Santonin gr. ij-
Mild chloride of mercury gr. ss.
M. S. Every night for two or three nights, to a child five
or six years old. followed each morning by a purgative dose of
castor oil.
— Eustace Smith.
To Check Vomiting. — Powdered pimenta, five
grains, repeated in ten or fifteen minutes; or pulver-
ized pimenta, five grains, with calomel, one-tenth
grain.— -A. S. Dolloff, Beverly Farms, Mass.
RECORD. [September 12, 1896
Stomatitis in Small Children.—
1} Potassii chlorat Si.
Tinct. myrrh gtt. xx.
Elixir calisaya; 3 iij.
S. Teaspoonful in water ever)- four hours.
This prescription should not be used if there is pres-
ent a condition of acute nephritis. — Hare, Aledical
Summary.
Excessive Sweating of the Feet. —
B .Vlumnol,
Aristol aa 4 parts.
.Starch 15
Dust into the socks.
— Therapeutische Wochenschrift.
Dusting Powder for Eczema. —
B Pulv. amyli 3 i.
Pulv. zinci oxidi : 3 ij.
Pulv. camphor:^ 3 ss.
M, S. For external use.
— Hyde.
Powder for Genital Herpes. —
I? Po«-dered alum.
Powdered starch aa 10 gm.
M . For external use.
The balano-preputial region is dusted over with this
powder. Recovery is usually promptly obtained.— E.
Gaucher.
Dyspepsia. — For painful digestion with flatulence:
1} .^odii bromidi i6 parts.
Pepsini concentrat 12 "
Pulv. carb. ligni 8 "
Aqu.-e pur 32 "
Glycerin! 96 "
M. S. Teaspoonful after each meal.
— Lanphear, Am. Jour, of Surgery and Gynecology.
Hay Fever. —
I? Eucalyptol,
Glycerin aa 3 i.
Tinct. opii 3 ij-
Aquae destil ad 3 vi.
S. Use with atomizer three times a day.
— American Medical Re-i'iew.
Hemorrhoids
B Wood tar 3 parts.
Extract belladonna 3 "
Glycerin 30 "
— Rr,\ de Titer. Med. Chirurg.
Gastric Hyperacidity with Constipation. —
B Magnesia,
Rhubarb aa 7. 50 gm.
Bicarbonate sodium.
Carbonate sodium.
I'owd. sugar aa 15 gm.
Oil peppermint q.s.
S. Half to one teaspoonful in water two hours after each meal.
— Max Einhorn, Medical Weekly.
Erysipelas —
B Tannin 2 parts.
Camphor 3 "
Ether 15 "
S. Paint ever)- hour or two over affected part and adjacent
skin.
— Spernandino.
Chapped Skin. —
B Lanolin 3 iij.
Glycerin 3 iv.
Boric acid ." 3 iss.
Salol ■ 3 i.
Hoffman's anodyne 3 v.
Menthol .' gr. xv.
Oil of citronella "l iij.
—Journal des Pratifiens, February 22, 1896.
J
September 12, 1896]
MEDICAL RECORD.
393
Alcoholism. —
R Xit. stnch gr. viij.
Acid, salicylic gr- iv.
Alcohol 31-
Water 3 iij-
Make up antiseptically. ill xv. = -^ ol a. grain of strych-
nine. S. HI 15 hypodermically two or three limes daily.
— Flint.
Rheinstadter's Ergot Mixture. —
I^ Ergotini dialyati spissi 5 parts.
Aqune destillat;x; 35 "
Acidi salicy lici o. i "
Glycerini 10
A teaspoonful of this mixture, with two tablespoon-
fuls of lukewarm water, is injected by a rubber-ball
syringe into the rectum, after the bowel has been emp-
tied.— Schauta, Lchrbiich ikr gcsammtcn Gyncikologie.
Rectal Alimentation. —
I{ Cod-liver oil 3 V.
Yolk of one egg,
Lime water - x.
M. As a nutritive enema.
— Journal des Fraticieiis, March 14, 1896.
Pruritus Vulvae. —
K Chloral camph 3 ij.
Bismuth subnit 3 ij.
Aquas rosre 3 iv.
M. S. Apply to the parts.
Or,
'S, Argenti nitratis gr. xx.
Aqu.-e 3 i.
M. S. Paint over the affected parts.
— Bartholow.
Mother's Milk does not quench an infant's thirst.
Boiled water should be given freely and with regu-
larity between the nursing periods.
Insomnia of Neurasthenia. —
B, Paraldehyde gr. xx.Tviij.
Fluid extract of piscidia gr. Lxxv.
.Syrup of wild cherry 3 iss.
M. S. To be taken at once in a cup of orange-flower water.
— MoN'iN, Iihlepeiidaiice Med., July ist.
Epilepsy. — We read in a foreign e.xchange that the
only remedy of value in epilepsy is bromide of potas-
sium, and the dose should not be stopped for a single
d.iy during the period of treatment. Give five grams
the first week, si.x the second, seven the third, and re-
peat this order. Give bromide so that two-thirds of
the dose are taken two or three hours before the cus-
tomary time for an attack. .Always give in a very di-
lute solution. Small doses of salol combined with
the bromide are of value. The patient should not be
allowed to sleep during the day. After a year and a
half the dose of bromide may be diminished. — Joiir-
ihi/ J'raif. Med.
Diagnosis in Laryngeal Disease. — Until Senor
Manual Garcia, of London, in 1S55, practised success-
fully auto- laryngoscopy and thus opened the way for
Tiirck and Czermak, of Vienna, to use successfully the
laryngoscope on their patients, aphonia and dysphonia
with certain associated symptoms were the only guides
to the practitioner in making a diagnosis in laryngeal
disease. — Dr. Merrick, Maryland Medical Journal.
Headaches from Eye Strain Dr. S. Weir Mitchell
concludes in an article in the Medical Netcs, April 28,
1S94, that: 1. There are many headaches which are
due directly to disorders of the refractive or accommo-
dative apparatus of the eyes. 2. In some instances
the brain symptom is often the most prominent and
sometimes the sole prominent symptom of the eye
troubles, so that, while there may be no pain or sense
of fatigue in the eye, the strain with which it is used
may be interpreted solely by occipital or frontal head-
ache. 3. The long continuance of eye troubles may
be the unsuspected source of insomnia, vertigo,
nausea, and general failure of health. 4. In many
cases the eye trouble becomes suddenly mischievous,
owing to some failure of the general health, or to in-
creased sensitiveness of the brain from moral or men-
tal causes.
Taurocholate of Sodium, according to Sorrentino's
experiments upon animals, is to be ranged among the
cardiac remedies. Its action is marked by a slowing
of the beats and lowering of the blood pressure. In
large doses it always diminishes pressure,'but pro-
duces a more or less noticeable acceleration of the
beats. The slowing of the pulse is due to an excita-
tion of the moderator ganglia. The acceleration
which follows the use of toxic doses is due to paraly-
sis of these ganglia. The diminution in pressure is
in connection with excitation of the moderating ap-
paratus of the heart and with the vascular dilatation.
Toxic doses lower the pressure because they paralyze
the myocardium. Vascular dilatation is a conse-
quence of a peripheric action of the drug. Prolonged
use of taurocholate of sodium alters the blood's compo-
sition in diminishing the number of red globules and
the proportions of haemoglobin. — La Medicina Conlem-
poranea, January, i8g6.
Membranous Sore Throat. — Lennox Brown states
that twelve different varieties of membranous sore
throat exist. They are as follows: (i) Contains noth-
ing but the diphtheria bacillus. (2) The diphtheria
bacillus associated with streptococci. (3) Diphtheria
bacilli, streptococci, and staphylococci. (4) Diph-
theria bacilli, streptococci, and diplococci. (5) Diph-
theria bacilli and diplococci. (These are all varie-
ties of true diphtheria.) (6) The sixth variety of
membranous sore throat contains streptococci only.
(7) Streptococci and diplococci. (8) Staphylococci
only. (9) Staphylococci and diplococci. (10) Diplo-
cocci only. (11) Diplococci and a mycelium. (12)
The twelfth is indeterminate. These last seven varie-
ties are non-dfphtheritic, or pseudo-diphtheritic in
character. — Dr. Merritt, Occidental Medical Times,
April, 1896.
Uterine Cancer. — Dr. Kessler believes that the di-
agnosis of cancer is not very difficult in the majority
of cases. The text-books lead us to believe that it is
always associated with cachexia; the suffering expres-
sion of the face, very frequent hemorrhages, fetid dis-
charges, etc., are not always present. But a serous
discharge, a bleeding between menstrual periods, and
particularly a hemorrhage after the menopause, should
make one very suspicious of malignant disease. He
deprecates the practice of giving ergot or styptics in
uterine hemorrhages when one suspects carcinoma,
because while using these drugs the disease i.s progress-
ing and valuable time is lost. — St. Petersburg fned.
IVoclt., September 28, 1895.
Phthisis. — I. In early phthisis (catarrhal stage) to
give comparative rest and relaxation to atfected lung
tissue. 2. In the stage of consolidation, to secure the
same results, thereby limiting the risk of extension,
and to promote elimination of the disease products by
improving the circulation in and about the diseased
area, and to facilitate expectoration. 3. In the stage
of cavitation, to promote closing of cavities by direct-
ing healthy lung to encroach on the diseased area in-
stead of relying on natural processes of cicatrization.
4. Diminished tendency to hemorrhage by reduced
tension on vessels and cicatricial traction on vessel
walls. 5. The ultimate object is to obtain a smaller
thoracic cavity filled with healthy lung instead of an
enlarged thoracic cavity partly filled with diseased
lung. — Dr. Tidey, British Medical Journal.
394
MEDICAL RECORD.
[September 12, 1896
©ortcsp on cl enc e.
OUR LONDON LETTER.
(From our Special Correspondent,)
HOLIDAY AND LITERATURE BLUE BOOKS — VACCINA-
TION REPORT INFANT - LIFE PROTECTION POOR-
LAW SUPERANNUATION ACT IRISH WORKHOUSES —
THE WATER FAMINE— DENTAL ASSOCIATION — VIVI-
SECTION REPORT SIR F. R. CRUISE — THE LATE P.
V. GOM^LLAND.
London, August 28, 1896.
We are quite in tl".e autumn holiday. All who can do so
are either shooting or eating grouse. London is empty
— says society. But there are still some four million
of human beings in the metropolis, and an ample sup-
ply of doctors to attend them. When it is said all the
doctors are out of town, no more is intended than
when society so declares of every one. Amusement is
looked for by those who remain, but there is plenty of
work and the literature issued is not without a consid-
erable proportion of the heavy kind. Reports and
blue books are seldom light reading, but they have to
be grappled with, even in holiday time.
I have furnished you already with a brief notice of
the vaccination report, which " it is to be hoped," as
the commissioners say, " will stimulate belief in the
efficacy of vaccination." The report was completed
on the 13th, since which time a number of statements
have appeared as to its tenor, some difficult to reconcile
with others, but you may accept what I have previ-
ously written as accurate. The distribution of the
report to the public will probably be delayed for an-
other week or ten days, but of course some of us have
secured early copies. Some papers have been so early
with their reports that complaint is made of improper
or indiscreet revelations.
If all men were reasonable, this report, although
expressed in terms so cold that some already stigma-
tize it as half-hearted, would put an ?nd to agitation.
But the antivacs take their defeat badly, and we have
not yet done with them. The minority statement of
those dissenting from some of the views of the major-
ity is already held up, as showing that a royal com-
mission cannot be convinced to the extent of unanim-
ity. But this was, of course, expected when some of
the most prejudiced antivacs were nominated on the
commission. The minority claim that compulsion is
neither expedient nor just, as there exists a sufficient
amount of conscientious oljjection to making martyrs
of recalcitrants, and they say it is unjust to override
parental responsibility and disregard parental feeling.
Yet those who sign this must be aware that the law
does override such feelings for the good of the com-
munity. It is even necessary to restrain parents from
cruelty, negligence, and other things, while they are
compelled to educate their children and do other
things, too, which are for the child's good. Law may
be said to generally involve compulsion or restraint.
As to the "conscientious objection," it must seem
really funny to most people to couple conscience with
vaccination. If it had not been a profitable game to
set up agitation, no one would have heard of con-
science in the matter, and when brought forward by
agitators it is merely regarded as providing cranks
with an excuse. But the rights of conscience are se-
rious, and the commissioners have treated the objec-
tion seriously, though it is to be feared their logic
will not convert recalcitrants.
The extreme moderation of the report should be
more convincing than a stronger statement, and even-
tually will have full weight, though at present this
influence is scarcely felt. But I will pass on to other
subjects, for this one is likely to demand attention
later on.
The House of Lords committee on the infant-life
protection bill has finished its report. The bill was
among the "slaughtered innocents" of the session, but
from this report we may augur well for its future.
The committee sat seven days and examined nineteen
witnesses. Some evidence went to show that a single
infant is rarely taken with a view of profit, and is usu-
ally well lookod after. The committee, therefore, do
not propose to extend the act to the keeping of one,
but the farming;; of two will bring the persons under
its provisions, which in the main are satisfactory and
will to a great extent protect the children who are put
out.
The Lords, after all, rushed through the poor-law offi-
cers superannuation act, though it was so late that
most of the newspapers reported its loss. However,
"all's well that ends well," and the officers are ex-
pressing satisfaction. The act applies to a great army
of poor-law officials, including the medical. A de-
duction of from two to three per cent, of the salaries
is compulsory, and will secure a pension after sixty
years of age. It is allowed for those in the service to
exclude themselves from its operation by notice with-
in the next three months. Those who do not contem-
plate remaining in the service will, of course, do this.
I should think a great number of poor-law doctors do
not take up the service with a view of spending their
lives in it, and if they do not stay till they are sixty
they will lose their premiums. To the great disap-
pointment of the Irish service, the act does not extend
to Ireland.
This reminds me of the question of reform in Irish
workhouses, which has been demanded for some time
past. A number of persons in London'have been ac-
tive in this movement, and now a circular letter,
signed by Lord Monteagle, has been issued, inviting
us to meet in Dublin on October ist or 2d. As the
date coincides with the opening of the winter session
here, a number of medical men will be unable to ac-
cept.
The "water famine," as the scarcity at the East
End of London has been dubbed by the newspapers,
continues to cause great inconvenience and distress.
Many diseases are attributed to this cause by the pub-
lic, and the onduct of the water company will greatly
strengthen the cry for the abolition of the water mo-
nopolies and the control of the supply by a single rep-
resentative body.
The dentists succeeded the dermatologists with a
week's meeting in London, where the British Dental
Association held its annual meeting. Mr. Canton,
the president, dealt in his address with dental educa-
tion and politics. The great progress made since the
dental act has shown how large is the majority of
those who have shown themselves worthy professional
colleagues, and how desirous they are to put down
quackery in their department. .V number of careful
papers were submitted and discussed. There was
a reception at the College of Surgeons, the build-
ings having been granted by the council for this pur-
pose. Of course there were a dinner, a garden party,
and an excursion, to none of which did I go. The
most interesting part of the scientific proceedings was,
perhaps, the demonstrations. Microscopic prepara-
tions, micro-photographs, skiagraphs, and diagrams
abounded. The association numbers nine hundred
and thirty members, but there are several other socie-
ties devoted to the cultivation of the dental art, the
oldest being the Odontological, which dates from be-
fore the act of 1878, the mark of a new dental era in
England. Next year the association is to meet in
Dublin.
The report of the inspector under the vivisection
i
September 12, 1896]
MEDICAL RECORD.
395
acts for 189s has been issued. There were three hun-
dred and seventy-tive experiments performed under
license, excluding hypodermic injections and inocula-
tions, which numbered twenty-seven hundred and
forty-four. These last have really no claim to the
title of vivisection, and it seems absurd to subject to
supervision practically painless proceedings which are
daily undertaken on our patients without the faddists
objecting.
Dr. F. R. Cruise, of Dublin, has received a knight-
hood, to the satisfaction of his brethren.
Yesterday — no, the day before — the Chemists' Ex-
hibition offered a great number of articles of interest
to medical men for inspection by all and sundry.
The death, on August nth, of Mr. P. Y. GowUand,
F.R.C.S., removes a personality much respected among
leaders of the profession. He left Finsbury Square,
where he had practised some forty years, on his retire-
ment two or three years ago. He was assistant sur-
geon and teacher of anatomy at the London Hospital
for a few years in his early career, but became sur-
geon to St. Mark's Hospital for Fistula, from which
circumstance he devoted his powers to the specialty of
which he was for so long the chief ornament. As a
teacher he was popular with students, and regret was
felt when at quite an early age he resigned from the
London Hospital. This step, however, was necessi-
tated by his great success in practice and his devotion
to his specialty, which prevented him giving to the work
of teaching the time and energy which he felt were
due. Mr. Gowlland was an artist and would rapidly
sketch whatever he was demonstrating. He drew and
painted his most interesting cases, and so accumulated
an immense number of pathological illustrations of
diseased conditions of the rectum and adjoining parts.
I knew him well enough, and in looking over his col-
lections discussed with him which would be best for
publishing. Once I selected to illustrate some im-
portant points a certain set which he had shown me
and which he acknowledged should be published. I
arranged, too, for these to be lithographed for him
while he committed to paper his comments upon them.
But he was always too busy to do so, and the matter
remained in abeyance. He was almost fastidious in
this kind of work, and his efforts to combine accuracy
with artistic finish often resulted in his dissatisfaction
with work for which others had only admiration. He
was a keen sportsman, and when he could take a holi-
day it was with gun or line that he passed his time.
Circumstances separated us for some time, and he
retired and took a house at the West End. And now
at seventy-two years of age he has joined the majority,
leaving a widow and a married daughter. His son
died several years ago, to the lasting regret of his pa-
rents and sister.
THE MORPHOLOGY OF THE BLOOD IN
TUBERCULOSIS.
To THE Editor of the Medical Record.
Sir: In connection with the presentation of Dr.
Holmes' and my papers in last week's issue of the
Medical Record, will you please announce the ac-
tion of the Colorado State Medical Society in re-
newing the award and continuing the committee,
of which I have the honor to be chairman, to give a
prize of one hundred dollars for the best essay on
the detection of tuberculosis by the microscopical
examination of the blood. Of course, the award is
altogether too small, considering the labor and skill
required to accomplish this task, and should another
society, or any individual wish to increase the amount,
the committee will be only too glad to watch over
the contribution and see that it be not unworthilv
bestowed. The task requires not only that the disease
shall be diagnosed by the blood examination alone
(practically without the patient being seen), but that
the various manifestations of tuberculosis shall be
differentiated, and that the system of calculation as
well as the technique of procedure shall be plainly
elaborated, so that any skilled microscopist may arrive
at a similar conclusion.
It is a gratification to have brought so nearly in
sight the certainty of accomplishing what I have long
thought a possibility. We shall be pleased to have
others compete for the honor Dr. Holmes is striving
for, and will gladly enter into correspondence with
any such. Meantime, I will refer to Dr. Holmes'
excellent paper for the reason for this enthusiasm. It
is not only the diagnosis of tuberculosis in its various
phases which is at hand, but a means to measure ac-
curately the different methods of treatment, not exclud-
ing the equal of any yet advanced, that of the prefer-
able climate.
Charles Denison, M.D.
Denver, Col.
imcdical ^tcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending September 5, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-pox
Cases.
Deaths.
199
88
2S
8
22
4
I
I
26
4
142
27
0
0
A Portable Crematory for incinerating the bodies
of those who die in battle has been invented by a
Polish engineer.
Progress. — '' Medical science has made such prog-
ress," said the doctor, when speaking of his profes-
sion, " that it is almost impossible for anybody to be
buried alive now.'" Then he wondered why every-
body laughed. — Boston Courier.
Nature's Sarcasm. — People laughed a few years
ago when the worst-diseasetl herd of cattle in a New
England State were found on the farm of its agricul-
tural college. The valuable animals were killed and
the State stood the loss. So now people laugh when
they read the reports of the ravages of the army worm
here and there and notice that the greatest destruction
it has caused in this State is on the farm of our State
Agricultural College at Kingston. — Providence Tele-
gram.
Sufficiency of Milk after Birth Dr. Buchmann
{British Medical Jour7ial) wished to ascertain the pro-
portion of cases in which the mother was able to suckle
her child. Out of the one hundred and twenty-six
cases, eighty-three (or 65.9 per cent.) had sufficient
milk when discharged between the tenth and twelfth
day. The percentages recently reported from Basle
and Stuttgart were much lower. More statistics of
this kind are called for, as they throw much light on
the health and strength of women in different regions.
Results and Methods of Surgical Operations. —
Dr. Stimson {Annals of Surgery, vol. xxiii.. No. 6)
draws the following con lusions: (i) It may be con-
fidently expected that, with the aid of assistants
trained for and constantly e.\ercised in the prepara-
396
MEDICAL RECORD.
[September 12, 1S96
tions for and the conduct of operations, and with spe-
cial attention to the cleanliness of the hands, a clean
surgical wound will escape infection and will heal
without suppuration; but that without such skilled
aid, and without the security given by the constant
practice of the assistants in hospital, the same meas-
ure of success is not to be expected. {2) It is prob-
able that a certain measure of infection by germs in
the air, or in the patient himself, takes place in an
unknown proportion of cases, but that it is habitually
so slight that the resistant powers of the tissues are
able to prevent its manifestation and spread. We are
perhaps justified in offering the low vitality of the
patient as an e.xplanation of the occasional sporadic
cases of suppuration that occur in long series of other-
wise successful operations. (3) We have in large in-
travenous injections of salt solution, during or after
an operation or a severe injury, a valuable means of
averting an impending death by shock or hemorrhage.
(4) Habitual immunity from infection creates an op-
erative confidence that may lead to a neglect to give
full weight to such warnings or contraindications as
might be found in the probable severity of the opera-
tion or in the reduction of the patient's vitality, espe-
cially in malignant disease.
Puerperal Fever. — Dr. .Montgomer}- {Journal Amer-
ican Alcdital Association, August i, 1896) advises early
curettement. If the condition is due to putrid into.xi-
cation this procedure, followed by irrigation and drain-
age, will give prompt relief. In streptococcus infec-
tion the germs are embedded in the mucous membrane,
sinuses, and wall of the uterus, so that curettement
would not accomplish their complete removal and
would afford more surface for ptomain absorption.
Hysterectomy has been advocated, but it is a question
whether in this form of infection the tissues have not
been invaded to such a degree that the removal of the
uterus would be ineffectual. The first aim should be
the establishment of immunity; then local manifesta-
tions should be treated as they make their appearance,
with the assurance that farther spread will be avoided.
Gastric Ulcer. — Dr. Deale {Maryland Medical Jour-
nal) writes : " It was a surprising revelation to me that
numerous autopsies have shown gastric ulcer to be
present, either in the fresh state or as healed cica-
trices, in from two to five per cent, of deaths from all
causes, and it is only fair to add that the proportion
appro.ximates nearer the latter (five per cent.) than
the former."
Death after Flooding — Dr. Tarnier {Asclcpiad),
after pointing out that forceps are seldom or never
used in accouchement except in uterine inertia, a source
of hemorrhage, and giving an instance or two of the
necropsy of women who have died after flooding which
was not profuse enough to deplete the circulatory sys-
tem, advises physicians to be slow in finding fault
with a colleague for losing a patient after flooding, as
it frequently happens that a healthy-appearing woman
may have some radical organic affection coexistent
with pregnancy, which may carry her off without the
flooding being to blame.
Care of Premature Infants — Dr. (Gilbert, before
the Kentucky State Medical Society, June, 1896, said
that statistics show that twenty per cent, of infants born
at sixth month have survived, thirty-five per cent, at
seventh month, and at eighth month eighty-five per
cent. It is too often the custom to turn premature in-
fants over to old women, without any attention. A
physician is inexcusable if he allows a premature in-
fant to die from sheer neglect. To preserve life es-
pecial attention must be paid to the maintenance of
bodily temperature, proper feeding, prevention of in-
jury by handling. The temperature should be main-
tained at 100' F. ; evaporation of moisture goes on from
the body no matter how closely it is wrapped in cotton
or clothing. Incubation is the best method of main-
taining bodily temperature. The apparatus recom-
mended consists of two tin boxes, with a two-inch
space between for warm water. The water is heated
by a coal-oil lamp placed under a small copper water
box connecting with a water chamber by small pipes.
The top of the box is open to allow the infant air and
light. Any tight box may be improvised. Feeding
is important, mothers' milk being the best food: la-
vage may be used. A mixture which has proved suc-
cessful in the author's hands is as follows:
1} Sweet milk, fresh 3 ij. 60.
Cream, fresh 3 iij. go.
Warm water, sterilized ? x. 3CX).
Sugar of milk I i. 4.
Common salt 3i. 1.30
This should be diluted for a premature infant. The
infant after birth should be anointed with warm lard,
the vernix having been wiped off; no water should be
used at the first cleansing, nor should the infant be
washed until it is three weeks of age.
Ectopic Pregnancy. — Dr. MacMonagle (Southern
California Practitioner, May 26th), from a review of
the literature on this subject and from his own experi-
ence, draws the following conclusions: i. A large
majority of ectopic gestations begin in some part of
the tube. 2. Pain is an important and almost con-
stant symptom. 3. A growing ovum must burst the
tube. 4. Rupture must take place into either the
peritoneal cavity or the broad ligament. 5. When
discovered, ectopic pregnancy should be operated on
as soon as arrangements can be made for a careful
and perfectly aseptic operation. 6. An exploratory
incision is justified when there is a reasonable assur-
ance of ectopic pregnancy. 7. Rupture into the peri-
toneal cavity, with hemorrhage, demands operation at
once. 8. The suprapubic operation is the best in a
large majority of cases. 9. The vaginal operation
should be chosen in the cases in which one feels sure
the mass is well walled off from above and can be easily
reached from the vagina. 10. In doing the vaginal
operation one should be prepared to complete it from
above in case of complications, i i. Farly operation
and removal of the tube, sac, and contents will give
the best results.
Cocaine in Surgery — i. The u.se of cocaine should
not be abandoned because its irrational employment
has produced deleterious results. 2. Always make a
thorough physical examination of the patient before
injecting the drug. 3. It should not be used in cases
showing organic diseases of the brain, heart, lungs, or
kidneys, or in persons of neurotic diathesis. 4. Chil-
dren bear it fully as well as adults. 5. The patient
should always be placed in a recumbent position prior
to its employment. 6. Constriction should be used
whenever possible to limit the action of the drug to a
desired area. 7. Use a freshly prepared solution for
each case. 8. Distilled water should always be em-
ployed, to which phenic, salicylic, or boric acid should
be added, g. A two-per-cent. solution has a better
effect, and is safer than solutions of greater strength.
10. Never inject a larger quantity than one and one-
eighth grains when no constriction is used. 11.
About the head, face, and neck, one-third of a grain
should never be exceeded. 12. When constriction is
possible, the dose may be as large as two grains. 13.
Every slight physiological effect is not necessarily to
be taken as cause for alarm. 14. Cocaine does have
effect upon inflamed tissues. 15. In case alarming
symptoms occur, use amyl nitrite, strychnine, digitalis,
ether, or ammonia. — Codex Medicus.
I
Medical Record
A IVeekly yoiirnal of Medicine and Surgery
Vol. 50, No. 12.
Whole No. 1350.
New York, September 19, 1896.
$5.00 Per Annum.
Single Copies, loc.
(Dviciinal .Articles.
THE TREATMEXT OF PXEIMOMA.
uv w. N. Macartney, m.d.,
FORT POVINGTO-N, X. V.
The editor of the Medical Record, in the issue of
December i, 1894, says that "many drugs have a re-
puted value in pneumonia, but none are yet accepted
as in any sense standard remedies in the disease," and
there can be no doubt of the truthfulness of this state-
ment. During the past fifty years the treatment of
pneumonia has passed through many phases, radical
in their nature, from free venesection down through
tartar emetic, veratrum viride, and a host of other
"cures" to the more modern digitalis treatment, the
supporting and expectant plan, or the germ-from-Ger-
niany sero-therapy.
Much has been written on this subject, and right-
fully, since no disease merits more careful attention.
Pneumonia is an extremely common disease; it is
found in all countries and in all parts of our own
country. Every practitioner is familiar with it — per-
haps too familiar with it, for its prevalence and fatality
are often taken as a matter of course, although the
death rate from this malady is simply enormous.
The ravages made by this disease were forcibly
brought home to me in looking up the statistics in my
own localitv, when I found to my surprise that pneu-
monia headed the list of fatal diseases during the pre-
vious decade, with consumption second, while diph-
theria, then epidemic and causing from its severity
much alarm, took a low third place. That our experi-
ence was not an isolated one was also apparent, for sta-
tistics from various localities, which it is unnecessary
to dwell upon at length, showed this. Delafield, for in-
stance, gives the proportion of deaths from pneimionia
in the States above the thirty-ninth parallel as 61.43
per thousand deaths, while below that parallel it is
93.70. If this were not enough, Miller states that dur-
ing the past ten years 15,544 deaths occurred from re-
spiratory diseases in the Moscow Orphan Asylum, in a
total of 155,459 deaths from all causes, and that of
these 14,41 1, or 92 per cent., were from pneumonia.
In the city of New York, to quote a more recent ex-
ample, the mortality during the four weeks beginning
March i and ending March 28, 1896, the reports being
issued weekly, not by months, was 658, while the mor-
tality from consumption, the next highest on the list,
was but 409. The total fatality from small-pox, mea-
sles, scarlatina, diphtheria and croup, whooping-cough,
typhoid fever, malarial and cerebro-spinal fever during
this length of time was 363. It will be seen at a
glance that the death rate in the great metropolis dur-
ing these four weeks exceeded the sum total of the
mortality from all zymotic diseases by more than
eighty-one per cent., and that this^is not an exceptional
instance can be easily verified by a study of the records
from month to month. March reports from Philadel-
phia show much the same death rates.
W'alshe gives this affection the third place in the
catalogue of fatal diseases. On what grounds this es-
timate is based I cannot say, but undoubtedly of late
years it would stand much higher, owing to its greater
prevalence in connection with the grippe. Certainly all
records which I can find would go to show that at pres-
ent pneumonia has the greatest fatality of all diseases
in this broad land of ours. Have we become so ac-
customed to this appalling mortality that it e.xcites no
comment.' It would seem so, for should one-tenth the
number of people who die annually of pneumonia in
the United States lose their lives from Asiatic cholera
or in a Johnstown flood, the country would be wild
with horror. True, the latter would be to some ex-
tent preventable deaths, but can nothing be done to
diminish the enormous mortalirv' from this one puK
monarv disorder.'
During the years 1S90-1896 pneumonia prevailed
to an unusual extent in northern New York, owing in
a large measure to its association with epidemic influ-
enza. Previous to 1892 I treated pneumonia after es-
tablished methods, or at least after modern and popular
methods. The keynote of the treatment was to sup-
port the patient until the crisis was passed. Poultices
were applied, with cotton-batting jackets, absolute rest,
nutritious fluid food, stimulants, etc. A'.irious drugs
were used, as seemed indicated — quinine, Dover's pow-
der, aconite, digitalis, etc. Phenacetin, acetanilid,
and other coal-tar derivatives were tried, but soon
abandoned as decidedly injurious and unsafe. The
fever went down under their use. The patient fre-
quently followed.
Under this general supporting plan of treatment,
based on the view that pneumonia was a self-limited
disease, and the chief object of treatment was to keep
the patient ali\c long enough to allow^ the disease to
run its course and spend its energy — a plan of treat-
ment which I was taught at college, a plan which I had
afterward seen followed in the hospitals, a plan of
treatment which most of our modern text-books com-
mend, and which is generally endorsed by the profes-
sion at the present dav — under this general method,
based on the doctrine of self-limitation, my mortality
was about sixteen per cent., as nearly as it could be
estimated, for up to this time I had kept no very ac-
curate record of my pneumonia cases.
On looking up statistics, I found the mortality esti-
mated variously. " Hospital statistics show twenty to
forty per cent." The Montreal General Hospital gave
a mortality of 20.4 jjer cent. Of 3,969 cases at Char-
ity Hospital, New Orleans, 28.01 per cent. died. The
Massachusetts General Hospital records, according to
Drs. Townsend and Coolidge, showed a mortality of
28 per cent, of late years. These statistics should
have comforted me, and they did to some degree
afford consolation ; but the mortality in the Massachu-
setts General Hospital from 1822 to 1832 was shown
to be but 10 per cent., while the reasons advanced for
the increased fatality in the later years seemed to me
unsatisfactory. According to the report, when the in-
temperate, the aged, and the complicated cases were
excluded, the mortality was reduced from 28 per cent,
to 10 per cent., which, if an inherent feature of the
disease, was still a high mortality.
The closer my scrutiny of ail available records the
more dissatisfied did I become, and my own death rate.
398
MEDICAL RECORD.
[September 19, 1896
though averaging well, seemed unnecessarily large.
For these reasons and others, my confidence in the
etiolog)' and treatment of this disease was so shaken
that for a time I followed no definite mode of treat-
ment, but tried various methods or treated the cases
symptomatically, while eventually the result of this
state of uncertainty and skepticism was a radical and
sweeping change in my general manner of treating this
affection.
The central idea of the modern management of
pneumonia is, if I judge correctly, that this being a
self-limited disease, due to germ infection, the treat-
ment in accordance with this theory should be to place
the patient under the most favorable conditions, keep-
ing up his strength until the disease runs its course.
In other words, the treatment is purely expectant or
symptomatic, as the case may require. This view is
in marked contrast to that held years ago, when pneu-
monia was considered an infiammation of the lung
tissue, venesection and depletion being in vogue.
Which is right? Statistics certainly do not prove very
much for our later-day methods, and between the two
extremes there may be some truth.
What is the specific cause of pneumonia? It is
perhaps safest to say, siibjiuiice lis est. The pneumococ-
cus of Fraenkel is given as the immediate and direct
originator of croupous pneumonia ; but the pneumococ-
cus also occurs in catarrhal pneumonia, in middle-ear
disease, in endocarditis, in cerebro-spinal fever, in
pleurisies unconnected with pneumonia. It seems to
hit normally found in the human mouth. The bacillus
of Friedlander, bacillus of influenza, streptococcus py-
ogenes, and staphylococcus also '"cause" pneumonia.
Certain cases also have been reported as due to the
proteus vulgaris and the bacterium coli commune. The
microscope and the culture tube have so far given us
nothing we can rely on, and the evidence we have is
altogether too vague, too indefinite, to be accepted as
absolute proof of the microbic origin of this mal-
ady.
Clinically, also, there are many things which re-
quire explanation if pneumonia is to be regarded as
essentially of microbic origin. Why does it occur so
commonly in the later stages of exhausting diseases, in
old age, in connection with cardiac disorders? In
1888 I treated a case of dilatation of the heart through
four attacks of pneumonia within a period of three
months. Why should one attack predispose to others?
Why should it occur so often after fracture of the neck
of the femur? What is its mode of infection, its pe-
riod of incubation ?
Why can it be aborted or jugulated if it is a germ
disease? But some say pneumonia cannot be aborted.
Osier, for instance, says, in his '-Practice," p. 529:
" Pneumonia is a self-limited disease and runs its
course uninfiuenced in any way by medicine. It can
neither be aborted nor cut short by any known means
at our command." This is a very strong declaration
for even a man of his reputation to make. It is a
statement, moreover, which is opposed to the assertions
of men such as Austin Flint the elder, and others, who
say that pneumonia can be aborted and that they do
abort pneumonias. "We must never assume that
which is incapable of proof," says Lewes, in "The
Physiology of Common Life," and the position which
Osier takes is untenable. " There is a dilTerence be-
tween assertion and demonstration," as Macauley re-
marks, and the assertion that pneumonia cannot be cut
short is, on the face of it, too sweeping and practically
insusceptible of proof, for in order to establish this it
would be necessary to show that no case of pneumo-
nia ever has been or could be aborted, a thing mani-
festly impossible to demonstrate, requiring as it would
an accurate knowledge of every case since Adam and
Eve left paradise. Per contra, proof that a single
case has been jugulated by medicine or other means is
amply sufficient to disprove Osier's assertion.
Many authors there are who uphold the theory of
jugulation. All are not so conservative as Flint, who
says : " The disease is self-aborting or may be aborted
in some cases." I venture to say that there are few
physicians who have not seen pneumonia cut short in
its early stage. Within the last three years I have
treated one hundred and twenty cases of pneumonia,
and of this number sixty-seven, or 55.8 per cent., were
cut short, not running their full course. Many of
these were already well marked at my first visit, with
all the physical signs and symptoms, and to say that
in 55.8 per cent, of the cases there was a mistake in
diagnosis could hardly be called argument.
Some practitioners may never have seen pneumonia
cut short, and dead-house statistics will probably sub-
stantiate them. There are individuals who have never
seen partridges "drumming." They don't drum much
in confinement, nor would one readily discover how
they do it by examining them ever .so carefully as they
hang by their legs, heads down, in the market. So,
too, it is not easy to demonstrate by post-mortem ex-
aminations that pneumonia is ever jugulated, for these
patients, unfortunately for dead-house statisticians, get
well when the pneumonia aborts. Vet this does not
prove that partridges never drum or that pneumonia
never aborts, some of our modern authors to the con-
trary notwithstanding. Too large a number of able
diagnosticians, careful observers, logical reasoners,
have seen pneumonia cut short, to allow us to give ^uch
assertions as tiiat of Osier's credence.
If, on the other hand, pneumonia can be jugulated,
how reconcile this with the orUiodox doctrine of the
pneumococcus of Fraenkel tt a/.i Can we sweat out
small-pox or typhoid in a few hours, or have we a new-
style, unique, law-unto-itself sort of a germ to deal
with — a germ forever sitting in our outside gates, a
germ which threatens the ver)- citadels of life when
once admitted, which d ;fies antiseptics, eludes inocu-
lation, laughs at "trinity pills," but subsides quietly
and at once when the circulation is equalized? Sure-
ly a strange germ and an outlaw from its kind.
Is pneumonia infectious, contagious, or both?
Probably it is in the pathological laboratory; it has
hardly been satisfactorily proven by clinical records.
Certain instances are given in which several in the same
family or closely associated have developed the dis-
ease about the same time. I have a case in point.
Three persons — a man, iiis wife, and an adopted
daughter — living in a farmhouse some distance from
the road, were taken with infiuenza. There were but
two beds in the house, one of which was usually occu-
pied by the old couple, the girl sleeping in the other.
A neighbor calling in found all three sick, and I was
summoned. The woman was then suffering from pneu-
monia of two days' standing, while the man had pneu-
monia also of more recent origin, and on the following
day the girl developed the same malady. The woman
died, the other two recovering. It seemed a clear case
of pneumonic infection, possibly of contagion; yet on
closer scrutiny it appeared that in the beginning the
wife as nurse had put the husband and daughter in the
two beds, and she herself, the subject of the grippe, had
slept on a lounge. She then developed pneumonia,
took the bed occupied by her husband, he assuming
charge. Then the husband came down with pneumo-
nia while reclining on the lounge, and the girl arose,
gave him her room, took the lounge — and pneumonia.
It was ascertained that all three of them had developed
the pneumonic process while lying, with lungs irritated
and congested by the grippe and their systems depressed
by it, on the couch next an outside wall, in rough P'eb-
ruar)' weather, with the thermometer many degrees be-
low zero, and with a wide crack in the wall just below
September 19, 1896]
MEDICAL RECORD.
399
the level of the lounge, through which the cold wind
was freely blowing. U'ere these people the victims of
infection by the diplococcus pneumonia? They may
have been. Equally true. Mars may be inhabited.
But the crack in the wall was there; it did not require
a high-power objective for demonstration.
Then there are instances of epidemics of pneumonia
in barracks and prisons. These require more thor-
ough investigation before they can be accepted as
proof positive of its infectiousness, especially in view
of the possibility that some other infective agent may
have been at work. In some epidemics of scarlatina
nearly every case develops nephritis, yet we are hardly
warranted in considering nephritis either infectious or
contagious.
Pneumonia may be an infective disease with a pe-
riod of incubation extremely short and a specific or-
ganism as a causative agent. I am too thorough a
believer in the germ theory in general to deny this,
but a safe assertion would be that at the present day
we do not know its cause. This certainly is safer
than assuming a knowledge which we do not possess.
More light is needed before we accept theory as fact.
Theory is all well enough as theory, but it is well to
remember that it is not proof, and while the theory of
the bacterial origin of this disease has been furnished,
the proof is still incomplete, the obstacles in the way
of the unqualified acceptance of it being many and
troublesome.
What is the cause of the great mortality in pneumo-
nia.'' Is it an inherent and essential feature of the
disease? Is it that the disease is necessarily fatal in
about one out of four average cases? Are our meth-
ods of treatment faulty? Because of the enormous
mortality solely from this one disease, this is a subject
well worthy of careful and lucid consideration. To
one who keeps an eye on the obituary column in our
medical journals, it would seem to be a disease pecu-
liarly fatal to physicians, and that, verily, when we
have pneumonia,
" To our graves we walk
In the thick footprints of departed men."
Austin Flint says: "The treatment is in the main
supporting; . . . support the powers of life." Ac-
cording to Loomis: "The success of modern methods
of treatment based on this belief bears evidence to its
being a general self-limiting acute febrile disease.'"
The success of modern methods has been shown as a
mortalit)' of one out of every four cases. Loomis him-
self fell a victim to the disea.se, and the " evidence"
which the " treatment based on this belief" bears is
like the handwriting on the wall.
" .\nd we shall feed like oxen at a stall.
The better cherish'd still the nearer death."
Why should the treatment be supporting? Practically
all authors are agreed that the usual cause of death is
cardiac failure. Is this heart failure due to exhaus-
tion? It is a matter of common obser\-ation even
among the laity that robust people are often seemingly
overwhelmed with the disease; that it attacks the vig-
orous as well as the delicate. Does a strong, robust,
well-nourished man die of exhaustion on the fifth or
sixth day of a typhoid fever ? Does he not, on the con-
trar)', usually live through four weeks of high fever on
a liquid diet (or something lighter still if the fasting
treatment of Dr. Page be followed), and eventually re-
cover? I have seen patients dying of pneumonia
when their muscular strength was at the time greater
than that of their medical attendant, as evidenced by
the force required to restrain them in their delirium;
in whom the pulse was full and strong up to the time of
the superaddition of congestion and cedema. In com-
parison with that other acute febrile disease, typhoid,
does it seem that they died of exhaustion on the fourth
or fifth day? Is this common sense?
On the other hand, if the high temperature disor-
ganizes the heart muscle, why does it act so rapidly
in pneumonia and so slowly in typhoid and other fe-
brile disorders? When a pneumonia patient is in ex-
tremis, due to a temperature of 103^ F. for four or five
days, if phenacetin or acetanilid is given and his
temperature is thus reduced, will that lessen his ten-
dency to cardiac failure or increase it? Pepper says
the cardiac exhaustion is due to the poison of bacteria.
But what leucomain is produced by the pneumococcus
which is so prompt and powerful a cardiac poison as
to produce these rapid effects? Has this morbific
agent, this powerful toxin, toxalbumin, or pneumotox-
in been demonstrated? Theor)' is not proof. Specu-
lation and conjecture are not evidence.
The patient certainly does not die of pulmonar}- or
respiratory failure. Pleurisy gives us no such mortal-
ity, nor does it cause death by respirator)' exhaustion,
even though one lung is compressed by fluid effusion
into a small space the size of a hand. Empyema does
not kill in five days, though the fever may be high and
an entire lung rendered useless, with septic intoxication
added. In New York City, during the week ending
March 28, 1896 (the latest available report), to con-
trast the deaths from pneumonia with those from pleu-
risy, there were one hundred and eighty-two deaths
from the former, one from pleurisy, none from empy-
ema. Phthisical patients do not die of respiratory fail-
ure, though the lungs may be extensively disorganized.
Careful observations at the bedside show that respira-
tory failure is not the cause of death in pneumonia in
the vast majority of cases.
What kind of heart failure is it that kills off the
robust and the weak in such appalling numbers?
Much has been written of the morbid anatomy of
pneumonia, of the consolidation of lung, the fibrinous
exudate into the air vesicles being minutely described
and dwelt upon, while the vascular changes are dis-
missed with a few words descriptive of the hyperamic
condition. Prior to hepatization many of the air ves-
icles are collapsed from the pressure of the swollen
and tortuous vessels. The exudation occurs with the
stage of hepatization. Is the exudate the cause of the
hypereemia or the effect? Virchow has proved that
pneumonic processes can be established when large
laranches of the pulmonary artery are plugged. It is
thoroughly understood also that passive pulmonary hy-
peremia of long standing, due either to cardiac affec-
tions or to hypostasis, leads to the establishment of
pneumonic processes. Sudden chilling of the surface,
driving the blood to the internal organs, is the com-
monest exciting cause under which slowing of the pul-
monary circulation from congestion results; the lungs,
being spongy, elastic organs, furnish a point of small
resistance. Stasis should be followed by exudation
into the alveoli. Exudates occur in thrombosis and
in circulatory disturbances in general ; the exudates are
dependent upon the circulatory changes, and absorp-
tion is rapidly resultant when the circulation is re-
established on normal lines. How else but in some
similar way can we explain the quick clearing up of a
lung consolidated by pneumonia? The inflammatory
theory will not explain it, for this is not the course of
an inflammation. It is an open question, therefore, if
too much attention has not been paid to the exudate
into the air sacs and not enough to the vascular
changes. Certain it is that we have a coagulative
process resembling in some respects venous thrombo-
sis in the suddenness of its occurrence, in the vascular
changes resulting, in the fact that we have venous blood
in the pulmonary artery as a circulatory medium. We
do not understand the pathology of phlebitis. Neither
400
MEDICAL RECORD.
[September 19, 1896
do we understand that of pneumonia. Let us be as
candid in the one case as in the other.
It seems to me that Ribbert, of Bonn, makes a cen-
tre shot when he states that " pneumonic processes are
attended with coagula within the blood-vessels in the
form of fibrous thrombi, and within the capillaries."
Osier says: " If the lung has been removed before the
heart, it is not uncommon to find solid moulds of clot
filling the blood-vessels. . . . The heart is distended
with firm, tenacious coagula, which can be withdrawn
from the vessels as dendritic moulds. In no other
acute disease do we meet with coagula of such solidity
and firmness." Other authors have it that the pul-
monary vessels may contain thrombi with fibrin forma-
tions in the capillaries of the portion of lung affected
with the pneumonic process. The enormous increase
in the fibrin factors has long been known. Given
this condition referred to, and the exudate must fol-
low. Which is the primary process and therefore the
more important.'
Delafield says: "The pressure of exudate on the
blood-vessels may cause necrosis of the pulmonary tis-
sue with resulting gangrene." It seems difficult to
prove that the necrosis is brought about in this way.
Plugging of the pulmonary vessels may occur and the
•exudate may follow ; and the pressure of this exudate on
the bronchial vessels which furnish the remaining
blood supply might be sufficient to cause gangrene.
Looking at it in this way, it would be a logical se-
quence.
Pneumonia is largely fatal in proportion 10 the ex-
-tent of lung structure involved. Some authors deny
•this. Perhaps they prefer double pneumonias to one-
sided—most of us do not. Why this fatality when
much lung is involved.' The answer is, obstruction to
ihe pulmonary circulation. If the primary- trouble in
pneumonia were circulatory, it would explain many
things otherwise difficult of comprehension. It would
make manifest Loomis' statements that "most sudden
deaths in the old are from acute lobar pneumonia,"
and that " nine-tenths of all deaths after the sixty-fifth
year are caused by lobar pneumonia." One author
.asserts that " pneumonia is the natural death of the old
•man.'' It would account for the suddenness of onset
■of pneumonia, its occurrence after exposure, in con-
nection with cardiac diseases, in long-continued fevers,
in cases of fracture, of debility; it would render intel-
ligible the almost miraculous way in which resolution
of the consolidation takes place in so short a time; it
would make plain the cyanosis and the heart failure;
it would make clear much which under accepted views
is difficult of elucidation.
It is far from the purpose of the writer of this paper
to formulate a new theory of the essential and specific
•cause of pneumonia. The etiology of this affection is
still involved in obscurity and the various theories
offered are far in advance of the facts so far estab-
lished. We need more painstaking investigations and
less airing of individual opinions, but there is good
reason to believe that the morbid process, whatever its
origin, is more a circulatory than a strictly febrile or
inflammatory disturbance and the view that the pri-
mary seat of the pathological process will be found
•eventually in the vascular mechanism of the lung,
rather than in the air vesicles, commends itself to a
.sober judgment. In the absence of further knowledge
of the various pathogenic bacteria of pneumonia and
the precise role they play, they may be for the present
•disregarded as not essential to the purpose of this
paper. From the point of view that the disease proc-
ess is circulatory- the fibrinous exudate in the air-cells
is of small importance. See how quickly it will dis-
appear by absorption when the circulation is re-estab-
lished. Take the ligature from around your finger
and watch the swelling subside. Cardiac failure, not
respiratory failure, is to be feared, and we need to
study the circulatory changes, not the fibrinous exu-
date.
Oiven stasis from fibrous thrombi in the vessels of
a portion of the lung, and what would occur in natural
sequence? Increased labor thrown on the heart. Xot
on the heart as a whole, but on the right heart, the
light horse in the team. Ordinarily its work is not
difficult, its circuit being short and easy. It pumps
blood through the pulmonarv artery, through spongy
lungs, back into the left heart. There is little neces-
sity for thick muscular walls; therefore its walls are
thin. The left heart on the contrary is strong and
muscular, for it has a long difficult circuit, up-hill,
down-hill, and back again. It must be thick and
strong. F)Ut the right heart has comparatively little
lifting to do ordinarily. Then, if with pneumonia we
have fibrin formations or other obstructions in tile
capillaries and pulnionarv vessels of an extensive area
of lung tissue, congestion perhaps of the remaining
portion, possibly thrombi in the pulmonary vessels, or
perchance pressure on the ves.sels from the exudate,
insufficient, however, to cause necrosis, but enough
with the rest seriously to embarrass the lesser circu-
lation and heavily to tax the right heart, then what
naturally follows in severe cases.' Circulatory dis-
turbances from pulmonary obstruction, collateral hy-
peraemia and cedema, fulness of the pulmonary artery
from the obstruction, and — the beginning of the end
— dilatation of the right heart, which labors and strug-
gles. The natural outcome of this is fulness and
damming-up in the vena cava superior and inferior,
the right heart being unable to force the l)lood through
the obstructed lungs as freelv as usual, while the left
heart, unhampered, is filling the veins and sending
more blood to the right. Then comes the increased
enlargement of the liver and .spleen; the brain is con-
gested, engorged, and delirium occurs. The right
heart dilates further until possibly the valves no longer
are competent ; the heart, distended and choked with
its own blood, is failing rapidly. We may now have a
dicrotic pulse from insufficient filling of the vessels
on the farther side of the barrier. (General venous
congestion with increased hyper;vniia of the lungs,
cyanosis from the venous accumulation, is next in
order, while, the blue blooJ acting <jn the respiratoiy
centres in the medulla, the breathing is more rapiti,
labored, and irregular. The fibrin factors being in-
creased four hundred per cent,, the struggling heart
whips up the slowed blood current until, as a natural
result, heart clot may follow.
Death is due to heart failure — not to heart failure as
a whole, but essentially and specifically to failure of
the right heart, and this right-heart failure is not due
to fe\er, exhaustion, lack of oxygen, nor to septic poi-
soning, but is the legitimate result of a blockade in
the pulmonary circulation. ' In other words, the right-
heart failure is due directly to interference with the
work of the right heart. When it is remembered that
the right and left hearts are to a large degree separate
pieces of mechanism, that the obstruction in pneu-
monia is in the lesser circulation, and that the right
heart is the weaker, it seems almost trite to say that
the cardiac failure is a right-heart failure; but when
this doctrine is more fully established, its importance
more generally recognized, and when the treatment is
remodelled on this central idea, the mortality from
pneumonia will be much reduced and phenacetin and
acetanilid will be discarded in pneumonic cases.
As I have previously stated, the mortality in the
first series of cases was about sixteen per cent. In
the second series of one hundred and twenty consecu-
tive cases, treated after the general method which is
about to be described, the mortality was two, or 1.66
per cent. This list includes all cases, treated since
September 19, 1896]
MEDICAL RECORD.
401
the time referred to, in my general practice. Cases
seen in consultation, but under other plans of treat-
ment by their attending physicians, cannot properly be
included among my own cases and are tiierefore omit-
ted. The cases constituting this series occurred in
the same locality, under practically identical condi-
tions, with the same nursing and hygienic surround-
ings, and so far as I can judge were of the same gen-
eral severity as those previously mentioned. The sole
difference was in the treatment. Certainly many of
them were severe enough, so severe that I frequently
gave an unfavorable prognosis, in the light of previous
experience, and yet they recovered. Many of the pa-
tients were aged, a number being in their eighties.
Some were feeble ; some were alcoholic. A large num-
ter liad double pneumonia. There were two cases of
contusion pneumonia complicating fracture of the ribs.
Some had typhoid pneumonia. Some pleuro-pneu-
monia. Several cases followed whooping-cough, others
measles. Three cases occurred in asthmatics. Two
were followed by pulmonary abscess. Acute or chronic
cardiac diseases occurred in connection with many
cases. Two were complicated with jaundice: in each
instance the jaundice appeared on the fifth day of the
pneumonia and was followed by a sudden and unex-
pected drop in the temperature with rapid disappear-
ance of the pneumonic consolidation. Contrary to the
opinion of some authors, that jaundice is always a fatal
complication, both of these patients recovered. Of the
one hundred and twenty cases relapse occurred in one
abortive case and in one which ran its full course.
Of the two fatal cases, the first was that of a child
two years old, whom I had treated the year previouslv
through a run of pneumonia. In her second year,
uliile suffering from whooping-cough, she developed
measles of a severe tyjje, an epidemic of the latter
disease prevailing. With the measles she had a gen-
eral bronchitis and then a double pneumonia. This
little patient lived six miles away, at a time when the
roads were almost impassable, and daily visits were
sometimes out of the question. She struggled on to
the ninth day of her pneumonia and died. I sincerely
believe that had she had good nursing and constant
medical attendance she might have recovered.
The second fatal case was that of an old lady, seventy-
nine years of age, with a feeble dilated heart, rheumatic
endocarditis, and general dropsy. I saw her some
weeks previously to her pneumonic attack and sent for
the priest at the time, as her pulse was feeble, irregu-
lar, and intermittent. She would not take medicine
for her cardiac trouble, as she said she wanted to die,
having outlived her usefulness. She would not have
a nurse. She took the pneumonic chill one Sunday
several weeks later. I saw her for the first time in
this trouble on the Wednesday following. When I
arrived the patient was dying. This patient died really
of cardiac disease which ran on to its legitimate con-
clusion, owing to the fact that neither threats nor per-
suasion could induce her to take her medicine or any
reasonable precautions.
In the whole .series the plan of treatment was fairly
uniform and it had at least the merit of simplicity.
Comparatively few drags were used, and the chief re-
liance was placed on free and long-continued diapho-
resis. The history of an ordinary attack of pneumonia
is that of a sudden chill with internal congestion, the
chill being more constant and severe than in any other
acute disease, and a rational treatment is to bring the
i'lood again to the surface and equalize the circula-
tion. The routine treatment was as follows: the pa-
tient was put to bed : four or five bricks were heated
hot. dipped in hot water, wrapped in dry cloths, and
placed around him: he was then covered with blankets
and kept in a profuse jx-rspiration for from four to
forty-eight hours, depending upon the effect of the
treatment. If the temperature went down to normal^
he was allowed to dry oft slowly. He was not dried
oft with a towel nor permitted a change of linen. I
considered it wiser that the patient should lie in the
wet clothing until the temperature was normal, not
only to guard against exposure to the air, but because
the wet clothing assisted in reducing the fever by
evaporation and conduction. The principal reduction
in temperature was, however, undoubtedly eftected by
the diaphoresis, for with the occurrence of the latter
the fever fell, the patient breathed easily, and the-
pneumonic process subsided.
.As mentioned in a preceding paragraph, sixty-seven'
of these cases were aborted. A large proportion were-
seen reasonably early, with the result that they had a
normal temperature, freedom from pain and cough,
and easy respiration in a few hours: others yielded
only after two days of sweating and a mercurial
purge. I am fully convinced that many cases which
ran their full course would have been jugulated had.
the treatment been instituted early enough and faith-
fully adhered to. In the absence of a nurse it was-
often difficult, at times impossible, to have the treat-
ment properly carried out with young children and
with refractor)- patients. Human nature seems prone
to attach more importance to the administration of
drugs than to the other equally necessary measures,
and frequently the sweating was not thoroughly done
though the medicine was given exactly on time.
If treatment was begun early enough, say within
twenty-four hours after the inception, the disease was-
usually aborted readily. Occasionally it could be cut
short when the lungs were completely consolidated
and the brick-dust sputum copious. Typhoid pneu-
monias and pleuro-pneumonias alike yielded.
Free diaphoresis counteracts the effect of the chill
by its action on the vasomotor system, bringing the
blood to the surface. The cutaneous vessels dilate ;
internal congestion is thereby relieved; effete matter-
is thrown out: the volume of the blood is diminished
by the water poured out through the skin, amounting
to a very considerable quantity, as a rule; and the nor-
mal circulation is restored. In internal congestions-
the action of diaphoresis is in many respects similar
to that of venesection.
More than this, diaphoresis is pre-eminently tlie-
antipyretic in pneumonia. In these days, when coal-
tar antipyresis is being condemned and hydrother-
apy lauded, we are in danger of overlooking nature's
great antipyretic- — not cold baths, but free perspi-
ration. .\ moment's reflection, particularly on a
wann July afternoon, will convince any one of this..
Dalton, in his ''Physiology,'' says '"the most direct
and simplest means of moderating the temperature of
the body is that by the cutaneous perspiration."
.Michael Foster also states that " the great regulator
(of animal heat) is the skin; . . . any action of the
vasomotor mechanism which by causing dilatation of
the cutaneous vascular areas leads to a larger flow of
blood through the skin will tend to cool the body."^
Theoretically it is unnecessary to elaborate this idea.
We are all familiar with it: in this all physiologists
are agreed; but in practice many of us overlook it.
When we induce perspiration in pneumonia we do'
much more than reduce the temperature in nature's
own way, and, important though this be, the good effect
is largely due to the circulator)- changes induced.
Drugs played but a small part in the treatment.
Quinine was given at times: also Dover's powder, ta
assi.st in promoting perspiration and for the moral ef-
fect: occasionally hot drinks until diaphoresis was-
established. So far as my obser\-ations go, simple
diaphoresis by vapor baths was as effectual as when
resultant from the use of drugs, and in my judgment
quinine did not produce antipyresis except by the
402
MEDICAL RECORD.
[September 19, 1896
diaphoresis indMced. In other words, the tempera-
ture was reduced in proportion to the amount of per-
spiration it caused, not in proportion to the dose, and
the statement of Bartholow, that in acute febrile dis-
orders quinine reduces temperature by depression of
the heart and arterial tension, by suspension of the
oxidizing power of the blood, and by the inhibition of
the white corpuscles, was not borne out.
I think this general law holds true, and explains
the action of Dover's powder, veratrum viride, aconite,
acetanilid, phenacetin, and many other drugs used in
pneumonia, including carbonate and muriate of am-
monium, which according to the older writers are good
diaphoretics. Even tartar emetic is a powerful sweater
under favorable conditions (\V. H. Thomson, Pereira,
etc.). We have most contradictory reports regarding
some of these agents. Some physicians obtain remark-
ably good results from them ; others say they are use-
less or injurious. Conscientious observers do not
knowingly misrepresent these matters. It is altogether
probable that the good effects of veratrum and aconite,
for instance, are not due to the reduction in pulse so
much as to their diaphoretic action. Acetanilid and
phenacetin seem to have been used successfully at times.
It is possible that the profuse sweating characteristic
of the action of the latter drugs in fevers may be
beneficial in the early stage of pneumonia, when the
heart is still vigorous, but they are treacherous agents.
All these remedies, it will he remembered, are dia-
phoretics, vigorous diaphoretics. Ellis says, in regard
to pneumonia, '"when perspiration occurs and the py-
rexia is manifestly less, I discontinue the aconite;"
and Ringer states, in speaking of this drug, that " if
the aconite is given at the earliest stage, when the
chill is still on the patient, the dry, hot, and burning
skin becomes in a few hours comfortably moist, and
then in a little while is bathed in a profuse perspira-
tion, often to the extent that drops of sweat run down
the face and chest. With the sweating comes speedy
relief from many of the distressing symptoms." If
one physician gives aconite for pneumonia, or vera-
trum in full doses, keeps his patient lightly covered
in an airy apartment, while another with the same
drug and identical dosage keeps his patient hot-poul-
ticed, wadded with oil-silk jackets, and swathed in
blankets with the room at 75' P., it would be absurd
to expect similar results. The drug administration
would be the same, but the methods of treatment would
differ radically.
Poultices I do not use as a routine treatment, be-
lieving that the benefit resulting from their use is
largely on account of the local dilatation of the cuta-
neous vessels and the diaphoresis promoted by their
application. That they do good is not denied, but I
believe that the general application of moist heat is
infinitely superior to the local. Poultices al.so neces-
sitate in their renewal more or less exposure of the
patient while in a profuse sweat, a matter certainly
troublesome to the patient, possibly hazardous. More-
over, the use of poultices for days at a time all through
a pneumonia, until the skin over the chest is soggy
and sodden, while the circulation becomes sluggish
and the skin water-logged, is certainly illogical and
injurious. As a local application for the relief of
pain I use them occasionally, but this is seldom nec-
essary, since the pain is usually assuaged as soon as
free sweating is established.
In regard to the prostrating effects of the sweating,
so far as my experience goes, I can testify that this
prostration has never been sufficient to cause the least
anxiety. In no case was there collapse. The patient
sometimes complained that he felt weak, but also
" complained " that he was much better. A weakness
from sweating is a form of depression from which re-
covery is astonishingly rapid, and is surely less seri-
ous than a weakness from fever or from an obstructed
pulmonary circulation. It is obvious that the elimina-
tion of efTete material from the system is not harmful
and the loss of water is replaced in a few hours. In
this connection it is well to note that the natural
way for a pneumonia to terminate is by a critical
sweat. Critical sweats are common, too, in intermit-
tent fever, typhus, relapsing fever, and other diseases,
and with these crises comes a marked improvement.
If nature's method of regulating the body heat is by
the sudoriparous glands, surely this treatment is not
irrational.
When the pneumonia did not abort, the patient was
kept in a moderate perspiration all the way through
the pneumonic attack; fluid diet of a light nature and
moderate in amount was given as the patient required
it; no opiates, as a rule. Calomel, if the liver was in-
active, was occasionally given in the ordinary doses
and free purgation favored, not losing sight of the
fact that certain cases of pneumonia naturally end by
a critical diarrhcea.
Strychnine was often used and proved extremely
efficacious in the later stages. Some maintain that
strychnine acts directly on the right side of the heart,
and if this is so it seems strongly indicated. Certainly
this drug is a most useful remedy in pneumonia as a
reliable cardiac stimulant.
Digitalis was given also in certain cases when it
seemed to be indicated. With the niamniotii doses now
advocated by some writers, I have had little experience.
In two cases in which this remedy was pushed vigor-
ously alarming symptoms appeared, and its general
use in large doses was discontinued.
The ammonium salts, carbonate and muriate, were
frequently given in the cases whicii were not aborted,
in small doses frequently repeated. These amomnium
salts moisten the skin, promote expectoration, are
claimed to prevent fibrin formations, but more than
all are excellent cardiac stimulants; and I have found
them useful and reliable agents in this disease.
Iodide of ammonium was usually prescribed if reso-
lution was slow.
Alcoholic stimulants were not used, as a rule, but
when necessary wore given freely. When the first
sound of the heart resembled the second in character
they were given, and in alcoholic subjects full stimu-
lation was resorted to. In the ca.se of the aged, alcohol
was also employed.
Loomis states that pneumonia in the aged is usually
fatal. " After sixty, the prognosis is always unfavor-
able." Of my cases twenty-four were sixty years of
age or over, while ten ranged from seventy-five years
up. Of these aged patients the one referred to died.
In the old, circulatory disturbances are more serious;
the vessels being inelastic, collateral and compensa-
tory circulation is not so readily adjusted, and dis-
turbances of the vascular mechanism not so easily
equalized. In pneumonia, too, the rule holds good
that "a man is as old as his arteries."
In treating these cases, the condition of the circula-
tion was shown by the pulse, and the heart sounds w-ere
carefully watched and taken as a guide; the tempera-
ture range was considered of minor importance except
as indicating the necessity for free diaphoresis if it
rose too high. The diagnosis having been carefully
made in the beginning, freciuent examinations of the
chest were avoided, as productive of evil and of slight
benefit in furnishing indications for treatment. The
heart and the pulse can be readily watched in pneu-
monia without changing the patient's position, without
exposure to the air, and they furnish indications of
more value than the pulmonary physical signs.
When cyanosis appeared, even vigorous stimulation
usually failed to relieve it. The blueness of the fin-
ger nails and general duskiness are evidences of the
September 19, 1896]
MEDICAL RECORD.
403
right heart's choking from overdistention, and since
in this condition it is full to overflowing and the left
is comparatively empty, the reason for the compara-
tive failure of general cardiac stimulants is fairly
clear. Stimulation is not required for the left heart,
but the right has been laboring hard and is overbur-
dened. It needs relief from its load more than the
use of the whip. When cyanosis occurred, I bled if
possible, then gave cardiac stimulants.
This opens up the question of blood-letting in pneu-
monia, one that is of late being revived by several
earnest advocates of venesection in this disease. Is
bleeding ever nature's method of treatment, and if so
are we ever justified in following nature's lead.' I
have frequently heard old physicians, men of ripe
judgment, sa)' that they never saw a remedy so prompt
and effectual in full-blooded patients with pneumonia
as bleeding. I have heard an eminent professor of
practice in a medical college, a distinguished clini-
cian, state that he would bleed for pneumonia if he
dared. If bleeding is indicated in a pneumonic case,
if epista.xis occurs in a full-blooded man in the early
stage of the disease, why not dare to bleed.' Should
we follow public opinion or lead it.'
I resorted to venesection in a case of pneumonia for
the first time when a hospital interne. The patient was
a thick-necked, red-faced, plethoric young fellow.
The diagnosis was confirmed by admittedly competent
men. I bled him and the ne.\t day he was walking
about the ward. Since that time phlebotomy has been
employed by me on numerous occasions in the early
stage of the disease. All cases are not adapted for
this practice; there are prejudices to overcome, and
free diaphoresis is amply sufficient in the average
case to accomplish the same results; but my success
with venesection in the congestive stage has always
been highly satisfactory.
For nearly a dozen centuries blood-letting was in
vogue, the old doctors maintaining steadilv, with a
perseverance and consistency during all these years
which was certainly remarkable, and which in these
days of rapidly shifting medical fads must excite our
admiration, that venesection relieved pain, reduced
fever, moderated the force and Slowed the action of
the heart, removed morbific material from the blood,
lessened its volume, and reduced inflammation. To-
day a few of us still apply leeches and use dry or wet
cups occasionally to accomplish the same ends. Is
Hahnemann such a bugbear at the present day that
we should feel our courage oozing out at our finger
tips? If blood loss were so fraught with evil conse-
quences, our surgical operations would have a higher
mortality and each full moon would fill our church-
yards.
The old writers maintained also that of all dis-
eases in which phlebotomy was indicated, and in
which the most positive results could be expected,
pneumonia stood undeniably first. .\re we profession-
ally the descendants of a lot of fools? Were our
grandfathers deluded and deceived, going on day after
day, year after year, century after century, letting
blood with a foolish and germless idea that they were
doing good, without ever seeing any beneficial results
from venesection ? Is it possible that all the clear-
headed thinkers, all the good observers, all the logical
reasoners which ever adorned the medical profession.
were born in the latter half of the nineteenth century,
or may it not have been that the occasional good eft'ect
was so prompt, so marked, as to be beyond dispute,
misleading those of the older generation into using the
lancet too often? Blood-letting, like all great heresies,
was founded on a half truth, and the men who wrote
the constitution were not dunces, if the Monroe doc-
trine was as yet unknown ; so, too, their medical con-
temporaries may have been able to give us some
pointers in the absence of all knowledge of antirabic
inoculation.
The Medical Recokh, of September 28, 1895, in
commenting on the treatment of this disease by Dr. De
Duplaa de Garat, who bleeds in his pneumonia cases,
says: " Instead of burying all his pneumonia patients,
the writer claims that he cures them all without ex-
ception." Can we afford with a mortality of twenty
to forty per cent, in so commonly prevalent an affec-
tion as this to be even mildly sarcastic about the
"claims" of one who advocates some other practice?
Would it not be wise to investigate the matter, and
ascertain if his claims are true to fact on the one hand
or mere impudent effrontery on the other?
It is the common opinion of common people, most
of them reasonably familiar with this malady and some
of them possessed of fair powers of observation, that
"pneumonia goes hard with big, strong, healthy men."
The old family doctor, too, will tell you that such a
person is " a bad subject" for pneumonia. He may
not expain just why, but he has learned it by experi-
ence. Ana-mia is common enough in these days, but
is plethora never encountered? Frequently a defi-
ciency, but never an excess? Bleed these patients,
the full-blooded ones, in the early stage and they are
no longer bad subjects for a pneumonic attack. Fail
to do this, nourish them well, give them a full '"sup-
porting " treatment for a few days and a liberal pro-
portion will die with blueness of the nails and general
cyanosis.
There comes a time, too, when certain other cases
require venesection, some plethoric, some not. When
cyanosis develops during the course of the disease it is
usually considered a very unfavorable symptom. Upon
its appearance many physi ians make it a rule to
warn the friends that a fatal termination is to be ex-
pected. It is an indication of insuiTicient oxygenation
and approaching venous stasis. The patient is prac-
tically beyond the reach of medicine, and yet is his
case really hopeless? Is there no relief?
In this condition, when the ''swelling of the veins
of the hands," which Trousseau noted as dangerous,
may occur; when the portal and hepatic veins, the
vena cava superior and inferior are distended; when
the sound over the pulmonary valve becomes indis-
tinct;* when the right heart is choked and dilated, open
a vein and bleed freely or the chest will get '" rattly,"
despite resort to drugs and stimulants, the blueness
will increase slowly but progressively, and paralysis of
the right ventricle will result. Bleed until the con-
gestion under the nails perceptibly diminishes. Then
give cardiac stimulants, and the right heart, relieved
of its distention, able once more to approximate its
valves, goes to work with renewed energy and the dan-
ger is for the time over. The pneumonia is not cured,
but the pressure has been taken off the weak point.
Phlebotomy has been a pronounced success accord-
ing to my experience in what were otherwise appar-
ently hopeless cases. "Tying oft'" the limbs has
failed with me as a substitute in the few cases in
which it was tried. Cyanosis usually develops on the
fifth or sixth day and even a temporary relief will often
tide the patient over the critical point. Undoubtedly,
it weakens him, but it is better to be hydra;mic and
living than full of coagulated blood and cold. We
frequently meet with epistaxis at the crisis of a pneu-
monia. Can we not take a lesson from nature? It is
evident that the letting of blood must diminish the
congestion of the part of the lungs not affected by the
pneumonic process. It also seems clear that lessen-
ing of the accumulation of blood in the right heart
must diminish the labor of the lungs, since all the
blood must pass through the lungs after leaving the
heart, before it can be distributed to the remainder of
the body.
404
MEDICAL RECORD.
[September 19, 1896
Venesection is often necessary when cyanosis is
present, even though the pulse is small and weak, for,
the pulmonarj- circulation being obstructed, the left
ventricle with the arteries is practically empty, and I
have seen a pulse, weak and fluttering, come up strong
and full while the blood was still flowing from the
arm. This is explained by the lightening of the load
of the right heart.
In the Massachusetts General Hospital Report it is
shown that in the decade following 1822 the mortality
was only ten per cent. This was the period when
blood-letting was practised. It is now twenty-eight
per cent. The ditl'erence is attributed to greater age,
intemperance, complications, and a larger proportion
of foreigners. How much influence the greater age
may have had I cannot determine, as the original re-
)x>rt is not at hand. It seems difficult, however, to
prove that complications were really more frequent,
and if this were true it might be attributed with some
show of reason to difterence in treatment as well as to
other causes. Were there no alcoholics in 1822-32?
Are foreigners so peculiarly liable to develop and to
succumb to this disease that the fatality should be in-
creased nearly threefold ? Osier maintains that, " con-
trary to the general rule in infectious diseases, new-
comers and immigrants seem less susceptible than the
native inhabitants." Are these factors, even if proven,
sufficient to account for the difference? Those old
doctors must have had a marvellous streak of luck in
their favor if blood-letting is so injurious. They cer-
tainly had no oxygen cylinders and no knowledge of
tlie pneumococcus of Fraenkel.
Reverly Robinson in the Mkhicvi, Recorh, June 2,
1894, says: "Cases still occur where bleeding is the
only resource.'" Dr. William Watt Kerr and Dr.
Washington -Aver, of San Francisco, advocate vene-
section in the third stage (.\Ik.i>I( \i. Rkcokh, June 23,
1894). Osier strongly endorses bleeding in the early
stage, and while his results with venesection in the
later stage (twelve cases) have not been wholly satis-
factory, he considers it '■ a rational practice." Nu-
merous other writers endorse this view, and last, but
not least. Dr. Jacobi. in that much-quoted paper, " Non
N'ocere," says: " The pneumonia which, when delirium,
cyanosis, and dilatation of the right heart became
urgent dangers, was not relieved by a venesection
. . . must be a load on the practitioner's conscience.'"
This is well put. Is the pendulum on the return
swing?
In conclusion, I would enter an urgent plea for a
reconsideration of the etiology and treatment of pneu-
monia: for a more careful and systematic study of the
changes which occur in the lesser circulation, pul-
monary artery, capillaries, and \eins. including also
the bronchial vessels: for the use of dia])horesis as
a rational and consenative mode of treatment, as a
safe and powerful agent for the purpose of aborting
pneumonias, and as an antipyretic of remarkable effi-
cacy: for a more general recognition of the fact that
failure of the right heart is the usual cause of death;
and for venesection in certain cases of pneumonia in
the early stage: also in the late stage when it becomes
imiserative, or as a dt-mirr rcssnrt.
Urination after Labor.— i. Urination after labor,
in the majority of cases, follows spontaneously. 2.
("atheterization is but exceptionally required: if it be
necessary, it should be deferred as long as possible.
3. It is only indicated when the bladder assumes ab-
normal proportions, or if retention occurs. 4. Cathe-
terization is liable to occasion two e\ils — cy.stitis, in
spite of all precautions, and dependence of the blad-
der for a time upon the catheter. — Rr, . /iifrnurtioiia/
</■ Bibliosr. Med.
COLONIES FOR EPILEPTICS.'
Kv FREDERICK PETERSON, M.D.,
NEW YORK,
CONSl'LTINC NEVROLOCIST To RANDALL'S ISLAND HOSI-ITAL FOR IDIOTS;
CLISiCAJ, PROFESSOR OF INSANITY IX THE WOMAn's MEIUC.^L COLLEOC
<^V THE NEW YORK INFIRMARY ; CHIEF OF CLINIC, NERYOfS DEPARTMENT,
COLLEGE CiF PHYSICIANS AND SL'RGEONS, NEW YORK; PRESIDENT OF THE
BOARD OF MANAGERS OF CRAIG COL0N\.
The moral treatment of epilepsy has scarcely as yet
found its way into the text-books. In the most recent
works on neurology we are informed that the disease
is almost incurable, and a bewildering array of dnigs.
which may or may not be of benefit in some cases, is
presented in considerable detail. But the enormous
progress of therapeutics of epilepsy in the direction of
moral treatment has found as yet no place in such
works, even though the importance of this treatment is
in the present state of our knowledge vastly more sig-
nificant as regards the welfare of the patients than the
pages devoted to medicinal agents.
Epilepsy is one of the most common of nervous dis-
orders. It afflicts one to two in a thousand of the
population. It is also a malady not at all new to the
profession, for it was undergoing therapeutic experi-
ment at least three thousand years ago in India and
elsewhere to our certain knowledge.
Possibly ten per cent, of all cases of epilepsy be-
come insane, so that they require the custody of an
asylum. The remaining ninety per cent, are the cases
under consideration in the present pajjer. This dis-
ease differs from other diseases in that it consists of
jjeriodic .attacks of loss of consciousness, with or with-
out convulsions, lasting, as a rule, for but a brief space
of time — a few seconds to a few minutes. Before and
after these short seizures the patient is in as normal a
condition, and quite as capable of pursuing the ordi-
nary vocations of daily life, as other people. In some
the attacks recur frequently, several times daily, but
these are uncommon : in others they recur several
times a week: and again in others occasionally during
a month or several months. But, however infrequently
such seizures take place, the unfortunate sufferer from
epilepsy cannot be permitted to attend school, go to
church or entertainiTients, or play with other children,
and as he advances in age he finds himself debarred
by his malady from following any occupation, for no
one will employ him. Naturally, a life of this kind
closes to him the usual avenues for mental and nwral
development, and it is not surprising that many an
epileptic who under other conditions might acquire a
good education, be able to sustain himself by his own
etiorts. and even bring out talents of a high order
(such as have distinguished a number of epileptics
famili,\r in history and literature), should grow up fee-
ble-minded and ignorant and an easy prey to all of
the degenerative tendencies which are prone to show
themselves when a mind is left to follow, unguided
and uncared-for, its own instincts, appetites, an<i emo-
tions. It is because of their neglect and ill treatment
by communities that such large numbers of epileptics
have been forced to seek a refuge from their woes in
the almshouses and insane asylums. There has been
nowhere else for them to go.
It is nearly fifty years ago since John Bost l>egan
near P.ordeaux the system of caring for a variety of.
chronic cases, inclusi\e of epileptics, in cottages,
grouping them in little families, feeling that the true
home for such dependents is in the country, where
they may occupy themselves in the gardens and fields,
breathe the pure air. drink in the sunshine, and have
before them always the works of their Creator. The
little families grew into a prosperous and happy com-
munity, or, in otl>er words, a colony.
' kead before the American .Xcndenn of Mcilicine, .Atlanta,
May, 1896.
September ig, 1896]
MEDICAL RECORD.
405
About tliirty years ago Pastor von Uodelbchwingh
began with four epileptic patients a similar family life
in the suburbs of Bielefeld, Westphalia, Germany;
and year by year the families have increased in num-
ber, until now the Bethel Colonic is a village of two
or three thousand inhabitants, pursuing all the occu-
pations and enjoying all the recreations of a thri\ ing
and prosperous settlement. In the winter of 1886 and
18S7, while physician at the Hudson Ri\er State Hos-
pital for the Insane, where I had become familiar with
many of the troubles and misfortunes of epileptics, I
made a tour of Europe for the purpose of examining
various institutions; ' and in the course of my jour-
ney I visited the colony for epileptics at Bielefeld,
which made so deep an impression upon me tiiat im-
mediately upon my return home I wrote a descrip-
tion of it for a medical periodical in New York. I
had never seen an eleemosvnaiT conception so nobly
and so successfully carried out. 'I'he good pastor of
the Lutheran church who inaugurated this work will
never be forgotten, so long as there are unfortunates to
profit by his wisdom and benevolence. Here he cre-
ated an ideal refuge for a multitude of sufferers, a
home for such as were homeless or neglected, a hospi-
tal for the best treatment of their distressing malady,
a school in which the education denied them in the
outside world could be achieved, an industrial settle-
ment for all who were able to acquire a knowledge of
any trade or calling.
Since my visit many travellers have been there and
have borne witness to the marN'ellous success and
prosperity of this inspiring colony. I need refer to
the testimony of but one of them, for in the deservedly
popular volume entitled " .\ Colony of Mercy,'' " Julie
.Sutter has described it in full with a felicitous pen.
One of my early papers on the subject of the colo-
nization of epileptics was reprinted in England some
years ago, and a knowledge of the subject diffused
there by Miss Louisa Twining, and in Great Britain
there are now two or three homes for epileptics, small
beginnings of what are destined to be, no doubt, in
future time, institutions or colonies of considerable
size and importance.
France, Holland, Belgium, and other continental
countries have also turned their attention to this class
of patients, and are following more or less closely the
good example of Germany, which has now a number
of colonies for epileptics, in addition to the model set-
tlement in Bielefeld.
In this country, Ohio, New York, Pennsylvania,
Maryland, Massachusetts, Michigan, Wisconsin, Iowa,
Illinois, New Jersey, California, Minnesota, Texas,
and Virginia have either already established special
institutions for epileptics or are actively preparing for
it, to judge from the amount of correspondence I ha\e
had with physicians and others in these States inter-
ested in provision of this kind. The tendency with
most of them is to follow as far as possible some more
or less efficient scheme of colonization. But it is not
always easy to establish and develop an institution,
according to the most approved model, under the au-
thority and at the expense of a State. Legislatures
are only too apt to encourage, on the ground of econ-
omy, the housing of as many patients as possible in
large barrack-like buildings, while the communities in
which State institutions are about to be established
are too frequently misled by local pride to demand
something so colossal and monumental as to strike
at once the beholder's eye. While it is true of many
public institutions that it is more economical to house
a large number of patients in one building than in
cottages, it is perhaps less so in respect to epileptics,
' " Some Kuropean .Asvlums," American lournal of Insanity,
July, 1887.
' Published by Dodd, Mead \ Co., New Vork.
since they are for the most part able-bodied and effi-
cient workers, and their labor tends to more than make
up for the increase in the complexity of administrative
detail. But even were this not true, it is as much the
duty of the State to lighten the burden of misery for a
class affiicted with one of the most dreadful diseases,
as it is to provide for their mere sustenance and pro-
tection from the elements.
1 believe that in most States it will be found ad-
\ isable to begin such provision in a moderate way
with a large farm and two or three buildings, and to
permit the colony to follow a natural course of evolu-
tion, as justified by its success and by the number of
available patients.
.\ great deal of interest, both in this cou«trv and
abroad, has been manifested in the undertaking of the
State of New Vork to provide an industrial village for
its dependent epileptics, not only because Craig Col-
ony has become well known as the first real coloniza-
tion plan begun on this side of the Atlantic, but be-
cause of the magnitude of the enterprise. It was
necessary that provision should be made for a large
number of patients, for the epileptic population of the
State is great indeed, as will be seen from the follow-
ing statistics: According to the admirable report of
Dr. Charles S. Hoyt, superintendent of the State and
alien poor, published December 31, 1895, there are
in the county and city almshouses, 427 ; in institutions
for the feeble-minded. 152; in other charitable insti-
tutions, 109; and in family care, receiving public out-
door relief, 83 epileptics. But besides these, there
are in the Slate asylums for the insane about 1,000
epileptics, of whom, at the least estimate, fifteen per
cent, are perfectly able to live in the freedom of col-
ony life. I make this assertion based upon the state-
ments of several of the superintendents of the .said
asylums. Not only have many sane epileptics been
sent to asylums in the past, because there was no-
where else for them to go (except to the county alms-
house), but the recent passage of the State care act
led to the transfer to asylums of many epileptics, who
had previously lived for a long period in the alms-
houses without any difficulty. This transfer was
economical for the counties, and commitment for in-
sanity in the ca.se of epileptics is not a difficult matter,
while the State was thus made to bear the burden of
their care. Moreover, letters have been received by
the managers of Craig Colony from over one hundred
epileptics, not in institutions, but eking out some sort
of pitiable existence in the outside world, among pov-
erty-stricken relatives or on the support of charitable
friends. Thus the number of epileptics immediately
available for the purposes of colonization are: Epilep-
tics in poorhouses and other institutions, and receiv-
ing public outdoor poor relief, 771; fifteen per cent,
of the epileptic population of the State hospitals for
the insane, 150: dependent epileptics without means,
but not in institutions, 100. Whole number, 1,021.
This total of ten hundred and twenty-one epileptics
falls short of the actual number in the State of New
York who will ultimately become residents of the col-
ony, and who are truly desening of being benefi-
ciaries of the State. In my service of eight years in
the nervous department of the \'anderbilt clinic of
the College of Phvsicians and Surgeons, nearly nine
hundred epileptics have been under treatment there,
the most of them without occupation, unable to gain a
living, and supported by hard-working and struggling
relatives. This is an experience in but one out of the
thirty or more dispensaries of the city of New Vork,
and in but one of the large cities of the State. It
seems to me safe to say. therefore, that the number of
indigent epileptics throughout the State who merit the
care of Craig Colony is not overstated when it is
placed at one thousand, making a total of over two
4o6
MEDICAL RECORD.
[September 19, 1896
thousand. Such statistics proved the need of project-
ing the scheme of colonization in New York on a large
scale. The plan was favored, too, by the circum-
stances which led to the acquisition of a great tract of
land. Not even Bielefeld has so extensive a property,
and there is probably no eleemosynary institute of any
kind anywhere in the world with landed possessions
so magnificent. The Craig Colony had, in fact, al-
ready been a colony for fifty years or more, for the
sect of so-called Shakers selected, with their cus-
toniaiy sagacity, nearly nineteen hundred acres in the
garden valley of the State (the Genesee Valley), and
made it a remunerati\e property, with well-cultivated
fields, fine orchards, and pastures and productive mar-
ket gardens. They constructed here numerous sub-
stantial buildings (thirty or more), residences, barns,
and shops; for they were not only thrifty agricultur-
ists, but did a good business in broom making, can-
ning fruits and vegetables, and other industries. On
the grounds are good quarries of building stone, fine
deposits of brick clay, and acres of good timber, from
which they obtained materials for their houses. Two
streams pass through it; one of them, rushing swiftly
through a picturesque gorge and dividing the property
into two nearly equal halves, ran the colony's saw-
mill and flourmill.
But the Shakers, being celibates and failing to re-
cruit their organization as in past times by prosely-
tism and by the acquisition of orphan children, gradu-
ally diminished in numbers; and in 1892, at the time
that the State was seeking a site for a colony for epi-
leptics, the ten or twelve old Shakers left upon the
place offered the entire tract with all its buildings for
the purpose, at a sum ($115,000) about equal to the
value of the improvements alone. The State pur-
chased the property, and the little band of Shakers
went away to join the mother colony at Watervliet,
N. Y.
Oscar Craig, of Rochester, then president of the
State board of charities, was one of the commission-
ers engaged in the selection of tiie site. He died soon
afterward, and at the instance of Governor Flower the
colony is known by his name.
As soon as possible after the passage of the law es-
tablishing Craig Colony, the board of managers ap-
pointed bv the governor began the work of adapting
the old Shaker colony to its new purposes. Build-
ings had to be remodelled, renovated, and furnished,
and systems of heating, lighting, water supply, and
sewage had to be installed. In the neighborhood of
ten or twelve buildings are at present occupied for the
different purposes of the colony, cottages for the resi-
dences of the sujDerintendent, farmer, engineer, stew-
ard, and other employees, three houses for patients,
and .several others for store, industries, and the like.
In order to avoid any semblance to an institution on
the pavilion plan, where doubtless the buildings
would be designated as No. i, No. 2, No. 3, or "A,"
'■ B," " C," and so on, each separate structure at Craig
Colony has its own name. For instance, the superin-
tendent's cottage is called " Sonojowa," an Indian
word signifying hospitality. One of the first resolu-
tions passed by the board of managers was to name
the largest building in Craig Colony, used for admin-
istrative purposes as well as for patients, " Letchworth
House," in honor of the Hon. William P. Letchworth
of tiie State board of charities, who has been identi-
fied with charitable work for many years, who took an
especial interest w^ith Mr. Craig in selecting the site
for the epileptic colony, and who has shown a keen
sympathy with the work of its development. The old
chapel of the Shakers, for so many years the centre
for the gatherings of the elders and their brethren,
now metamorphosed into a villa with a solarium for
men patients, has been named in honor of its former
owners, "The House of the Elders." The farmer's
house is designated as '"The Grange." The steward's
cottage, occupied by the steward's family and several
officers and employees, was named "Tall Chief Cot-
tage" after the Indian chieftain who in the old lime
called this particular tract " Sonyea," meaning the
warm or sunny place. Sonyea is now the name of the
post office of the colony and of the station of the W.
N. Y. & P. R. R. on the grounds of Craig Colony.
The colony has its own post, express and telegraph
offices, and, besides the railway station already men-
tioned, the Erie Railroad has a station on the grounds,
and the Delaware tv: Lackawanna trunk line passes
within a quarter of a mile of the colony. Other build-
ings have been named "The Elms," "The Store,"
"The School," and so on. The present legislature
is e.xpected to give us an appropriation for a hos-
pital of twenty beds, a mortuar)-, farmhouse, and
funds for remodelling, renovating, and furnishing a
half-dozen of the old buildings already on the tract,
for the use of another hundred patients. The group
of buildings now occupied is lighted by electricity,
and the system of intermittent filtration was adopted
for sewage. The water supply is excellent, springs
being made use of for drinking and culinary purposes,
the creek water for toilet, fire protection, etc. Rain
baths have been introduced.
Very soon after the managers took charge of the
property, the Messrs. Olmstead, Olmstead & Eliot, of
Brookline, Mass., were engaged as landscape archi-
tects to prepare a general design of the grounds, in
accordance with the organic law requiring the adop-
tion of a general design and the arrangement of the
property on the village plan, to which all new and old
buildings must conform. Such a plan takes two or
three years to perfect, but the main features, such as
the village green, streets, lanes, paths, sites for shops,
residences, chapel, dair)- and farm buildings, schools,
and the like, have now been designed upon the best
principles, in order to take advantage of the natural
beauty of the land, its gorge, lake, streams, hills,
meadows, and woodlands, and at the same time to sub-
serve as far as possible economy of administration
and general utility. The details in the execution of
such general design are to be worked out under proper
guidance by the patients themselves.
Craig Colony was informally opened nearly four
months ago. It has a present capacity for two hun-
dred patients, and the provision for new patients will
be gradually increased year by year. The present resi-
dents of the colony have been taken from the alms-
houses of the various counties in proportion to the
epileptic population, and as fast as they have been re-
ceived they have been put at some occupation com-
patible with their conditions and in accordance with
their wishes and abilities. It is the aim of the man-
agement to provide out-of-door employment as far as
possible for both men and women, feeling that great
benefit in the treatment of the disease will he derived
from work in the sunshine and open air. 'I'hcrefore,
agriculture, Jiorticulture, iioriculture, and market gar-
dening will form a large proportion of the labor of the
inhabitants for at least six months of the year. The
women will gain great good from employment in rais-
ing small fruits, fiowers, and vegetables.
The deposits of excellent clay are to be utilized by
the patients for making brick to be used in the con-
struction of new cottages and of walks throughout the
village lanes.
The dietar}- for patients aftlicted with epilepsy is
simpler than that needed for other classes of patients,
so that almost ever)-thing in the way of food stuffs re-
quired by a large population can be produced from
the land itself by the labor of the colonists. During
the year previous to the opening of the colony, the
September 19, 1896]
MEDICAL RECORD.
407
managers by renting out tracts of land on shares
cleared seven or eight thousand dollars, which is evi-
dence of its productiveness and of what may be ex-
pected of it when each acre is made to yield its
treasures to the unremitting care and attention of the
colonists. There is already a large flock of sheep, a
goodly herd of cows, and other stock of various kinds
under the care of the patients.
But in addition to these features whicli characterize
it to a great degree as an agricultural and stock-rais-
ing settlement, numerous other trades and callings
will need to be summoned into being with the gradual
evolution of a self-supporting and independent colony.
There must of necessity be masons, painters, carpen-
ters, cabinetmakers, printers, bookbinders, smiths,
tailors, shoemakers, and the like; and there will be
plenty of indoor work for women in the way of sewing,
tailoring, knitting, fancy work, illumination of mot-
toes, bookbinding, the preser\'ing of fruits, vegetables,
seeds, etc. Indeed, the aim is to diversify occupa-
tion in every possible way, to consult the patient's
own wishes as to his or her special proclivities and
abilities, and to make the labor not only of value from
the economical standpoint, but also from the stand-
point of therapeutics, for we feel that the exercise,
the life out of doors, the manual and industrial train-
ing, and the mental occupation will best bring about
the bodily and psychic conditions which conduce to
improvement and recovery.
It has been found by actual experience in other col-
onies, and this is already borne out by observations
at Craig Colony, that the number of attacks in most
patients diminishes after entering upon such colony
life; that the patients do not affect each other detri-
mentally, but that on the contrary each feels that he
is on an equality with his associates and no longer
isolated, for he is bound together with them by the
ties of a common affliction and a common purpose.
Out of the negligence, monotony, hopelessness, and
often squalor of an almshouse or a wretched home,
he comes into the brightness of this new existence.
He gains fresh interests, and new hopes and ambi-
tions rouse him from his long apathy. He is made to
feel that he may follow the bent of his nature as re-
gards education and occupation, and no longer be de-
barred from the opportunities for progress in mental
development, for recreations and enjoyment, and for
social intercourse, so abundantly offered his more for-
tunate brethren of the outer world.
In addition to the moral therapeutics thus outlined,
it is the object of Craig Colony to make every effort
to treat each case of epilepsy entrusted to its charge
in the best manner possible, in accordance with the
latest researches of science in this field, and to carry
on original investigations, clinical, chemical, patho-
logical, and therapeutical with the object constantly
in view of discovering the causes of and best remedies
for the malady. For this purpose chemico-physio-
logical and pathological laboratories are in course of
construction.
The colony is designed essentially for State patients,
that is, patients upon public charge, but as soon as
these have been provided for, private patients will be
received whenever there are accommodations for them.
There is no restriction as regards admission, except
the single one of insanity. Insane epileptics are ex-
cluded. It is probable that in the course of time
some sort of provision will be made in the colony for
epileptics who become temporarily insane while resi-
dents, but that is a matter which has not as yet been
given careful attention.
In closing I wish to outline briefly the main points
which need to be considered in planning and organ-
izing a colony of this kind. In the first place such a
scheme aims to provide:
(a) A home for a class of individuals cut off all
their lives from ordinary pursuits and social pleasures
by a malady which robs them of their faculties in
most instances for but a few moments each day, or
week, or month, or once' in a period of several
months.
(l>) A school. Debarred from the public schools,
the epileptic should be given precisely the same op-
portunities of acquiring an education as he would en-
joy if well and living in the outside world.
(r) An industrial education. The usual trades and
callings of a village should be introduced, and each
colonist should be permitted to take up any pursuit
for which he seems best fitted.
(</) Treatment for epilepsy. Every case should be
carefully studied and treated according to the best
scientific methods.
Having in mind the aims of the colony, the follow-
ing points should be kept in view in establishing it:
1. There should be an abundance of land, for the
community is to be given largely to agriculture and
kindred pursuits, and there is economy in securing a
large and productive tract.
2. The site selected should be near the centre of
population and convenient of access to the managers
and patients and their friends.
3. The countrj'-village idea should never be lost
sight of, and everything savoring in any degree of
'■ institution," '" asylum,'" " pavilion plan," etc., should
be avoided. A general design should be adopted,
with system in the arrangement of the buildings, but
no such symmetr)- as would in any way suggest a pub-
lic institution. The cottages, villas, and shops should
be simple, independent, and homelike, with their own
little gardens, hedges, etc.
4. As far as possible, each home circle should be
limited to ten or fifteen patients; much greater aggre-
gations than this are apt to destroy the family charac-
ter of colony life.
5. The houses need not be especially planned to
meet the wants of a particular class of patients, but
should be as much as possible like ordinar)- village
houses, though fireproof.
6. A small hospital, say with twenty beds, will be
needed to ser\-e as an observation station for new
cases admitted and for such as are bed-ridden from
intercurrent illness or accident.
7. In addition to hospital, cottages, villas, shops,
schools, etc., a chapel, librar}', museum, reading-
room, gymnasium, swimming-bath, rain bath, lecture
hall, and well-equipped laboratories should be pro-
vided. Some of these, being luxuries, may doubtless
be obtained by private foundation as memorials.
8. In developing the industries of the colony, the
first object is to establish such as will subserve econ-
omy. The aim should be to produce most of the food
stuffs required, to make the wearing-apparel, to carry
on domestic work, to make all ordinary repairs, and
to lay out the grounds. As the industrial side of the
colony increases in usefulness, the trained workers
should plan, construct, and furnish completely all new-
buildings needed, and other industries should be un-
dertaken which will lead to a profit to be expended in
the interests of the colonists.
9. The educational features should never be lost
sight of, and in addition to the schools an'd industrial
training, everything that can in any way be helpful in
furthering such purpose should be encouraged. The
trees and flowers should be labelled with their names
whenever possible, and a botanical and zoological
garden be estaljlished, as far as commensurate with
the means at command. The collection of objects in
natural history for presenation in the museum should
be a part of the recreation of the inhabitants, and
there are many other features too numerous to mention
.408
MEDICAL RECORD.
[September 19, 1896
"here which will conduce to the success and prosperity
of the colony.
10. Finally I would caution the promoters of such
plans for the various States not to hurrv their devel-
opment, but from small beginnings gradually to
evolve an institution which shall reflect credit upon
.themselves and their undertaking.
lUBLIOGK.M'HV.
The Bielefeld Epileptic Colony, by the writer, .\ew \'ork
Medic.-vi. Record, April 13, 1S87.
The Colonization of Epileptics, by the writer. Journal of
Ner\ous and .Mental Disease, I lecember, i SSi).
A Plea for the Epileptic, by the writer. State Charities Record,
June, 1890.
State Provision for Epileptics, by the writer, .\ddress of
Chairman, American Social Science .\ssociation, Saratoga, Sep-
tember, iBgl.
Slate Care of Epileptics, by the writer. New ^'ork Sun, janu-
;3ry 1 1, iSgi.
The Care of the Epileptic, by the writer and Dr. Jacoby, State
Charities Record, February, iSyi.
Outline of a Plan for an Epileptic Colony, by the w riter. New
"York Medical Journal, July 23, 1S92.
The Care and Colonization of Epileptics, by the writer. Journal
.of Nervous and Mental Disease, .\ugust, 1892.
On the Care of Epileptics, by the writer. Journal of .\merican
Medical .Vssociation, .September 30, 1893, and .-\merican Journal
of Insanitv, January, 1S94.
The Care of Epileptics, by the writer. Supplement to Wood's
Reference Handbook of the .Medical Sciences, Wni. Wood \ Co.,
JNew York.
Craig Colony, by the writer. Pediatrics, February 15, 1896.
For further information see the publications of the .State boards
■*>f charities of New York and Ohio ; The Colony of .Mercy,
.fcy Julie Sutter, already referred to; and a volume on The Epi-
leptic and Crippled, published in London by Swan, Sonnen-
-schein iV Co. in the Charity Organization Series ; also the circu-
Jlars of the National Society for the F^niployment of the F^pileptic
<(Honorary Secretary, Nliss Burdon-Sanderson, liranksome,
•Creenhill Road, N. W., London).
60 West Futieth Street, New York.
JiCCIDENTAL GUNSHOT WOLXDS: A MKD-
ICO-LFX;.AL STl;DV.
By
N. ll.M.l., M.n.
MEMBER OF THE MEDICO-I.ECAI. SOCIETY* OF NEW VORk", ETC.
In order that one may properly interpret certain signs
ihat may be found in the investigation of deaths from
gunshot wounds, he should be familiar with the com-
mon causes of accidents in handling firearms. I shall
•omit any consideration of the fractures, bruises, and
other injuries, many of which I have observed,
caused by the recoil of the weapon, although this is
by far the most fruitful source of injuries from fire-
arms, because, obviously, they are not gunshot wounds.
Many of the cases I shall quote would scarcely call
for a medico-legal examination, because of the cir-
cumstances under which they occurred; but the study
of them will none the less be profitable.
It is pretty well known that most of the accidents
from the use of firearms occur from ignorance or care-
lessness in handling them. .\t times a gun bursts
from a defect in the metal or from imperfect workman-
ship, but such an accident is rare after the rigid tests
to which the barrels are subjected at the factory, or, in
many countries, at the government proof house. Old
weapons bVirst from becoming " burnt out" from long
and hard shooting, occasionally, but probably not
without the use of an excessive charge. Many guns
.are burst by the use of new powders, the effects of
which, under different climatic and other conditions,
have not been thoroughly studied. I have seen the
head of a brass shell separated from the rim in using
a new nitro-powder, apparently because the powder
was subjected to prolonged heating, having been left
in the left-hand barrel of a double gun on a hot Au-
gust day, while many charges were fired from the other
barrel. An increased action in the same direction
might well burst the barrel. I have several times
seen a similar accident from the use of black powder
so fine that its initial pressure was too great for the
kind of weapon in which it was used, although the
danger of bursting the arm from this cause is certainly
much less than from the nitro-powders, which produce
a much more sudden explosion. I have never seen an
unobstructed barrel burst by a charge of black pow-
der of reasonable size, although I have known many
shotguns and one rifle cf excellent make either burst
or loosened at the breech by some of the nitro-pow-
ders.
The cases of injury to the shooter by the bursting
of a barrel obstructed by sand, mud, or snow, or by
pressure against the earth or a fallen animal in giving
it its death-blow, are generally obvious enough, so that
no question could arise as to their being accidental or
otherwise. In one such case, in which a young man
attempted to shoot a skunk which had taken refuge in
a burrow, four persons were injured besides the shoot-
er by the (lying parts of the weapon, as reported to me
by Dr. Hawes, of Colorado. It is notable in the>e
cases that the charge it.self does little damage, its
force being dissipated in the act of bursting the barrel.
The flying parts, chiefly of the ribs and barrel, are the
effective missiles in such accidents. When the arm
bursts from too great a load, the charge is more likely
to be effective. In a recent case c)f mine, the boy who
supported the muzzle of a gun which burst from this
cause was nearly as much injured as the one at the
breech, from the fragments of the barrel, but I could
not learn what force the load had exerted in its proper
direction, for both the boys were too badly hurt to note
this point.
It should be noted that even the lightest snow in the
muzzle will endanger the gun from the cause men-
tioned. The tompion used to stop the muzzle of the
army rifle occasionally makes trouble, because of the
soldier's ha\ing forgotten to remove it. With the
heavy rifles used in hunting, there seems to be more
danger of blowing parts of the breech mechanism
back into or just over the head of the shooter. Thus,
a companion fired a twelve-pound Sharp's rifle at a
deer, after having by accident filled the muzzle with
sand. The firing pin passed through his hat, but the
barrel, which I afterward examined, was iminjured
and was in use for years afterward. The shotgun gen-
erally gives way at the thinner parts near the muzzle
or in the middle, although I have seen several burst
near the breech by nitro-powders. About a dozen ex-
amples of bursting in shotguns from the various
causes mentioned have come under my observation.
It should be noted that after a misfire, and espe-
cially after the shot escapes from a shell from the dis-
lodgment of the top wad, as occasionally? occurs, por-
tions of the load, and especially the wadding, may
remain in the barrel and may cau.se an otherwise in-
explicable explosion of the weapon. The bullet itself
may stick in old and foul weapons, the gases of com-
bustion escaping at the rear, through ill-fitting breech
parts. I have known several bullets to accumulate
in the same barrel from this cause, both in a small
rifle and an old revolver.
It is somewhat dangerous to discharge very old gun.'-,
because of the fact that repeated jarring may cause
the molecules of metal to rearrange themselves in crvs-
talline form, when they will stand much less strain
than before. One of the old guns in the Tower of
London, subjected for a long time to the jarring inci-
dent to testing amis in the same building, broke
merely from falling to the floor. The tendency t"
such crystallization is well known to be one of the
faults of cast-iron ordnance.
September 19, 1896]
MEDICAL RECORD.
409
Slight obstacles and especially "leading" or accu-
niulation of lead and dirt in the grooves of the riHe,
often cause the gun to shoot ''wild.'' This is espe-
cially true if the trouble is just within the muzzle.
One might easily meet with an accident if shooting
such a weapon, provided anyone stood near the line of
fire. Accidents in the shooting of the apple from the
head, 1} la William Tell, several of which have been
reported, probably occur at times from this cause, al-
though in at least one instance the fatal result was
attributed to faulty ammunition. A physician of my
acquaintance informed me that he nearly killed a ne-
gro who insisted upon marking for him when trying a
new ritle, because the sights were misplaced, the
weapon shooting nearly five yards to the right at one
hundred yards' distance. I have known many narrow
escapes from injury from the various causes mentioned
in this paragraph.
Many injuries occur in using breech-loading weap-
ons from having the breech chamber so foul that the
shell sticks, and the pressure of the lever causes it to
e.xplode. This happens easily if the firing pin does
not work freely or if the primer be not seated well
down in the cavity prepared for it in the head of the
shell. Shells swollen from repeated reloading give
rise to the same accident even more frequently, and
especially when, in the presence of game, the shooter
is especially anxious to shoot rapidly. I have re-
cently seen three accidents occurring under such cir-
cumstances, and all giving the more or less character-
istic staining of the face, especially of the right side,
with a few grains of powder blown into the conjunc-
tiva, a result commonly associated with this form of
accident.
I have known the fi\e loads in the magazine of a
repeating shotgun to be discharged through the end
of the tube, without damage to the shooter, from the
accidental admission of sand to the rear end of the
magazine. Probably the spring which forces the shells
backward in reloading forced the primer of the rear
one against a bit of gravel in the bottom of the maga-
zine, causing it to discharge its shell, and then
each shell exploded the one in front of it. Similar
accidents formerly happened in the use of magazine
rifles, from the temporary sticking of the spring from
rust or other cause; becoming suddenly loosened, the
spring pushed the cartridges backward over a greater
distance than normal, because of the removal of one
or two shells previously, and hence with unusual force,
and the primer of one shell being struck by the tip of
the bullet of the one behind it, an explosion occurred.
This danger has been, I believe, entirely obviated by
flattening the tip of the bullet, sinking the primer
about a thirty-second of an inch into the head of the
shell, and using brass instead of the softer copper for
the primers of rifle shells, these primers requiring a
stronger blew for discharge.
Accidents to the shooter are more common when the
barrel is unusually short, for the reason that in event
of a fall or slip such a weapon is brought to bear
more easily upon the person of the one cariying it.
I have known several injuries, chiefly to the feet and
legs, from this cause. In two cases the great toe was
shot off.
A great number of accidents arise from the slipping
of the finger upon the trigger, or, more commonly
even, upon the hammer, in attempting to cock the
weapon or to let the hammer down. If the weather is
cold, the fingers often become benumbed, so that the
shooter is not aware of the contact with the part or
else is unable to properly estimate the amount of force
applied. If the fingers are wet or if a glove be worn,
and especially if the latter become wet, the hammer
often slips out from under the finger or thumb in
handling it. If a hair trigger be used, as upon many
rifles, such accidents are very common, for the least
touch fires the weapon. If any one be in range, or parts
of the shooter's person, a wound results. Many shots
at game are missed from the causes mentioned — I
have missed several myself.
In «ing shooting, I have known several narrow es-
cajjes from serious injur)- from swinging the shotgun,,
in following a bird, directly upon another shooter :^
and I have twice known dogs to be killed, once in
this manner and once because the dog suddenly raised
his head into the line of fire as the trigger was pulled..
It is unsafe to hold the rein of one's horse wheii'
shooting, because a sudden pull may deflect one's aim
and injure either the horse or another shooter. I
treated one wound caused in this manner.
The foreman of a gang of cowboys, driving cattle
from Texas years ago, took a violent dislike to a
friend of mine, and rode up alongside of him on
horseback, with a loaded shotgun across the saddle,
the muzzle toward the latter. Suddenly the weapors.
was discharged, the load passing between the rider and
the horn of the saddle. The foreman had previously
killed a rider near Abilene, Kan., and undoubtedly
intended to kill this one and have it attributed to ac-
cident. The rider took the hint that he was not
agreeable, and left the outfit. I have no doubt that
many so-called accidents have some such origin as-
this one had.
It is not uncommon for one to be injured in clean-
ing up an old gun supposedly empty. Thus, I know
of one accident from inserting such a weapon into the-
fire to clean it more eft'ectually, the owner holding it
by the muzzle meanwhile. Attempts at removal of a
"stuck'' cartridge in a breech loader are often fol-
lowed by explosion of the shell and injury by the
bullet. The latter has but little penetrative force^
however, if the shell be not firmly supported in the-
rear; and it is not commonly well supported in these
cases, because the breech of the weapon is open. In
one such case of mine, the ball from a small pistol did
not penetrate the skin of the left thumb, the force of
the powder being expended apparently in blowing the
shell backward, and dissipated in the air about the
open breech. I have seen many accidents from care-
less handling of loaded shells, as, for example, fron*
the attempt to remove the primer of the shell before
removing the powder, or setting the bullet in a rifle
shell without placing the head upon a proper base, so
that some solid substance came against the primer:
but these cases are sufficiently obvious to the exam-
iner.
The left hand of the shooter is at times injured iit
supporting a revolving weapon in front of the chamber,
from the running of the fire from one chamber of the
arm to the next. I have never known of such an ac-
cident in a weapon using fixed ammunition. Occa-
sionally the old "pepper-box" pistol blew the hamjner
back and revolved the cylinder, as a result of the es-
cape of gas through the nipple, so that two or three
shots were discharged instead of one, as intended.
Weapons of the kind mentioned here, however, have
become nearly obsolete in this country.
Many accidents ha\e happened from the use of set
or trap guns, either for protection against burglars or
in killing game. I have quoted elsewhere ' a case in
which a dog ran against a gun as it lay across a log,
causing it to shoot the hunter, several feet away.
Several cases are quoted in English works bearing
upon this subject. In one case a fowl trod upon the
trigger of a cocked gun, which the owner had left
standing against a corn bin, and the man was struck by
the load at a distance of several yards. In another
case a dog ran against a gun lying upon the ground,
and shot the brother of his master. Taylor mentions
' Medico-I.egal Journal, December, 1895.
4IO
MEDICAL RECORD.
[September ig, 1896
a case in which, in the attempt to put the cap on to
the nipple of the second barrel, the tirst was fired, and
the gun, from the recoil, jumped out of the hand of
the shooter and flew back in such a manner as to fire
the second barrel, the contents striking the man"s
body.
If either sight of a weapon becomes displaced, the
bullet may easily strike one marking at the target, as
previously mentioned, or supporting an object shot at.
Near-sighted individuals, and even those with fair vi-
sion, at times mistake objects through the sights, and
in that way shoot at the wrong mark. 1 have quoted
elsewhere the case of an acquaintance who from
this error shot through the clothing of the marker at
the target.
I have read of three accidental shootings in this
State, during my residence here, from mistaking a
hunter for a deer. In two of them the injured man
wore buckskin clothing, so that the color approached
that of the game in question. It is needless to say
that it is utterly unjustifiable to shoot at anything un-
til its character is known. I have known a man to
kill a donkey on the supposition that it was a moun-
tain sheep which he had been following.
In the use of the rifle accidents often occur from
the deflection of the ball by some hard substance with
•which it comes in contact. I have known a bullet to
glance from the limb of a tree and become so much
deflected upward that it went over the hill which was
used as a butt for target shooting, and almost struck a
man three-fourths of a mile away. A town marshal
near this city shot at a dog across a city square, and
the ball, glancing on the stone sidewalk, struck a
passerby on the opposite sidewalk. The dog escaped.
I have known a policeman to shoot at a dog tied to a
stone wall, with the result that the ball glanced and
struck the man in the foot. In another case the pistol
ball glanced from the head of a dog and struck a
young lady in the back of the neck, with serious but
not fatal result. She stood some sixty feet from the
dog. The latter animal was finished with a club. At
Fort Russell, Wyom., about si.x years ago, a ball struck
a nail head in the target, a part of it glanced down-
ward, and the marker, being in the pit directly under
the target, received this portion in the chest, dying
shortly afterward. An instance was reported some
time ago of a man who shot into an iron pot with a
rounded bottom, with a pistol. It was stated that the
ball glanced in such a way as to return and strike the
shooter. Small bullets fired at a hardwood target
from a revolver, with a very small powder charge, may
rebound and strike the shooter, not penetrating the
wood sufficiently to stick. Such rebounds may be
entirely harmless, as I have e.xperienced them on two
or three occasions in making experiments' the ball not
having force enough in rebounding to cairy it more
than the length of an ordinary room.
Hunters, in dispatching a fallen animal, occasion-
ally in their excitement place the muzzle of the gun
directly against it, and thus cause the barrel to burst.
The effect of the shot in such a case is often nearly
lost. Many suicides, from making a similar mistake,
fail to accomplish their object, placing the pistol
directly in contact with the body, with the result that
the ball bruises the flesh but does not penetrate.
At times it may fall almost harmlessly to the floor. I
have quoted one such case in the Bostou Medical and
Surgical Journal, May, 1895, although not in the at-
tempt at suicide.
The self-cocking revolver is the source of many ac-
cidental shootings. In one's excitement the trigger
is almost involuntarily pulled, and, the weapon being
short, it may be pointed either at the person of the_
shooter or at a bystander. One patient of mine shot
him.self in the foot through such an accident. Anoth-
er, carrying in his right-hand trousers' pocket a small
revolver of the pattern mentioned, with his hand upon
the trigger and apparently studying over the matter of
how he would punish the man whom he was pursuing,
unconsciously grasped the weapon too tightly and shot
the bullet out through his clothing into the sidewalk,
the powder burning his genital organs. A year or
two later, the very man he was then pursuing and who
owed his escape in part to this accident, in the attempt
to strike an assailant over the head with a similar re-
volver, accidently killed him, and was the subject of
the case reported in the Boston Medical and Surgical
Journal, August 14, :8go.
With cannon, and especially with the small ones
used in celebrations, accidents frequently occur from
the forgetfulness or carelessness of the person desig-
nated to "thumb the vent" in reloading. If the
thumb stall be thin, the hot metal bums his thumb,
and he withdraws it while the rammer is inserting the
powder charge, causing an instantaneous discharge in
certain cases. I have known of two serious accidents
of this nature, one causing a death and the other in-
juring two men severely; while in a third, which oc-
curred under my own eye, the rammer was but slightly
burned.
It is not uncommon to have accidental injury from
attempts to perform tricks with the revolver. I treated
a man some years since, who, in trying to whirl his
45-calibre weapon around his finger, after t}'ing the
trigger back, and fire it at each revolution by catching
the hammer with his thumb, succeeded in shooting
himself in the leg. I knew of another similar acci-
dent which happened in the same region.
Where pistols are carried habitually, many persons
are injured from the dropping of the weapon from the
holster or pocket in mounting a horse or getting into a
wagon, or in the attempt to draw the weapon quickly.
One friend of mine shot his horse, on which he was
sitting, from the latter cause. A friend reported to
me an accident from the catching, upon the counter of
a store, of the hammer of a revolver carried in the
pocket, when the owner tried to lift himself up back-
ward to sit upon tiie counter. The ball entered his
clothing, but did no serious harm. A case has been
recently reported, in which a man was kicked by a
horse in the region of the hip pocket, in which he had
a revolver. It was discharged and the bullet entered
his leg. All of the injuries from catching the ham-
mer which have come to my notice have been in the
lower extremities, while those from the dropping of
the weapon in mounting a horse or entering a wagon
have been generally in a direction upward, and hence
have been in the trunk at times as well as in the legs.
I have known of one case in which a man shot his
great toe off, firing at a target at long range, having
assumed the position so common in this sport, in
which the barrel is rested between the knees as one
lies upon his back. He had unconsciously stretched
his feet out until one was in front of the muzzle. In
another instance the shooter burned the toe of his boot
in similar manner.
Many boys are wounded in the left hand with small
revolvers and toy pistols, while holding the barrel in
the left hand and attempting to dislodge a cartridge
stuck in the breech chamber or to close the weapon
under such circumstances. Many such cases show a
pebble in the hand, this having been used in lieu of a
bullet in a small pistol, over a blank cartridge. At
the Massachusetts General Hospital, on the morning
of June iS, 1880, following the celebration of the an-
niversaiy of the battle of Hunker Hill, I saw six such
cases, and during the following two years many such
cases presented themselves at the Boston City Hospi-
tal. At that time a particular variety of toy pistol,
using a blank cartridge, was greatly in vogue among
September 19, 1896]
MEDICAL RECORD.
411
the boys of that region. Five deaths from tetanus fol-
lowing such wounds occurred in one month during my
service as hou^e officer.
Many men have been killed in taking a loaded gun
through a fence, or from a wagon, or out from under a
tent or bedding in camp. It is commonly supposed
to be empty or else the person handling it carelessly
gets in front of the muzzle. Many accidents occur
from riding behind a loaded gun in a wagon or buggy.
Three fatal accidents and one non-fatal of these varie-
ties occurred in a few years within a radius of fifty
miles of the town in which I practised. One patient
of mine shot himself through the body with a govern-
ment rifle, in the attempt to draw it toward him as he
sat upon the seat of his wagon. Many fingers are
lost by holding them over the muzzle, or having them
in contact with the cleaning-stick or ramrod when a
shell sticks or a load misses fire and an investigation
is being made. One patient of mine shot off his right
forefinger, having held it over the muzzle while trying
to shut the lever of his shotgun.
Many accidents have happened to poachers from
carrying short weapons, which for concealment are
carried in the pockets after being detached. A rela-
tive of an Irishman with whom I hunted one fall was
killed in crossing a stone wall, by the charge from the
barrels of a double gun which he had concealed in
his coat-tail pocket. As he raised the tails of the coat
to step over the wall, the barrels, which were muzzle
down in the long pocket, fell downward, and the cap
of one barrel striking on the wall, the charge passed
upward into his abdomen. Several similar accidents
are on record in English works.
In the struggle for a weapon with which one person
has assaulted another, many injuries take origin. In
one of my cases the revolver was discharged when held
over the shoulder of the owner, and a fatal wound re-
sulted, the ball passing through the heart. In a case
which I saw with Ur. Parkhill, of Colorado, the bullet
passed in a similar case through the left lung, and the
patient recovered. The history given by the patient
was that, in the attempt to shoot a highwayman in the
night, the latter seized the weapon and pointed it at
the chest of the owner, and it was discharged while in
that position. In a Denver case, which I did not see,
the pistol ball cut off two fingers of the woman who
was trying to use the weapon upon a man employed
about the ranch. One can easily see that any variety
of wound might come from the very unusual positions
in which a pistol might be placed in such a struggle.
There can be little doubt, however, that at times sui-
cide is attempted with an unsuccessful result, and that
the intending suicide then tells a story of an attack
upon himself by another, of his attempt to shoot the
attacking party, and of a consequent wound from his
own weapon. I feel sure that I know of one such
case, for the injured man was known to be despondent
over a love affair; but one shot was heard instead of
three as he stated, and but one chamber of his pistol
was empty. He claimed to have fired twice at the re-
treating highwayman after being himself shot in the
scuffle; but there was no evidence outside of his state-
ment that he had done so, nor was there evidence that
any other person had been near him at the time of the
shooting. In another case reported to the Denver
police, a man claimed to have shot himself by accident.
He had a wound of entrance on the rear aspect of his
leg, and some bystanders had heard three reports, so
that it was thought that his story was not true, but that
for some reason he did not wish to have it known that
another had been concerned in the shooting.
I have quoted elsewhere ' the case of a man who
drilled a vent hole in the end of the cast-iron sleeve
which fits over the wooden axle of a wagon. When he
' Medico- Legal Journal, December, 1895.
filled it with powder and fired it, it burst, and he lost
his thigh as a result, being struck by one of the frag-
ments, as reported to me by Dr. Hawes, of Colorado.
In a recently reported case, a turntable bolt burst with
fatal effect in a similar manner. These cases are,
however, so common and so obvious, even to one not
especially familiar with the subject, that I need not
quote other cases.
Perhaps the most prolific cause of accidental shoot-
ings is to be found in the habit of pointing a weapon
at another in fun, under the impression that it is not
loaded. These cases are reported in every community
with great frequency. In one case reported from Po-
catello, Id., a Bannock Indian withdrew the charge
from his muzzle-loading gun, and then tried it upon a
brother Indian brave. Apparently a second load re-
mained in the barrel, for he killed the object of his
sport. Witnesses had seen him remove one load from
the barrel in question. In the town in which I first
practised, a cowboy showed his revoher to his sweet-
heart and shot her through the body through some
unaccountable accident. Children learn to shoot toy
pistols and are permitted to fire them at one another
with impunity. Then, obtaining a revolver in some
manner, they use it in similar fashion. In one of my
cases, a boy of only three years shot an older one
through the knee in this way.
Sheer foolhardiness is responsible for an enormous
number of accidents. A friend of mine had his fore-
arm shot full of bird shot as the result of his compan-
ion's trying a gun, which had missed fire many times,
upon him. In one case I knew a boy to allow such a
weapon to be fired at him at forty yards for twenty-five
cents. Curiously, it failed to shoot — the only instance
I have known in which a gun failed to do its work in
such a case.
An acquaintance of mine followed a hunter through
some thick brush, the latter's shotgun being over his
shoulder. The trigger caught upon a branch, and the
load passed over my friend's head. Many fatal acci-
dents have resulted from just such causes.
One of the most frequent sources of accidental in-
jury from firearms has been done away with very
largely by the introduction of breech-loading weapons.
With the muzzle loader, many people were hurt from
ignorantly using an enormous load or from placing
two loads in the same barrel. In one of the cases I
have already quoted, two boys placed four inches of
powder and thirteen leaden bullets in a shotgun, and
were both injured by the explosion. The left hand
is the one commonly hurt by the flying parts, from the
position in which it is held.
If the shooter put the cap in position before loading,
at times the powder flask or shot pouch would be
dropped, and, striking the hammer, carry it backward
far enough to allow it to strike the cap with force suffi-
cient to fire the weapon, the charge often striking the
head of the man loading it. Occasionally after the
removal of the cap from the nipple, the gun being con-
sidered perfectly harmless, it was snapped at another
person, and caused death. The explanation is that
the white substance seen in the bottom of the inverted
percussion cap, the fulminate of mercur\', became de-
tached and remained upon the nipple, being still just
as effective as when contained in the cap. Accidents
continually happened from loading the empty barrel
with the other at full cock. In one case the hunter
stood upon a log, after killing a rabbit, that he might
watch for others while reloading. His foot slipped,
the hammer of the loaded barrel struck the log, and the
charge entered the man's abdomen. The jarring off
of the second barrel in badly worn guns from the shock
of the first commonly harms only the shooter, and then
only by the recoil. The "hangfires" commonly do
no further harm than to cause a miss, but obviously
4i:
MEDICAL RECORD.
[September 19, 1896
might be serious if one had changed his aim sufficiently
to bring some one in range. Many accidents are
quoted from the attempt to withdraw the charge of a
double gun before removing the cap, or after removing
it but leaving the fulminate in place.
Finally, I have known several accidental discharges
of weapons from attempts of amateurs to change the
action of the lock of the arm, and especially from fil-
ing away the notch holding the hammer in position at
full cock, to make the trigger pull of the gun lighter.
|Voorc55 of iU edical *cicticc.
Corrigan's Pulse, it seems, should be called Vieus-
sen"s pulse, as he described it in 1715. According to
Huchard, Corrigan's pulse is the "' jerking," water-
hammer pulse due to aortic regurgitation. — Medical
Exitmiiiei-.
Chorea. — Sir Dyce Duckworth (IVn/ur mediziiiisc/ie
BUitter, .wii., 1S94) says chorea is simply another
variety of rheumatism, in which the brain is affected
instead of the joints. He considers that the defini-
tion of Andrew Clark, "■ rheumatism of the brain,"' is
very appropriate.
Dysmenorrhcea. — Dr. H.Talley {J'/iitadcIp/iia J'oly-
diiiic) states that a mi.xture of caffeine, potassium bro-
mide, and tincture of gelsemium is of much value in
tlie treatment of dysmenorrhn-a. 'I'his should be ad-
ministered for a few days before menstruation.
Vomiting of Pregnancy. — The di/hu/a Mcilica! Rec-
ord advisijs putting .i blister over the fourth and fifth
dorsal vertebra;. Some writer is quoted as saying,
'■ F!y a single vesication I have never failed to put an
end at once to the sickness of pregnancy for the whole
remaining period of gestation, no matter at what stage
I was consulted."
Treatment of the Funis Dr. Abraham Jacobi
{New York Medical Journal) states that in wrapping
up the end of the cord oil must not be used, as mois-
ture and the e.\clusion of air favor gangrene, while
warmth and dryness favor mummification. Powdered
bismutli subnitrate, zinc o.\ide, iodoform, or salicylic
acid, one part with ten of starch, may be dusted around
the stump daily. The latter is not useless as an an-
tiseptic. The normal process of separation usually
occupies from twelve to fifteen days, but careless
handling, local irritation, and infectious influences
may prolong the process for weeks. I'nder such cir-
cumstances local treatment is required. Carbolic
acid should be avoided, as infants are.easily affected
by its toxic properties. Solution of lead, zinc, or
alum answers quite as well. Dr. Jacobi recommends
powders of zinc o.xide, bismuth subnitrate, alum with
starch, and salicylic acid witii starch or iodoform.
Neither iron perchloride nor iron sulphate should be
used, as secretions will accumulate under the coagulum
formed by its application.
The Arrest of Rheumatic Endocarditis. — Dr.
Caton, in a paper read before the JJritish Medical As-
sociation, urges the importance of a more active treat-
ment of rheumatic endocarditis than is usually em-
ployed, with the view of arresting the disease if
possible in its initial stages. As soon as any bruit is
detected, a series of small blisters, each the size of a
florin, is applied along the course of the third, fourth,
fifth, and sixth intercostal nerves in front and at the
sides. Only one is applied at a time, and the differ-
ent exit points are covered consecutively. In this way
the blisters give rise to no pain or inconvenience. At
the same time sodium or potassium iodide, in eight or
ten grain doses, thrice daily, is administered, and the
ordinary salicylate treatment is continued. Lastly,
the patient is kept in hospital for six weeks, most of
the time in bed. Under this treatment most of the
writer's cases (twenty-nine out of forty) in which
symptoms of acute endocarditis had supervened left
the hospital with, so far as could be detected, a per-
fectly normal heart.
Effects of Lactation on Menstruation and Im-
pregnation. — Dr. L. Remfre)', in a paper read before
the Obstetrical Society, London, concludes as follows:
I. Of nursing women, fifty-seven per cent, only have
absolute amenorrhcta. 2. Forty-three per cent, men-
struate more or less, but twenty per cent, have abso-
lute regularity. 3. Impregnation does not take place
so readily during lactation as at other times, but this
is not true to such an extent as has been imagined.
4. If absolute amenorrhcca is present during lactation,
the chances of impregnation occurring are only six out
of one hundred. 5. If menstruation occurs during
lactation, the ciiances are sixty in one hundred. 6.
The more regular a woman is during lactation the
more likely is she to become pregnant. 7. During a
menstruating lactation the changes in the uterus are
presumably similar to those connected with the ordi-
nary monthly periods, and the mucous membrane
forms a nidus for the ovum. 8. In the woman who
does not suckle at all, the menses appear, as a rule,
some time in the first six weeks after delivery.
Acute Gout. — Dr. Jaccoud (La Semaine Medicale)
divides this subject into three parts, according as one
has to deal with the acute attack proper, the subacute
attack, or the recurrent disease. In the acute attack
proper he does nothing during the first five days ex-
cept to promote diuresis by the mo.st simple means, as
the administration of a litre or so of Evian or Vittel
water daily, perhaps adding a little acetate of potas-
sium. He refrains from giving milk, as he prefers
that the "explosi\e energy'' of the disease be ex-
pended on the organic tissues themselves. He ap-
plies anodyne embrocations to the joints and covers
with a thick coat of wadding. If at the end of five
days the fever and pains have subsided, the attack is
nearing its end and no further treatment is necessary.
Now, milk should always be given. If there is no im-
provement. Dr. Jaccoud gives one and a half grains of
hydrobromate of quinine with three-quarters of a grain
of digitalis powder in pill form five or six times a
day; this nearly always produces the desired effect in
two days. If the pains are worse at the fifth day than
at the onset, salicylate of sodium in thirty to forty
grain doses should be given if the urine is free from
albumin : after the second dose the urine is to be
tested with ferric chloride, and, if the salicylate reac-
tion is either feeble or wanting, the drug should be
stopped. The subacute form of the disease is charac-
terized mainly by its prolonged duration. If the above
treatment does not cut short the attack on the ninth or
tenth day, we must resort to colchicuni. The author
gives this in the form of pills. He uses Becquerel's
formula, each pill containing one-half grain of extract
of digitalis, two grains of sulphate, or, better, hydro-
bromate of quinine, and one-half grain of colchicum
seed. In order to avoid excessive purgation, not more
than two pills should be given a day. No special
antigout medication is to be employed between the
attacks. Recurrent gout is treated in about the same
way as the subacute form. Visceral gout unassoci-
ated with articular symptoms is a late complication,
coming on only after years of typical gout. If there
is no joint affection within twenty-four hours, colchi-
cum is to be given at once. The joints usually af-
fected are to be covered with powerful revulsants and
vigorously blistered.
September 19, 1896]
MEDICAL RECORD.
413
Medical Record:
A Weekly Journal of Medicine and Sjirgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Pl'BI.ISHF-RS
WM. WOOD &. CO., 43, 45, &. 47 East Tenth Street.
New York, September 19, 1896.
THE PARALYSES OF TOXIC ORIGIN.
The so-called toxic paralyses are characterized espe-
cially by their peripheral localization and symmetry
of distribution. They involve particularly the e.xten-
sor muscles and exceptionally also the optic, phrenic,
and pneumogastric nerves. The affected muscles un-
dergo atrophv and lose their contractility, while the
invaded members become fixed in partial flexion from
unopposed action of the unparalyzed muscles. The
paralysis extends, as a rule, from below upward, and
may be designated "ascending."' The motor mani-
festations are usually preceded by subjective disturb-
ances of general sensibilitv, such as pricking, numb-
ness, tingling, symmetrical in distribution and local-
ized especially in the extremities of the members.
In addition, there are objective disturbances of general
sensibility, of similar distribution, with almost con-
stant integrity of special sensibility. Finally, there
occur vasomotor and trophic disturbances, also sym-
metrical in distribution, and, as a rule, of maximum se-
verity in the lower extremities, though occasionallv
found in the upper.
Among the intoxications in connection with which
the paralyses under consideration have been observed
are those due to lead, arsenic, mercury, alcohol, and
the infectious diseases generally. The source and
origin of these intoxications are sometimes so obscure
and the symptoms to which they give rise occasionally
-SO anomalous, that one must constantly be on his guard
lest he go astray in diagnosis and, as a result, fail in
his treatment. So like the symptoms of posterior
spinal sclerosis are the manifestations of some of these
cases, that they have been injudiciously designated
"pseudo-tabes."
It has been observed by Lancereaux ' that arsenical
paralysis maybe attended with febrile symptoms, thus
simulating typhoid fever or acute miliary tuberculosis,
or other continued fever, and he reports two illustrati\e
cases. A girl, thirteen years old, previously in good
health, was seized with vomiting, vague pains, a sen.se
of fatigue and backache, to which soon was added ele-
vation of temperature, at times reaching as high as
104° F. The pulse was accelerated, but there was
no headache and sleep was fairly good, and there was
no evidence of organic disease. The symptoms thus
continued for four or five weeks, when numbness at
' Bullclln lie r.Xcailcmic ile Medecinc, iSg6, No. 2S, p. 41.
the tips of the fingers and toes was complained of.
Next the feet became painful and movement difficult.
The nutrition, which had hitherto been maintained, now
began to fail and the patient was disturbed by dreams.
The skin became dry and rough, and the complexion
assumed a leaden aspect. The legs were partially
Hexed upon the thighs and the toes upon the feet, from
weakness and wasting of the extensor muscles. At
this time, more than three months after the beginning
of the illness, the possibility of a toxic paralysis sug-
gested itself, and on inquiry it was learned that the
patient had been under treatment with arsenic for three
years, for the relief of a generalized psoriasis. Under
appropriate treatment, especially of a symptomatic
character, improvement at once set in and progressed
fa\orably.
In the .second case, which occurred in a woman
thirty-eight years old, who had been taking daily for
ten months from ten to fifteen drops of Fowler's solu-
tion for the dissipation of enlarged cervical and axil-
larv lymphatic glands, it was decided without a
knowledge of this fact to prescribe the same medica-
ment, in doses of from ten to thirty drops in the
twenty-four hours. In the course of three weeks fever
manifested itself, with vomiting and looseness of the
bowels. There was also complaint of dryness of the
throat and of the inner surface of the cheeks, with
difficulty in mastication ; also of headache, w ith a
sense of constriction about the forehead; and, finallv,
of numbness, tingling, prickling, and burning in the
fingers, especially at night. Later there was actual
impairment of sensibility and of motility as well, with
abolition of the refiexes and ctdema of the lower ex-
tremities, followed by desquamation. Upon the with-
drawal of the medicament the temperature declined,
although tiie pulse remained accelerated. When the
drug was resinned, however, the previous symptoms
also were renewed.
These two observations not only confirm the knowl-
edge that small doses of arsenic taken for long periods
are capable of exerting a toxic influence upon the ner-
vous system rather than upon the gastro- intestinal ap-
paratus, but they also show that they may give rise to
febrile symptoms whose origin is likely to escape de-
tection unless the clinician be on the alert. They
further enjoin especial care in the administration of
arsenic for therapeutic purposes. It remains to be
seen if similar manifestations attend other forms of
toxic paralysis.
THE COURSE OF TYPHOID FEVER.
In comparison with some cases of typhoid fever, few
other diseases cause the physician greater hesitancy
in diagnosis or greater anxiety as to final outcome.
When the nature of the affection is not perfectly clear,
he hesitates to say that the case is not one of typhoid
fever for reasons some of which urge him as .strongly
to withhold that diagnosis — long days of vigilance,
search for the source of infection, disinfection and dis-
posal of passages, and protracted dietary and course
of treatment, etc. In a study of the evolution of ty-
phoid fever by Bernheim, of France, some light is
4T4
MEDICAL RECORD.
[September 19, 1S96
IhrowTi on the cause of the irregular course and vary-
ing symptom complex of this disease.
Bernheim says that the so-called normal type of ty-
phoid, such as described by Wunderlich (period of
augmentation of three to four days: stationary period,
twelfth to fourteenth day: and period of decline, five
to six days), is not the most common. While this
may be retained as a schema, alongside of it should
be mentioned typhoid with shortening of the stationary
period, or abortive typhoid; and typhoid with pro-
longation of the .stationary period, or prolonged ty-
phoid. In the first the microbic evolution is aborted
and the lesions in Peyer's patches resolve without ul-
ceration. In the second the microbic evolution is not
continuous, but occurs by steps. Pathological anatomy
shows that the lesions are not all contemporaneous,
some being in a state of ulceration or cicatrization,
while others are in the stage of hyperplasia.
According to whether the first microbic evolution is
only in a state of regression or whether convalescence
has acutally begun when a second evolution sets in,
would he call it a recrudescence or a relapse. In both
instances, however, the cause is the same — successive
evolutions of the typhoid germs. He found relapses in
one-fourth of the cases, and, adding together the cases
with recrudescence and those with relapse, the number
amounted to one-third of the whole. The recurrences
may be abortive, but at other times they are long con-
tinued and grave. Tiie persistence of the typhoid
bacillus in the economy for several months after con-
valescence, as shown by OrlofT, Oupre, and others,
goes to confirm this view, based on the clinical history.
I'lie relapses may cause no other symptoms than rise
of temperature, which may continue for weeks or for
only a few days. An irregular fever may follow and
be due to secondary infection from staphylococci or at-
tenuated streptococci. Hemorrhages, pneumonia, myo-
carditis, etc., may alter the regular course of typhoid.
While this theory of the development of typhoid fe-
ver by successive stages of microbic infection, giving
rise to a varying clinical picture and influencing the
prognosis, may be new to the general profession, yet
we presume that fiernheim would not disclaim the pos-
sibility of its having occurred to others during the
twenty years that he has himself entertained it, espe-
cially since it might be suggested by what seems to be
a more or less analogous condition seen in pneumonia,
diphtheria, and perhaps other infectious di.seases.
TIIK COMMISSIONERS OF PUBLIC CHAR-
ll'IKS AM) THK PUBLIC HOSPITALS.
Wiiii tlie return of physicians to town and the advent
of autumn, the ve.xed question which, during the past
winter, has troubled the medical profession with re-
gard to the appointment of physicians to the various
medical positions in the gift of the commissioners will
come up again for consideration, for the matter is by
no means settled, nor can it ever be settled to the sat-
isfaction of the medical profession of this city until
its rights are fully recognized both by the commission-
ers and by the medical colleges.
The question underlying this subject is not with re-
gard to the reappointment of the men who lost their
positions, for it is fully recognized that the commis-
sioners had the undoubted right to declare their po-
sitions vacant if they saw fit; but that the right of
nomination, and it may almost be said that of appoint-
ment, should rest with the colleges, to the debarment of
the general profession, unless the candidates have the
stamp of the colleges, is a matter of such gross injus-
tice that until this wrong is righted no re.st will come
to either the commissioners, the medical profession,
or the colleges. But were the right of nomination
taken away from the colleges, upon any vacancy occur-
ring the commissioners would at once be besieged by
requests frotn medical men for appointment, and their
lives would be made more or less of a burden in trying
to adjudicate this question upon equitable grounds.
To the non-political mind it seems extraordinary that
the commissioners should voluntarily place this bur-
den upon their backs, when it can so easily be got-
ten rid of with comfort to themselves, benefit to the
hospitals in their care, and advantage to the public as
well as to the medical profession. If the commission-
ers should make the service a continuous one, appoint-
ing one man to each division of the hospitals, and
make the positions salaried ones, the method of ap-
pointment would be much simplified: for the moment
these positions are made salaried ones, they come
under the action of the civil-ser\-ice law, and the
commissioners could at once refer all applicants to the
civil service examining board, which would pass upon
their capacity and fitness to hold the positions to
which they desired to be appointed. Nor is this an
impossibility or without precedent. The New York
Dispensary, after trying the old plan of appointment,
has now made its medical and surgical positions sala-
ried ones, with advantage both to the men holding the
positions and to the dispensary under their control.
The same is believed to be true also of the Good Sa-
maritan Dispensary (the old Eastern Dispensary) :
and in order to supply funds for the payment of its
medical ofticers — for the medical laborer is worthy of
his hire — the schools should be required to pay a
stated sum for each student who enjoys the hospital
facilities furnished by the city. At the McGill
University of Montreal, we understand, the students
are charged for a hospital ticket, and there is no
reason why the medical schools here should not be re-
quired to pay for the.se advantages to their students.
This would at once raise the position held to one of
dignity and honor to the profession, and prevent the
unseemly scramble and intrigue which goes on to ob-
tain hospital appointments in the municipal .service.
It is dithcult to .see what reasonable objection there
could be to this plan, and certainly, so far as the com-
missioners themselves are concerned, it would free
them from this annoying feature of their labors and
give tlieni more time for the study of the duties with
which tiiey are entrusted and the proper study of
which wduld fully occupy their time.
" All Kinds of Hot and Cold X-Rays now on Ex-
hibition " is the mysterious legend over a booth at one
of the popular seashore resorts near this city.
September 19, i8g6]
MEDICAL RFXORD.
415
Jlcius ot the 'SxEccIi.
The Hack Tuke Memorial. — It has been suggested
that the memory of the hite Dr. 1). Hack Tuke should
be perpetuated in connection with the work to which
he devoted his life, viz.. the amelioration of the con-
dition of the insane and the advancement of neurologi-
cal and psychological medicine. With the view of
carrying out this object, a committee has been ap-
pointed to solicit subscriptions in the United States
and Canada. The fund obtained will probably be
used to found a library in connection with the Brit-
ish Medico- Psychological Association, to which Dr.
Tuke's personal library has already been given. Sub-
scriptions may be sent to Dr. Charles \V. Pilgrim,
Poughkeepsie, N. Y. ; Dr. Charles G. Hill, 317 North
Charles Street, Baltimore, Md. ; or Dr. Frank C.
Hoyt, Clarinda, la.
The Death Rate in New York during the hot week
ending August 15th, was 48.65. The number of deaths
was 1,810, of which 615 were from heatstroke.
A Ladies' Quarrel. — The life of a British army
surgeon is not a pleasant one. The commander-in-
chief of the army treats the members of the medical
corps as menials and snubs them at every opportunity;
and now it is said that their wives are treated as in-
feriors by the wives of the combatants, and unhappi-
ness reigns.
The Dirty Sponge — Professor Lang, of Vienna,
declares that sponges, owing to the impossibility of
destroying germs in them, have long since been ban-
ished from the surgeon's table, and should also be ex-
cluded from the bathroom and washstand.
Sewage Farms. — In Paris one-fifth of the sewage
is utilized for sewage-farm purposes. For some twenty
years the municipality at Gennevilliers, outside Paris,
has had several himdreds of acres (once waste land )
irrigated, and they now bear magnificent crops of
roots and kitchen-garden products. The sewage, after
percolating the soil, exudes as pure water. The mu-
nicipal council, after local opposition, acquired two
thousand acres of a Sahara-sandy lightness in the for-
est of Saint Germain. For two years this district has
been irrigated with sewage, and is now covered with
luxuriant agricultural and gardening crops. — Afedical
J'rrss.
Suggestion in the Prevention of Seasickness
Dr. (iorodichze recently reported to the Paris Society
for Hypnology that he had succeeded, by means of
hypnotic suggestion, in preventing seasickness, even
in the case of persons who had always been violently
affected by it.
Theses de Paris. — .\ proposal was recently made,
and we belie\e ccjnsidered by the authorities of the
Paris Faculty, that the ihesis which forms the final act
in the process of examinational evolution of the doc-
tor of medicine should be aliolished. Whether this
.indent institution is seriouslv threatened we cannot
say, but there is certainly no sign of its immediate
suppression. During July no fewer than two hundred
and thirty-six theses were presented, making a total
for the past academic year of five hundred and ninety-
four. This is the largest number ever presented in one
year. The total number presented since 1798, from
which the faculty in its present form dates its exis-
tence, up to the end of July, 1896, is thirty thousand
nine hundred and fifteen. — RrHishAIeilical Joiinml.
Dr. John B. Hamilton, the able editor of \\\e: Jciir-
tial of tJic American Medical Association, and also sur-
geon in the Marine Hospital Service, has been ordered,
in the latter capacity, to leave Chicago and proceed to
the station at San Francisco. The association can ill
aflford to lose Dr. Hamilton's services, for he has done
much to make the Journal what it is, and we trust a
way may be found to reconcile his present conflicting
duties. The Journal, under Dr. Hamilton's editorial
management, has been an active opponent of the pro-
ject to entrust to the Marine Hospital Service the du-
ties of the proposed department of public health.
Match-Making by Machinery. — The French gov-
ernment has been endeavoring to prevent the use of
white phosphorus in the making of matches, but finds
that to forbid it would be practically the same as pro-
hibiting the making of matches. It has, therefore,
sent an engineer to this country to report upon the
machines u.sed here for making matches, with a view
to their adoption in the French factories, so as to do
away with the making of matches by hand.
The Jenner Centenary in Russia will be cele-
brated in St. Petersburg, on October 24th. The Rus-
sian correspondent of the British McJica/ Journal ss.\s
that the preparations of the Russian National Health
Society for this commemoration are proceeding apace.
The centenary edition of the society's publication,
containing a life of Jenner and translations of all
his works, as well as a historical notice of the de-
velopment of vaccination in Russia and other Eu-
ropean countries, will be a worthy memorial of the
occasion. It will contain considerably over a hun-
dred illustrations, manv of them most admirable re-
productions of Jenner's original drawings; it will also
contain portraits of Jenner, views of the Berkeley
neighborhood, and a ho,st of other Jenneriana, which
should make the volume one well worth possessing,
notwithstanding that the letterpress will be in Rus-
sian. The sub.scription for the edition is the small
one of 3 roubles, or rather over 6.f., which will proba-
bly be less than the cost of production. Already the
society has received a large number of loans and gifts
for the exhibition, which it is proposed to hold in con-
nection with the commemoration. These objects have
come from almost every part of the world; there are
contributors from such distant countries as Japan, the
Cape of (iood Hope, the Fast Indies, and Brazil.
Port Physician of Wilmington, Del Dr. M. J.
Hughes has been appointed by Governor Watson jjort
])hysician of Wilmington, in succession to Dr. Willard
Springer, resigned. The port physician is also fx-
officio a member of the city board of health.
4i6
MEDICAL RECORD.
[September 19, 1896
Vital Statistics of Philadelphia. — For the week
ending September 5th there were reported in the city
of Philadelphia 362 deaths, as compared with 356 for
the preceding week and 355 for the corresponding pe-
riod of last year. The deaths were distributed among
200 adults and 162 minors; 196 males and 170 fe-
males. Ninety-six occurred in children under one
year of age; 38 in adults between sixty and seventy;
36 between fifty and sixty; 35 between thirty and
forty; 30 between twenty and thirty; 25 in children
between one and two; 23 in adults between forty and
fifty; 22 between seventy and eighty. The most con-
spicuous causes of death were : Pulmonary tuberculo-
sis, 44; marasmus, ^3; cholera infantum, 22; senil-
ity, 19.
Pathological Society of Philadelphia.— At the
stated meeting of the Pathological Society of Phila-
delphia, on September loth. Dr. C. W. Burr exhibited
a diffuse meningeal tumor from the left frontal region,
probably a round-cell sarcoma, in association with
syringomyelia, in a case of chronic nephritis present-
ing during life right hemiplegia and immediately be-
fore death general convulsions followed by coma. Dr.
J. Dutton Steele presented tuberculous suprarenal
glands from a case exhibiting also tuberculosis of the
lungs, intestines, and mesenteric glands, but free from
obtrusive symptoms of Addison's disease. Dr. Joseph
McFarland presented a specimen of extensive neo-
plastic involvement of the abdominal cavity, matting
together stomach, transverse colon, spleen, liver, and
omentum above, and the uterus and the pelvic contents
below. The interior of the stomach was free. The
growth was believed to be an endothelioma, but the
point of origin remained obscure. Dr. A. E. Taylor
made some remarks on the epithelium and the lym-
phatic tissues of the fcetal vermiform apjx^ndix, and
exhibited sections stained by ditt'erential methods.
iJr. H. W. Cattell presented a fresh specimen of an-
eurism of the arch of the aorta without rupture, and
;ilso one of multiple sacculi of the bladder.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States Navy for the week ending
September 12, 1896: September 10th. — Passed Assis-
tant Surgeon C. F. Stokes, orders of July 21st modi-
fied, detached from duty as member of the naval and
medical examining boards. New York, and ordered to
continue as recorder.
Philadelphia County Medical Society. — .M the
staled meeting of the Philadelphia County Medical
Society, held on September 9th, Dr. G. Betton Massey
read a paper entitled " Electricity in Gynecology at
the Howard Hospital; Report of Cases." One hun-
dred and two cases treated by these means were ana-
lyzed, the results reported being in the majority of a
mo.st favorable character. The largest number were
cases of fibroid tumor of the uterus.' Dr. John Lind-
say made a " Report of a Case of Prostatic Abscess,"
wliich presented symptoms resembling those of influ-
enza and terminated by spontaneous rupture into the
urethra. 'I'he condition was recognized by the detection
through the rectum of enlargement of the prostate gland.
Dr. J. B. Roberts referred to a similar case, in which
rupture took place through the urethra and through
the rectum as well: an abscess also formed in the
scrotum.
Obituary Notes. — Dr. Alf.x.anper H. McAdam, a
well-known and successful practitioner, died at Phila-
delphia, on September 9th, in his fifty-seventh year.
He was graduated from the I'niversity of Pennsylvania
in 1863, and he was for a number of years a member
of the select council. At the time of his death he was
a member of the board of education. — Dr. Edocard
Nu:.-MSK, of Paris, died of pneumonia in that city, in
the latter part of August. He was born in 1838, and
was graduated in medicine in 1866. He was surgeon
to the Hopital Laennec, and for a number of years was
editor of the Rtviit- de Chinngie. — Dr. \Villi.\m T.
Turner died at Philadelphia on September 9th, at
the age of twenty-two years. He was graduated from
the University of Pennsylvania in 1895. — Dr. Wil-
liam Cranch Bond FiFiF.i.n died at his home in Bos-
ton, Mass., on September 9th, aged seventy-eight.
He was a graduate of Harvard Medical School in
185 I, and of the Royal College of Surgeons in Eng-
land.— Dr. Nicholas Ri'dinckr, professor of anatomy
at Munich I'niversity, died on .August 24th, at 'I'ul-
zing, in Bavaria. He was born in 1832, at Biides-
heim, in Hesse. After studying medicine at Heidel-
berg and Giessen, he was appointed prosector at the
anatomical institute at Munich in 1855, and in 1880
was made professor of anatomy at the university. —
Dr. He.vrv K. Pusev died at Garnettsvilie, Ky., on
September 2d, at the age of seventy years. He was
graduated from' the medical department of the Uni-
versity of Louisville in 1849. He was for a number
of years superintendent of the Lakeland Insane Asy-
lum.— Dr. Hakkv Hodgen, of St. Louis, died at
Alma, Mich., on August 28th. He was a son of the
late Dr. John T. Hodgen, and was born in 1855. He
was graduated from the St. Louis Medical College in
1883, and was professor of orthopetlic surgery in the
same institution at the time of his death. — Dr. Joh.v
Louis Hopki.ns, of New York, died .Vugust 2TSt, from
heart disease. He was born at Carthage, N. Y., in
1 86 1, was educated in the Carthage .Academy, and was
graduated in medicine from the New \'ork Uni\ersily
in 1887. He soon acquired a remunerative practice,
and, like many physicians, he was himself the last to
receive his consideration. So far, indeed, had he car-
ried this self-abnegation, that his fatal illness seized
him while in the midst of his work and he died two
days after taking to bed.
An Association of Nurses. ^ — \ number of nurses,
repre.senting training-.schools and alumn;u associations,
met at Manhattan Beach Hotel, on .September 2d, to
organize an association of nurses which shall cover
the I'nited States and Canada. A constitution was
drafted, which will be submitted for ratification to
the different bodies represented. The object of the
proposed association is to bring the nurses of the
country into closer union, to protect them in their
rights, and to elevate the profession of nursing.
September 19, 1896]
MEDICAL RECORD.
417
^ocietvj Reports.
MEDICAL SOCIETY OF THE STATE OF
VIRGINTA.
T7i'enty-Sevenili Annual Session, Held at Rockbridge
Alum Springs, Septonhcr S, g, and lO. l8g6.
(^Special Report for the Medical Record).
First Day — Tuesday, Scptanher 8tli.
The meeting was called to order at 8 p.m. After
a prayer and the report of the committee on appli-
cants for fellowship, Mk. Alexander H. Gr.\ham.
of Austin, Tex., delivered an address of welcome to
the assembled doctors.
Moderation an Aim in Education was the subject
of the address to the public and profession by Dr.
Elliott E. Bradv, of Chatham Hill. \'a. In this he
claimed that moderation is a natural law, and that the
violation of the law brings with it appropriate penalties.
He denied the theor}' of the inheritance of evil pro-
pensities, and advocated the early education of chil-
dren, beginning in absolute infancy. He claimed that
at the age of five years, the time usually chosen for
beginning educational methods, the tempers and tem-
peraments of children were almost unalterably formed.
He called attention to the fact that the theory of non-
accountability of criminals and ■ drunkards, on the
ground of hereditary tendency, has a tendency to affect
injuriously our criminal laws. He styled the theory
as the greatest social and moral error of the century,
saying, in the course of his remarks, that " the theory
invented by experts in excess to shield a criminal be-
hind the mythical scapegoat of parentage, has saved
many a neck which laws inaugurated by common sense
had prepared ropes to stretch."
Second Day — Wednesday, September gt/i.
The Progress of Medicine in Relation to the
Prevention of Infectious Diseases Dr. W. L.
Robinson, of Danville, the president-elect, delivered
an address with this title. The points discussed were
the evidence of the bacterial origin of disease and the
prophylactic value of orrhotherapy : the special modes
of infection of typhoid fever and tuberculosis and the
means to be employed in stamping out these diseases;
the establishment of a department of public health of
the central goxernment, the chief of which should be
a member of the President's cabinet.
Intestinal Indigestion. — Dr. L. G. Pei>igo, of
Crockett Springs, Shawsville, opened the discussion on
this subject with a paper on the treatment of this con-
dition. He said that the subject illustrates most for-
cibly the notion of the interdependence of the various
organs. It teaches us how impracticable it is to di-
vide up the various organs and assign them to the cor-
responding specialists for treatment, as a mere ma-
chine might be repaired. He set forth the indications
of treatment as follows: (i) To see that gastric diges-
tion is as nearly normal as possible; (2) to attend to
the removal of all obstruction from the colon; (31 to
endeavor to restore muscular tone to the entire alimen-
tar)- canal and to promote regular peristalsis; {4) to
obtain a careful regulation of the liver in all its func-
tions; (s) to see to it that the pancreatic and salivary
secretions are normal in quality and quantity; (6) to
promote intestinal antisepsis, or the prevention of the
abnormal fermentation; (7) to do all possible to fa-
vor certain of those forms of so-called "fermentation"
(diastasic action) on which intestinal digestion de-
pends; (8 ) to prevent the absorption of the toxins from
the intestines; (9) to secure the elimination of these
toxins through various channels, chiefly the kidneys;
(10) to prevent and remedy the depressant and destruc-
tive effects of the toxins upon the nerve centres; and
(11) in the after-treatment to build up the blood,
which has been impoverished. These indications, the
speaker said, are to be met by physical, dietetic, hy-
gienic, and medicinal measures. Antisepsis was ap-
proved, but the difficulties in the way of its accom-
plishment were pointed out, and the reasons shown
why it was disappointing in its effects when employed
without due preparation of the patient. Great stress
was laid upon flushing the colon, washing out the
stomach, regulating the functions of the liver, a care-
ful line of diet, and systematic exercise "from the
hips up.'' Among special intestinal antiseptics, sub-
gallate of bismuth was highly spoken of, the practice
of the author being to combine it with large doses of
subnitrate of bismuth. Salol was also praised for se-
lected cases, and beta-naphthol-bisniuth was favorably
mentioned. Of diastasic agents, a well-prepared pan-
creatin should be used.
Dr. Upshur, of Richmond, called attention to the
necessity of a more careful analysis of cases and a con-
sideration of the underlying physiological principles.
He divided the cases into functional and organic, and
discussed the various causes, whether located in the
intestine, stomach. li\er, pancreas, or kidnev, or ner-
vous in character. He called attention to the trouble
in children from mental strain at school. The effect
of taking more food than the system requires, dress,
and habitual faulty positions of the body were con-
sidered, and a correction of these causative conditions
was urged as essential. Dr. Upshur also called atten-
tion to the ill-effect of tobacco in its physiological
action on the salivary glands and pancreas. He re-
viewed the symptoms fully from ever)- standpoint, call-
ing attention to the sigtiificant fact of pain in the right
hypochondrium coming on, in the chronic form, from
one to three hours after eating. Fhe neurasthenic
symptoms were also discussed. The prognosis, he
said, depends upon the acuteness of the case and the
nature of the complications, functional or organic.
Dr. J.acob Michaux, of Richmond, expressed sur-
prise at the general misconception as to the cause and
management of the disease. He believed in the em-
ployment of muscular exercise, but did not believe
walking sufficient, and urged his patients to employ
all the exercise possible in the oi^en air. A very suc-
cessful remedy in his hands had been a brine sponge
bath upon rising in the morning. Tepid water was
employed in cold weather. He also was in the habit
of rubbing a saturated solution of salt into the skin.
In the form of chronic diarrhcea he gave his patients
milk, either alone or with lime water or salt. When
they could not stand milk, he gave animal broths. He
adhered strictly to a liquid diet. -\s regards drugs, he
had found the digestive ferments of the greatest ser-
vice. Tonics were rather hurtful. Iron would do
more harm than good until substantial food could be
digested. (Quinine had been shown to be an irritant
in most cases. He had been in the habit of relying
largely upon pepsin and lactic and hydrochloric acids
after meals, or a solution of the chloride of arsenic in
minute doses. In some cases he gave from twenty to
sixty grains of bismuth, with five grains of salicin.two
hours before meals: and two hours after meals he
used the extract of opium. Active medicines he re-
garded as dangerous. He had found the keynote of
success to consist in strict attention to diet.
Dr. I. S. Stone, of Washington, D. C, said that he
did not regard such fine distinctions between cases of
intestinal indigestion as at all essential. While he
most heartily approved the views of the gentlemen
who had spoken, he thought a more practical method
of diagnosis and treatment could be devised and prac-
4i8
MEDICAL RECORD.
[September 19, 1896
tised. Intestinal indigestion was due to either func-
tional or organic disease. The organic cases were not
necessarily difficult to treat. The functional were
often due to nervous causes. Treatment addressed to
the general condition of the patient would cure, while
remedies generally given for dyspepsia would fail.
Lavage, used before breakfast, or the use of a pint of
hot water sipped slowly, would wash out the collec-
tion of mucus sometimes found in the stomach. Hy-
drochloric acid, in addition to this, would also prove
useful. Massage, proper exercise, and a suitable en-
vironment were often necessary, and without these
the usual remedies, especially the so-called digestive
ferments, were useless.
Dr. W. S. Gordon, of Richmond, thought that most
cases of biliousness begin in the stomach. He laid
great stress upon the influence of the nervous system
in intestinal disturbance. Functional diseases of the
alimentary tract do not show post mortem. Gas in
the stomach is not always due to intestinal indigestion.
He had seen cases of periodic flatulence well marked
in children, which he was sure were due to a nervous
condition of the stomach. He had found asafcetida a
most invaluable remedy in such cases. Hysterical
women often suffer greatly from flatulence, which he
was convinced was due to exosmosis of gas from the
blood into the intestinal canal.
The presence of oxalate of lime in the urine does
not possess much diagnostic value. When it develops
in the duodenum it is always present in the urine.
He had relieved this condition temporarily by the
use of muriatic acid. He gave mercury for its sial-
ogogue action on the pancreas. Pancreatin does not
act with much power upon the stomach.
Dr. R. M. Slaughter, of Theological Seminarj',
Fairfax County, had obtained the most uniform bene-
fit from the employment of the stomach pump. He
also used copious enemata with a two-foot colon tube.
He thought the pancreatic solvents did good. Vege-
table pepsin had cured a case of ten years' standing.
For washing out the stomach he used plain boiled
water. He used the stomach tube three or four hours
after meals, but gave enemata only once a da)-.
Dr. Upshur thought that Dr. Stone was right as
far as he went, but did not go far enough. The con-
dition begins in the stomach and reflex action is from
there set up. A hard-worked doctor who suffers from
intestinal dyspepsia wants rest and not exercise.
Very often a faulty condition of the kidneys forces
the stomach to act vicariously as an excretory organ.
He used nitroglycerin to relieve vascular tension
and so enable the kidneys to resume their proper
function. He was opposed to the employment of in-
testinal ferments. He sometimes used pepsin as a
base mixed v.ith phosphoric acid or strychnine.
When any digestive was indicated, he used pancreatin
pure and simple. He was opposed to the indiscrimi-
nate employment of medical preparations of unknown
composition.
Dr. Pedigo said that exercise, to be useful, must be
of the proper kind. He did not regard ana;mia in these
cases as due to lack of nourishment, but to the pres-
ence of toxins in the intestinal canal. It is the func-
tion of the kidneys to eliminate this poison from the
blood. This toxic wave of elimination is always
passing through the system. If it stops, sickness or
death super\'enes. In cases of suggestive intestinal
indigestion the nervous condition is due to the action
of these poisons on the nervous system and so to reflex
symptoms. The speaker was very cautious in the ad-
ministration of tonics. He thought that Dr. Michaux's
suggestion of brine baths was excellent. He usually
regarded diarrhoea in intestinal indigestion as inci-
dental and did not combat it actively. He had excel-
lent results with hot-water injections in this diarrhoea.
Cold enemata following the hot were also useful when
it was necessary to check it. He used quinine only
in cases in which he suspected a malarial element.
Typho-Malarial Fever — Dr. Willia.m S. Gordon,
of Richmond, read a paper on the nature of this fever,
taking the ground that there was doubt as to the exist-
ence of such a disease. He claimed that it is a typi-
cal typhoid and adduced arguments to prove his
position from a clinical standpoint. He denied that
the existence of a new disease with a specific germ
has been proven. He also denied the existence of a
hybrid disease, and was inclined to regard it as doubt-
ful whether two specific fever germs could be present
and active at the same time in the same body and
produce a modified disease. The histor)- of these
cases proves that they cannot be distinguished in
many instances from a group of cases resulting from
typhoid poison, and the speaker held that it is more
reasonable to prove them typical typhoid than to as-
sume them typho-malarial. He would not absolutely
deny that there is such a disease as typho-malarial
fever until the point has been settled by bacteriologi-
cal investigation. He denied the existence of catar-
rhal and gastric fever as distinct diseases. The
history of malarial fevers as ordinarily described,
especally from the standpoint of epidemics, shows
them to be of typhoid nature. From the patient's
standpoint, therefore, it is far better to suspect and
treat the case as one of typical typhoid fever than to
let the patient walk about in a disease supposed to be
of small moment. The paper presented the question
from both an argumentative and a clinical standpoint.
It was discussed by a number of the members, but
no new arguments bearing upon the existence or non-
existence of such a condition as that under discussion
were brought forward.
Hysterectomy. — Dr. I. S. Stone, of Washington,
D. C, read a siiort paper on " Extirpation of the Uterus
for Pelvic Suppurative Disease." The author gave
his reasons for abandoning the vaginal operation save
in exceptional instances. He was struck with the
admirable reports of Jacobs and others, and had made
an effort to apply the new or vaginal method in his
practice, but he had returned to the abdominal method,
by which he had obtained most satisfactory results.
A brief allusion was made to the technique of the
method employed in order to show its reasonable su-
periority over the former method. The pus sac is
removed if possible without rupture. The perito-
neum is not soiled. The cornua of the uterus are
e.xsected and if necessary all of the uterus is removed.
The uterus, if it is to be left in the pelvis, may be
sutured to the abdominal wall. Xo ligatures en masse
are used, the vessels being tied with small silk, a
needle being used which permits fixation of ligatures,
preventing any possibility of slipping.
The wound is not infected, the scar remaining is a
mere pin scratch, and the patient does not think much
about its presence. The vaginal method will never
be adopted by any one having perfect results from the
abdominal operation. The surgeon's imperfect work
may be to .some extent hidden from view when the
vaginal method is selected, and it is possible that in
some cases the mutilation is excessive and unneces-
sary, as the sacrifice of the uterus is absolutely guar-
anteed from the start. It is obviously true that when
tlie abdominal method is chosen, the uterus may pos-
sibly be left and the appendages on one side at least.
Many cases could be cited in which pregnancy fol-
lowed the removal of the adnexa of one side only for
pyosalpingitis.
Dr. George Tucker Harrison, of New York,
thought it was all important in young women to spare
the ovaries. He objected to the suprapubic method
because by the vaginal route conservation was practised
September 19, 1896]
MEDICAL RECORD.
419
and no wound of the abdominal cavity was made.
There is always danger from hemorrhage by the
abdominal route. The tendency of modern surgeons
is to take the vaginal route.
Dr. George Benjamin Johnston, of Richmond,
thought it was difficult to operate in this way when
the vagina was small and the perineum rigid. He
preferred the suprapubic route. The operation can
thus be done without rupture of tubes. There is also
no special danger of infection.
Dr. J. McFadden Gaston, of Atlanta, thought the
tendency of modern gynecology was to go through the
abdomen. It is especially unnecessary to extirpate
the uterus. He urged conservatism.
Dr. William L. Robinson, of Danville, said we
could not see so well in the vaginal operation. There
are adhesions and suppuration in most cases. The
cleaner and better mode is by abdomen, as these ad-
hesions have to be removed.
Dr. Stone thought that he and Dr. Harrison were
considering a different class of cases. The vaginal
operation will not do when the case is severe. The
vaginal way is a good one for preliminary investiga-
tion.
Third Day — Thursday, September lOth.
Dr. R. J. Preston, superintendent of the State Asy-
lum for the Insane at Marion, Va., offered a resolution
that a commission be appointed to cgnsider the recom-
mendations and suggestions contained in the presi-
dent's address, especially in reference to State and na-
tional hygiene, and that said commission recommend
such action as it might think advisable.
Election of President. — Dr. George Benja.min
Johnson, of Richmond, was elected President.
Surgical Immunization Dr. J. McFadden Gas-
ton, of Atlanta, read a paper on " Surgical Immuniza-
tion Compared with Susceptibility and Predisposition
to Infection," in which he reached the following con-
clusions:
" I. Various agencies are at work in rendering the
human organism to a greater or less extent free from
the injurious impressions of surgical procedures.
"2. Local and constitutional influences operate in
conferring immunity, and the environments of individ-
uals, with their habits and customs of life, exert great
control over the vital powers.
"3. Certain marked changes in the conditions of
the nervous system, constituting shock, in course of
surgical operations, may be averted by proper meas-
ures in advance; and in default of such precautions
should be corrected by rigorous means of treatment.
" 4. The immunity for normal structures in opera-
tive work, which was supposed to be given by germi-
cidal solutions, has proved to be a delusion and a
snare, and that they are only admissible in septic con-
tamination of the tissues.
" 5. That a preliminary examination of all the func-
tions of vital organs should precede surgical opera-
tions of every kind, and that efficient correctives
should be resorted to for their derangements. The is-
sue of the case depends materially upon proper means
of preparation for an operation.
" 6. It is not essential for the management of a sur-
gical case that the patient be placed in a hospital, but
cleanliness in private quarters with proper nursing
may secure entirely satisfactory results, by conforming
to the ordinary surroundings of the patient.
"7. A thorough comprehension of the reciprocal
relations of immunity and susceptibility should lead
to the adoption of conservative measures in the prac-
tice of general surgery, and the use of the most radi-
cal and aggressive measures when indicated by the
nature of the case.
"8. Those appliances which may promote surgical
immunization should be adopted, and those measures
which lessen susceptibility and predisposition to in-
fection are warranted in all cases of surgical interfer-
ence."
Dr. Edward Maguire, of Richmond, took strong
grounds against the practical possibilities of asep-
sis. Patients brought in with crushed or mangled
limbs cannot be treated aseptically. -The germs are
already in the wounds. The unbroken skin or mucous
membrane is proof against the entrance of germs.
Oxygen in Anaesthesia.— Dr. T. L. Pedi(,o re-
ferred to the use of oxygen in ether or chloroform nar-
cosis. The use of oxygen is frequently impracticable.
Recently, efforts have been made to use oxygen con-
tinuously through the period of anaesthesia, with a
view to preventing failure of respiration and heart's
action. High professional authorities differ as to the
measure of success. Some are pleased with the re-
sults; others equally eminent condemn the method
because of the delay in the effect of the anasthetic.
He referred to the use of nitrite of amyl to revive a
patient from ether or chloroform narcosis (originally
suggested by the late Dr. Dabney, of Virginia). He
spoke of having saved at least two lives by this treat-
ment. This method has something in common with
the use of oxygen, since it promotes oxygenation of the
blood by stimulating the respiratory function. He
referred in some detail to the effect of amyl nitrite on
the blood, as observed in experiments of his own on
the antagonism between amyl nitrite and prussic acid,
made some years ago. He was now engaged on a
series of additional laboratory experiments, the results
of which he hoped to present to this society twelve
months hence.
Treatment of Epilepsy, Medical and Surgical. —
Dr. J. Allison Hodges, of Richmond, read a paper
with this title. As there is no known anatomical ba-
sis of this disease, its treatment must be empirical.
We should exclude all causes of organic disease, and
treat the affection as a neurosis. It was most impor-
tant to look to the diet and to proper exercise as ad-
juvants in the treatment. The speaker recommended
a periodical change of treatment, and also an occa-
sional change of location. He insisted upon the ad-
vantages of the sanatorium or colonization plan. He
had given with benefit the bromides in small doses
during the day, and trional at night. Other measures
which he had found useful were Flechsig's opium-
bromide treatment, nitroglycerin hypodermatically
to abort attacks, and intestinal antiseptics and laxa-
tives for putrefactive fermentations and autotoxa;mias.
Regarding surgical treatment, he reported nine patients
operated upon, with two seemingly cured after eigh-
teen months' interval; but he doubted the permanency
of the results in these cases. For relief of reflex epi-
lepsy, the remedying of defects in his experience served
but to effect a temporarv amelioration; yet he invaria-
bly removed the exciting causes if the disease ap-
peared indubitably referable to them.
Chronic Diarrhoea Dr. Jacob Michaux, of Rich-
mond, read a paper on this subject. He briefly dis-
cussed the etiology, symptomatology, and pathology of
the disease, and devoted considerable time to the treat-
ment. The greatest importance was attached to the
absolute enforcement of his rules as to diet. These
were based upon the physiology of digestion. He
insisted upon the exclusion of fattv and amylaceous
articles of diet, the substances allowed being in every
case liquid or semi-liquid and such as experience has
shown to be most easy of digestion. To milk was
given the first place. This could be taken without
any addition or change, but if it v.ere not well borne
it should be boiled; this failing, a little salt might be
added, just sufficient to impart an agreeably salt taste.
420
MEDICAL RECORD.
[September 19, 1S96
If these measures failed the inilk might be predigested.
Broths of beef or chicken should be used when milk
was not tolerated. These, if made properly and not
too poor (though without grease), he regarded as ex-
ceedingly valuable. Soft-boiled eggs and raw oysters
or carefully stewed ones might be used. The speaker
strongly deprecated the use of any but the mildest and
most un irritating drugs, confining his drug treatment
to [sepsin and nitro-muriatic acid and lactic acid for
the aid of gastric digestion and to malt extract for
the intestinal. He gave bismuth subnitrate in full
doses to control the diarrhcea, with five grains of sa-
licin to each dose, say, three, four, five, or six times a
da\-. In severe cases of long standing in which there
is inflammation of the mucosae, opium, lead, and cam-
phor should be given as required, but he insisted that
opiates be not used except for the purpose of mode-
rating the diarrhcea and relieving pain.
Orrhotherapy of Tuberculosis. — Dk. Paul P.\-
(jui.v, of St. Louis, Mo., read a paper on this subject.
His system of producing antitubercle serum consists
of injections of tuberculin and tubercle toxalbumins
in the horse daily for from three to six months and
then using the serum of the horse's blood (thus ren-
dered antagonistic to the germ of tuberculosis) by
hvpodermic or rectal injections in doses of from five to
one hundred and twenty minims, daily or on alternate
days. He reported two hundred and twenty-six cases of
pulmonary consumption of various stages, among which
not ten were in an early stage. The results were as
follows: Recoveries (apparently complete), 40: im-
provement (to the point of the patient returning to his
usual duties), iio: unimproved or remained station-
ary, 76.
Dr. L.-vndo.v 1!. Kdwards reported fourteen cases
treated with serum. Two patients who were in the
throes of death when treatment began died. Three of
them, one an acute case (galloping consumption),
recovered completely. Three are no longer declining
and six are improved.
The society was then adjourned to meet next year
at White Sulphur Springs.
THIRD FRENCH Mf:DICAL CONGRESS.
Held at Nancy, An;;nst 6-12. ifSi)6.
The Application of Blood Serums in the Treat-
ment of Diseases. — This was the first of the subjects
for set discussion. Dk. G. H. Roger opened the dis-
cussion by giving an historical review of this subject.
Hericourt and Richet first showed that a fatal dose of
the staphylococcus for the rabbit could sometimes be
offset by a subsequent injection of the blood of a dog,
but the treatment failed three times in four. They
then observed the important fact that all the rabbits
recovered if the blood were taken from a dog whicli
had itself previously been inoculated. In 1890 Bou-
chard made known that blood could be replaced by
serum in the treatment of infectious diseases. Mean-
while, the bactericidal action of normal blood, and
especially of the vaccinated subject, was studied.
Behring and Kitasato demonstrated the highly impor-
tant fact that the lilood of animals vaccinated against
the bacilli of diphtlieria or of tetanus possessed the
property of neutralizing the poisons produced by these
microbes in proportions truly extraordinary. Hut it
was to Roux, Martin, and Chaillou that honor was due
for having rendered orrhotherapy practical.
It was necessary to choose an animal, such as the
horse, capable of furnishing the serum in large quan-
tity and free from toxic properties. Tlie vaccination
could be effected either by inoculation of living mi-
crobes, the injection of toxins obtained from artificial
cultures, or by injection of toxins taken from the sick.
The first method would expose the patient to great
danger. The second and third were employed accord-
ing to the case. As to the organic liquids which could
be utilized, serum had been used above all others, be-
ing injected under the skin. Milk was ten times less
active.
Regarding the application of serum therapy, it could
be said to have been tried in all known microbic dis-
eases, and also in most of those in which the patho-
genic agent had not yet been discovered, although sup-
posed to be infectious: likewise in intoxication with
venoms, alcohol, etc.
Taking up the infectious diseases of which the
pathogenic agent was known, Selano and Marchoux
had produced immunity from charbon or anthrax by
sheep's serum, and it was expected to be applicable in
the treatment of malignant pustule in man. Speaking
of the serums against cholera, the most that he said by
way of encouragement for this form of treatment was
that it could be tried in man.
The serum of rabbits vaccinated against the pneu-
mococcus had been tried by various physicians in
thirty-nine cases of pneumonia in man, with encourag-
ing results. Roger thought meningitis of i)neumo-
coccic origin deserved a trial of this method.
Regarding the streptococcus, in 1895 Marniorek
succeeded in preparing a serum by means of cultures
of incredible virulence; a rabbit succumbed to a dose
of one-ten-millionth part of a cubic centimetre. He
easily immunized animals and obtained a most active
antistreptococcus serum. Antistreptococcic serum
was first applied to the treatment of erysipelas
by Roger in 1895. Since then many trials had been
made, but the results given had been so diverse that
a definite opinion could not yet be formulated; still
one could say that antistreptococcus serum was a use-
ful adjuvant in the treatment of puerperal fever and
grave erysipelas. The diverse results might depend
upon mixed infection, and perhaps upon different va-
rieties of the streptococci being unequally sensitive to
the serum.
Experiments of all sorts had been made with regard
to tuberculosis. I'he researches of Maragliano were
very encouraging. The serum which he had prepared
was bactericidal and antitoxic, curing tuberculous ani-
mals in the proportion of 16.26 per 100, and causing
amelioration in 48.05 per 100. In man the serum
rendered the tuberculous patient insusceptible to the
action of large doses of tuberculin.
The treatment of variola with the serum produced
by Beclere, Chambon, and B(fnard, used in large
doses, deserved trial. The serum therapy of several
other diseases was mentioned, but that of diphtheria
and tetanus was left for other authors, .\mong intoxi-
cants, Phisalix and Contejean had shown that curare
was dejjrived of its effects by the blood of the terres-
trial salamander, which was almost insusceptible to
this toxic agent.
In brief, vaccination by the serums possessed the
advantage of vaccination by attenuation of microbes
or their soluble products, in that its action was imme-
diate. Being preventive, it could be used for prophy-
laxis, but the immnnily which it produced was only
passing.
Accidents of Orrhotherapy These were: abscess
(from want of antisepsis), exanthems and passing ar-
thropathies, fever, polyuria. The author thought ne-
phritis could not be attributed to the serum, for it was
not produced in experiments. Regarding death, it
was possible that, like other therapeutic agents, se-
rums might prove fatal under special conditions of
susceptibility.
Speaking of the mode of action of the serums, the
author thought serum-therapy was only a variety of an-
J
September 19, 1896]
MEDICAL RECORD.
421
tidotiil medication. W'iiL-n it concerned an antibac-
leric serum, tliere was introduced into the organism
a specific antiseptic whicli influenced imfavorablv the
growth or function of the microbe. When it concerned
an antitoxic serum, a substance was introduced which
produced its effects upon the cells, augmenting their
resistance or hindering their impregnation, \^'ere we
to believe that serum therapy was to become a panacea ?
jVot at all. Diseased man was not comparable to an
inoculated animal. .\ series of influences of diverse
nature intervened in the evolution of the malady, the
auto-intoxications, for example, and sometimes the em-
ployment of an artificial physiological serum might be
indicated concurrently with a specific antitoxic serum.
The Application of the Serums to the Treatment
of Diphtheria and Tetanus In a paper on this sub-
ject, J)r. Hatshai.ter said the action of normal horse
serum was only slightly toxic compared with other
serums. But the injection of therapeutic doses of an-
titoxic serum in healthy rabbits was far from being
innoxious, producing, according to Kossoroff, hypera;-
mia of the liver and kidneys, parenchymatous degen-
eration, etc.
Mode of action: .\11 serums (normal, antitoxic, or
artificial) possessed in virtue of their salts power to
influence dialysis by modifying the constitution of the
plasma; of acting dynamically upon the nervous sys-
tem, favoring the development of local lesions; of fix-
ing in part the bacterial secretions; of exciting and
stimulating the phagocytes. Aside from these common
properties, serums possessed toxic properties due to
the albumins and ferments which they contained.
The serums of the immunized also had germicidal and
antitoxic properties, for the most part specific (Char-
rin and Desgrez).
Mortality: Collective statistics showed that since
the introduction of serum therapy there had been a
general diminution of mortality in diphtheria, croup
had become less frequent, recovery after tracheotomy
and intubation had been much more frequent.
As to tetanus, the work of Roux and Vaillard had
shown that serum could be preventive, but that it pos-
sessed no therapeutic property in cases of confirmed
tetanus.
Mechanism of Immunity in the Rabbit against
the Pneumococcus, and the Action of Antipneumo-
coccic Serum of the Horse upon the Rabbit. — Dr.
Dexvs, of Louvain, concluded from experiments on
rabbits made in his laboratory by Mennes, that the
immunity against the pneumococcus in rabbits was
identical, in the action of the serum upon the leuco-
cytes, with that observed in the same animal for the
streptococcus, for the bacillus of diphtheria, and for the
colon bacillus. In the course of four months, Mennes
had produced a serum by hypervaccination of the
horse which gave most excellent results when injected
into rabbits experimented upon with the pneumococ-
cus. The serum had a preventive and a curative ac-
tion, and also the property of neutralizing the toxin
produced by the pneumococcus. The opportunity liad
not yet presented itself for trying it upon man.
Dr. Rondot, in using Marmorek's serum for ery-
sipelas, had observed rapid improvement of the gene-
ral condition, with fall of the fever and diminution in
the gravity and duration of the disease.
Immunizing Power of Normal Horse Serum
against Diphtheria. — Dr. Ferk, of Bordeaux, had
found that normal horse serum injected into guinea-
pigs in some cases produced no immunizing effects
against diphtheria, in others slight effects, and in others
again marked effects. This would explain certain
favorable results in the treatment of diphtheria in man
■with normal horse serum.
Contribution to the Experimental Study of Post-
Orrhotherapic Accidents. — Drs. liKci.KRK, ('ha\u:i>s.
and Menard in some experiments injected the normal
serum of the horse into heifers, with the result of pro-
ducing fever and polymorphous eruptions simulating
urticaria and rubeola, and e\en arthropathies — acci-
dents similar to those frequently seen in man during
serum therapy. On the other hand, heifers injected
with serum of the same species and with that of the
ass showed no such lesions. In the first-named ex-
periments no microbe was found in the heifers to ac-
count for the symptoms, which it was concluded were
of toxic origin. The authors concluded that the acci-
dents attending the use of horse serum in man as well
as in animals are not due to anything pertaining to
the antitoxin, for which property it is administered, but
to the serum itself, which serves as a vehicle.
A. Trelle had not succeeded in some attempts at
treating quartan ague with serum therapy — serum of
Roux.
Significance of Phenomena Consecutive to Injec-
tions of Antidiphtheritic Serum.— Bose, of Mont-
pellier, in this paper considered the value or signifi-
cance of fever, circulatory disturbances, and albumi-
nuria, after injecting antidiphtheritic serum. These
were normal reactions to the injection of sodium
chloride and certain other agents in healthy animals,
and in disease might, according to their characteristics,
be beneficial. The same could be said of injection of
antidiphtheritic serum — according to the character-
istics of the reactions named might they be inferred
to be beneficial or injurious in the case under treat-
ment.
Serum Diagnosis of Typhoid Fever. — Dr. F.
W'iDAL gave his further experience in the diagnosis of
typhoid by the action of the serum of the individual
(sick or convalescent) upon cultures of Eberth's bacil-
lus. His study, pertaining to the serum of nearly a
hundred persons, enabled him to affirm that the serum
of typhoid patients, like tJiat of patients convalescent
from the disease, amas.sed the bacilli of F^berth sus-
pended in bouillon, and agglutinated them in masses
visible under the microscope. This action was so
powerful that it could be observed in certain cases in
which the mixture was in the proportion of one of the
serum to sixty of the bouillon. The serum of persons
never having had typhoid possessed no such aggluti-
nating influence upon the bacilli of Eberth. ( )thers
had confirmed these observations. In actual stud}- the
proportion used should be one of serum to ten of
bouillon culture, and the more recent the latter the
better, although an older culture could be rejuvenated
for the purpose. The agglutinative influence was
manifest not only during convalescence, but also dur-
ing the typhoidal attack. It was, therefore, of value
in differential diagnosis. In twelve persons who had
had typhoid fever from a year to nineteen years pre-
\iously, it was manifest in only two, and of these one
had had typhoid three years before, one seven years
before. The phenomenon, therefore, seldom showed
itself longer than a year after recovery. It could be
relied upon in diagnosis by the sixth or seventh day
of typhoid. The serum in producing the phenomenon
did not sterilize the culture.
Dr. Vedel, of Montpellier, insisted upon similar
agglutinating property for the serum of persons af-
fected with coli-bacillary iiifections when introduced
in cultures of P'.bertli bacilli.
Thyroid Medication. — Dr. Bourxeville gave re-
cent results with thyroid medication. F'our patients
with myxccdema, two of whom he had presented before,
liad continued to advance intellectually under the treat-
ment, and the other two had increased in size, particu-
larly in height. The oldest was fifteen years of age.
The treatment had also been efficacious in four cases
of obesity in patients under fifteen years and had
caused slight growth in four cases of retarded develop-
422
MEDICAL RECORD.
[September 19, 1896
ment in patients from eighteen to twenty-five years of
age. For the most part he used the fresh gland, giv-
ing half a lobe every second or every day.
Pathogenesis of intravascular Blood Coagulation.
— Dr. Mavf:t read a paper in which he discussed the
following conditions: i, coagulation produced by vas-
cular changes from causes outside the vein (contu-
sions, etc.) ; 2, coagulations caused primarily by path-
ological changes within the vein (aneurism, etc.) ; 3,
coagulations from modifications of the blood acting
upon the nutrition of the walls of the vessels (chlo-
rosis) ; 4, coagulation from blood changes aided by
local circulator)' trouble; 5, infectious coagulation
(puerperal fever, etc.).
Pathogenesis of Intravenous Coagulation.— M.\r-
RKi. in a paper on this subject drew certain conclusions,
two of which were : ( i ) in most cases the thrombi were
at their commencement leucocytic; (2) thrombi may
be fibrinous or non-fibrinous, the former usually being
of microbic origin.
Drs. Sabrazes and Mongour had found along the
thrombic veins in phlegmasia alba dolens of cancerous
and tuberculous patients chains of glands, which
pointed to an infectious origin of the phlebitis. In
some the tubercle bacillus was found.
Dr. Widal then reported a case of slow oblitera-
tion of the right primar)' iliac vein, the process e.\-
tending over years.
Infection and Symmetry : Pathogenesis of Bilat-
eral Lesions.— Dr. Charrix said that as to nephritis
occurring during the course of infection, it was sym-
metry of function which caused symmetry of lesion.
Certain viruses produced microbic infarctions on the
right as well as on the left side, the calibre of the ob-
literated capillaries being previously diminished by
paralysis of the vasodilators through action of the
toxins upon the ner%-ous centres. The action upon
the centres — vasoconstrictor for the microbe of blue
pus, vasodilator for others — was capable of modify-
ing homologous areas, as in the members, and in those
homologous areas symmetrical infection might take
place through germs of the skin or those carried by
the circulation. A lesion primarily local might sec-
ondarily become bilateral by analogous process. The
inrtuence of the nervous system was shown in paraly-
sis, in which bilateral vaccination produced a greater
lesion on the paralvzed side.
Difference in Virulence of the Tubercle Bacilli.
— Dr. Louis Dubois said that grave general tubercu-
losis always corresponded to e.xtremely virulent bacilli.
Orrhotherapy in Diphtheria at Marseilles.— Dr.
d'-Astkos, between January i, 1S95, ;ind July i, 1896,
had found diphtheria in six hundred and si.xty-eight
cases out of one thousand and sixty-four f^acteriologi-
cal examinations, three hundred and ninety-nine not
associated with other bacilli. The total mortality of
cases treated with serum was 17.7 per cent.
Orrhotherapy in Variola. — Dr. A. HficLfcRE had
used the serum of the vaccinated heifer again.st variola
in two infants, both of which recovered. A large
quantity of serum, the twentieth part of the infant's
weight, was introduced under the skin. Sometimes
an eruption occurred six or ten days after the injec-
tion, but he regarded the treatment as inoffensive and
rational. The serum of the heifer was better sup-
ported by the human organism than the serum of the
horse.
Drs. Boureau and Chaumier reported some studies
upon the microbes of vaccin, and Saint Yves-M£nard
stated that he had some very old vaccin which was at
the disposition of the members, which had been shown
to be sterile to culture, yet it retained perfectly its
virulence.
Rheumatic Phlebitis with Autopsy. — Drs. Widal
and Sicard reported the case, that of a woman, aged
twenty-eight, who had once before had polyarticular
rheumatism. On the present occasion the rheumatism
involved the four limbs, had lasted ten days, was im-
proving under hospital treatment, when plilebitis de-
veloped in the arm. The heart became arythmic and
death took place in asphyxia ten days after the occur-
rence of the ctdema due to the phlebitis. The lesion
localized in the axilla presented nothing histologically
except the changes of phlebitis. Bacteriological study
showed absence of secondary infection. The phle-
bitis could only be attributed to the rheumatism in
this instance. There was endocarditis. The authors
stated that only sixteen cases of rheumatic phlebitis
had been authenticated; in only two had autopsy been
made, in only one with both histological and bacterio-
logical study.
Dr. G. f.riENNE reported a case of death during the "
course of typhoid fever in a man aged eighteen, in
which autopsy showed thrombosis of the large coro-
nary vein, histological study leaving no doubt as to
the nature of the lesion.
Thrombosis of the Inferior Vena Cava. — Drs.
Hauhhai/ikk and Ktienxe reported three cases of
thrombosis of the inferior vena cava producing only
slight symptoms. The explanation was, as proven by
autopsy, that the peripheral veins remained free to
carrj- the blood back to the general circulation. In
cases in which the peripheral veins are involved one
sees cedema, and involvement of the small veins of
the nerves causes pain, the case then showing the
syndrome phlegmasia alba dolens. These three pa-
tients were tuberculous, a condition which sometimes
led to phlebitis and venous coagulation by proximity
of infected and enlarged glands.
A Case of Endarteritis Obliterans. — Dr. A. Hey-
DENREicH descril^ed a case of obliterating endarteritis
which first involved the toes, then the fingers, causing
the nails to fall, producing pain, dry and humid gan-
grene, disappearance of the pulse. The disease con-
tinued to extend for five years and a half, involving
the femorals, etc., and finally proving fatal by occlu-
sion of tlie coronary arteries.
Meningism and Mental Confusion. — Drs. J. 86-
oi.as and K. DvvKi. made such a classification of cases
of mental confusion frequently seen in infections, in-
toxication.s, etc., presenting some of the symptoms of
meningitis, but without the lesions of this disease.
Trophic Changes in the Teeth in Hysterical
Subjects. — Dr. Faui. Sollier reported two ca.ses of
trophic changes in the teeth with rapid erosion and
pain, in hysterical persons.
Hysterical Hemiplegia and Mutism. — Dr. Fer-
rier related the case, which occurred in a soldier, and
stated that it was not exceptional for hysteria, like
other hereditary taints, to manifest itself in young sol-
diers subjected to change of habit, to fatigue, and to
homesickness. In the present case the man had served
two years and a half.
Changes in the Cord and Nerve Roots in Ty-
phoid Fever. — Dr. A'oikot, of Nancy, had examined
the spinal cord and roots of the nerves in ten cases of
typhoid fever, and in all had found pathological
changes in the myelin, in the axis cylinder, and in
the nerve cells, but never in the connective tissue,
neuroglia, nor blood-vessels.
Antistaphylococcic Immunization and Orrhother-
apy Dr. C'Ar-MAX, of Montpellier, gave an account
of his experiments in this direction on dogs, rabbits,
and other animals. He had been only moderately
successful.
Addison's Disease with Congenital Abscence of
the Suprarenal Capsules.— Dr. .\. Rispai, reported
a case of .\ddison's disease in which autopsy revealed
congenital absence of the suprarenal capsules. No
other lesions were found. Only two similar cases had
September 19, 1896]
MEDICAL RECORD.
425
been reported. The patient was twenty-four years of
age, tlie symptoms of Addison's disease — melano-
derma, pains, wasting, cachexia, progressive asthenia,
gastro-intestinal disturbance — proved fatal in ten
months.
Nail Favus. — Ro.se and G.al.a.vielle reported some
studies of trichophitic onychomycosis, which led S.a-
BR.AZES to say that he was first to demonstrate by cul-
tures and inoculation the causal diagnosis of the afifec-
tion. In two cases of favus of the nails he had made
cultures which, when inoculated into mice, caused
death.
Diagnostic Value of the Cerebro-Spinal Fluid. —
Dr. G. Deniges and J. S.aer.azes, of Bordeaux. Out
of fourteen cases of lumbar puncture the result was
positive in eight. Of the eight cases six were acute
tuberculous meningitis, one epilepsy, one hydrophobia.
The fluid was never clear, sometimes bloody in men-
ingitis, while in other cases, as hydrophobia, it might
come out clear. Three times in tuberculosis Koch's
bacillus was very numerous in the fluid. In the case
of hydrophobia the fluid injected under the dura mater
of the dog caused violent rabies after two months.
Chemically the fluids differed in the several cases,
and the authors thought further study might result in
the discovery of a formula corresponding to each type
of meningeal infection.
Thjn'oid Treatment of Myxoedema. — Dr. Simox
presented a child, aged five years, with congenital
myxcedema, which had increased perceptibly in height
and shown general improvement during two months'
thvroid medication.
Auscultatory Sounds in Pleurisy. — Dr. Her-
vouEX expressed the view in this paper that the pleu-
ritic soufilie and egophony informed us of the state of
the lung, not of the pleura and pleuritic effusion. If
compression of the lung by fluid were the cause, these
sounds should always be present in pleuritic effu-
sion, but they were not.
Simulation of Pulmonary Tuberculosis by Cer-
tain Acute Bronchial Infections. — Dr. E. Cass.aet
emphasized the importance of bacteriological control
to clinical diagnosis of acute affections of the bronchi
and lungs.
The Pathology and Clinical Varieties of Palu-
dal Ascites. — Dr. H. de Brun, of Beyroot, read a
paper with this title, in which he held that paludal or
malarial ascites was seen under two very different
conditions, namely, with and without other collections
of fluid or oedema. Usually there was more or less
general anasarca. It was to the rare form that he di-
rected attention. Pathologically there were three sets
of cases: i, with paludal atrophy of the liver, of which
he cited two cases; 2, with perisplenitis and great
pain in the hypertrophied organ; 3, with peritoneal
congestion analogous to pulmonary, renal, and splenic
congestion preceding paludal sclerosis.
Phosphatic Calculus in the Stomach. — Dr. Gar-
NiER presented a voluminous phosphatic calculus
found in the stomach — entirely too large to have
passed up from the intestine through the pylorus.
Ovarian Medication. — Drs. Spill.man and G. £ti-
EXNE had employed ovarian medication in six cases
of chlorosis. With the first do.se all the patients had
marked abdominal pain, headache, vague muscular
pains; two had some elevation of the temperature.
Three of the patients soon showed marked improve-
ment, and in two the suppressed menses returned. The
authors thought the treatment favored elimination of
toxins, and in introducing an antitoxic principle seemed
to act favorably on the general health, to increase the
number of blood globules, and to re-establish men-
struation.
Treatment of Diabetic Arthritism by Dosage of
Alimentation. — Dr. K. MAikEi. had treated sixteen
diabetics with arthritic manifestations by food dosage,
ten cases resulting in recovery, the other six in marked
improvement. The treatment was equallv important
in other forms of joint affection.
Dr. MiissE gave experience with the administration
of antipyrin, pancreas extract, etc., in diabetes, which
was not very satisfctor}-. He had found a regulation
of the diet the most important part of treatment.
Upon a Tremor Combined with the Cheyne-
Stokes Respiratory Rhythm.— Dr. Pic, of Lyons, re-
ported a case of uramia which had enabled him to
study the pathogenesis of periodic respiration, going
to confirm the view of Pachon, that the cerebral cortex
participated in the production of the Cheyne-Stokes
phenomenon.
The Prognosis of the Albuminurias. — This sub-
ject was treated of in two reports, one made by Dr.
X. Arnoz.\n, the other by Dr. Ch. T.alamon, followed
by a discussion participated in by Drs. Teissier, Bard,
Crocq, Maurel, Garxier, Schmidt, Linossier, and
others. Dr. Talamon, as reporter, stated that the
elements of prognosis in albuminuria should be looked
for in (i) the character of the albuminuria itself: I 2) the
composition of the urinary medium: (3) the etiological
or pathogenic conditions of the albuminuria: (4) the
special and general condition of the patient: (5) the
conditions associated with the renal lesion. He con-
sidered these five divisions separately.
Dr. Lixossier said with regard to the character of
the precipitate by the cold nitric-acid test that usually
slow formation of the ring, its lesser opacitv, its greater
diffusion, its formation in the upper part of the fluid,
were signs of a favorable prognosis.
Treatment of Rheumatism by Applications of
Methyl Salicylate. — Drs. Laxxois and Lixossier
had employed methyl salicylate locally in the differ-
ent forms of rheumatism and in various painful peri-
pheral affections, such as neuralgias, etc. In these
various affections they had found the action beneficial
in varying degree according to the case and condition.
In rheumatism it was as useful, often more useful, than
when taken internally, and avoided disturbance of the
stomach. In the acute attack the pain might prevent
rubbing it in and make oral administration necessarv.
The Anatomical and Clinical Significance of
Polyvisceral Interstitial Inflammations Dr. Bard
read a paper on this subject. He said that the pres-
ence of scleroses in conjunction with the cardiopa-
thies presumed inflammations, subacute and intersti-
tial. In cardiac cedema with chronic thickening the
condition was one of interstitial demiatitis. These
were local inflammations, and not stases which gave
rise to scleroses. Ischa;mic atrophies differed from
scleroses connected with arteritis of inflammatory na-
ture. Aside from the lesions of arterial origin, there
were scleroses due to inflammations primarily affect-
ing the interstitial tissue. These inflammations were
polyvisceral, and the symptoms depended upon the
lesions themselves, their association, and the organs
affected. Briefly, inflammations were necessarv- to
produce true interstitial scleroses which increased the
weight of the organs: these inflammations were not
always of arterial origin, but often were primarily in-
terstitial.
Application of the Roentgen Rays to the Medi-
cal Sciences. — Drs. Barfhelemy and Oudix first gave
an historical review and presented photographs of
their own work, showing the progress made during
the few months since Roentgen's discovery. Much
depended upon the details of technique. For instance,
Thompson's tube was better adapted to deeply seated
organs in the adult, while Collardeau's gave remark-
able results in fineness of details for the adult extrem-
ities and bodies of infants. The time required had
been so reduced that the method was applicable even
424
MEDICAL RECORD.
[September 19, 1S96
to infants and others who could not remain long im-
mobile. Their first photographs showed only the
bony skeleton, while later ones showed also muscle-
bundles, their tendinous insertion, and the nails witli
the bones back of them.
Dr. Vedel showed an .v-ray photograph which
had enabled him to differentiate between pseudo-
osteo-arthropathy and true osteo-arthropathy, the case
illustrating the former condition.
Treatment of Affections of the Respiratory Pas-
sages by Warm Baths — Dr. Le.moixe had treated
and cured sixty cases of affections of the respiratory
passages, such as inflammations of the tubes and
lungs, etc., with baths of temperature of 37.5'' C.
Cold baths should not be used in these cases, however
effectual they might be in typhoid. Spillmann, Bard,
and Cassaet, on the other hand, had found the cold
bath sometimes useful, especially the first two or three
days of acute inflammation.
A Case of Labio-Glosso-Laryngeal Paralysis of
Cerebral Origin. — Dks. Picut and Hcikbs, of Kor-
deau-x, gave the history and autopsy in the case of a
man, aged si.\ty-si-\, who had had several apoplectic
strokes, and three months before admission to the hos-
pital was taken suddenly with paralysis affecting the
lips, tongue, pharynx, and larynx. The velum palati
and muscles of mastication were not involved. The
sudden and simultaneous occurrence of the paralytic
symptoms led to the diagnosis of labio-glosso-lar}-n-
geal paralysis of cerebral, not bulbar, origin. The
man died eight months after the accident, without no-
ticeable progress or change in the paralysis. The au-
topsy confirmed the diagnosis of cerebral origin of the
trouble, the bulbar origin of the cranial nerves being
intact, while there were a number of small old hemor-
rhagic foci in the anterior and middle hemispheres,
two of which had probably been the cause of the labio-
glosso-laryngeal paralysis, one having destroyed on
the right a part of the caudate nucleus and avant-mur,
and in addition a small focus in the middle of the an-
terior portion of the centrum ovale on the left side.
Angina Pectoris of Bright's. — Dr. Rondot treated
angina pectoris of Bright's di.sease by regulating uri-
nary insufficiencv.
Clinical Value of Hyperacidity of the Stomach.
— Dr. Hervoukt read this paper. He said that
there might be a great excess of hydrochloric acid in
persons not even dyspeptic. Treatment by dilute hy-
drochloric acid was equally efficacious in such cases
and in cases of deficiency of hydrochloric acid, and
did not aggravate the symptoms of the former.
Drs. Auch(^; and Carriere read a contribution to
the study of the histology of hemorrhagic effusions of
the pleura. The findings differed greatly in the dif-
ferent cases.
Urology in Typhus. -Dr. Spill.m.\.\, of Nancy,
found in the urine in typhus albuminuria constantly,
urobilinuria frequently, uric acid increased, duerin
had isolated from this urine a toxalbumin which caused
diarrhtta and dyspnaa in rabbits, but not death. The
urinarv toxicity was diMiinished.
Duodenal Stenosis Simulating Pyloric Stenosis. —
Dr. Pic, of Lyons, related a case in which the symp-
toms and physical signs pointed to a hepatic colic and
stenosis of the pylorus from adhesion connected with
the gall bladder, the seat of stone. Laparotomy was
performed and the diagnosis of the band was con-
finned, but its nature remained undetermined. Gas-
tro-enierostomy was made. Autopsy showed neoplasm
of the bladder and a peritoneal band con.stricting the
duodenum at its upper portion. The clinical picture
had been one of true pyloric stenosis.
Hystero-Paludism.— Dr. DtcAMP related a case of
malaria in which the tremor of the chills was exagger-
ated and modified by the hysterical tendency of the
patient, this hysterical attack having been excited by
the malaria.
A Case of Syphilitic Reinfection. — Dr. Fourrier
related a case of syphilis occurring the second time
fifteen years after the first attack.
Dr. B.^rthelemy remarked that Fourrier had not
proven his case by inoculation of the chancre. Syph-
ilitic reinoculation seemed not to be admitted in
France; in all instances one had to do only with
syphiloid or tertiary affections.
The Malarial Spleen. — Dr. Ferrier gave the an-
atomical findings in some malarial spleens which he
had had occasion to study. They related chiefly to
(in two cases) the extreme abundance of small round
cells, giving the cut somewiiat an embryonic appear-
ance; also to the abundance of dark pigment.
Post-Anaesthetic Paralysis. — Dr. N'At trix reported
three cases of paralysis following anasthesia, seen by
himself. One involved the deltoid, biceps, and bra-
chialis anticus on the right side, and gradual im-
provement had taken place during the six years of its
existence, .\nother was of the deltoid and long supi-
nator on the right; the third was facial. In the last
two the paralysis soon disappeared entirely. The an-
aesthetic used was chloroform, but the accident might
follow other anaesthetics. It might be peripheral or
central; in the latter hemorrhagic.
The Place of Production of Uric Acid Dr. K.
Laval cited the theories v, hich liad been offered as
to the place of origin of uric acid in the system; one
had said that it was formed in the liver, another in the
spleen, a third in the blood, and finally in what one
might call the leucocytic system. All these theories
were correct, for uric acid was formed in the liver as
well as in the kidneys, in the spleen as well as in other
organs, wherever white blood cells were to be found.
Lesions of Intestinal Strangulation and Engorge-
ment ; Passage of Microbes through the Walls. —
Hd.se and Blanc gave results of clinical and experi-
mental study of this subject. .After staling the gross
and microscopical appearances, they called attention
to the close relation existing between the necrosis and
hemorrhagia; hence the clinical importance of the
subperitoneal ecchymosis. The transverse muscular
fibres represented the most resisting part of the intes-
tinal walls, to the importance of which fact the au-
thors called attention. The rapid necrosis and hem-
orrhagia were explained in part by the action of the
colon bacilli and their toxins; we knew their power
to produce dilatation of the vessels, hemorrhage, and
degeneration. As long as the lesions were light,
without desquamation of the epithelium, no micro-
organism was found either in the walls or on the peri-
toneum. When the lesions were more marked, micro-
organisms were found in the mucous, submucous, and
deeper tissues, on the peritoneum, and in small num-
bers in the vessels. The colon bacillus more espe-
cially was present, and combined hemorrhagia :.nd
necrosis made of the mucous and submucous tissue a
\eritable bouillon culture.
Multiple Neuritis Engrafted upon a Nervous
Diathesis. — Hlr.nhelm related some experience in
which multiple neuritis developed in persons of ner-
vous diathesis. In the case of a young lady in love
with a man whose father withheld consent to marriage,
he was able to cure the hysterical element by hypnotic
suggestion, whereas this had no effect upon the para-
lytic and other symptoms of multiple neuritis.
The Melbourne Hospital has two ladies on its house
staff, Drs. .\lfrida Hilda Gamble and Janet Lindsay
Greig, who won their appointment by ranking among
the highest six graduates in the final honor list of
Melbourne L'niversitv .Medical School.
i
September 19. 1S96]
MEDICAL RECORD.
425
(Clinical 3cpavtmcnt.
TREATMENT OF OLD DISLOCATIONS OF
THE ELEOW.
Ky W.
WELSH, M.I).
BA7I.EV, MO.
In districts where tlie practice of medicine and sur
jiery is regulated by laws rigidly enforced, old dislo-
cations are e.xtremely uncommon, but in districts
where quacks and uneducated men do much practice
such cases are common. We know how difficult it is
to reduce dislocation of the elbow, even under anes-
thesia when a few hours have elapsed since the acci-
dent. When a week or two or a month has passed
and the dislocation remains unreduced, it is exceed-
ingly difficult, and when several months have elapsed
without correction of the deformity it is almost im-
possible in most cases, and it may be dangerous to
use much force.
The dangers of using much force are patent to all.
and if the pulleys be employed, tlie surgeon is liable
to use more force tlian is justifiable before he realizes
it, and he may suddenly do irreparable damage, even
when he thinks he has employed but little force. In
old cases in which the radius and ulna are dislocated
backward the surgeon may have force applied, and
in a right direction. He may skilfully use every pos-
sible manipulative effort. He may think he has nearly
accomplished his object and that just in one moment
more all will be right, but the more power he uses in a
right direction, the more plainly and beautifully ag-
gravating does the tendon of the triceps stand out.
showing that the object cannot be accomplished in
this way. In such cases it is rash to use much
force. It is plain to be seen that the olecranon
is the offending member. Excellent writers on the
subject have advised subcutaneous section of the
tendon of the triceps. This, however, ^ a danger-
ous proceeding and may be disappointing. No
knowledge of anatomy that the surgeon may possess
can make the operation a safe one. Any one who has
seen the inside of such a joint and surrounding tis-
sues, and noted the number and strangely diverse ad-
hesions and changes in the parts, may well shudder at
the possibilities of doing such work in tlie dark. It
has long seemed to me that the better plan is to cut
into the joint, sever the tendon of the triceps, remove
the olecranon, dissect them both out, and then by
proper and careful manipulation to bring the radius
and ulna forward into their proper places and retain
them there with the view of establishing ankylosis.
I have had an opportunity of seeing this carried into
effect. Miss ^I , aged sixteen years, had been
thrown from a horse: the radius and ulna of the left
arm were dislocated backward. The accident had oc-
curred six months before she was seen by the members
of the Crocker District Medical .Society. The lower
end of the humerus could be seen in front of the ulna
and radius ; the arm was stiff and useless, was straight,
could not be fie.xed one particle, and was only in the
wa\'. As she was an orphan the society agreed to take
her under its protection and see what could be
done. The pulleys were first thoroughly and skilfully
applied, but all efforts failed. Subcutaneous section
was considered dangerous. Three or four of the
members agreed to cut down on the tendon of the
triceps and olecranon and remove them. Under anaes-
thesia every ju.stifiable effort was again made with
pulleys and manipulation, without avail. The joint was
cut into and the olecranon and tendon of the triceps
were removed, thorough antiseptic precautions being
obser\-ed. The radius and ulna were brought forward
and the bones set at right angles to the humerus. The
following day the patient was found to be doing well.
The arm was put up in plaster-of-Paris dressing. The
case progressed nicely. The operation was done
March, 1893. I saw the patient the following Au-
gust. She was working at her vocation of housekeep-
ing; could wash, iron, and do all kinds of housework:
could put her hand on top of her head ; could fasten
pins and buttons with it. In short, the arm was ap-
parently as useful a member as could be desired. As
none of the members of the society- had ever seen the
operation before, it was practically an experiment
which resulted in a brilliant success. No one who
has not seen a straight stiff' arm from such a cause can
appreciate the deformity and unpleasantness resulting
from such a misfortune. The limb is useless and only
in the way, and the patient is rendered miserable. If
the deformity cannot be remedied, the patient would
be better off with the limb removed.
In drawing the radius and ulna forward into their
proper places, one thing should be foremost in the
mind of the surgeon, and that is to draw the bones
fully forward and upward into their old relations.
The radius should be brought well up past the lower
end of the humerus and the ulna well up in front.
The joint should be set at a slightly acute angle and
the limb put up in a plaster-of-Paris dressing. The
limb should be kept in permanent dressing until firm
adhesions have taken place. If the radius and ulna
have been well drawn up in front of the condyles of
the humerus and retained there for a long time, the
adhesions that take place will go far toward replacing
the support which the tendon of the triceps fonnerly
gave.
Intractable ankylosis need not be feared, as time
and use will largely restore the functions of the limb,
including the rotary movement of the forearm. The
joint will be strong and will regain most of its former
functions.
CONGENITAL IRREDUCIBLE UMBILICAL
HERNIA.
l!v JAMKS ll.VRVEV KAV.MtlXD, M.I).,
WAILUKl, M. I.
Ox April 3, 1896, I was called to attend a Portuguese
woman, aged thirty-two, a primipara, poorly nour-
ished, who had been delivered a few hours before my
arrival by a midwife. Nothing could be learned of
her previous history nor of her family history. The
midwife had forcibly extracted a portion of the pla-
centa, leaving the remainder in the uterus. The patient
was anaesthetized and upon careful examination a large
interstitial fibro-myoma was discovered. I carefully
curetted the uterus and flushed it out with a solution
of boric acid, and the patient was then taken to the
Malulani Hospital, where antiseptic douches were
gi\en twice daily and stimulants were regularly ad-
ministered. Recovery was uninterrupted and she was
discharged fifteen days later.
My attention was called on the day of delivery to
the peculiar condition of the child, which had a large
hard swelling in the umbilical region, covered with
the dilated parietal peritoneum, to which the cord was
attached. I incised the membrane and found the
swelling to l>e the entire liver, enlarged to such an
extent as to be absolutely irreducible.
The child died shortly after the operation. The
weight of the child was two thousand and forty -one
grams; that of the liver one hundred and thirteen
grams. The diameter of the child's thorax at the
base was nine centimetres. The transverse diameter
of the liver was six centimetres.
426
MEDICAL RECORD.
[September 19, 1896
" MALARIAL H.EMATURLA."
By LUKE FLEMING, M.D.
TABRVTOWN, N. V.
Having read in the Medical Record of August 8th
an article by Dr. Bush on " Malarial Ha;maturia, or
Hemorrhagic Fever," I am anxious to give a report of
a case which may in connection with the above article
be interesting. In July, 1895, I was called to see
Mary C , a domestic, aged forty-two, who was suf-
fering from malarial fever, in which the chief symp-
toms were a severe purpura hieniorrhagica covering
the greater surface of the body, togetiier with severe
hemorrhage from the buccal and vaginal mucous
membranes. Her family history was unreliable. Her
own history was that for three or four days previous
to my visit she had been suffering from chills, pains,
and sweats. Twenty-four hours before my visit she
had taken fifteen grains of quinine and shortly after
this the above hemorrhagic symptoms appeared.
Quinine in large doses was stopped and small doses
of Warburg's tincture with arsenic w'ere substituted.
Under this treatment she recovered after a convales-
cence of two weeks. Five months later I was again
called to see her and found her in a condition simi-
lar to that in which I found her at my first visit.
Questioning elicited the fact that she had again
attempted to ''break up" a malarial chill by quinine
and that the hemorrhage had not appeared until after
the drug had been taken. Under the previous treat-
ment she recovered. This summer I was called to
see her for the third time. Now she was suffering
from malaria but had taken no quinine. Wishing to
test the case, I prescribed quinine and the hemorrhage
appeared. I then substituted methylene blue, and she
recovered. Now, with this case in mind, I am led to
inquire whether the cases of so-called hemorrhagic
fevers of Dr. Bush may not have been pure malarial
fevers complicated by treatment.
REPORT OF A LAPARO-SPLENECTOMY.'
By B. ILVTCHETT, M.D.,
FOKT SMITH, AKK.
I REPORT the following case because of the infre-
quency of the operation of splenectomy, and hence to
some degree its general interest.
Mrs. N. E. B: , a native of Arkansas, now a citi-
zen of South Canadian, I. T., applied for treatment,
August 5, 189s, and was admitted to St. John's Hos-
pital. Her clinical history, as she told it, was that
she was thirty-five years old, married eighteen years,
and liad nine children. She had one premature birth
four years ago, from which time she dated the begin-
ning of her ill health, though she had borne one child
to full term since. She had been confined to bed with
fever and pain for four months previous to my seeing
her.
Si.x years ago she had an enlarged spleen which gave
her considerable trouble, but recovered with treatment.
Two years later, and soon after her miscarriage, she
noticed a small tumor low down in her abdomen in the
median line. It gave but little pain and grew slowly
until she was stricken down with fever, when its growth
became rapid and cau-sed much distress.
At the time of my first examination the patient was
exceedingly feeble, anremic, and nervous. Tempera-
ture 103° F. Her abdomen was considerably distended
and ])ainful to touch at all points, evidencing the ex-
istence of a diffused peritonitis.
A large, round, semi-resilient tumor prominently
' Extract from a paper, " Reports of Cases of Abdominal
Lesions," read before the Arkansas Medical Society, May i, 1896.
projected from a low position in the pelvis. Diagnosis
as to the character of tumor was doubtful, but the opin-
ion was given that it was ovarian in origin. Her condi-
tion was by no means favorable for immediate opera-
tion, and as I was on the point of leaving the city for
a vacation. Dr. L. L. Saunders kindly undertook the
task of caring for her for one month, and succeeded
in improving her general state greatly, though she still
had fever and peritonitis.
Operation, September 3, 1895. L'nder A. C. E.
mi.xture narcosis, a median incision was made below
the umbilicus, when the tumor was recognized as the
spleen. The incision was then prolonged, adhesions
w^ere broken loose, and the enlarged organ was deliv-
ered from the pelvis and lifted into the wound. The
pedicle was long and easily handled, with no loss of
blood. It was transfi.\ed with a Crawford needle, and
the two halves separately ligated with strong braided
silk; a clamp was applied at a more distal point, and
the removal completed by cutting between ligation and
clamp with strong scissors.
The stump was sterilized, found to be safe from
hemorrhage, and dropped into the abdominal cavity.
The usual laparotomy toilet was carefully made, and
the patient came out of the ordeal as well as could be
desired.
The extirpated spleen weighed six pounds. Its sur-
face was of a dark slate color, dotted over at various
points with cystic accumulations of sero-purulent
fiuid. The capsule was easily torn and showed the
pulp and trabecule of the organ to be very much dis-
organized, broken down, and presenting that condition
of degeneration which has been designated as " splenic
mud." Under the microscope this brownish-purple
substance, or " mud," was shown to be composed
largely of dark granules, granular bodies, and broken-
down extravasated blood cells.
The same material was found thickly coating the
internal walls of the large blood-vessels at the point
where they were severed in the pedicle.
The patient did as well after the operation as one
could wish after the most simple laparotomy. Her
temperature began to decline almost at once, and never
ran higher than 99 F. after the third day. Pain sub-
sided, peritonitis gave way, appetite returned, and a
general feeling of comfort was enjoyed during the days
of convalescence. The sutures in the abdominal wound
were removed on the ninth day with no sign of pus —
not even the smallest stitch-hole abscess. She walked
on the thirteenth day after the operation, and on the
eighteenth day left for home feeling quite well, with
improved complexion, appetite, digestion, etc.
On October 6th, two weeks after her discharge, I
had a letter from Mrs. B , stating that she weighed
ninety-three pounds on reaching home, and that her
weight was one hundred and three at writing. She
had had a little fever at different times, and an occa-
sional sharp pain in her abdomen.
November loth, a month later, she wrote that her
weight was one hundred and twenty-five pounds, and
complexion good; there was some pain in the lower
abdomen.
A few days ago, being nine months since the opera-
tion, I had the following letter from my patient:
"Your inquiry about my health has been received.
In reply I will state that I am in better health than I
have been for ten years, and as well as I ever was in
my life. My appetite is good and my complexion is
clear. I have no pains as a result of my former ail-
ment, and can speak only words of praise and thank-
fulness for my recovery."
I made several microscopical examinations of this
woman's blood, and found the relative proportion of
the red and white corpuscles but little if any more
disturbed than would ordinarily occur in any simple
September 19, 1896]
MEDICAL RECORD.
427
anaemic condition. Lukjemia was tlius shown to be
absent, and hence the e.xceedingly good results ob-
tained, for I believe most operations prove rapidly fatal
when the luka-mic state exists.
Unfortunately, our knowledge of the physiology of
the spleen is still left in a state of confusion, and
hence the discussion of the propriety of its removal
under various conditions is unsatisfactory. The sta-
tistics of the comparatively few operations so far re-
corded are not encouraging.
SLIGHT RESULTS OF A SEVERE INJURY.
By ROBERT H. McNAIR, M.D.,
NEW HAVEN, CONN.
ADHESIONS OF THE MENINGES FOLLOW-
ING CEREBRO-SPINAL FEVER.
Bv M.\RV JORDAN FIXLEY, M.D.,
MANSFIELD, O.
Dr. J. Lewis Smith says in his article on cerebro-
spinal fever in " Cyclopedia of Diseases of Children :"
"" No post-mortem examinations, so far as I am aware,
have yet revealed the state of the brain and its me-
ninges in those who have had this malady at some
former time and recovered ; whether there may not be
some traces of it that are permanent, as opacity or ad-
hesions."
The following notes of a case occurring twelve years
ago and of autopsy made after death from suicide a fevi'
weeks since may be of value. I regret that they are
not more full.
On March 17. 18S4, I was called to see Thomas
J. Kellar, aged thirty-eight years, suffering from a well-
marked- attack of cerebro-spinal fever, which was at
that time rather prevalent here, as it has been twice
since, once in 1889 and at the present time.
There were intense pain in the head, nausea, and
vomiting; temperature was 102 F. The face was
flushed and the eyes were injected; there was great
restlessness. On the second day there was less pain
and less fever, and the general condition seemed much
better. The third day brought an exacerbation of all
the symptoms: temperature, 103' F. ; extreme restless-
ness, slight delirium, head retracted, legs drawn up but
contraction not marked. There was a sparse eruption
on the face and trunk resembling roseola.
On the fourth day temperature was lower; restless-
ness and delirium had given place to a stupor, from
which the patient could be easily aroused, when he
complained of pain in legs and general hyperes-
thesia.
Improvement continued until the sixth day, when
pain in the head was again very severe.
After this improvement was steady, and by the end
of the second week convalescence was well established
and my visits ceased. The case went on to an appar-
ently complete recovery, leaving neither mental nor
physical change.
The man was lazy, worthless, and a periodic drinker
after his illness, as he had been before it, and man-
aged to live on his pension and his wits, just as before.
The pension had been granted for a crippled hand.
In the last year he had had fits of depression after
his sprees, and in one of these, on the 28th of April,
he shot himself through the head. The following de-
scription of the brain and meninges is taken from the
report of the autopsy by iJrs. John E. Speer and John
Stevens: "The membranes were adherent to the brain
along the crest of both hemispheres for a space half an
inch wide and between three and four inches long.
On these spots the dura mater, arachnoid, pia mater,
and brain were closely connected with old white
cicatricial tissue, which had to be cut way with the
knife. There was some opacity of the arachnoid in
the region near to the adhesions. There was no evi-
dence of recent inflammatory action."
I WAS called on March 25th to attend a case of ap-
parently serious and extensive injury to the testes.
The patient, J. G , aged fifty-two, while using a
piece of lead pipe as a lever and standing astride of
the same, was thrown with considerable violence into
the air by the end of the pipe, which in making its
ascent punctured the scrotum midway between the ex-
tremities of the testes, making a laceration tw-o inches
in length, and, passing straight upward, wounded the
tunica vaginalis testis by an opening large enough to
admit the end of the examining finger. There were
necessarily contusion to the surrounding parts and pro-
fuse hemorrhage, and after a careful examination I
thought that I should find at the next visit a scrotum
about half the size of the patient's head. After con-
trolling hemorrhage and thoroughly cleansing anti-
septically, I closed the lacerations and ordered cold
compresses, to be applied at frequent intervals for
twenty-four hours. There was no shock and but com-
paratively little pain.
Upon visiting the patient the following morning I
was surprised to find ven,- slight swelling and no more
inrtammatory action than necessary for the repair of
an injury of less consequence. There w-as no dis-
comfort except soreness at the scrotal wound. The
patient insisted upon resuming his duties on the fourth
day after receiving the injury, and with the suppcirt of
a suspensory bandage he returned to his engine on a
New Vork express train, which necessarily kept him
on his feet most of the day. He was not incon-
venienced any more than would have resulted from a
simple incised wound on a less delicate part. Hence
the reminder again of what Dame Nature is capable of
doing in her workshop, regardless of surgical inter-
ference.
STRYCHNINE IN UTERINE INERTIA.
By F. E. BEAL, M.D.,
PAPILLION, NEB.
Mr.s. L. M , aged thirty-seven, married, German,
farmer's wife. Previous history as follows : Oldest of
family of six children, all of whom are living. No
evidence of syphilitic, tuberculous, or other dyscrasiae
could be obtained by closest questioning. Since ma-
turity she has weighed about one hundred and fifty
pounds and has always been a hard worker. She was
married at the age of thirty, since which time she has
had five children at three confinements: twins at the
age of thirty-one; single at the age of thirty-three;
and again twins at the age of thirty-five. Of these
but one child was bom alive, one of the twins of the
first birth. All of these labors were characterized
by absolute inertia of the womb and excessive hemor-
rhage during the entire three stages of labor, and
even the following two and two and a half days,
necessitating the constant attention of from one to
three physicians, who had to use the most heroic
measures to keep the patient from bleeding to death.
-All of her children have had to be taken by high in-
strumental delivery, simply because of the absolute
absence of uterine contractions, and for the same
reason each placenta has had to be delivered by the
hand thrust into the uterus. Both husband and wife
being quite intelligent, they gave me a good descrip-
tion of the treatment that had been employed, and
assured me that the mother had faithfully taken ergot
both internally and subcutaneously to its fullest ex-
tent, quinine, etc., to promote labor pains, but in vain.
The bleeding, especially that post partum, could be
428
MEDICAL RECORD.
[September 19, 1896
controlled only in a degree by active and repeated ap-
plications of styptics within the womb.
On May 25th I was called seven miles into the coun-
try to attend her in her fourth confinement. I knew
nothing about the nature of the case when called,
getting the above history at the time and since. I
found the woman in a semi-faint; there was a pro-
nounced general relaxation over the entire body; the
pulse was 106 and weak; the pupils were dilated; the
lower extremities were cold and clammy. Vaginal
e.xamination disclosed a large flabby os about two-
tiiirds dilated: the position of the child was normal.
The woman had been bleeding rather profusely for two
hours, the hemorrhage having begun suddenly on the
e.xpulsion of the amniotic fluid. There was entire
absence of pain and uterine contractions, the walls of
the womb being soft and flabby, and all manipulation
seemed only to increase the flow of blood.
Being, of course, averse to using ergot before the com-
pletion of the third stage of labor, and being assured
by all present that the woman was in exactly the same
•state as she had been each time before, and that neither
ergot nor any other medicine would do her any good,
I determined to try strychnine in large doses subcuta-
neously. I immediatelv injected one-tenth grain of
strychnine sulphate into the arm and in half an hour
liie bleeding had ceased; the pulse rose to 96 and
became stronger, and the uterine pains were strong
enough to make the woman complain. Those present
asserted t'lat it was the first time she ever had a labor
pain. Four hours from the first injection I repeated
with one-twentieth grain, because the pains, while
regular, were not of suHicient force. At the end of
eiglit hours from the first injection she was delivered
of a healthy eight-pound boy, the placenta being ex-
pelled with a good hard afterpain in eight minutes
after the birth of the child. There was no post-partum
hemorrhage, the uterus contracting nicely and remain-
ing contracted. In short, it has never been my good
fortune to meet with a labor and entire puerperium
that were more entirely normal — after the first injec-
tion of strvchnine.
«uvoicat S-uijiKstions.
The Totirniquet. — When a rubber tourniquet is
applied to the thigh, care should be taken to use a
wide rubber band and not a rubber tube, since cu-
mulative pressure of the rubber tubing is sometimes
great enough to injure the ner\'e. — Dr. Wyeth, Jii-
tiiiiiitioiuil JoitriHil of Surgery.
Takers of Leg. —
U Acidi carboi ;: jiarts.
.\cidi borici 10 "
I'ulv. camphor 7J^ "
IchthTOl 20
01. andropogi nardi q.s.
L ng. zinci o.\idi q.s. ad 100
S. .\pply once a day.
— F.DLEx, iWfi' York Medical Journal .
Malignant Tumors.- Dr. Senn says the essential
features of the modern treatment of malignant tumors
maybe summed up as follows: "Operate early and
thoroughly. The treatment of unoperable sarcoma by
injections of the sterilized toxins of the strepto-
coccus of erj'sipelas and the bacillus prodigiosus has
not had the expected results."
Empyema of Antrum of Highmore. — Dr. Cobb
{Bost,>ii Mctiiiol ami Siir^h,fl Journal. May 7th) writes
that Dr. Mackenzie has suggested that the pus dis-
charge l)e examined for bacilli. This has been done,
with no important results as regards diagnosis. The
staphylococcus pyogenes aureus, albus, and citreus,
and the pneumococcus of Telamon-Fraenkel have been
found. The latter is of interest, as pneumonia has
followed antral disease.
Abscess of Ovaiy. — Dr. J. H. Etheridge {American
Journal of Mal/col Sciences, April, 1896) reports three
cases of abscess of ovary due to pneumococcus. So
far as could be ascertained, no case of ovarian abscess
produced by this microbe has been reported previously.
'• The majority of abscesses of the ovary are the work
of the staphylococcus. A few ovarian abscesses con-
tain the colon bacillus."
Continuous Submersion — Dr. Hodges writes in
the Journal oj the American Aleilical Association, April
25, 1896, as follows:
I. Continuous "nibniersion is harmless. 2. Contin-
uous submersion will almost instantly limit infectious
gangrene and control septicamia and sapremia. 3.
Continuous submersion will quicklv relieve the pain
and discomfort of phlegmonous inflammation or cellu-
litis. 4. Continuous submersion will speedily reduce
temperature and pulse and overcome the consequent
depression of the patient's vital forces.
Mixed Infection — A fact of practical importance
to the surgeon is that an area infected by one form of
pathogenic organism maybe invaded by another form.
This is known as a mixed infection, and consists of a
primary infection with one organism and a secondary
infection with another. Koch found both bacilli and
micrococci in the same lesion of tubercle. A soil
filled with pneumococci is favorable to the growth of
pus cocci and tubercle bacilli. Tuberculous and
syphilitic lesions may be attacked by erysipelas.
Chancre and chancroid may exist together. A
syphilitic ulcer is a good culture ground for tubercle
bacilli rSchnitzler). Suppuration in lesions of tuber-
culosis means a secondar)- infection with pus cocci. —
Dr. D\ Cos I a. Manual of Modern Surf^ery, p. 30.
Prevalence of Trachoma. — Dr. Van Millingen, of
Constantinople, reports in the Annoles d' Oculisliijue,
vol. cxix.. No. 3, that from an extended study of the sub-
ject and correspondence with ophthalmic surgeons in
all parts of the world he has reached the following con-
clusions: I. Trachoma is an infectious and contagious
disease, which predominates in uncivilized countries
and tends to disappear with the progress of hygiene.
Hygiene and cleanliness are the best preservatives
against trachoma. 2. Trachoma is not influenced by
altitude: it may .spread wherever people are uncleanly
and live in poverty quite as easily at altitudes of from
1,000 to 5,000 metres as on plains. 3. .All races are
equally susceptible. An immunity for certain races
does not exist.
Circumstances under which Chloroform is Pref-
erablj to Ether. — Though it is settled beyond a
doubt that chloroform is more dangerous as an ana.'s-
thetic than ether. Dr. George \V. Gay, of Boston, in dis-
cussing the question concludes that chloroform should
be used in the following diseases and conditions;
All cases requiring tracheotomy or oesophagotomy :
as membranous croup, laryngitis, acute, chronic, trau-
matic, specific, or tuberculous; (tdema of larjnx and
glottis; malignant disease of the throat and neck;
deep cervical cellulitis; deep tumors of tlie neck, as
bronchocele; foreign bodies in the air passages or
oesophagus: bronchitis in the aged; and asthma. Dr.
Gay admits that there may be other cases also ia
which chloroform is preferalile.
After-Treatment of Tracheotomy Cases of Mem-
branous Croup. — Dr. R. M. Harbin, of Rome, draws
the following conclusions in a discussion of the above
September 19, 1896]
MEDICAL RECORD.
429
subject at a meeting of the Medical Association of
■Georgia.
I. Croup, whether diphtheritic or membranous, is
ahnost invariably fatal without surgical treatment, and
the few cases in which patients recover by medicinal
treatment alone are not to be considered. 2. So far
as the practical indications for tracheotomy are con-
cerned, it makes no difference whether croup be diph-
theritic or membranous. 3. Tracheotomy has the ad-
vantage over intubation, in that it gives a better means
of expectorating the membranes and furnishes free
■drainage from the site of septic infection. 4. Trache-
otomy is a justifiable surgical procedure and should
be performed in all cases where our therapeutic re-
sources have been e.vhausted, and when the patient is
in imminent danger of suffocation. It should be done
iu hopeless cases, since it either offers a chance for
the patient or promotes euthanasia. 5. Tracheotomy
keeps the patient alive until the pseudo-membrane dis-
integrates and resolves into a muco-purulent liquid
and is expectorated through the tube. 6. The after-
treatment is the most important part of the procedure,
and the author attributes the successful results reported
to the persistent use of limewater.
Partial Convulsions Occurring Prior to Delivery.
— Emory Lamphear, M.I)., Ph.D. (Aiiierican Journal of
Surgery and Gyiiicology, April, 1896) makes the follow-
ing rules: ist, chloroform the patient; 2d, send for an
assistant, if possible to get one quickly; if not, let the
husband or some one else give the chloroform under
close watching, as extreme haste is necesssary; 3d,
empty the uterus at once; the prime object is immedi-
ate delivery of the ftetus. The practice Dr. Lamphear
follows is this: If the os be dilating and dilatable, he
rapidly enlarges the opening until the long forceps can
be applied to the engaging head, or the hand can be
introduced to perform version and speedy delivery.
Often this can be done inside of a half-hour. If not,
then the proper thing to do is to cut the cervix freely
upon each side up to the cervico-vaginal junction,
thus producing an artificial double laceration of the cer-
vix uteri, (are must be taken not to cut through the
vaginal wall. If the outlet is very close, as in primi-
pariE, he cuts even through the perineum, but not
through the muscle near the anus. As soon as he re-
moves the placenta, the os is caught and pulled down,
so as to allow six or more catgut sutures to be in-
troduced in the cuts in the cervix. If the perineum be
injured, it is sewed, irrigation practised, and then the
anaesthesia is discontinued.
Vertebral Caries. — Dr. Thorbum (American Journal
of the Medial Seicnces, Mav, 1895 1 gives the following
indications for operation :
(i ) A steady increase in symptoms in spite of favor-
able conditions and treatment. (2) The presence of
symptoms which directly threaten life. (3) The per-
sistence of symptoms in spite of complete rest is the
indication which has been most generally adopted.
(4) In posterior caries (caries of the arches) opera-
tion is clearly indicated, as here we can readily both
treat the paraplegia and remove the whole of the
tuberculous tissue. (5) The existence of severe pain,
if the patient is being exhausted thereby. (6) Chil-
dren, as a rule, yield better results than do adults.
Subclavian Aneurisms Of 115 cases of all sorts,
79 presented complications (about 60 per cent.), of
which 17 recovered (about 19 percent.).
(i) Hemorrhage occurred in 48, of which 10 re-
covered (about 20 per cent.). (2) Infiammation, sup-
puration, sepsis occurred in 15, of which 5 recovered
{},}, percent.). (3) Pleuritis, pneumonia, pericarditis,
bronchitis occurred 7 times, and they all died. (4)
Phlebitis occurred in 2 cases, of which i recovered.
(5) Cerebral symptoms in 5 cases, and they all died.
(6) Gangrene occurred in 4 cases, of which three
recovered (75 per cent.). (7) Penetration of air in
veins occurred in 1 case in external jugular vein; it
recovered. (8) Wound of thoracic duct occurred in i
case; it recovered. (9J \\'ound of pleura occurred in
I case; it recovered. (10) Shock in 1; it died. —
Annals oj' Surgery, December, 1895.
Cancer of the Breast. — Drs. Thomas Jones and
John E. Piatt present in The I.aneet, August 31, 1895,
p. 522, the following conclusions in regard to results of
operations:
(i) Cancer of the breast, although a formidable
disease, is amenable to treatment by operation, and the
proportion of cures so obtained may confidently be put
down at twelve per cent. (2) Non-success after oper-
ation is very frequently due to the extensive character
of the disease when it first comes under observation ;
probably if relief were sought earlier, a much larger
proportion of cures could be obtained. (3) Moderate
enlargement of the axillary glands is no bar to oper-
ation or to a successful issue, provided they are sys-
tematically and carefully removed, and the axillary
space thoroughly cleared. (4) It is well-nigh impos-
sible to discover trifling enlargement of the axillary
glands by an examination through the unbroken skin.
(5) No operation for remoxal of cancer of the breast
can be considered complete unless the axilla be ex-
amined through the wound, the additional risks of
such a procedure being \ery slight. (6) The large
number of cases in which recurrence occurs locally
points to the necessity of very free removal of the dis-
ease; all doubtful skin must be taken away and great
care must be exercised not to leave any outlying por-
tions of breast tissue. (7) Operation is contraindi-
cated when the whole of the growth cannot be re-
moved or when the supraclavicular glands are en-
larged. The only condition which might render an
operation justifiable under such circumstances would
be the presence of a foul cancerous ulcer, the removal
of which is desirable on account of the great incon-
venience which it occasions.
Furor Secandi. — It would seem that every tyro im-
agines that surgery offers the quickest route to success,
and that fame is to be attained only through blood.
Hence every case the symptoms of which are directed to
McBurney's point is necessarily a case of appendicitis,
for which the only sovereign remedy is the knife; or,
if it be a woman, and her suffering is referred to the
ovarian region, or she have a fibroma, however small
and barren of symptoms of importance, not only must
she be subjected to cceliotomy at once, but in nine cases
out of ten has her uterus or uterus and ovaries sacri-
ficed, thus unsexing her without the slightest effort
being made to spare these organs and preserve to the
woman her distinguishing function. — R. Bevkri.v
Cole.
Caesarean Section : Suture of the Uterus versus
Total Extirpation. — Dr. Henry C. Coe {Medical
Neii's, May 30) says the following are the advantages
that the radical operation presents: i. Rapidity of
execution. Ligation of the broad ligaments and
separation of the bladder are more easily accom-
plished than the same steps in an ordinary hyster-
ectomy. In one of the writer's cases of cceliotomy
for rupture of the parturient uterus, clamps being
used, it required only five minutes; another in which
ligatures were used required ten minutes. It is not
necessary to elevate the patient in Trendelenburg's
posture. Time is often a very important factor.
There is no more shock or loss of blood than after
suture of the uterus. 2. By removing the entire
uterus we are reasonably sure that no infected tissue
remains. In one Porro case the patient recovered.
430
MEDICAL RECORD.
[September 19, 1896
but the cen'ix, being infected, sloughed out entirely.
Free drainage per vaginam may save the most desper-
ate case. No sutures are left to give subsequent
trouble. 3. Neoplasms of the ovaries, or uterus, or
diseased appendages are removed at the same time.
Removal of the adne.\a after Cesarean section always
seems fraught with considerable danger, since the
large soft stumps, with their distended veins, are ex-
posed to more or less traction during uterine contrac-
tions. Fibroids apparently not large enough to justify
a Porro operation are left behind to cause future trouble.
4. Convalescence is quite as rapid as when the uterus
is sutured. Dr. Coe says that in his experience the ob-
jection with regard to weakening of the vaginal roof by
removing the cervix is largely theoretical, in puerperal
hysterectomy as well as in total extirpation for any
cause. The writer says he has found no case of
vaginal enterocele among one hundred cases of his
own or those of his friends who practise total extirpa-
tion. He concludes by saying that the indications for
Ceesarean section are becoming every year more clearly
defined and the operation will probably be more rarely
performed in the future. Total extirpation has the
additional advantage of preventing the risk of a second
operation.
Curettage of the Uterus. — This procedure should
always precede abdominal section for the removal of
the uterine appendages, because in these cases the en-
dometrium is usually so diseased as to interfere with
the recovery of the patient if this part of the operation
is omitted, and because thorough cleansing of the
uterus, vagina, and vulva is imperative in case vaginal
drainage is required. ^Watkins, Mediial News, Au-
gust 8, 1896.
©orrcspo udeuce.
LOCAL TREATMENT OF AFFECTIONS OF
TRACHEA, BRONCHI, AND LUNGS.
To THE Editor of the Medical Recokd.
Sir: An article in your issue of August i, 1896, by Dr.
Joshua Lindley Barton, on the treatment of the above-
mentioned group of affections by intratracheal injec-
tion, makes it desirable for me to publish a few words
anent the topical treatment of these diseases, as I have
been using it these many years.
Dr. Barton gives due credit to Horace Greene's
works in 1838, when he passed a small sponge satu-
rated with a solution of nitrate of silver through the
glottis into the trachea, in lieu of which method he
afterward adopted catheterism and injection of liquids
into the air passages. This method required special
preparation of the patient. The autlior justly remarks
how much these endolaryngeal applicaticms have been
facilitated by laryngoscopy and the discovery of co-
caine. He duly appreciates the workings of Ber-
geron, Pernice, Kirke, Coakley, and Joseph Muir.
He recommends previous sponging of the throat,
then the introduction of the laryngeal mirror and
the use of Muir's syringe with laryngeal tube. He
continues, verbatim : " If care is taken, when insert-
ing the tube, to avoid touching the glosso-epiglottic
or the aryteno-epiglottic folds or the interarytenoid
space, each of which seems to act as a cough centre,
the irritation caused by this procedure will be found
to be surprisingly slight."
Now, first of all, I suppose all physicians will agree
how much local treatment, as a rule, whenever it is
possible, is to be preferred to internal medication.
And for this reason local treatment of the abo\e-quoted
affections deser\-es much more attention than it has
until now received. 1 have never tried the intro-
duction of medicated sponges or the nozzle of the la-
ryngeal syringe. The method is not quite so easy as
it would appear to be from a consideration of the pas-
sage quoted above.
For the last twelve or fifteen years I have used in-
tratracheal injections made with a Pravaz syringe, the
needle of which is inserted into the windpipe through
the crico-thyroid ligament, or according to circum-
stances, through any accessible intercartilaginous
space of the trachea. If this injection be applied in
the recumbent posture of the patient, with his head
slightly elevated, the injected liquid flows down the
posterior surface of the trachea, causing only excep-
tionally any inconvenience. I really cannot under-
stand why in laryngeal diphtheria this method is not
oftener made use of for the local application of con-
venient remedies to the larynx.
But mucli oftener than these injections I have used
insufflations of medicated powders, as the use of the
needle is always somewhat unpleasant to the patient
or family, who oppose much less the use of the in-
sufflation tube.
The insufflations are applied once, twice, or everv
thrice a day, with nitrate of silver, opium, alum, co-
caine, etc., always made up into a fine powder with
sugar.
An obvious objection will be that a violent access-
of cough and strangling must necessarily follow the
introduction of powder into the air passages. But not
so, gentle reader. If proper care be taken that the in-
sufflation is done just when the patient takes a deep
breath, no cough will follow.
The instrument used is an india-rubber tube with a
shortly curved end, which is not intended to penetrate
into the larynx, but to be held in the posterior fauces,
behind the root of the tongue and over the aditus la-
ryngis. The tube is provided with a flexible rubber
extension to be held between the physician's lips, and
must have a big terminal opening at its laryngeal end.
If the insufflation be done by means of a rubber ball, the
movement of squeezing that will unavoidably change
the direction of the instrument. Besides, as no laryn-
geal mirror is required, the physician will have one of
his hands free to hold the patient's tongue, which the
former will do better than the latter.
I have used the.se insufflations in various affections
of the larynx, windpipe, and bronchial tubes, always
with satisfactory and prompt results, so far as the na-
ture of the disease will allow it. If, as in consump-
tion, it does not cure, it alleviates that troublesome
symptom, "cough.'"
Whether this method of insufflation is original with
me or not, I am hot able to say, shut off as I am from
libraries and scientific intercourse. But I make no
claims in that direction. I shall be contented if this
method, simplified as I give it, is more general ly,ap-
plied. It will prove satisfactory to the physician and
to his patients. F. Semeleder, M.D.
CuRDovA, Mexico.
A Double Expiration — A Paris newspaper pro-
vides its subscribers with free medical attendance.
Recently the manager of the paper gave notice to one
of the physicians ''not to prescribe for X any more:
his subscription has expired." The doctor replied:
■■ So has X/"— Tit-Bits.
Toothache. — When patients complain almost con-
tinuously of toothache or sensitive teeth, it is usually
an indication to administer the phosphate of lime. —
Dental Register.
Gonorrhcea is claimed by .-Vsmus to be cured in a
few davs bv injections of an emulsion of creosote of a
strength of from 0.2 to 1 per cent.
September 19, 1S96]
MEDICAL RECORD.
431
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending September 12, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Cases.
Deaths.
162
IOC
51
10
21
I
I
2
42
4
127
24
0
0
Small-Pox in Germany claimed sixty-five thousand
victims annually a century ago. Now the average
number of deaths is but one hundred and fourteen a
The Pasteur Institute in Athens was established
by Dr. Pampoukis in 1S94. During the first sixteen
months two hundred and one cases were treated, with
but one death.
Poison Ivy is said to be antidoted by the brook
balsam, spotted touch-me-not, or jewel weed (Impa-
tiens fulva), which grows freely in this latitude along
the banks of brooks. Its leaves and stems are bruised
and applied as a poultice to the inflamed parts.
Oxygen Inhalations after Chloroform. — Dr. Lan-
dau, of Berlin, prefers chloroform to ether, provided
oxygen be administered afterward. He finds that if
the patient inhales oxygen for a few minutes as soon
as the chloroform is withdrawn, subsequent head-
aches, nausea, and vomiting are avoided. Further,
consciousness is more quickly restored, the pulse be-
comes fuller and slower, and the dusky hue of the face
disappears more quickly. Physiologically this is what
would be expected when the oxygen is restored to the
blood. From the excellent results and freedom from
danger he thinks it is the duty of the physician to tr)-
the oxygen inhalation for the relief of the unpleasant
after-effects of the anaesthetic.
Prevention of Diseases and Mortality in Infancy
and Childhood. — Dr. Jane L. Herson (Journal of
Medicine and Science) recommends wrapjaing the new-
born child with a warm blanket and holding it in an
inverted position for some minutes when asphyxiation
is threatened. This causes the blood in the liver
(one-quarter the entire volume of blood at this time)
to flow to the heart and medulla, causing a physiologi-
cal stimulation of respiration. Much gastro-intestinal
disease may be relieved by avoiding overfeeding or
too frequent feeding. Food administered once in
three or four hours is sufficient. Eye disorders may
be avoided by substituting kindergarten instruction for
book study until children are ten years old, and after
that lime by insisting that schoolrooms be properly
lighted and only books with good print be used.
Xight study should not be required nor permitted be-
fore twelve years of age.
New Scheme for Treatment of Female Inebri-
ates.— Lady Henry Somerset is of the opinion that
nothing could be worse for habitual drunkards than
the sedentar)- employment usually assigned to them in
reformatory homes. She has obtained possession of
one hundred and eighty acres of land in the town of
Duxhurst, situated beyond easy reach of all drinkable
forms of alcoliol. She has begun the construction of
a small village upon this tract. It is to consist of
scattered cottages, which the patients will occupy.
There will be a hospital, a chapel, a children's home,
office buildings, and laundr}- for general use. Six
patients will occupy each cottage and they will be ex-
pected to take part in the industries which are being
organized on the estate. There will be light agricul-
tural work, poultry raising, bee keeping, dairy work,
flower culture, jam making, and a small amount of
needle work and washing. The idea is to put the
women to work where tjiey can see and take pride in
the results of their labor. The institution cannot af-
ford to take free patients, so there will be a minimum
charge of Si. 25 per week. If a patient works out the
cost of her maintenance, the amount is credited to her
and handed over to her when she leaves the institu-
tion. The English public is being asked to furnish
money for the development. — Ne^^^ York Sun.
Micro - Organisms in the Healthy Nose. — In a
paper published in the '" Medico-Chirurgical Trans-
actions," vol. l.xxviii., Drs. St. Clair Thomson and R.
T. Hewlett give the results of some experiments,
made to determine the nature and number of micro-
organisms in the healthy nose. In the entire litera-
ture of the bacteriology of the nose, they say, there
are only two articles wholly devoted to the normal or
physiological condition. One of these is by Dr. Jona-
than Wright, the other by L. von Besser, both pub-
lished in 1889. The following is a summary of the
conclusions formulated by Drs. Thomson and Hew-
lett: (i) That in all bacterioscopic investigations of
the nasal fossa, in all researches as to the action of
the nasal mucus, etc., a clear distinction must be made
between the vestibule of the nose and the proper mu-
cous cavity. The former is lined with skin and is-
furnished with hairs and with sudoriferous and se-
baceous glands; and it is not part of the nose cavity
proper, but only leads to it. (2) The neglect of this
distinction may account for the discrepancies in pre-
vious observations on the subject. Contamination
with the lining of the vestibule is difficult to avoid,
even when this source of error has been realized. (3)
In the dust and crusts of mucus and debris deposited
among the vibrissa of healthy subjects, mi ro-organ-
isms are never absent. They are rarely scanty in
number; as a rule they are abundant. (4) On the
Schneiderian membrane the reverse is the case. They
do not assert that micro-organisms are completely ab-
sent; obviously some must occasionally occur, but
under normal conditions they are never plentiful : they
are rarely even numerous, and in more than eighty per
cent, of their observations they failed to find any,,
and the mucus was completely sterile. These obser-
vations were limited to the anterior part of the nose,
and, as not more than a fourth of the cavity is acces-
sible to inspection and examination, it is reasonable
to conclude that germs would be found still more in-
frequently in the deeper portions of the fossa;. (5)
The occurrence of pathogenic organisms must be so-
infrequent that their presence in the pituitary mem-
brane can be regarded only as quite exceptional.
Insanity in Children. — Dr. Conrads gi\es a lengthy
review of the subject of infantile mental derangement,
which is referred to in Pediatrics, as follows: First,
he notices the variety of insanity in children and gives
an extended notice of the literature. .As regards the
question of the relative frequency of insanity of the
two sexes in children it cannot be definitely stated
with our present statistics, .\mong the causes hered-
ity is first; next comes the condition of the child's
bringing up, his education and training, the manage-
ment by nurses by frightening their charges, the dis-
cipline and methods at school, etc. Psychic causes,
fear, shame, and especially mental shock, are not to-
432
MEDICAL RECORD.
[September 19, 1896
be underestimated. Emminghaus found twenty-three
per cent, of the cases he collected in the literature to
be due to these causes; homesickness is not common,
but cases have been known. Conrads lays some stress
on the evil effects of religious excitement in predis-
posed older children. Contagious (mental) and epi-
demic influence need mention, as they have been re-
peatedly ob.served. Onanism has been undoubtedly
overestimated as a cause, but in predisposed persons
it may have its effects. AmoBg the somatic causes,
acute infectious fevers are first in frequency. Em-
minghaus found these as a cause in twenty-five per
cent, of his cases. Trauma, especially of the head,
insolation, exposure, etc., have all had their victims.
Ear disease and dentition may alTect the mental con-
dition, and the effects of nasal disease, adenoid vege-
tations, and tonsillar enlargements are suggestive.
Middle-ear disease has been demonstrated by Bouchut
and Emminghaus as causes of infantile derangement;
intestinal parasites, tuberculosis, and cardiac weak-
ness are also factors. Hereditary syphilis is the cause
of juvenile paresis; whether it acts in producing other
forms of insanity is uncertain. Long-continued sup-
puration has been the cause of melancholia, as in one
case of Conrad's own observation. Retlex psychoses,
aside from those of the ear and intestinal disorders,
have been observed to follow wounds, extraction of
teeth, etc. Various poisons — lead, mercury, cocaine,
tobacco, etc. — have caused mental disease in children
as well as in adults, and alcoliolic insanity has been
often reported. Conrads gives briefly a case of acute
hallucinatory delirium observed by him in a child of
two and one-half years, from this cause. The perma-
nent psychoses of children occur usually in degenerate
individuals, who sooner or later reveal their stigmata.
The first symptoms of insanity can naturally only be
looked for after the conscious perceptions have be-
come manifest in the child and must consist in aber-
rations of these. The earliest age at which halluci-
nations have been obser\'ed is fourteen and one-half
months (Marce). Visual hallucinations are far the
most frequent. Delusions can show themselves only
after a certain stage of mental development. The
types of mental disease in children fall under two
heads — the pure psychoses and the forms connected
with the neuroses. Of the former it is difficult to say
wjiether mania or melancholia is most frequent in the
earlier years, and both are most frequent toward pu-
berty. Maniagenerally begins without the prodromal,
depressed phases, runs a subacute course, and gener-
ally ends in recovery. Melancholia may assume any
of its types, is commonly gradual in its onset, and is
subject to remissions. Its course and prognosis are
the same as mania. Suicide in children should l>e
mentioned in this connection, and from the statistics
of France and Prussia seems to be steadily on the in-
crease. It is, however, still infre()uent. Conrads,
taking the proportions of adults and children in Prus-
sia in connection with the statistics of suicide, finds
that it is forty-six times less common in the latter than
in the former. Periodic insanity in children is usu-
ally of the maniacal type, and, with circular insanity,
has an absolutely unfavorable prognosis. Hut few
cases of either are found in the literature. Under hal-
lucinatory insanity, Conrads includes two types-
acute hallucinatory paranoia and transitory insanity
— both characterized by hallucinations, the former the
more chronic and the latter the acute type. In the
former occur the stuporous cases that are often con-
founded with melancholia. The prognosis of both,
except when they succumb to exhaustion or suicide, is
favorable.
Paranoia of the pure type is rare in childhood, but
the degenerative prodromal stage of the original para-
noia of Sander is \erv common. These candidates for
paranoia are usually of the male sex: in all there is
a hereditar)- taint. They are generally quiet, senti-
mental, and hypochondriacal children, who are liable
to feel themselves slighted by their parents, and often
conceive notions of self-importance, which are tlie in-
cipiency of their delusions. Hypochondria is closely
allied to paranoia, and while its occurrence is rather
rare, and has been denied in children, it is sometimes
met with and is usually a degenerative sign. Its
prognosis is only favorable in the milder cases. Im-
perative conceptions and acts are also met with, and
frequently indicate a degenerative taint, and are often
connected with masturbation as an exciting cause, but
they are not so serious in their prognosis. The so-
called "impulsive insanity" is diagnostically indistin-
guishable from these impulsive acts, though it has
been accepted as a special type. It is always degen-
erative and of unfavorable significance. Passing by
wiiat is said of idiocy, a word can be given to moral
insanity. This, Conrads claims, rarely exists without
some mental impairment, and sexual perversion is
often present. Recovery is as improbable as in idi-
ocy; the apparent recoveries are, perhaps, only re-
missions of long duration. Paresis in children has
been lately reported by various authors. Its connec-
tion with hereditary syphilis has already been noted.
Among the neurotic insanities, that connected with
epilepsy takes the first rank. Hysteria is commoner
in children than it is generally supposed, especially in
girls. Hereditary is its most important etiological
factor. The mental di-sorders of chorea consist mostly
in capriciousness, irritability, and a great tendency to
sudden emotional disturbances. Hallucinations, il-
lusions, and maniacal delirium may also occur, and
Leidesdorf has observed hallucinatory paranoia.
Very recently Moebius has directed attention to the
resemblance of choreic to toxic insanity as supporting
the view that chorea may be of infectious origin.
As regards the therapy, it would be best if all cases,
except the milder forms of mania and melancholia,
hypochondria, and the cases of imperative concep-
tions, and the stuporous cases, were treated early in
a special a.sylum, very few if any of which, unfortu-
nately, exist for children. Prophylaxis is still more
important, and should properly begin literally ab ovo.
The marriage of degenerates, insane, drunkards, etc.,
is a most prolific cause of infantile insanity and idiocy.
Where the tendency exists in the child, its bringing \\\)
and education must be the subject of the greatest
care. Ignorant and reckless nurses, especially if
given to drink, may do the greatest injury, and in no
case should alcohol in any form be allowed to a child
under ten years, excepting, of course, as medicine in
acute infectious diseases. Special care should be
given to the points of masturbation and the general
habits of the ciiild; to the possibility of nurses or
others working injuriously upon its fears and imagina-
tion: to the educational methods and discipline. It
would be well were teachers obliged to study mental
patliology in their professional preparation.
As a summary of the ]X)ints in regard to which it is
desirable to direct attention in relation to the psycho-
ses of children, Conrads concluded his paper with the
following as desiderata: i. Statistics of infantile in-
sanity, by means of circulars of inquiry to the medi-
cal profession, as to the actual number of insane chil-
dren in their knowledge. 2. Information as to re-
lapses, by communication from medical men as to the
mental disorder of persons who had been insane in
childhood. These could best be obtained from family
physicians, who are usually able to follow the family
history back for a lengthy period. 3. Special asylums
for insane children. 4. Sufficient knowledge of teach-
ers of the psychopathic states in childhood, and greater
care in schools to mentallv defective children.
I
Medical Record
A Weekly youmal of Medicine and Surgery
Vol. 50, No. 13.
Whole No. 1351.
New York, September 26, 1896.
$5.00 Per Annum.
Single Copies, loc.
(Dvioiual ^vticles.
THE DIAGNOSTIC VALUE OF BLOOD EX-
AMINATIONS.
By GEORGE P. SPRAGUE, M.D.,
DANVERS, MASS.,
ASSIST.U.'T PHYSICIAN, DANVERS LUNATIC HOSPITAL.
Although Swammerdam discovered the corpuscles
of the blood as early as 1658, and many others since
his time have investigated its phvsical and chemical
properties, it has been only within the past fifteen
years that the blood has been carefully studied from a
clinical standpoint. It is true that Virchow and Ben-
nett and Craigie in 1845 first noted the enormous in-
crease in white corpuscles in leuksrriia, and that Dun-
can in 1867 recorded the decrease of haemoglobin in
chlorosis. But it was not until the discover}' of the
Plasmodium malariie by Laveran in 1880 that a care-
ful study of the relation of blood changes to disease
processes was initiated.
This long delay in exact work was due largely to a
lack of the instruments to which — coupled with the
use of the differential staining qualities of aniline
coloring matters — we owe most of our present knowl-
edge of the conditions of the bood in disease.
The normal histology of the blood, as at present
understood, embraces, roughly, the red biconcave
discs, the white globular cells, the blood plates, and
the plasma. The white cells are divided — in accord-
ance with the way in which they stain with aniline
colors — into lymphocytes, large mononuclear forms,
polynuclear leucocytes, and eosinophiles. In addition
to these, other forms are found in disease, the most
prominent of which are the nucleated red corpuscles
and a fifth variety of white cell, the mvelocyte.
To make a thorough clinical analysis of the blood
we must determine the number of red cells; the
number of white cells; the proportion of white cells to
red ones; the amount of haemoglobin; its proportion
to the number of red cells; the number of each variet}'
of white cells and its proportion to each of the other
forms of white cells, and to their combined numbers;
the sizes and shapes of the cells; whether or not they
contain nuclei or pigment in any form, and finally as
to the presence or absence of any pathological sub-
stance floating freely in the plasma. It is along
these lines that I wish to present a few facts concern-
ing the diagnosis of disease.
The diseases in which a blood examination most
naturally suggests itself are the various forms of
anasmia, in many cases of which nothing else will give
an early diagnosis. And by anaemia is meant not all
cases in which the skin is apparently bloodless, but
only those in which the amount of hremoglobin or
the number of red cells is below normal; for there
are cases of persistent pallor, due perhaps to some pe-
culiarity of the vasomotor system at the surface, in
which the blood is normal.
As an illustration of the value of a blood count in
anamia may be cited the following case: Miss J., aged
eighteen, blond, resembles her mother and maternal
aunt, both of whom died of phthisis. About two years
ago, after nursing her father until his death, she began
to lose strength, had poor appetite, slight fever, and
cough, with shortness of breath on exertion. Al-
though the fever and cough soon disappeared, she con-
tinued to lose strength, and it was feared that she had
phthisis until she came under observation several
months later, when it was found that she had 4,000,-
000 red cells per cubic millimetre, but only 36 per
cent, of hajmoglobin, and although her skin was not
colorless, it was plain that she had chlorosis. The
daily use of carbonate of iron for three months gave a
count of red cells of 6,000,000, with a haemoglobin
percentage of 84. Of course in a young girl the age
usually suggests the likelihood of chlorosis in cases
of gradual loss of strength with shortness of breath on
exertion. It had not done so in this case, however, and
in the rare cases of chlorosis in boys, this possibility is
even less likely to be considered. But when in any given
case in adolescents we find that the red cells are either
in normal number or but slightly lessened, while the
haemoglobin is in half or in less than half the normal
amount, we may safely make a diagnosis of chlorosis;
and, on the other hand, we must not consider a case to
be one of chlorosis unless there is this lessened pro-
portion of haemoglobin to red cells.
On this point Striimpell's statements that there is
more or less pallor of the skin and mucous mem-
branes as a constant and essential symptom of
chlorosis, and that there is usually a decided decrease
in the number of red corpuscles, are misleading.
Chlorosis rubra is a well-marked form, and Osier and
Thayer, Griffith, Graber, Henry, Vierordt, Hayeni, and
others place the average number of red corpuscles in
this disease at about eighty per cent. It may there-
fore be considered that the lessened haemoglobin rich-
ness of the individual red cell is the essential diag-
nostic point in chlorosis.
At the opposite e.xtreme as regards the relative
proportion of red corpuscles and hemoglobin we find
pernicious anamia. While a typical case of this latter
disease, like a typical case of chlorosis, may offer but
little obstacle to a correct diagnosis, many cases of it
have been mistaken for chlorosis, simple anaemia, or
Bright's disease.
To illustrate its resemblance to the latter may be
mentioned a case occurring in the service of my col-
league. Dr. Worcester, who has kindly placed this and
other cases at my disposal.
Mrs. L., aged fifty-two, who has been a patient in
the Danvers Lunatic Hospital since October, 1884,
continued in fair bodily health until about eighteen
months ago, when she began to lose color, the face
appearing wa.xen, and to have cedema of the feet and
ankles. The urine was examined, and was found to
contain a small amount of albumin and a few casts.
Her symptoms suggested Bright's disease. About the
same time she began to have dyspnoea on slight exer-
tion, but did not lose much or any in weight.
Soon after the close of last year she had become so
yellow and short-breathed, and the ankles so cede-
matous, without any increase in the amount of albumin
or in the number of casts, that the blood was examined,
with the following result: red cells, 1,250,000 (about
434
MEDICAL RECORD.
[September 26, 1896
25 per cent.. of normal); leucocytes, 6,360, of which 5
per cent, were large mononuclear, 42 per cent, poh-
nuclear, and 53 per cent, lymphocytes. The red cells
varied from very small to very large, and many of
them were irregular in shape. She had been taking
iron without any improvement, but the condition of the
blood, coupled with the other symptoms, pointed so
strongly to pernicious ansemia that she was at once
put on Fowler's solution. A haemoglobin examination
was secured soon after this and showed 30 per
cent.
After si.\ weeks of the arsenic treatment the blood
count showed 1,902,000 red cells and 45 per cent, of
haemoglobin. A month later the red cells numbered
3,700,000, and the hamoglobin showed a percentage
of 60. The red cells were nearly normal in size and
shape.
Bristowe thinks that no positive diagnosis between
chlorosis and pernicious anaemia can be made, and
Henr)- maintains that pernicious anaemia is simply the
terminal stage of some cases of chlorosis and secon-
dary anaemia. This position is stoutly assailed by
many observers, and the argument in favor of con-
sidering it a separate disease seem to be the stronger.
Whatever the etiology, the use of iron, which is a
specific in chlorosis, is rarely of advantage in per-
nicious anaemia, and the proportion of hamoglobin to
each red cell is usually above the normal in pernicious
anffimia, while it is below the normal in chlorosis.
These differences, together with the markedly altered
size and shape of the red cells in pernicious anaemia,
and the practically normal condition in these respects
of the red cells in chlorosis, should render a diagnosis
comparatively easy.
Before considering the disease ne.xt to be mentioned
it may be well to define a term or two and to refer to
the differential staining of blood cells.
Diagnoses of disease are now being made based
upon the presence or absence of leucocytosis, and in
using this term I shall abide by the definition of it
recently given by Cabot, who says that " leucocytosis
is the presence in the blood of an increased number of
white cells of the same varieties morphologically as
those in normal blood, a plurality and generally an
overwhelming plurality being polynuclear.""
This is a very important distinction, as evidenced
by one of his cases, that of a woman who entered the
hospital with a diagnosis of malignant tumor. There
was so much pallor that a blood count was made, which
disclosed a vast increase in the number of white cells
(reaching the proportion of one white cell to thirty-
nine red cells). This fact, taken in connection with
the size and nature of the tumor, led to a diagnosis of
leukaemia. But later a differential count of the blood
was made with the triple stain, and at once it was seen
that the disease was not leukaemia, as ninety-five per
cent, of the white cells were polynuclear.
The use of stains in blood examinations was intro-
duced by Ehrlich in 1878-1879. In his study of the
white cells — the leucocytes — he found that the
granules contained in them were differently affected
by certain coloring matters, and that they had a
special affinity for the aniline colors. Further than
this, that some forms of leucocytes were stained only
by acid aniline colors, while others were stained only
by the basic coloring matters.
In accordance with these peculiarities a triple stain
containing an acid coloring matter, such as eosin, and
a basic one, such as methyl blue, in a lluid, with the
acid in excess, is commonly used in staining blood.
A popular staining fluid is that known as the Ehrlich-
Biondi, which contains acid fuchsin, methyl green,
and orange G. This stain colors the nuclei of the
white cells green, those of the nucleated red cells
nearly black, the red corpuscles themselves a light
orange, the eosinophilic granules red, and the neutro-
philic granules a deep violet.
In normal blood these various forms of leucocytes
bear a definite relation to each other in number, and
this proportion is often much changed in disease; in
some complaints the change may be pathognomonic.
It is agreed by all authorities that leukaemia can
be diagnosticated only by an examination of the
blood. But while this has long been an easy matter
in advanced cases, it is not easy in the early stages, in
which alone we can hope for cures through treatment.
The history^ of the disease is marked with cases of
leukaemia which have been mistaken for scrofula,
cancer, congenital syphilis with enlarged spleen,
kidney disease, ovarian tumors, or malaria.
The difficulty of making a diagnosis from malaria
in the early stages is well shown in the following
case: Mr. M., aged thirty-one. Twenty-two months
before presenting himself he had had a severe chill
and remained in bed for four days, but had no fever.
He continued weak and sickly up to the time of ex-
amination. He was said to have had malaria every
spring, but could give no reasons for that diagnosis
e.xcept the splenic enlargement. At the time of exam-
ination lie was very weak and pale, and the spleen
extended from the diaphragm to the pubis and latei-
ally to beyond the median line. A blood count showed
fifty times the normal number of white cells, and 4,-
000,000 red cells.
Of course the blood count made a diagnosis beyond
question, as only in leukaemia is there such an enor-
mous increase of the leucocytes. But in active diges-
tion, pregnancy, the puerperal state, and in young
children there is a physiological increase to perhaps
double the standard number of 8,000. There is also
a very large increase of leucocytes in various septic
conditions, and in any one of these conditions a mere
count of the white cells would not be suflFicient to ex-
clude leukamia.
But if in a differential count we find, instead of the
normal, from 20 to 30 per cent, of lymphocytes, from
60 to 75 per cent, of polynuclear, 6 per cent, of mono-
nuclear, and from 2 to 3 per cent, of eosinophiles, a
great decrease of lymphocytes with the presence of
enough of a new form, the myelocytes, to replace the
deficiency, there-is no longer any doubt of the diag-
nosis.
In pseudo-leukjemia, or Hodgkin's disease, there
may be a leucocytosis, w hich, together w ith a decrease
of red cells, may so closely resemble true leukaemia
that only a differential count of the blood cells will
decide.
Bremer has recently perfected a method of making
a diagnosis in diabetes by blood staining. He uses a
mixture of eosin and methylene blue compounded in
a very complex manner, and stains the red cells with
it. Diabetic or glycosuric blood is stained a sap- or
bluish-green, while non-diabetic blood stains a red-
dish violet. He claims this test to be so delicate that
an amount of sugar too small to show in the urine will
give the reaction in the blood.
In cases of simple leucocytosis very valuable infor-
mation may be gained without staining the blood.
Several writers, including a number of German
authors, have claimed that leucocytosis is present in
all febrile affections with increased activity of the
lymph glands, but many niicroscopica] tests by careful
observers have shown that this is too sweeping a state-
ment. For instance, while there is at times a leu-
cocytosis in tuberculosis it is only while the tissue
destruction is active. In typhoid fever there is no leu-
cocytosis, and this fact is of very great importance in
deciding in a doubtful case between typhoid fever and
purulent affections such as meningitis, appendicitis,
abscess, and general infection.
September 26, 1896]
MEDICAL RECORD.
435
But in pneumonia there is a marked leucocytosis
except in cases that prove fatal, and in doubtful cases
in the early stages a blood count would aid in the
diagnosis; and in making a diagnosis between it and
the grippe, in which there is no leucocytosis, the exam-
ination of the blood may be of very great use, espe-
cially when depressive drugs are used for the grippe.
In gynecological work an examination of the blood
should be of use in a few cases in determining whether
the symptoms are due to the irregular pelvic neuralgias
with which we sometimes meet, or to a beginning pus
tube or malignant disease.
In rise of temperature after operation a count of the
leucocytes may be of value in determining the pres-
ence or absence of pus. In a recent case in which I
had removed a carcinomatous breast, the temperature
rose to 101° F. after having been at nonnal, and the
question suggested itself whether there was pus or
whether the tension of some of the stitches, coupled
with the excitability of the patient, was the cause of
the high temperature. A blood count showed ig,ooo
leucocytes, and with the removal of two or three
stitches a small amount of pus was discharged, and
the temperature fell.
In deciding whether a case is one of appendicitis
or some condition such as intestinal obstruction, or
even constipation, which sometimes resembles appen-
dicitis, the absence of leucocytosis should make the
surgeon hesitate about operating.
The blood parasites offer very valuable diagnostic
information. The most important of these yet known
is the Plasmodium of malaria. When Laveran first
announced his discovery of this hematozoon his claims
were denied by others who could not find the germ he
described. And though its presence is easily demon-
strable with a little perseverance, so little interest was
taken in the subject that it was several years before its
existence was admitted by leading clinicians, and even
now there are men of repute who declare that the so-
called malarial parasite is found in the blood in all
conditions.
But the masterly treatise of Manson is alone suiTi-
sient to set this matter at rest; and in addition to
that, any one may decide it for himself with a high-
power microscope. All that is neded is to put a
drop of fresh blood on a clean glass slip and carefully
examine it under a j\ inch oil-immersion lens,
though it may be seen, if one knows what to look
for, vi'ith a less powerful lens.
The main difficulty which confronted the earlier
observers was the fact that the malarial parasite is
not the same in appearance in all stages of the dis-
ease. Thus, if we examine the blood in a case of be-
nign malaria, just before the rigor, we find a cluster
of bodies in a blood cell arranged so as to resemble
somewhat a rosette with a small mass of pigment in
its centre. If we again examine it an hour or so after
the chill, while the temperature is still rising, we may
see a number of small bodies in a blood cell arranged
in an irregular circle near its periphery and in active
motion. If the examination is repeated several hours
later, these actively moving bodies have disappeared,
and in their stead are seen larger amoeboid bodies, each
body being pale but containing one or more grains of
a very dark red or intensely black pigment, which if
carefully observed is seen to be constantly changing
its position. If we once more examine the blood a
few hours before the next paroxysm is due, we find
that these pale bodies nearly fill the blood cells they
occupy and are no longer actively amoeboid, and that
the granules of pigment are coarser, more numerous,
and nearly stationary. The cycle of change is then
complete. These forms and changes are slightly dif-
ferent in quartan from those in malignant malaria, and
it is quite possible that the germ is not the same.
Some form of the parasite may be seen in every case
of true malaria during the activity of the symptoms,
though in some mild cases many microscopic fields
may have to be examined before detecting it. Al-
though the diagnosis of a case of malaria may gener-
ally be made and the appropriate treatment used, other
affections, such as hectic fever, deep-seated suppura-
tions, nervous chill, and the chill of catheterization
may be mistaken for it, unless the blood is examined.
The last blood parasite I shall consider — that of
anthrax — is famous, as being the first germ proven to
be the cause of a specific disease.
This disease is rare in this country, but occurs in all
sections of it. Nearly every case recovers if properly
treated at its inception, while in those of late diag-
nosis the mortality is as high as sixty per cent.
The bacillus cannot always be found in early cases,
but is so large and distinctive (being a straight rod
with a length equal to twice or three times the
diameter of a red corpuscle) that a diagnosis can at
once be made upon seeing it.
In conclusion I would like to call attention to the
possibilities there appear to be in this field of study.
What has been done thus far is merely a beginning in
the field of ha;matological investigation.
There are several diseases in which the blood has
not been examined in its clinical aspects and many
others in which the work done is as yet so small that
no positive opinion can be based upon it.
It will be noticed that most of those diseases in
which the results of blood examinations have been
most marked are among the members of that group of
so-called essential or idiopathic diseases. It may be
that through the blood we can not only determine
their character but also discover their causes and
their cure. Bremer thinks that, while his test for dia-
betes is effective only in the presence of grape sugar,
it is not the sugar alone, or even primarily, that is the es-
sential characteristic in this disease, but that its clini-
cal symptoms are due to some other foreign substance in
the blood. The study of blood offers an excellent op-
portunity to any careful observer, for, although the best
results are not mathematically exact, the error is so
small that it may be disregarded. But on the other
hand, the slightest neglect of details may cause an
error of fifty per cent, without the operator's being
aware of any mistake.
Infectious Diarrhoea in Infants Dr. H. M. Mc-
Clanahansays: " Stop the food supply. Remove the
products of imperfect digestion from the intestinal
tract by irrigation, continued until the water returns
free from admixture of fecal matter. Inject solution
of twenty grains of tannic acid in a pint or more of
sterilized water, and have it retained in the bowel
about an hour. When vomiting persists the stomach
should be washed out also. To neutralize the toxins
calomel in one-tenth grain doses hourly for the first
twenty-four hours is recommended. First among an-
tipyretics is the cooled bath. When watery discharges
continue after the irrigation, hypodermics of one-one-
hundredth grain of morphine and one-eight-hundredth
grain of atropine can be given. Stimulants are indi-
cated in the severe cases, and whiskey is the best that
can be given. After the urgent symptoms have sub-
sided the child can be nourished with the white of an
egg stirred in cold water or the mixture recommended
by Jacobi : Five ounces of barley water, the white of
one egg, one or two teaspoonfuls of brandy or whiskey,
some salt and sugar. A teaspoonful every five or ten
minutes as indicated. No milk should be given for
several days." — Aiiwrirafi Journal oj Obstetrics and
Diseases of Women and Children.
43^
MEDICAL RECORD.
[September 26, 1896
A MEDICO-LEGAL CONSIDERATION OF
SOME OF THE GENERAL FEATURES.
SIGNS, AND SYMPTOMS OF THE SIMPLE
TRAUMATIC NEUROSES.'
By a. L. hall, M.D..
FAIR HAVEN. N. Y.
Viewed from a medico-legal standpoint, there is no
more important and interesting subject in neurolog)'
than the traumatic neuroses.
Much of the importance which attaches to this sub-
ject is due to the frequency with w'hich cases are made
the basis of an action for damages for bodily injuries
arising from accidents.
It is interesting, chiefly, on account of the complex
and varying nature of the symptoms, the absence of
special objective signs, and the want of reliable tests
for detecting simulation.
For many years the subject received consideration
only at the hands of the surgeon, and not until the
appearance of Erichsen's treatise upon spinal concus-
sion were the nervous aspects of the disease brought
into special prominence. Since then neurologists in-
spired by the writings of Page have investigated the
various nervous phenomena of the affection and as a
result of their labors about three hundred articles
upon the traumatic neuroses and questions connected
therewith have been published.
In consequence of the incorrectness of many of
Erichsen's conclusions respecting the pathology of the
disease, the ability of the surgeon properly to elucidate
its nature is seriously questioned by the neurologists.
As an outcome many, if not most, of our surgeons
have retired from the field of investigation, leaving the
inquiry to the neurological e.xpert, who with his instru-
ments of precision attempts a scientific determination
of the signs and symptoms, without sufficient regard,
in many instances, for the practical deductions.
The object of adverting to the tendency of the neu-
rologist to usurp the entire field of investigation, to the
exclusion of the surgeon, is not to discredit the
former, but for the purpose of showing that the sur-
geon, by reason of his earlier and usually prolonged
connection with the case, is in a better position, if he
has made a careful study of the remote effects of trau-
matism, than the neurologist — and as well qualified —
to determine correctly its gravity and final outcome.
For these reasons, the surgeon should maintain his
equality as an authority with the neurologist respect-
ing the sequences of trauma upon the functions and
structure of the nervous system.
Definitively considered, the condition known as
traumatic neurosis is a state of chronic general ner-
vous depression with or without accompanying hysteri-
cal manifestation consequent upon physical or pyschi-
cal shock. Usually, e.xcept that it originates from
trauma, it differs symptomatically in no important
respect from the ordinar}' exhibitions and combina-
tions of idiopathic neurasthenia. In ordinary cases
the symptom complex is expressed somewhat as fol-
lows: There is a loss of nervous tone and the patient
suffers from a peculiar train of bodily feelings depen-
dent upon a depressed and irritative condition of all
the vital functions. The mental state is one of anx-
ious foreboding, irritability, and distress of mind. The
attention, will jwvver, and thought concentration are
weakened, and there is a keen dislike, or actual in-
ability, for the assumption of any business responsi-
bilities. The muscular power is lessened, tremor and
inco-ordination are present, and the reflexes are exag-
gerated, while at times there may be paresis or paraly-
sis. The special senses are involved. Anaesthesia,
hyperxsthesia, and some of the various forms of par-
' Read at a meeting of the Syracuse Academy of Medicine,
June 16, 1S96.
EBSthesia are usually present. Visual disturbances,
such as photophobia, asthenopia, and an enlarged and
sluggish state of the pupil, are seldom absent, while at
times contracted visual field and the graver defects of
vision are observed. The senses of hearing, smell,
and taste are perverted, but seldom to the extent of
occasioning serious annoyance; while sleeplessness,
headache, vertigo, loss of apjjetite, impaired nutrition,
spinal pain, and a host of minor derangements com-
plete the wretched state of the subject.
The great majority of cases of the affection occur
between the twentieth and fiftieth years of life and
are met with very much oftener in men than in
women. Most of the cases seen in this country are of
the neurasthenic type, although the hysterical element
may be detected in a small proportion of the cases.
The average age for hysterical cases is said to be less
than that for the neurasthenical. This assertion rests
up>on no substantial data and is scarcely worthy of
acceptance. According to the writings of foreign
authorities it has striking national peculiarities. In
France the hysterical cases preponderate; in Germany
the hypochondriacal; and in England the neuras-
thenical. It is extremely questionable if these differ-
ences in symptoms exist in the degree that has been
claimed for these countries. Undoubtedly much of
these differences may with greater propriety be
ascribed to the methods and personal bearing of the
observer. The slowly ]K'rformed, methodical exami-
nation best develops the hyjsochondriacal side of the
disorder, while hy.sterical or neurasthenical tone may
be produced and given undue coloring as the result of
the bearings and suggestions of the examiner upon the
subject. For the most part, however, the symptom
complex is determined by the nature of the injury and
the prexious state of patient. If the subject had
always been a neurotic the disorder would tend to as-
sume the neurasthenical fonn ; if emotional to an
unusual degree prior to the accident, the hysterical
type of the trouble would probably develop.
Not infrequently is witnessed in our courts the spec-
tacle of a serious contention arising through the dis-
agreement of the experts concerning the precise nature
of the neurosis encountered; whether it be hysteria, or
neurasthenia, or an intermingling of the symptoms
peculiar to tliese affections. Hysteria may have
existed prior to the injury, and proof of its existence
would go far toward establishing a successful defence
to an action for damages if hysterical expression were
the chief or only manifestation exhibited after the in-
jury. Again it might be alleged as a defence that the
claimant was a "neurotic" before the injur}' occurred.
If such allegations were sustained by competent evi-
dence compensation would as a matter of justice be
lessened or withheld by our courts. Thus it may
happen that the particular phase which the neurosis
assumes is sometimes of more importance than any
other question connected with a given case.
The claim made by some of the leading neurologists
of to-day that neurasthenia and hysteria are due to
disintegration of the nervous system is plausible
enough and possibly may be true; but unfortunately,
like too many other claims of modern medicine, it is,
in our present state of knowledge and with the means
at our command, incapable of satisfactory demonstra-
tion. The older tneory of dynamical disturbance of
the nerve elements as causative of hysteria and neuras-
thenia is by no means exploded by the newer theory
of nerve disintegration. Both theories are tenable,
but one is no more proven than the other.
Statistics have been introduced into the current
literature of the subject which appear to prove con- I
clusively that the traumatic neuroses are developed with I
greater frequency and with more intensity at or near
the large centres of population, while the converse oc-
September 26, 1896]
MEDICAL RECORD.
437
curs in the remote country districts. Without doubt
the affection is oftener seen at populous points, but
not to the extent that has been claimed. In country
districts such conditions are not so well understood
nor so readily recognized by physicians; while, upon
the contrary-, the physicians of the cities not only
recognize these traumatic states but they put their
patients by their instructions in a position to realize
the importance of the dangers which may remotely re-
sult from traumatic influence. Resulting, then, as it
may, from a great variety of causes, traumatic neurosis
is by no means of infrequent occurrence in countiy
districts, for it is highly improbable that one could
fail to lind the histories of at least a half-dozen or
more well-marked cases in an aggregation of a thou-
sand people anywhere in this country — be it ever so re-
mote from the centres of population. For this reason
the affection is a very important one to the country
practitioner and he has no just excuse if he does not
possess the ability to detect and intelligently treat it.
The question of alcoholic or syphilitic taint may
arise and its determination may be an important ele-
ment in the adjudication of a case. Syphilitic infec-
tion is oftentimes set up as a defence, and is usuallv
introduced for its bugbear effect. The syphilitic and
alcoholic neuroses are usually not specially difficult
of detection ; nevertheless, it should not be forgotten
that a very profound syphilitic cachexia may manifest
itself in a way which may be mistaken for some
serious nervous condition, even by very competent ob-
ser\-ers.
In the consideration of the ultimate effects of
trauma upon the nervous structure the physician en-
counters problems which lie more within the domain
of psychology than of medicine proper. The bestowal
of compensation upon the industrial classes for slight
or imagined injuries has not only its medical aspects
for the ph3'sician to deal with, but it is a matter of
more than passing sociological importance, which,
sooner or later, will make itself perniciously felt upon
the morals of the people of this countr}% the same as it
has already done in some of the countries of Europe.
It behooves, then, the physician who assumes the role
of the expert to give the most careful consideration to
the weight of his utterances respecting the nature and
sequence of the trauma which he has to consider. It
is no doubt true that if the baneful effects upon the pa-
tient of the injudicious suggestions of the friends and
attending physician could have been removed from
the cases which have been the subject of litigation,
more than one-half of the damages heretofore awarded
in this country as compensation would never have been
bestowed. That many of the symptoms which follow
nearly even' case of trauma can be accounted for on
purely psychical grounds, there is now no dispute. The
evils of introspection are in many instances greater
than the evils of the suggestions of those having rela-
tions with the patient. When these two influences are
brought to bear upon a given case, they constitute evils
the most powerful and pernicious with which we have
to contend in arriving at a correct estimate of the
actual damage sustained by the nervous system. .\s
is generally known, it is possible for persons in-
fluenced by introspection and suggestion to construct
an organized symptom complex identical with the re-
mote symptoms of profound trauma upon the nervous
system, and while in this state escape detection and
secure a heavy award of money from some luck-
less individual or corporation without having ever
undergone physical or psychical injury. .Such simu-
lation is too often witnessed to require the introduc-
tion of direct proof of its existence. It may be con-
sciously or unconsciously performed; nevertheless, it
is a simulation in its most subtle form. Symptoms
so successfully simulated cannot be differentiated
from the symptoms of true cases of traumatic neurosis,
except by a historj^ of the case ; and in the absence of
this knowledge, we have no certain means at our com-
mand for the detection of the deception. Use may be
made of the various so-called objective signs of the
expert neurologist, and instruments of precision with-
out number may be brougiit into requisition, and, not-
withstanding these aids, the acumen and ability of the
investigator is unequal to the task of unmasking the
imposition, and the case, in the absence of an accurate
history, is regarded as genuine. Neurologists, as has
been adverted to before, have recently evolved the
theory that the traumatic neuroses, in whatever form
manifested, are the result of the disintegration of
ner\ous matter. This theory neither sustains nor
strengthens the connnonly accepted doctrine of the
changeable nature of the symptoms of the affection ;
but, on the contrary, tends to confirm the teaching of
those observers who maintain that changeableness of
the s\'mptoms indicates exaggeration or simulation.
Disintegration of nen-ous matter is unqualifiedly a
definite pathological process and must of necessity
give rise to definite symptoms. Changeability of
symptoms denotes a converse state of things, or the
absence of a fixed pathological condition such as dis-
integration of the nervous system implies; hence it is
evident that the theory of causation is wrong, or else
changeableness of the symptoms is either an erroneous
conclusion or is due to simulation. Traumatic neu-
rosis, in this country, is usually met with as a neuras-
thenia. Writers agree that the symptoms of the idio-
pathic and traumatic varieties of neurasthenia are
identical; and the idiopathic form is acknowledged,
on their part, to have definite symptoms of sufficient
stability to warrant an easy and unfailing diagnosis,
while the traumatic t)'pe, according to the neuro-
logical ex]Dert, has changeable symptoms which re-
quire special skill and the use of instruments of pre-
cision for their determination. It is utterly impossible
for any one having a knowledge of the admitted facts
pertaining to the forms of neurasthenia under discus-
sion to reconcile conclusions of this character. The
disagreement is apparently due to the zealousness of
investigators who have originated special tests for the
detection of malingering. These tests are intended to
establish the presence of objective signs or sj'mptoms
which in themselves constitute an unfailing means for
obtaining a correct diagnosis in suspected or doubtful
cases. Much could be given in the way of description
of these signs, but suffice it to say that, as yet, there
are no known special signs, alone sufficient, whereby
a case of traumatic neurosis can be differentiated from
one of ordinary idiopathic neurasthenia. The pres-
ence of sprains and other objective evidences of recent
injury, together with an authentic historj- and a
stable, we 11 -organized symptom complex, constitute
the only reliable factors for differentiating, with cer-
tainty, the genuine from the simulated cases of trau-
matic neurosis. Instruments of precision and special
tests are, at times, very valuable aids to diagnosis, but
their employment under ordinary circumstances is un-
necessary. There are numerous instances in which
simulators have successfully maintained their impos-
ture against the tests and armamentarium of the spe-
cialist, and oftentimes a little common sense is of more
use in diagnosis than all the special tests and diag-
nostic appliances combined.
"The stumbling-block in the whole matter of the
accident neuroses,'" says a late editorial writer, "lies
in the interpretation and significance of the term sim-
ulation." According to some obser\-ers it is extremely
difficult to find many cases of simulation : while, upon
the other hand, authorities of equal repute persistently
affirm that a large percentage of the number is noth-
ing but wilful, well-disguised cases of simulation.
438
MEDICAL RECORD.
[September 26, 1896
The controversy over the matter has been long and ac-
rimonious, and has resulted in no special advantage to
either side of the question. The discussion, however,
has given us the term " simulationists" as a name for
those who believe in the existence of a large amount
of simulation. The final settlement of the question of
simulation will be reached when the matter of the
patholog}' of traumatic neurosis shall rest upon indis-
putable grounds. If the theory of the disintegration
of the ner\-ous system prevails, then stability of the
symptoms, whether physical or psychical, will denote
genuineness of the affection, and instability- of symp-
tom expression will indicate exaggeration or simula-
tion. From what has been said it is evident that the
employment of special tests for the determination of
doubtful cases has, thus far, failed to give satisfac-
tory results, but, instead, has given rise to an endless
discussion, confusion, and disagreement among the
experts. Therefore, in view of w-hat we know of the
subject, it is evidently always best to stick to the prac-
tical methods of examination, even in determining the
status of the doubtful cases of traumatic neurosis.
Conclusions:
(1) The surgeon should be an equal authority with
the neurologist in determining the sequences of trauma
upon the ner\'ous system.
(2) Neurasthenia is the usual form under which
traumatic neurosis expresses itself, and its symptoms
are indistinguishable from neurasthenia arising from
other than traumatic influences.
(3) The actual condition of the patient previous to
the accident must be known in order to reach a correct
estimate of the damage from injury sustained by the
nervous system.
(4) The type of symptoms manifested by the neu-
rosis, whether neurasthenical or hysterical, is often-
times a question of vital importance in the adjudica-
tion of a claim for damages.
(5) Traumatic neurosis occurs oftenest at the
centres of population, but it is by no means a rare
affection in the countr}' districts.
(6) It is probable that traumatic neurosis is depen-
dent upon some definite — yet unknown — change in
the arrangement and structure of the cellular elements
of the nervous system, which gives rise to stable rather
than unstable symptoms.
(7) A stable, well-organized symptom complex in-
dicates damage to the nervous structures; \\hile insta-
bility of symptoms and want of orderly arrangement
denotes trivial injur)- — and, if long continued, simula-
tion is rendered probable.
(8) The so-called "objective symptoms" depend
upon the psychical rather than the physical state of
the subject, and are unreliable guides to diagnosis.
(9) A correct diagnosis is best obtained from a re-
liable account of the accident, the history of the pre-
vious state of the patient, the presence of surgical
troubles and the existence of a stable, well-defined,
organized symptom complex.
(10) The term "traumatic neurosis" is an expres-
sion for an indefinite condition, and a simplification
of the subject is desirable from a clinical standpoint.
Scabies.— Dr. Hare, in Medical Worlds says: "The
' itch ' (scabies) is often hard to treat successfully.
Sulphur ointment well rubbed in will often allay, but
frequently fails of curing because of the depth of the
furrows made by the female acarus. It is therefore
best, before the application of the ointment, to give
the patient a thorough hot bath, lasting half an hour,
■with strongly alkaline soap, in order to soften the epi-
dermis and uncover the burrow of the worm. The
ointment mav then be used with much benefit."
THE SURGERY OF EMPYEMA.'
By T. N. RAFFERTY, M.D.,
ROBINSON, ILL.
The fact that empyema was not only recognized but
treated surgically in the remotest days of antiquity
adds interest to the discussions of the present day as
to the best surgical procedures for its relief. The
surgical treatment of the disease is said to owe its
origin to the mythological legend which tells us that
Jason, seeking death in the midst of battle, received a
spear wound in the chest and was thus artificially re-
lieved of an empyema. The same story, with a dif-
ferent hero, is related by Plinius in the seventh book
of his " History of Nature." We also have the oft-
quoted case of Kinesiros, whose pleura is said to have
been opened by the actual cautery by Euryphon of
Knidos. Traced, as it can be certainly, from Hip-
pocrates down through this long series of years, the
surgical relief of empyema has afforded a theme
for animated discussion as to the proper indica-
tions for its performance. Hippocrates' operated
by incision with the knife, by actual cautery, and by
perforation of the ribs; and operations of this sort
seem to have been common enough in his day. An-
other striking fact is that Hippocrates taught and
practised frequent washing of these patients before the
operation, and thus really practised what is now known
as aseptic surgery. From soon after the days of Hip-
pocrates there is no further account of surgical treat-
ment of empyema for more than two thousand years,
when it was revived by Sedillot, but was not looked
on with favor by other surgeons, and even Dupuytren
said he would rather die of the disease than be killed
by the doctors. Since the revival of the operation by
Sedillot, however, it has never again been remanded
into obscurity, but has gradually come to be consid-
ered, in some of its forms, indicated in all cases of
empyema that threaten life and cannot be cured by
other means. Up to 1850, however, there was no real
certainty or agreement as to its use, except as a last
resort. About this time Trousseau laid down the
proposition that in pleuritic effusions, no matter what
their character, we ought not to wait till death is im-
minent, but operate with the view of warding off dan-
gerous attacks of dyspnaa, which may unexpectedly
seize the patient and carry him off with great rapidity.
The great Frenchman encountered opposition to his
views from every side, notwithstanding his successful
results; and the operation would perhaps again have
fallen back to its former limited sphere had not Dr.
Bow-ditch, of Boston, begun his brilliant advocacy of
Trousseau's doctrine, which was soon aided by the in-
vention by Dr. Wyman, another American, of his suc-
tion instrument, and aspiration made possible. Dr.
Bowditch operated for empyema two hundred and fifty
times, and published papers on the subject in the Ain-
erii-ati Journal of ilic Medical Seieiiees, April, 1852 ; Tlie
jMcdieal Monthly, January, 1853; Boston Medical and
Surgical Journal, May, 1857; and read his last paper
on the subject before the New York Academy of Medi-
cine in 1870. Leaving out the treatment with drugs
and counter-irritants, by which it is hoped to produce
absorption of the pleural efiusion, the lines of treat-
ment now advocated are about as follows: ist, simple
aspiration; 2d, aspiration followed by irrigation with
antiseptic solutions; 3d, aspiration followed by per-
manent drainage, Beulau's method; 4th, simjjle inci-
sion; 5th, resection of small portion of a rib to insure
free drainage; 6th, resection of larger portions of ribs
sufficient to secure drainage and produce retraction of
' Read before the /F.sculapian Society of the Wabash Valley,
at Terre Haute, Ind., June j, i8g6.
' " De -\Iorbis," Hippocrates.
September 26, 1896]
MEDICAL RECORD.
439
chest wall, Estlander's operation; 7th, thoracoplasty,
or removal of the chest wall, Schede's operation.
Dr. Carl Beck, who is a strong advocate of the
resection of one or more ribs in the treatment of all
operative cases of empyema, regards it as deporable
that there should be any difference of opinion in
regard to the advisability of this method in prefer-
ence to any and all others. His sarcastic assertion,
that an explanation of this deplorable difference of
opinion is only to be found in the fact that the "gen-
eral practitioner " has had the effrontery to attempt
the solution of surgical problems, certainly has no
scientific weight in deciding the best method of treat-
ing a condition that varies so much in different cases
as does pyothora.x.
Many cases of empyema occur in children, and, for
reasons which we shall see later on, it is quite prob-
able they may do well with a less radical treatment
than is required in adult cases. So the chronicity of
cases, the condition of the lung, and the viscidity of
the pus contained in the cavity are all factors that
should be considered in deciding whether aspiration,
incision, or resection of ribs will be best suited to any
particular case. It has been suggested by Ur. Tiffany,'
of Baltimore, that much depends on the character of
the pus found in these cases, not only as regards prog-
nosis, but in deciding the character of the operation
required. He advises the use of the hypodermatic
needle for withdrawing a suiificient amount of the pus
for bacteriological examination, and believes that if the
patient has pyasmic cocci he will die under any form
of treatment; while if there are only staphylococci, or
pneumococci, removal only is necessary without ir-
rigation ; but if streptococci are found, resection and
washing out are necessary. Cases due to simple in-
fection by pneumococci or staphylococci are therefore
to be regarded as benign; those caused by sapro-
phytes, in which case the infection is putrid, as in the
highest degree unfavorable; while those arising from
streptococcus infection occupy a middle ground as re-
gards their danger to life." However, in many pleu-
ritic effusions, both serous and purulent, no microbes''
can be found. It has been assumed that such cases
are tuberculous, but there seems no sufficient reason for
such conclusion. If the empyema is due to a mixed
infection, the gravity of the case depends on the pre-
dominance of the more virulent bacteria present in
the exudate. The very fact that surgeons still differ
as to plans of treatment, and show equally good re-
sults from their favorite methods, is a striking proof
that all cases should not be treated alike. Any effort
to inculcate a different doctrine, for the gratification
of personal pride in one's own particular method,
savors of an egotism that is dogmatic and unscientific.
All operative measures in the treatment of empy-
ema have for their chief end two objects: first, to
evacuate the pus or other fluid contained in the cavity;
and second, the obliteration of the cavity by bringing
together its walls. The latter is best done by that
method w-hich closes the cavity by expansion of the
lung and not by retraction of the bony thorax.
The first question to be decided in any case is
whether any operation is necessary for its relief. This
question was discussed in a paper by Dr. John Ash-
hurst, Jr., of Philadelphia, read at the meeting of the
American Surgical Association in 1894. He then
said: "No operation is justifiable unless the presence
of pus is certain; unless thorough treatment by medi-
cinal agents, blisters, etc., has failed; or unless the
dyspnoea and other symptoms are so urgent as to de-
mand immediate relief." Since the presence of pus
is never absolutely certain, it follows that we should
'Transactions .\merican Surgical Society, 1894.
'"American Text-Uook of Medicine," p. 522.
• Koplik: " American Text-Book of Diseases of Children."
not, in ordinary cases, oper?te unless the symptoms
are urgent. If operation is decided on, a simple aspi-
ration should be done unless it seems certain that this
will not be sufficient. The aspiration should be done
under strictest antiseptic precautions, and with the
same care in this regard as though it were a major
operation, because on our care in so doing depends
the certainty almost of changing a serous effusion, if
such is found, into a purulent one.
The point usually selected for aspiration is the
sixth intercostal space, but the exact location is
largely a matter of choice of the operator. It should
be low enough to permit of the emptying of the cavity,
and high enough to be out of the way of the dia-
phragm, which moves upward as the fluid flows out.
If the fluid evacuated is serous, and thorough asepsis
has been secured, the chances are favorable that noth-
ing more will be required. Following this first aspi-
ration irrigation with antiseptic solutions should not
be done. If the fluid is purulent, a reaccumulation
is likely to occur, in which case either simple inci-
sion or puncture and permanent drainage (Beulau's
method) should be practised, 'i'hese methods favor
the obliteration of the cavity by expansion of the lung,
and if this takes place the patient is left in much
better condition than when retraction of chest wall
occurs. If from any cause sufficient drainage cannot
be had by either of these methods, then a small por-
tion of rib (an inch is ample) may be excised. If,
however, the lung is bound down by adhesions so that
expansion is impossible, then the operation of Est-
lander is certainly indicated, in which case there must
be sufficient excision of ribs that by collapse of the
bony thora.x the costal pleura will be brought in con-
tact with the layers next the lung.
A good many writers on this subject seem to have
confounded simple resection of a small portion of one
rib, for the purpose of securing and maintaining better
drainage than can be had by simple incision, with the
operation known as Estlander's, which has for its ob-
ject an entirely different purpose. The Estlander op-
eration, as before stated, aims at retraction of the
chest wall in cases in which the already crippled lung
cannot expand, and consists in the removal of exten-
sive sections of two or more ribs. In many cases,
however, it has been demonstrated that the mechanism
of the cure of empyema is not dependent upon the re-
traction of the chest walls, and hence a resort to the
Estlander operation is not necessary in all cases, even
of protracted and extensive pyothorax. Such at least
was the report of the committee appointed by the Bel-
gian Academy of Medicine,' who, with M. Deroubaix
as their chairman, made exhaustive study of the sur-
gery of empyema. Their report, however, retains the
Estlander operation in the list of legitimate surgical
practice, and leaves the selection or rejection of tiiis
operation to the tact and judgment of the surgeon in
each particular case. Verebelyi, of Vienna, thinks
resection of ribs ' is generally unnecessary, and is only
indicated when by approximation of the ribs a free
exit of pus is hindered. Moullin" favors a trial of as-
piration, and states that in children it is often success-
ful and in case of adults is always worth the attempt.
If this is not successful he advises incision and the
insertion of as large a drainage tube as the space be-
tween the ribs will permit. He resorts to resection
only in extreme cases, when there is such an overlap-
ping of ribs that drainage through a tube cannot be
accomplished: and regards washing out the cavity
with antiseptics as unnecessary and dangerous. Re-
section certainly increases the liability to pya-mia
and produces deformity of the chest. .Vnother and
most serious objection to it is that its performance
' S,-ijous' .\nnual.
^ Treatise in Surgery, p. 836.
440
MEDICAL RECORD.
[September 26, 1896
necessitates the use of anaesthetics, which not only are
not well borne, but are absolutely dangerous in these
cases. To operate without an anaesthetic is brutal in
the extreme, and only the direst necessity should ever
be a sufficient reason for its undertaking. Notwith-
standing these and other objections to an operation
which is certainly not devoid of danger, it is the plan
advocated by many eminent surgeons, among whom
may be mentioned Koenig, Schede, Weir, Bull, Mc-
Burney, and Beck. Dr. Achutz, in a paper on " The
Treatment of Empyema in Children," read before a
meeting of the Medical Society of Hamburg recently,
emphasized the necessity of costal resection in all of
these cases, and reports eighteen operations and six-
teen recoveries. He deprecates all forms of expectant
treatment and performs the radical operation as soon
as the diagnosis is made that effusion exists.
As showing how favorable results are sometimes
secured, under unfavorable circumstances and from
methods of treatment that would not be considered
good surgery by the extreme ad\ocates of resection in
all cases of empyema, the following report of two
cases is offered. These cases are not reported as em-
bodying all the writer's experience with empyema, nor
for the purpose of " deducing classical rules from the
results and observation of two cases," but for the
reasons above stated.
Case I. — E. T , eight-year-old girl, was seen
ten years ago in consultation. There was a large ef-
fusion in the left pleural cavity, following an attack of
pleuropneumonia. The heart was displaced, and its
apex beat was to the right of the sternum. The
symptoms were urgent and the dyspncea was extreme.
\Vith no antiseptic precautions, the fluid, which was
sero-purulent, was aspirated — at least enough of it to
relieve the urgent symptoms. The point of puncture
was covered with adhesive plaster, which was pushed
off very soon afterward by the escape of fluid. This
discharge continued for about five months, gradually
diminishing, finallv ceased altogether, and the fistula
closed. The child recovered her health permanently
and perfectly, and is now a robust, red-faced young
lady, with no chest deformity whatever.
Case II. — J. R , aged forty-eight years, has had
chronic tuberculosis for years. In December, 1893,
he became much worse and was confined to his bed
for the next four months. With the advent of warm
weather he rallied and seemed much better. At this
lime no effusion was discovered. Three or four
months later he came to my oflice, and on examination
a large effusion in the right pleural cavity was diag-
nosed. The next day, under antiseptic precautions,
sixty ounces of pus were removed by aspiration, much
to Ills relief. At this time, more than a year and a
half afterward, there has been no reaccumulation, the
tuberculous process has been latent or nearly so, and
he has been in very fair condition.
.\ study of recent literature and observations made
at a number of tiie largest clinics of this country, both
east and west, have led me to question the propriety
of the extensive resection of ribs in any but the most
desperate cases. And while there are, no doubt, many
cases in which the resection of a portion of a rib gives
better results than the simpler methods, there have
been many cases thus operated more for the sake of
doing the major operation than with the belief that it
was necessary. Especially is this true of the opera-
tion of Estlander and the thoracoplasty of Schede.
.\s for other novel procedures occasionally advocated,
such as curetting the pleural cavity, etc., they need
only to be mentioned to be condemned.
So, too, the indiscriminate use of antiseptic injec-
tions is to be strongly deprecated. Many fatal re-
sults are recorded as immediately following this prac-
tice; and in the operation for ordinary empyema it is
an unnecessary and dangerous procedure. If done
at all it should be at later periods, and then the ut-
most caution should be observed. Surgeons should
ha.ve " A'O'i »cifere " for their motto more often than
they do, and not allow the/t/mr opetaiuii to drive it
from their memory. Many, ver)- many, cases of pleu-
ritic effusion do well without any operation whatever,
and when operation is necessary the simplest one
that will cure the patient is the best.
SOME NOTES ON THE B.\CTERIOLOGY OF
MUMPS.
By r. M. MECRAY, M.D.,
CAMDEN, N". J.,
AND
J. J. W.VLSH, A.M., M.n.,
PHILADELPHIA, PA.
An epidemic of mumps in the Camden Home for
Friendless Children, in the service of Dr. Mecray,
suggested the idea of looking for the cause of the dis-
ease in the secretion from the parotid as found in
Steno's duct before its entrance into the mouth. The
study itself was too incomplete to make the conclu-
sions from it very definitely satisfactoiy, and the notes
are published with the idea that, as we are not in a
position to go on with the work, they may prove sug-
gestive to others working in the same line. There is
not very much in the literature as to the bacteriology
of mumps. The text-books almost without exception
ignore it entirely. Much of our work had been done
before we found in the periodicals anything \er}' defi-
nite or materially suggestive.
The " American Text-Book of Diseases of Children"
refers to the investigations of Capitan and Charrin,
but does not say where an account of them may be
found. We suppose the reference is to their re-
port to the Society of Biology in 1881.' This work
was done before Koch's classical papers, practi-
cally laying the solid foundation of the modern
science of bacteriology, had been published, and
it is almost necessarily meagre, indefinite, and un-
satisfactory. A number of microbes, spherical and
bacillary, are described as occurring in the blood
and saliva. The flora of the mouth was very little
known at that time, and the precautions necessary
to prevent contamination from the skin, in making
cultures from the blood, were not well understood,
so that the findings have not much of scientific value.
The conclusion suggested by the research, however,
seemed to be that a form of bacillus was concerned in
the etiology of mumps.
Previous studies are apt to have an influence in the
conclusions of after-observers, and so Bouchard ' and
Boisnet,' in isolated cases, and Bordas* in a series of
cases found in the blood and saliva bacilli that they
considered the cause of the disease.
Considerable study has been devoted to the micro-
organism found in parotitis in which the inflammation
had gone on to suppuration, but in these cases there
had been a mixed infection and pus cocci were of
course demonstrable. The infrequency of abscess
complicating parotitis makes it extremely unlikely
that the mumps organism of itself would ever cause
suppuration.
Micrococci distinct from pus cocci were found in
the blood and saliva in a severe case of mumps in
1885 by Dr. Netter at La Pitie," and a coccus that they
' Comptes Rendus Soc. Biol., May 28, 1881.
' Bouchard: These de Paris, 18S3.
' Boisnet : I, yon Medicale, 1S85.
■• Bordas: Comptes Rendus Soc. Biol., November 16, 1889.
' " I.efons de Clinique de Jaccoud," I'aris, 1895.
September 26, 1896]
MEDICAL RECORD.
441
thought specific was found by Laveran and Catrin in
an epidemic of mumps that occurred among some
regiments quartered in Paris in 1893. In their re-
port to the Society of Biology, January 28, 1893, they
describe the organism as a micrococcus seen most fre-
quently in the form of a diplococcus, though some-
times found in fours, or as zoogloea. They grow well
on the ordinary media, though rather slowly, clouding
bouillon somewhat in twenty-four hours, and appear-
ing on gelatin after forty-eight hours as small white
punctiform colonies, which develop very slowly and
liquefy some considerable time after coalescence.
They grow on potato and give a whitish appearance
not easy to detect.
In a further communication to the society. May 20,
1893, they report that they had found the organism in
sixty- seven out of ninety-tw-o cases of mumps exam-
ined. In the exudate of the inflamed gland obtained
by puncture with a syringe, they found it thirty-nine
times out of fifty-six in pure culture and twice in
mixed cultures. The fifteen negative results they con-
sider due to the fact that but an extremely small quan-
tity of the exudate could be obtained. In the exudate
from the metastatic orchitis of mumps the organism
was found in twelve out of sixteen cases, in pure cul-
tures. The blood of patients gave pure cultures of
their " diplococcus " ten times in fifteen trials when
taken during the fever. In all cases growths of the
micro-organism had to be obtained, as it could not be
found in the blood or secretions by the microscope
directly, the number of cocci present seemingly being
very small.
This micrococcus form, usually seen as a diplococ-
cus, was the principal feature of our findings in cul-
tures from Steno's duct made during the height of the
disease, and we had isolated and noted its mode of
growth on various media before we knew of Laveran
and Catrin's work. The method was as follows: The
mouth was thoroughly washed out with a saturated
solution of boric acid, and the orifice of the duct, after
some slight massage of the cheek to empty it, was
covered by a swab of cotton soaked in the solution,
and this was allowed to remain between the jaw^ and
cheek for five minutes. A bit of sterile silkworm gut
was then introduced into the duct and from it an agar
slant was inoculated.
Out of ten tubes six had a mixed growth, but in all
of them there was noted a small, white, slow -growing
colony. This was isolated in plate cultures and was
found to contain two different organisms, one a strep-
tococcus form, the other a micrococcus, nearly always
seen as a diplococcus. Further culture showed that
the streptococcus grew more rapidly and liquefied gel-
atin sooner (in three to five days) than the micrococ-
cus. It did not occur in the original cultures as con-
stantly as the latter, the diplococcus form, occurring
for certain in eight of the ten tubes and being consid-
ered to be present in the others, though this could not
be demonstrated with certainty, owing to invasion of
the colonies by the more rapidly growing cocci so
common in the mouth, which our precautions had not
succeeded in entirely eliminating.
We had been studying only the cultures from the
duct, but, as Laveran and Catrin had reported the
presence of the organism in the blood, we made cul-
tures from the blood in eight cases. The blood was
drawn from the lobe of the ear, and to avoid contami-
nation by micro-organisms from the skin thorough
cleansing was employed. The part was washed with
soap and water, then with alcohol, then with i to 500
bichloride, then with alcohol again, which was al-
lowed to evaporate; puncture was made with a sterile
needle, the ear being supported by a sterile towel (all
these precautions, almost impossible in private prac-
tice, were comparatively easy to be carried out in a pub-
lic institution). Out of the eight tubes two gave an en-
tirely negative result, three gave pure cultures of the
characteristic diplococcus, and three gave a mixed re-
sult, the diplococci being found, but with them other
cocci, notably a staphylococcus form, probably the
staphylococcus epidermidis albus.
Control tests made from the blood of five healthy
children gave absolutely negative results. Cultures
made from Steno's duct in these same children gave
us various oral micro-organisms in four cases, but not
the diplococcus found in the mumps cases.
" Beyond this our observations did not go. Though
a single case ' has been reported in which a dog play-
ing with a child that had mumps suffered from swell-
ing of the parotids, malaise, etc., this must have been
a coincidence, or a number of cases would have been
reported, as domestic animals are so often exposed to
the contagion and yet do not acquire it. Laveran and
Catrin found that the injection into the testicle of
pure cultures of the micrococcus isolated by them set
up orchitis, but, as almost any irritant would do this
in tissues so susceptible and highly organized,
the observation does not seem of much scientific
value.
Micrococci of various kinds are so common about
the mouth and so easily contaminate cultures made
from the blood, that the suggestion of such a form
as the specific bacterial cause for one of the in-
fectious fevers is usually set down as due to insuffi-
cient precautions in avoiding contamination while
making the cultures. The characteristics of the
growth of the micrococcus described are sufficiently
like those of that very common organism, the staphy-
lococcus epidermidis albus (Welch) to greatly
strengthen the impression that perhaps this or some
degenerate form of the ordinary cutaneous and oral
micrococci is here described.
The diplocccus we found, however, seemed to grow
even more slowly and to liquefy gelatin after a con-
siderably longer time than the staphylococcus de-
scribed by Welch. The negative results in the cases
of healthy children living under just the same circum-
stances, and on whom the same precautions were em-
ployed, would seem to show that it was not an organ-
ism ordinarily present.
What etiological connection it may have in the
absence of the possibility of producing the disease in
animals it is hard to say, but there is certainly to be
found pretty constantly in the blood and parotid se-
cretion of mumps cases this diplococcus which is not
found ill children unaffected by the disease.
As a number of forms of cocci are known to invade
the parotid gland and set up a non-specific parotitis
in systemic septic conditions or during states of low-
ered vitality, it does not seem so improbable as it
might on first thought that the specific cause of infec-
tious parotitis is a form of coccus.
The micrococcus isolated by us grows in pairs, oc-
casionally in fours, rarely in larger groups. Each in-
dividual coccus is very regularly rounded, and about
the size of the ordinary pus coccus. The colonies are
small, white, glistening, distinctly defined, regularly
circular spots, at first discrete and of very slow growth,
gradually coalescing. The slow growth is a marked
characteristic. In making pure cultures three days
after inoculation gelatin tubes were set aside as fail-
ures, no growth being noted; three days later the small
white colonies were distinctly visible. At ordinary
temperatures gelatin does not begin to liquefy for from
ten to twelve days and liquefaction proceeds slowly.
A faint white streak appears on the third day on potato
and slowly spreads as a delicate whitish film. On
blood serum growth is more rapid than on other media,
and the colony is not so distinctly white in color.
'Whittaker; ".Mumps," Pepper's " Te.\t-Book."
442
MEDICAL RECORD.
[September 26, 1896
Litmus milk changes to pink on tlie third day and
coagulation' takes place. Milk seems an excellent
nutrient medium for it and a ready means of spread-
ing contagion.
NOTES UPON THE ESTIMATION OF THE
NUMBER OF BACTERIA IX MILK.'
]!v MAUD J. FKVP:, M.D.,
BrFFALO,
CLINICAL INSTRUCTOR IN DISEASES OF CHILDREN, UNIVERSITY OF BUFFALO ;
VISITING PHYSICIAN TO THE ERIE COUNTY HOSPITAL, CHILDREN'S WARD.
The examinations of milk which this paper reports
were undertaken on account of the writer's interest in
paediatrics, the object in doing the work being to learn,
so far as such a bacteriological test would teach, the
fitness of milk from various sources for infant feeding.
The facilities of the pathological laboratory of the
University of Buffalo were at the experimenter's dis-
posal, and the work was done under the direction of
Dr. Herbert U. Williams.
The method used for counting bateria in milk was
as follows: To a test tube containing a definite quan-
tity of sterile water, say 50 c.c, 0.5 c.c. of milk was
added and the contents of the tube thoroughly shaken.
One cubic centimetre of this mixture, containing 0.0 1
c.c. of milk, by means of a sterile pipette was added
to a test tube containing liquefied sterile nutrient
gelatin or agar. This tube was then whirled or agi-
tated until the gelatin and diluted milk were thor-
oughly mixed. The contents of the tube were then
poured into a sterile Petri plate. These plates,
whether gelatin or agar was used, were kept at the
room temperature. At the end of forty-eight hours in
sunnner, after seventy-two or more in winter, the
colonies were counted. The apparatus used for this
was devised in the laborator\'. The Petri dish was
placed over a piece of glass, the under surface of
which was painted black, the upper surface ruled in
square centimetres. Then with the aid of a small
magnifying glass, which in this case was an ordinary
engraver's lens, the colonies were counted. If not
many were present the entire surface was gone over;
if the number was great, ten alternate squares were
counted and tlie number on the plate estimated from
the area of the dish. The number of colonies repre-
sented approximately the number of bacteria in 0.0 1
c.c. of milk. At the time of making the culture two
control plates, one of the water used in diluting, one
of the medium, were made. So long as these remained
sterile whatever grew on the milk plates necessarih
had its origin in the milk.
l"he dilution of milk is necessary for two reasons:
First, To add to the gelatin even 0.5 c.c. of milk would
make a mixture so opaque that the little grayish or
creamy white colonies would be indiscernible.
Second, even in the best milk the number of bacteria
in 0.5 c.c. is so great that it would be almost impossible
to count them. Indeed it is only the best milk that
requires so little dilution. .At this time of the year
(June) for grocery milk a .second dilution is done and
cultures are made from a mixture of which i c.c. con-
tains approximately o.oooi c.c. of milk. Of course so
much dilution increases materially the chance for
error.
(lelatin was used as a culture metlium luitil the
weather became so warm that it liquefied at the room
temperature, when agar was substituted. Either
medium has its disadvantages. The rapid develop-
ment of liciuefying organisms in gelatin soon renders
counting impossible. Xo less an objection is the
cloudiness which certain bacteria produce in agar.
In which medium the greater number of colonies
' Read before the Buffalo Academy of Medicine, June i6, 1896.
develop was not determined. One experiment showed
about the same number in each.
The influence of temperature on the number of
bacteria in milk is noticed in comparing tiie results of
examinations of the same milk supply made last
winter and this spring and summer.
A point of some interest is that all bacteria do not
develop with equal rapidity. There will be a con-
siderable increase beyond the number found on the
usual day of counting.
Certified milk plated February 6th on- February
nth showed 88 colonies, on the 13th, 139.
Grocer}' milk plated March 2ist showed on tiie 23d
246 colonies; on the 24th, 369.
Sterilized milk (from dairy) plated April 2d gave
8 colonies on the 7th, :o on the i ith. No furiiier in-
crease was found, though the culture was kept one
month.
Creche milk plated May 13th showed on the i6th,
84 colonies; on the 18th, 158.
Certified milk plated May 9th showed on tiie 12th,
255; on the 14th, 323. The same plated May i6th
gave on the i8th, 350; on the 19th, 480. The same
in agar June loth siiowed on the 12th, 44; on the
13th, 58.
It is well known that milk is a medium in which
bacteria multiply with great rapidity. Indeed the
enormous numbers found in milk depend probably not
so much on the extent of the original contamination
as upon the length of time and the conditions under
which the milk has been kept. But one experiment
illustrating this has been done. Certified milk of
that day's milking was brought to the laboratory and
directly plated. Two days later the plates showed
57,600 bacteria to the cubic centimetre. The milk
was left in laboratory, covered as it is sold, for four
hours, the room temperature being from 68"' to 72° F.
A second plate was then made which at the end of
forty-eight hours showed 747,200 per c.c.
The examinations of which records have been kept
give the following results:
Taiu.e I. — Mii.K AS Delivered to the Consumer.
1. December 2S, iSg5, bottled milk 400,000 to c.c.
2. January 2S, iSy6, sold by measure. . . . 590,000
3. May 27th. sold by measure 24,613,900
4. May 29th (same as No. 3) 9,820,000 ) Many
;. May 30th, brought from dairy 9,963,000 \ moulds.
6. May 31st, bottled milk 796,800
7. June 3d (same as No. i and No. 8)... . 48,000
8. June nth (same as No. i and No. 7). .. 6,630,000
9. June 1 Ith, brought from dairy 43,600,000
The conditions under which cultures 3 and 4 were
made were not fair, as the milk had stood some time
in the laboratory before being plated. They merely
illustrate the possibilities of milk as a culture medium.
In all other cases the milk, which was brought to the
laboratory in sterile bottles, or in the bottles in which
it was delivered to the consumer, was immediately
plated. The specimens brought from dairies were in
botli cases got in the afternoon. Morning cultures
would show fewer colonies, yet the milk is bought
even for little children in the afternoon.
Taiu.e II. — ('.kockrv Mii.k.
1. January 26th 25,000 to c.c.
2. March 23d 246,000
3. May 25th 2,619,900
4. May 29th (culture at 4 I'. M.) 25,090,000 Moulds.
5. June loth (same as No i) 1,220,000
6. June nth (culture at ri a.m.; same as
No. 4) 7,390,000
The milk sold at the grocery which supplied the
material for cultures i and 5 is received each morn-
ing from the country. The first culture was made
during extremely cold weather, and probably does not
September 26. 1896]
MEDICAL RECORD.
443
represent the average condition of that milk in winter.
Grocery milk compares very favorably with that from
other sources.
Table III. gives the results of examinations of
"certified milk." This milk comes from a dairy
located some distance out of Buffalo, the manager of
which endea\ors to supply clean and wholesome milk.
The stables are kept scrupulously clean ; the cow's, all
of which have been submitted to the tuberculin test,
are daily groomed; the food and water supply of the
cattle receive careful attention; the milkers are re-
quired to be clean, and the pails, bottles, etc., are
bacteriologially clean. The milk is shipped and de-
livered packed in ice. The name "certified'" is given
to the milk from the fact that a committee of physicians
certify to their knowledge of its condition, a bacterio-
logical examination being made semi-monthly by Dr.
Herbert M. Hill to determine how nearly clean the
milk is kept.
Tablf. III. — Cf.rtifiku Mh.k.
1. January 20th 13,000 to c.c.
2. February 1 itli 10,000
3. May I2tli 25,900
4. May iSth 35, 000
5. June 2d 132,720
6. June loth 4,400
7. June ijth 57.600
A culture made by Dr. Hill of the same milk on
May iSth, a different medium being used, gave 26,000,
which we regard as a confirmation of our results.
Table IV. is milk prepared for the infants recei\ed
at the Fitch Creche, a day nursery for the children of
working women. Milk sent from the country on the
morning of the day it is used is sterilized in the
Arnold sterilizer, being kept at the boiling point for
forty-five minutes. The cream used is prepared in
the same way. The bottles containing milk and cream
are stoppered with absorbent cotton, cooled, and put
into the ice chest. Boiled water is kept in a fruit
can in the ice chest. The lime water
used is made at the creche, with boil-
ing water. The milk sugar is dis-
solved fresh in boiling water each
time. These ingredients are mi-xed
for each feeding as needed. The
bottles are filled after using with cold
water, then as soon as possible scald-
ed and filled and left to stand with a
solution of borax. All dishes used
in making up the mi.xture are kept for
this purpose alone, and are well
scalded after use. That the prepar-
ing of the food is carefully done I
am confident. Yet examinations of
the mixture give the following results :
T.Mii.K I\'. — Creche Standard .Mixture.
1. May 1 6th 8,400 to c.c.
2. May 29lh 17,600
3. June 1st 456,320
4. June I2th 31,000
5. June 13th 851,440
6. June T5th 1.002,400
The fault in this process is that
the bottles have to be opened repeat-
edly, giving chance for contamination.
But the bacteria in this mixture,
really only a relatively small num-
ber, seem harmless. At any rate the
babies thrive on it.
Some points which may Ije noted
are these :
Certified milk contains compara-
tively few liquefying organisms, cul-
tures occasionally showing none at
all. The hay bacillus and the potato bacillus, both
liquefying organisms common to milk, and both by
some accused of an active part in certain digestive
troubles of infancy, may be said to be present in this
milk in small numbers if at all.
No count is anything more than approximately
correct. All estimates probably fall far short of the
actual number of bacteria present.
Counts, to be of value in comparing the purity of
various kinds of milk, must be made under identical
conditions as regards medium, temperature of room,
and time of counting.
This work was begun with but little faith in its
value, but as it went on the conviction grew that by
ascertaining tlie number of bacteria in a given quan-
tity of milk we had a valuable test as to its fitness for
food; the original amount of contamination, the
length of time the milk has been kept, and the condi-
tions of temperature and cleanliness determining the
luxuriance of bacterial growth.
Pathological Labokatorv, University of Buffalo.
A CASE OF INFECTIOUS ENDOCARDITIS.
Bv EDWIX GLADMON, Phar.D., M.D..
WASHINGTON, D. C. ,
MEMBER OF THE MEDICAL ASSOCIATION OF THE DISTRICT OF COLOMBIA AND
OF THE AMERICAN MEDICAL ASSOCIATION.
G. A. F , male, white, American, aged forty-five
years; neurotic temperament ; occupation, bookbinder;
temperate habits. Father and one uncle died sud-
denly with heart disease ; the mother's death due prob-
ably to phthisis. There was a history of so-called
bilious attacks for the past ten years, one or two of
which confined him to bed for three months.
He first came under the writer's care about five years
ago duruig one of these attacks. They were ushered in,
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Chart i.— Temperature from November 2 to November 8, 1895. Four obsen'ations daily.
444
MEDICAL RECORD.
[September 26, 1896
as a rule, without warning. Sudden vertigo was fol-
lowed by immediate vomiting, with violent pain either
centring solely in the umbilical region or radiating
from there to the liver; constipation was always pres-
ent, though never in a marked degree; there was slight
fever, with full, rapid pulse for a few days. Vomiting
was always incessant, and enormous quantities of wind
would be belched for several days. He was usually
confined to bed for a week or ten days. The attacks
occurred at intervals of about six months, until Febru-
ary, 1894, the date of the last until the beginning of
his final sickness, July 25, 1895.
He had been granted leave from office and was
ready to leave the city the following day. His two
boys had been sent on to Connecticut by themselves.
Coming back from the depot, he seemed much worried
about the risk he ran in sending the children on
alone. In this nervous condition he sat down to
room, and in a lesser degree could be noticed in both
iliac arteries.
The next three weeks no improvement whatever was
noted. The epigastric pain increased, and while there
was no nausea, vomiting occurred spontaneously every
three or four days after taking food. Gastric carcino-
ma was suspected, though the acid test was not made.
August 22d he went to Boston by steamer, but missed
the boat coming home, and was thrown into a crowd
of returning excursionists, becoming very much ex-
hausted. He was taken to the sea.shore, and, his pain
increasing and his general condition showing no im-
provement, he was brought back to Washington, Sep-
tember 4th. No fever was noted before he went, though
temperature was not taken. On his return, fever of an
irregular type came on, and in about two weeks Dr. S.
S. Adams was called in consultation. He was then
more or less hysterical, having frequent crying-spells
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Chart 2. — Temperature from November 9 to November 18, 1895. Four observations daily.
luncheon, and was at once taken with what seemed to
be one of his "old spells." The colon was irrigated
(he had since his last attack been using a colon tube) ;
bismuth, lactopeptin, carbolic acid, and hot solutions of
phosphate of soda were given, with seemingly good re-
sults. The acute symptoms subsided much sooner than
in his previous attacks, and the difference between tlie
two then became noticeable.
First was noted a marked intermittence in the
heart's action. Strychnine was given with good re-
sults, and when he left the city three weeks later his
pulse was full and regular. The ne.\t difference noted
was pain at the epigastrium, radiating to the back.
This became so violent as to prevent sleep and re-
quired morphine for its relief. It was not influenced
by eating or drinking. This was followed or rather
accompanied by an utter and complete physical pros-
tration. His appetite was fair and the food of a nour-
ishing character, but his decline in strength was con-
tinuous. Epigastric pulsation was visible across the
and an idea that something was growing in him. Rec-
tal nutrient enemata were given, with brandy and large
doses of bromide of potassium. Nothing was given by
mouth. 'I'he epigastric pain disappeared, vomiting
ceased, and he seemed to improve. Murmur, most in-
tense at apex, was detected.
In about a week, October :st, a severe rigor was
followed by high fever and profuse sweating. Fever
seemed of a quartan type, and he was given quinine,
dialyzed iron, and arsenic. This irregular fever con-
tinued about three weeks.
From October 21st to November 2d fever ranged
from 97.6 to 99.5" F.
November 2d. 6 p.m., severe rigor; temperature,
107" F., followed in a few hours by a fall to 98° F.
From that time to the day of death (about one
month), with the exception of two or three days, fever
was never absent. It was of hectic type, two, three, or
more exacerbations daily, accompanied irregularly by
chills and sweats. There was bronchial catarrh during
September 26, 1S96J
MEDICAL RECORD.
Chakt 3.-Temptrature fr,i,n November 19 tu .XcvemUr 28, 1895. Four observations daily.
Chart 4.— Temperature from November 29 to December 6,
1815 , Fuur observatioQS daily.
446
MEDICAL RECORD.
[September 26, 1896
ihe hist month. The sputa and urine were repeatedly
examined by Dr. George N. Acker, with negative re-
sults. Abscess of liver was suspected, from its en-
largement. Dr. W. W. Johnston, who had also been
called in consultation, aspirated the liver, with no re-
sult. Aortic murmur was very loud.
From about October 1st to death, iJetechifE appeared
on different parts of the body, principally on the hands
and feet. These were preceded by a circumscribed
redness, about two inches by three, on the inner side of
the right thigh, accompanied by intense burning and
itching. Several joints became aiTected. First the hip,
simulating sciatica ; then the right wrist, left shoulder,
left wrist, and left foot. Just before death, the right
foot seemed to be the only joint affected, and was
much swollen and very painful. Pain was occasionally
complained of in the left loin and over the right lobe of
the liver. A swellingof the size of a large walnut ap-
peared on the left frontal bone, and was painful. The
latter part of his illness was characterized by a phthisi-
cal buoyancy of mind, as contrasted with the hysterical
morbidness of the first part. His meals, as a rule,
were eaten at a table to within a week of death, and
he rarely spent a whole day in bed.
Five days before death pulmonary oedema of both
lungs ensued and was followed by collapse. Recov-
ery under heart stimulants and ammonium iodide and
chloride was slow. Ascites then developed, but les-
sened considerably before death. There was amnesic
aphasia for five days before death, with more or less
delirium. Flapping in and out of both cheeks was
noticed, but it was not persistent. There was retention
of urine during the last two days and several times
previously.
Notes of autopsy by Dr. J. R. Welington: E. A.
F -, white, aged forty-five. Three hours after
death: No rigor mortis; considerably emaciated.
Pericardial fluid increased in amount; the heart, par-
ticularly the left ventricle, very much enlarged. The
arch of the aorta dilated and infiltrated with calca-
reous deposits. Endocardium not e.xamined. Lungs
emphysematous around edges, otherwise normal. Liver
larger than normal, e.xtending to within two inches
of umbilicus; very friable, light in color, showing
signs of apparently fatty degeneration. Spleen slight-
ly larger than normal, and on being incised was found
to contain two abscess cavities of about the size of a
walnut, with a dirty brown pus. Stomach distended;
intestines normal. Kidneys each showed large infarc-
tions of long standing. Brain not e.\amined.
Report of examination of heart, spleen, and kid-
neys, by Dr. D. S. Lamb, pathologist to the .Vrniy
Medical Museum, Washington, D. C. .
■' Heart shows hypertrophy and dilatation of left
side (left auriculo-ventricular orifice stuffed with cot-
ton). Edge of anterior leaflet of mitral valve much
thickened, and is capped with a large irregular mass
of fibrin, which was removed in jiandling and now
lies loose. Left ventricle contained wasiied and dark
clots, which have been removed. Leaflets of aortic
valve are irregularly tiiickened and edges nodulated;
right leaflet shows atheromatous abscess perforating
into myocardium and into ventricle, and also a large
vegetation. Both valves are stenosed and incompetent.
.\orta and innominate artery are much thickened, and
show fibrous and calcareous atheroma. Coronary ar-
teries are rigid with calcareous deposit.
"Spleen, coronally bisected, shows one large solid
and two softened infarctions.
" Kidneys show large infarctions."
Dr. Walter Reed, U. S. A., says that he found diplo-
coccus lanceolatus in the vegetation of the heart
valves. On inoculating an animal, however, there was
no pathogenic result, perhaps because the virulencv
had diminished or ended.
COUNTER- IRRITATION IN THE TREAT-
MENT OF HERPES.
By THEODORE WILKINS. M.I)..
POMO.NA, CAL.
A xu.MBER of 3 ears ago I came across an article in
some medical journal — I think, the Medical Record
— to the effect that some man, whose name I have for-
gotten, had treated herpes zoster by applying a fly blis-
ter over the affected nerve trunk posteriorly, in every
case aborting the attack.
The treatment seemed so simple and withal so ra-
tional that it commended itself to my mind, and since
then on various occasions I have treated herpes by
counter-irritation, with the happiest results. Under
these circumstances it seems to me this method of
treatment should not be forgotten; for that reason I
report the following cases.
Herpes is now generally recognized as a disease of
the nerves, producing trophic changes in the skin.
As a rule, it lasts for several weeks, and is often very
painful. If counter-irritation will restore the integrity
of the affected nerve or enable it to hold its own
against possible bacterial infection, it is certainly a
useful measure which ought to be known and practised
early in all cases of herpes.
In all or nearly all cases of herpes search will re-
veal a tender spot higher up over the nerve trunk.
This was found in all but one of my cases, and over
this the blister was always applied. In that case.
Case I., there was a curious anomaly — herpes in the
terminal branches of the sciatic nene was accompanied
by a tender spot in the anterior crural, and promptly
cured by a blister there applied. I do not pretend to
explain this — I merely present the facts.
Case I. — Mrs. B , a stout lady, forty-six years
of age, came with a well-marked herpetic eruption
over the upper contiguous edges and surfaces of the
great and second toes of the right foot, which had
troubled her for some days, causing great pain. It
corresponded to the distribution of one of the liistal
branches of the great sciatic nerve. ,\ very tender
spot was found in the coarse of the anterior crural
nerve, in the region of the saphenous opening, and
here a blister the size of a half-dollar was applied.
The pain in the toes soon ceased, and the eruption
dried up within twenty-four hours. There was no oth-
er medication of any kind.
Case II. — Mr. C. B. O , an elderly gentleman
of stout habit, but very temperate in all things and a
total abstainer. This was a case of herpes zoster
which I considered intercostal neuralgia fintil the
characteristic eruption began to appear. This was
first recognized by his wife, who had herself had
" shingles," and she came in great distress to tell me of
her discovery. Blisters were applied posteriorly over
the sensitive nerve trunks, with cure in twenty-four
hours, to the great deligh- of himself and wife.
Cask III. — Mrs. H , a middle-aged, fairly
healtiiy woman, who had been under a great nervous
strain, associated with deep sorrow, for many months.
One day she showed me a "sore" wiiich had troubled
her for some time. It was a well-marked herpetic
lesion, situated about two inches below the knee on
the anterior inner aspect of the leg. A few 'iiches
above the knee, in the course of the antenor tibial
nerve, was a very tender spot. A small fly blister o\er
this cured the lower sore promptly.
The next two cases, almost exactly similar in all
particulars except the final result, and occurring with-
in a short time of each other, seemed made for a "con-
trol experiment,' and as such one of them unfortu-
nately served. They both occurred in young women of
the same general type — tall, slender, delicate, neurotic
societv ladies
September 26, 1896]
MEDICAL RECORD.
447
Case IV. — Miss B. C^ had suffered just before
from a mild parotitis of the right side, probably
mumps. She came complaining of a very sensitive
lump, about the size of a hazelnut, in front of the
right ear; another, smaller but equally sensitive, was
situated lower down in the neck. In addition, there
were three soft, red, burning, painful swellings on
the forehead, in the region of distribution of the
supra-orbital nerve, the central and largest one exactly
over the notch and perhaps one-half inch above it.
At this time I did not connect the glandular enlarge-
ment with the eruption on the forehead, especially as
the patient was subject to eczema, though she herself
recognized this as sonietiiing very different. I belie\ed
that a rather severe glandular infection from the paro-
titis had taken place, and directed her to use turpentine
locally long and often, not as a counter-irritant but
as an efficient and penetrating antiseptic, capable of
killing the poison in situ. For the eruption in the
face I prescribed a bismuth ointment and hot water.
This treatment produced a rapid and complete cure.
Case V. — A few days later Miss E. M came
in, presenting almost exactly the same clinical picture
as the preceding case, but not quite so severe. There
were the same tender glands in front of the ear and in
the neck, and on the forehead the same hot, red, pain-
ful little swelling over the right supra-orbital notch,
like the central lesion in the other case. In this case
there was no previous infection that I knew of, though
she was in a weakened general condition from too
much society and piano practice. Because I knew of
"no infection I did not deem the turpentine necessary,
but prescribed — she was already on tonics — the bis-
muth ointment and hot water, measures which had
proved so successful in my other case, as I thought.
But the ne.xt day there was no improvement. On the
contrary, the pain and burning were more severe and
the swelling on the forehead was thickly studded, over
an area exactly rectangular and perhaps five-eighths of
an inch long by one-third of an inch wide, with mi-
nute transparent vesicles. A smaller similar swelling
was appearing on each side. I now recognized the
herpetic nature of the case, and directed the use of the
turpentine as in Case IV., with the result of aborting
the later lesions. But, w ithout consulting me, the pa-
tient had kept the central lesion covered with court
'plaster most of the time, thus converting what would
probably have healed in a short time into a deep,
slowly-healing, rectangular ulcer, leaving at last an
unsightly rectangular scar.
In these last two cases it seems the turpentine must
either have acted sufficiently as a counter-irritant to
have relieved the trouble in the deep-lying trunk of
the fifth nerve, or that it was able to penetrate and de-
stroy some infection which had invaded this nerve
trunk or its trophic ganglion. Perhaps it acted in
toth wavs at once.
Hemorrhoid. — An inflamed hemorrhoid will often
cause exquisite pain. The little mass is bluish, hard,
and is with difficulty ]3ut back into the rectum, if, in-
deed, this be at all possible. The treatment is evacu-
ation of the thrombus by a cut radiating from the cen-
tre of the anus. Relief is immediate. — Iiiternational
Joiirna! of Surgery.
Angina Pectoris — Sir Benjamin Ward Richardson
in the Asiicpiad says : '' From a study of forty-three
cases I have reached the conclusion that this affection
is a sympathetic neurosis, bearing much the same re-
lation to the sympathetic nervous system as epilepsy
does to the brain. Heart lesions and coronary dis-
ease are often absent, and when present are probably
merely coincidental."
Amputation of the Breast for Carcinoma.— Dr.
Tansini [Rif. Mc-d., April 5, 1896) calls attention to
the fact that many times a cancer of the breast recurs
in the apparently healthy skin along the scar. To
avoid this possibility, he advocates the removal of the
entire skin from the breast and a strip four inches
wide extending into the axilla. The author removes
all glands and the pectoral muscle. To cover this
defect he twists a flap from the back on a pedicle near
the axilla and sews it into the wound.
Erysipelas in Infants. — Dr. J. Lewis Smith ad-
vises for a child from one to two years old the inter-
nal use of four drops of the tincture of the chloride of
iron every three hours, either alone or with one of the
preparations of cinchona. He applies externally an
ointment of ichthyol, a drachm to the ounce of cold
cream. High temperature should be reduced by
sponging, the wet pack, or the bath. Antipyretic
drugs should be employed with caution, only in mini-
mum doses and guarded by a heart stimulant. For
delirium the temperature should be reduced. If the
delirium does not abate, bromide of potash, chloral, or
as a last resort, opium are to be given. In using car-
bolic acid care must be taken to guard against poison-
ing. The first evidence of poisoning is shown by the
urine leaving a pink stain on the napkin after ex-
posure to the air for half an hour. — Fctiiatrics, May i,
1896.
Muscular Macroglossia. — Dr. H. v. Ranke {Jahrb.
f. Kindcr/icilkundc, xli., No. 3, 1896) names three va-
rieties of the above affection occurring in children : i.
That in which the enlargement of the tongue is caused
chiefly by increase of interstitial tissues. There may or
may not be atrophy of the ordinary tissue of the tongue.
The number of blood-vessels or lymphatics may be
much increased, forming tissue resembling an angioma
or lymphangioma. 2. There may be an increase of the
tongue due to hyperplasia of all the different tissues
of the tongue. 3. There may be an increase of the
special tissues of the tongue due to hyperplasia of the
muscles which make up its structure. The condition
generally occurs in conjunction with other congenital
deformities, such as abnormality of the intestine, of
the arms, or of other parts of the body. It may be re-
lated to a general muscular atrophy or to a general
muscular hypertrophy or pseudo-hypertrophy. Cretin-
ism or rachitis may be closely connected with the con-
dition.
Infectious Vulvo-Vaginitis in Children. — Dr.
Sheffield, in the Aincriiaii Medical Bulletin, Mav 30,
1896, summarizes his views upon this subject as fol-
lows: I. Infectious vulvo-vaginitis in children is of
gonorrhoeal nature; the diplococcus present in the
purulent discharge is invariably identical with that of
Neisser, decolorizing by Gram's method. 2. The in-
fection can be conveyed through common privies,
baths, beds, clothing, etc. 3. The symptoms accom-
panying the disease are far less severe than those de-
scribed in most text-books. 4. Most of the complica-
tions are preventable. 5. The value of boric acid or
mild siher-nitrate solutions as prophylactics of puru-
lent ophthalmia is very doubtful. 6. Silver nitrate in
strong solution is a reliable abortive of purulent oph-
thalmia, if used in the very earliest stage. 7. The
mere presence of gonorrha-al discharge in a small girl,
without injury to the genitalia, does not prove that
rape has been attempted. 8. I'hysir'Mis in charge of
asylums or .similar institutions sli_.!.' be ori tlieir
guard not to admit girls with vaginal discharge, unless
September 26, 1896]
MEDICAL RECORD.
449
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO.. 43, 45. & 47 East Tenth Street.
New York, September 26, 1896.
THE INFLUENCE UPON LEUCOCYTOSIS OF
LARGE SALINE INJECTIONS.
There is increasing evidence of the usefulness of co-
pious saline injections, either into the subcutaneous
connective tissues or into the veins, in the treatment
of a number of infectious diseases; but the mode of
action is yet a matter of speculation. It is easy to
imagine that the good results thus brought about are
due, in part at least, to a dilution Of toxic substances
circulating in the blood and their elimination, espe-
cially through the kidneys, and in part to the in-
creased circulatory activity resulting from herghtened
arterial tension in consequence of the addition to the
fluid elements of the blood. The rapidity with which
the resulting amelioration of symptoms and reduction
of temperature take place in cases that respond to this
mode of treatment is, however, indicative of a more
profound influence upon the organism, than can be
accounted for merely by the increased arterial tension
or elimination of toxins. It has been shown that a
condition of leucocytosis is a constant concomitant of
a number of infectious processes, subsiding with the
onset of convalescence. With this thought in mind,
Claisse ' has made a study of the changes in the blood
that take place in cases of infectious disease treated
with saline injections. The outcome of these obser-
vations indicates that a relation exists between the
resulting improvement and the state of the blood.
Thus, in a case of generalized purulent streptococcus
infection, an intravenous injection of fifteen hundred
grams of saline solution was followed in an hour and
a half by a rise of the temperature from 102.9^ to
105.8° F., while the number of red blood corpuscles
to the cubic millimetre declined from 3,968,000 to
3,596,000, and the number of colorless corpuscles
from 13,547 to 7,804. In the course of three hours
the temperature had fallen to 98.6° F. In the case of
a man, sixty-four years old, with a diffuse phlegmon
of the arm, subcutaneous infusion of a litre of saline
fluid was followed by a diminution in the number of
red blood corpuscles from 3,565,000 to 3,255,000, and
of the colorless corpuscles from 26,660 to 11,346. In
a case of profound puerperal infection, an intravenous
injection was immediately followed by an alteration
in the relation between the red and the colorless blood
corpuscles of from 1 to 228 to i to 344. It is pointed
' Comptes Rendus de la Societe de Biologie, 1S96.
out that the manifestations following saline injections
— depression of temperature, lessening of leucocytosis,
amelioration of the symptoms of infection, often with
a period of reaction — are analogous to those that have
been described as following the employment of the
antitoxin of diphtheria. The observations are obvi-
ously too few to justify a final conclusion, but they are
not without interest or significance, and should be
confirmed or contradicted by others. They may fui-
ther furnish certain prognostic indications, as witli
proper restrictions the discovery of a leucocytosis may
be viewed as pointing to the existence of some infec-
tive process.
THE SUNDAY PENALTY OF
FEEDING.
IRREGULAR
The American people pride themselves on being en-
lightened and highly civilized, using their reasoning
powers to such advantage that by systems of quaran-
tine, vaccination, etc., they are able to exclude or con-
trol almost all epidemics of infectious diseases. These
intelligent people would resent a statement that in
some of their routine customs they were only slightly
above the level of barbarians, yet the unhappv truth
remains that such a statement may be made without
fear of refutation.
In our evolution from barbarism we have created
or established a race of people with whom regularit\
in eating and sleeping is the fundamental essential to
good health. The digestive secretions are poured out
and ready for action with the regularity of clockwork,
so that a man can tell by his feelings almost the min-
ute at which his dinner hour comes. If this regular-
ity, so long established, is violated and the regular
dinner hour is passed without food being ingested, the
violator not only suffers bodily discomfort, but an ac-
tual injury occurs to the digestive apparatus. The
stomach and other secretory organs resemble the mus-
cular system in a certain degree, as they must have a
certain amount of work to perform in order to keep in
the best working condition. Also, like the muscu-
lar system, overexertion leads to disorder, and disuse
invites a variety of pathological conditions. But, un-
like the muscular system, the digestive organs have
been so educated by custom that they require, not only
a definite amount of work to perform, but an absolute
regularity in the time of performing that work. The
gounnand who overtaxes his stomach is certain to
meet his retribution. The drunkard who stimulates
the mucous membrane of his stomach with alcohol and
gives his secretions nothing to act upon in the way of
solid food, finds shortly that his stomach refuses to se-
crete at all, as just punishment for his abuse and negli-
gence. Almost as certain a result, if not so rapid, is
sure to follow indiscretions of irregularity in eating.
The stomach, having poured out its secretions at the
customary time, waits only a short time before it al-
lows such secretions to be absorbed without the ac-
companying production of nutritious pabulum that
goes to assist in the formation of more secretions.
.\fter a few such experiences the secretions become
less in amount and in activity, even when food is in-
450
MEDICAL RECORD.
[September 26, 1896
troduced into the digestive tract, and we have result-
ing indigestion, so common in all communities.
The dyspeptic is cautioned and advised by his phy-
sician to take his meals ut absolutely regular intervals,
not only as a treatment of existing evils but as pro-
phylactic against future disorders. One indiscretion
of irregularity in such cases often causes the patient a
week of misery. If this regimen is a standard prophy-
lactic with confirmed dyspeptics, how much should any
one in our artificial civilization allow himself to de^■i-
ate from so simple a rule, when an absolutely normal
stomach at ail times is almost unknown?
Vet this ver}' invitation to gastric disorders is issued
every seventh day by ninety-nine per cent, of the peo-
ple of this country. Once in seven days comes our
so-called day of "rest" — the day on which tiie three
regular meals at morning, noon, and night are replaced
by a vicious system of late rising and abstinence, fol-
lowed by gluttony. The gastric secretions know noth-
ing of a seventh day of rest. They are ready at the
customary si.\-day morning-breakfast time, but no food
comes to them and they are absorbed. A second pe-
riod of the day comes and the same process is repeat-
ed, with the additional injury that from two to four
hours after the customary meal the stomach is loaded
unusually full of food, whereas the secretion is no
longer there in sufficient quantity to digest it. The
result is the regulation Sunday afternoon discomfort
of gourmandizing, with the accompanying absence of
appetite for the evening meal. What wonder that the
following day is "Blue Monday!"
The barbarian gourmandizes to-day and fasts to-
morrow, and he n«ver has gastric disorders. We still
exemplify our hereditary traits by imitating him one
day of each week, but unfortunately we have not main-
tained the barbarian standard of excellence in gastric
digestion. It would seem as if our process of evolu-
tion had reached a stage where we might expect soon
to rise above our prehistoric ancestors in our system
of eating. We certainly cannot do so until we do
away with our custom of alternate fasting and over-
feeding. Monday would lose something of its azure
hue and some "digestive-ferment" manufacturers
might be obliged to make assignments if such a pro-
gressive step were to be taken, but the general satis-
faction would in a measure compensate for the dam-
age done these ancient institutions.
THE USE OF ARSENIC IN CHOREA.
We believe the prevailing method of treating chorea
in this country is by arsenic, and the usual form in
which this drug is administered is Fowler's solution.
In France Boudin's solution of arsenic seems to be
much employed, and as it is much weaker than Fow-
ler's it is said to admit of easier and more exact do-
sage. Dr. Jules Comby, of Paris, writing in La Metlc-
cine Modenic, August 19, 1S96, describes his method
of using this solution. He puts ten grams of the
strength of 1-1,000 into one hundred and twenty
grams of a syrupy solution, and gives to a child not
under seven years two spoonfuls of this ever}' two
hours for tlie first day, and increases the amount of
Uoudin's solution by five grams each day until he ar-
rives at thiily-five grams; then begins to decrease the
daily amount by five grams down to zero, when the
patient will be found cured. This method is rather
more heroic than that pursued here, and we are not
surprised to learn that out of twelve cases which the
author reports as having been thus treated and cured
in the short period of from seven to thirteen days,
some had nausea or vomiting, two had notable gastric
embarrassment, one had arsenical paralysis (although
this disappeared entirely), and one had passing pig-
mentation of the upper extremities. The treatment
which the author says Grancher carries out at the hos-
pital for children in Paris is preferable and is more
in line with that practised here, except that he gives
Boudin's solution instead of Fowler's. He prescribes
four grams the first day, and increases the amount by
two grams daily to the point of tolerance, but does not
advise going beyond thirty grams a day. Another
method of treatment in vogue in Paris is by anti-
pyrin, but that remedy is slower and less reliable
than arsenic.
Jlcatis 0f tlxc "SSlccIi.
"The Atlanta Clinic" is now under the editorial
management of Dr. Lucien Lofton.
A Member of a Medical Society in Vienna has
been expelled for criticising a fellow-member in one
of the daily papers.
Dr. William Thayer Smith, professor of physiol-
ogy in Dartmouth Medical College, has been ap-
pointed dean in that institution, to fill the vacancy
caused by the death of Prof. Carleton P. Frost.
The New Building of the medical department of
the Creighton University at Omaha, Neb., is nearing
completion. It is a handsome four-.story and base-
ment building. This and the St. Joseph's Hospital
are gifts of Mr. J. A. Creighton.
The Russian Physician, so it is said, considers it
beneath his dignity to send an account to a patient,
but leaves it to the latter to pay what he thinks proper.
Many think it proper to pay nothing.
The Floating Hospital of St. John's Guild car-
ried during the season of 1896, 46,253 women and
children. Over seven liundred sick children were
treated, without a death taking place on board. Four
trips only were omitted between July 8th and Sep-
tember 3d, and these were due to bad weather.
<< Official Cheek " is what the editor of the Cleve-
land Journal of Medicine calls the request of the treas-
urer of the American Medical Association for five dol-
lars in payment of the annual dues for 1896. As the
association has declared that the members of the Cleve-
land Medical Society are no longer to be recognized
as in good standing in the association, this character-
ization of a demand for dues would not appear to be
unjustified.
September 20. 1896]
MEDICAL RECORD.
451
Dr. George A. Gibson is to assume editorial con-
trol of X\ie Edinburgh Medical /ourna/ with the new
year.
A New Consumption Cure is that of Dr. Langheld.
It is claimed that the remedy kills the germs by carrj--
ing ozone to them. It has been tried in Berlin and
Vienna, and it is reported that some of the patients
are still alive.
The Bender Hygienic Laboratory, in connection
with the Albany Medical College, is now completed,
and will be ready for use during the coming session.
Special dedicatory exercises will be held during Oc-
tober. Dr. George Blumer, late of Johns Hopkins
University, has been appointed director of the labora-
tory.
<< The Charlotte Medical Journal " has recently
changed its appearance by enlarging its pages and
making double columns, thus increasing very consid-
erably the amount of reading matter. Our esteemed
contemporar)' is evidently enlarging its sphere of use-
fulness very materially, and we congratulate its tal-
ented editors upon the well-deserved success of their
undertaking.
A Polish Medical Society has been organized in
Chicago and will be known as the "Towarzystwo Le-
karzy Polskich.'' Drs. E. Czerniewski, D. Dowiat,
M. Orglert-Kaczorowska, J. P. Kaczorowski, M. P.
Kossakowski, W. Kuflewski, J. Piszczak, W. J. Siemi-
nowicz, W. Statkiewicz, B. F. Strzyzowski, J. Ziolkow-
ski, and R. L. Lande are the founders of the society.
Vaccination and Railway Accidents One of the
arguments used by those who oppose the compulsory
vaccination law in England is that vaccination is
more dangerous to life than is railway travel. There
is one fatal termination to every 14,159 cases of vac-
cination, while of railway travellers only one is killed
among every 35,500,000.
Cheap Doctoring. — Two private hospitals have re-
cently been established in St. Louis, in which the
members of the association supporting them may be
treated free. The fee for membership in the associa-
tion is fifty cents a month. A new health-insurance
society in California is cheaper than that, as it pro-
vides free medical attendance to all who will pay five
dollars a year.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
September ig, 1896. September 14th. — Medical In-
spector Daniel McMurtrie promoted to medical di-
rector from September 3d. September i8th. — Surgeon
L. G. Heneberger detached from naval hospital.
Widow's Island, Me., and ordered home to await
further orders.
A Campaign against City Noises has been begun
by Health Commissioner Rempster, of Milwaukee.
The noisiest thing of all and the most trying he thinks
is the church bell. Another nuisance that is useless
and ought to be abolished is the factory whistle. The
effect of these and other noises, he says, is greatly to
injure health and to shock and irritate the sick and
those suffering from nervous troubles. He proposes
to stop these noises, if he can, and we wish him a full
measure of success.
Ammonia in Alcoholism Dr. Baratier recom-
mends in El Sigh Medico the addition of ammonia
to wine or liquor in order to produce a distaste for
alcoholic beverages. After a few doses the disgust
to the mi.Kture becomes so intense that even the sight
or smell of wine is unpleasant.
Medical Society of the State of New York.—
The business committee of the Medical Society of
the State of New York, recently appointed, consists
of the following members: Dr. Seneca D. Powell, 12
West 40th Street, New York, chairman; Dr. Willis
G. Macdonald, 27 Eagle Street, Albany: and Dr. Er-
nest Wende, 471 Delaw-are Avenue, Buffalo. Com-
munications regarding papers to be presented at the
next meeting of the society, to be held at Albany,
January 26th-28th next, may be addressed to either
member of this committee or to the president of the
society. Dr. James D. Spencer, of Watertown.
Quarantine has been finally abolished in the Brit-
ish Islands. For many years there has really been
none, yet two vessels with a full staff of medical offi-
cers were kept on the south coast of England. There
w^as nothing to do at the station, but it was main-
tained from year to year, apparently because it never
occurred to any one in Parliament to do away with it.
Clergymen and Physicians — An amusing debate
is being carried on in the columns of The Medical
Times concerning the question of taking fees from
clergymen in payment of medical services. One
writer, "A Country Parson," who heaped abuse on all
"medicos" who would not give him what he called
"colored water" for nothing, was reminded by another
correspondent that " in our great hospitals the ma-
ligned 'medicos' unreser\edly— too unreservedly —
and gratuitously render to the poor services which, if
estimated by the tariff obtaining in their private work,
would find their expression in millions of pounds per
annum. The chaplain, whose duty it is to administer
that consolation which is 'without money and without
price,' absorbs a respectable amount of the hospital
funds."
Epidemic Disease in Cuba The latest published
reports of the Marine Hospital Service state that there
is no abatement of yellow fever in Cuba, nor is the dis-
ease less virulent than it has been all summer. The
United States sanitary inspector at Santiago de Cuba,
however, reports that small-pox is steadily decreasing,
and expresses the belief that in about a month the epi-
demic will be practically over. Concerning yellow
fever, he writes that the disease is causing many deaths
among the soldiers, and if the records do not show this
it is because the deaths take place in the hospitals
outside the city and in the detachments in the sur-
rounding villages. At the Daiquiri mines, for exam-
ple, the inspector says that he has the positive infor-
mation that there is about one death from yellow fever
daily.
45:
MEDICAL RECORD.
[September :.o, 1890
Generous Provision for Free Beds By the will
ui the late Dr. A. H. McAdam, of Philadelphia, the
income of $5,000 is bequeathed to a sister, upon
whose death the principal is to revert to the Episcopal
Hospital, for the establishment and maintenance of a
free bed, to be named, after the testator's wife, as the
Anna W. McAdam bed. The sum of $4,000 is to be
held for the benefit of another sister, upon whose
death it, together with an additional $1,000, is to be
given to the Hospital of the University of Pennsylva-
nia for the endowment of a free bed to be known as
the Dr. Alexander H. McAdam bed.
Typhoid Fever is unusually prevalent in Chicago,
Denver, and various other cities. In Chicago, we
learn from the Journal of the American Alcdical Associ-
ation, on September 4th seven people died from ty-
phoid fever, breaking the record since 1892. The
health department says the prevalence of the disease
is due to impurities in the drinking-water. During
-August of this year typhoid claimed si,\ty-four vic-
tims, against fifty-nine for the corresponding period
of 1895. About five hundred ca.ses are reported at
present in that city. In Denver, the Colorado Medical
Journal says, there is now raging an epidemic of
typhoid fever which has more victims and a greater
fatality than any epidemic since 1892. It is probably
due to a polluted water supply. \ number of phy-
sicians in the city are affected.
A Hospital for Tuberculosis in Philadelphia. — At
a recent meeting of the Philadelphia board of health,
the president of that body. Dr. William H. Ford, pro-
posed the establishment of a hospital for tuberculous
patients, under the direct care of the board of health,
in analogy with the care of cases of contagious disease
at the Municipal Hospital. It was suggested that the
old Lazaretto Station in Delaware County, now no lon-
ger used and the sale of which has been authorized,
could be well devoted to the purpose in hand. A res-
olution was accordingly offered, requesting the repeal
of the ordinance authorizing the sale of the Lazaretto
property, as well as authority for the establishment of
the proposed hospital and an appropriation of $19,500
for maintenance. Dr. Ford's argument was that as tu-
berculosis is an infectious disease, whose spread may
be limited by the adoption of certain precautionary
measures, while many die from the disease as a result
of ignorance, neglect, and want, a grave responsibility
devolves upon the municipality, which has been only
partially and inadequately met through the efforts of
philanthropic societies and individuals, and princi-
pally in the way of establishing hospitals for the sick.
" If any progress is to be made in checking the rav-
ages of tuberculosis, isolation and treatment in hospi-
tals must be depended upon as a most important means
to this end. The municipality is obligated to provide
lor the indigent sick, but especially urgent is this de-
mand when such sick persons, uni)rovided for, jeopard
the public health.'" The contention is made that tu-
berculosis "should be under the supervision of the
health authorities, just as other dangerous diseases are,
and the day is not far distant when this disease will
be required to be reported to the hoard of health, as
other contagious diseases are now under the law. But
time is necessary for the consent of the people to this
new requirement. It would, therefore, seem that the
hospital contemplated should most appropriately be
placed under the supervision of the board of health, in
conformity with the provisions of the law and as a
means of simplifying the management of the disease.
The main question, however, is the prompt organiza-
tion of such a hospital, for which the opportunity is
very favorable. The question of administration is of
secondary importance."
Dedication of a Hospital Annex at Trenton, N. J.
— A new anne.x to St. Francis Hospital at Trenton,
N. J., was dedicated on September 17th, the blessing
being offered by Bishop McFaul, assisted by a num-
ber of priests. The new building is a four-story
structure, 50 x 65 feet, with a single-story addition
twenty-eight feet square, fitted up as one of the best-
equipped operating-rooms in the country. The new
building cost $34,000 and will add forty-five beds to
the present capacity of the hospital, which is one hun-
dred and five beds.
Obituary Notes. — Dr. Theoda Wilkins, of Po-
mona, Cal., died on August 28th from injuries re-
ceived in a runaway accident. She was a graduate of
the Woman's Medical College of the New York In-
firmary in 1885, and was an active member of the
Pomona Valley Medical Society. — Dr. James Edgar
Chancellor, of Charlottesville, Va., died on Septem-
ber 9th. He was born in Chancellorsville in 1826,
and was graduated in medicine from the Jefferson
Medical College in 1848. He served as surgeon in
the Confederate army, and at the close of the war set-
tled in Charlottesville. He was a member of the
State examining board of Virginia, of the State soci-
ety, of the American Medical Association, and of
the Public Health Association. — Dr. Charles Ber-
NACKi died at Schandau, Saxony, on September 17th.
He was born at Starasol in Galicia in j8i2, and was
graduated in medicine from the University of Vienna
in 1839. About ten years later he came to New York
where he practised for the rest of his life. A widow
and a daughter sur\-ive him. — Dr. Thomas R. Mc-
Cresson died at his home at City Island on September
i8th. He was born in this city in 1851 and was
graduated from the New York University Medical
School in 1879. — Dr. Stephen Congar died in Pon-
tiac, Mich., on September i8th. He was born in
Newark, N. J., eighty-six years ago, and after obtain-
ing his degree from the College of Physicians and
Surgeons in this city, began the practice of medicine
in Newark. He always took a great interest in the
public schools, and served as member of the school
committee, superintendent of schools, and president
of the board of education for many years. In 1859
he removed to Pontiac, where he resided up to the
time of his death.— Mr. Wickershf.lmf.k, the inventor
of the preparation bearing his name for preserving
pathological specimens, died in Berlin on September
4th. — Dr. W. L. Frisbie died at his home in Potter-
ville, Bradford Co., Pa., on September 15th, at the
age of sixty-two years.
September 26, 1896]
MEDICAL RECORD.
453
SECOND INTERNATIONAL CONGRESS OF
GYNECOLOGY AND OBSTETRICS.
Hi-ld at Geneva, August ji and Sepfcinbcr i, 2, j,
4, and 5, i8g6.
In the afternoon of the first day there was a reunion
of the permanent international committee and the or-
ganizing members of the congress. In the evening a
reception was given at the Palace Eynard by the Con-
seil d'fitat of the Swiss Republic and the Conseil
Administratif of the city of Geneva.
The Surgical Treatment of Pelvic Suppuration
was the first set subject for discussion. This was
opened by Dr. Bouili.v, of Paris. From the point of
view of surgical interference, he said, pelvic abscesses
may be classified as follows: (a) Cellular abscesses,
perimetritis, periuterine phlegmons. {h) Abscesses
of the ovaries or the tubes, pyosalpingitis, and suppu-
rative ovaritis. (c) Primitive peritoneal abscesses,
pelviperitonitis, suppurative hematocele, {ii) Simul-
taneous suppurations of various pelvic organs, consti-
tuting purulent collections or complicated with fistulfe,
bursting either through tjie skin or into the neighboring
cavities, or in various places, at the same time.
An exploratoiy puncture offers us the only certain
means of diagnosis. The three principal methods of
treatment of pelvic suppurations are: i. Simple in-
cision followed by drainage through the abdominal or
vaginal wall. 2. Opening or ablation of the suppu-
rating cavities by laparotomy. 3. Opening or abla-
tion of the suppurating cavities through the vagina, by
means of previous vaginal hysterectomy with or w-ith-
out morcellation of tiie uterus. 4. As derived from
these principal methods can be considered : [a) The
ablation through the vagina of small unilateral collec-
tions, with preservation of the uterus and appendages
of the opposite side. {U) The simultaneous ablation
of the appendages and uterus through the abdomen.
The method of election is simple incision followed
by drainage: (a) For the opening of acute pelvic ab-
scesses originating in the cellular tissue. The inci-
sion mu.st be made where the collection bulges out
either on the abodminal wall or in the vagina. (l>)
For the opening of primary peritoneal collections,
either acute or subacute, or those following perito-
neal infection, after operation, abortion, childbirth,
or gonorrhoea, (c) For the opening of suppurative
hsematocele. (d) In the treatment of pelvic encysted
abscesses of the appendages. In those cases it can
be applied safely only when the sac is unilateral, thin-
walled, fluctuating, and lying low by the side of the
uterus, or wiien it can by pressure on the hypogastrium
be brought into contact with the vaginal wall. The
failure of the vaginal incision does not prevent the
success of ulterior vaginal hysterectomy.
Laparotomy and vaginal hysterectomy as applied to
the treatment of pelvic suppurations are not rival
methods; both have their indications and advantages.
When the patient is young and whenever there is any
doubt as to the bilaterality of the lesions, laparotomy,
which affords the sight of the opposite side, is to be
selected. Laparotomy shall be selected in case of
doubt as to the nature of lesions (possible e-xistence
of an ovarian simple or dermoid cyst or of extra-uter-
ine gestation). However, the matter is generally set-
tled in such a case by the fact that the purulent
collection is unilateral. In the cases of bilateral
lesions, when there is any doubt as to the two opera-
tions, the situation of the two purulent sacs in regard
to the uterus and the vaginal culs-de-sac becomes a
leading factor in the indications. With these excep-
tions founded upon the unilateral seat of the lesions,
uncertainty about the nature of this lesion, the high
position of the abscess, vaginal hysterectomy applied
to the treatment of pelvic suppurations allows the
pus tubes, the small pyosalpinx, the suppurating ova-
ries to be removed. It allows us to reach and cure
lesions against which laparotomy is either powerless
or too dangerous. It is the method to be selected in
the treatment of large adherent sacs, which cannot
be enucleated. It is better than any other method
in chronic suppurations of the periuterine cellu-
lar tissue which have discharged spontaneously, most
often communicating with neighboring organs. In
these cases the operation must almost always remain
merely one for evacuation. Ablation of the uterus
gives us ideal drainage, owing to which the collections
are emptied. For this reason, insisting upon the ex-
tirpation of the sac would be removing from the
operation all the advantages of its simplicity and be-
nignity, and failing to recognize one of the principal
roles of vaginal hysterectomy in the treatment of pel-
vic suppurations.
K good many laparotomists recognize nowadays the
necessity of ablation of the uterus. This ablation
insures firstly perfect drainage; secondly, it prevents
future troubles which may be brought about by the
uterus if left in situ; and so immediate cure is more
common and the ultimate results are better.
On the whole, the speaker held that, in most cases
in which simple incision was not possible, vaginal
hysterectomy is the best method of treatment of pelvic
suppurations; and laparotomy is to be performed only
when contraindications to vaginal hysterectomy exist
Dr. Henrotin, of Chicago, advocated conser\ative
vaginal work. He believed that patients undergoing
radical surgical operations are oftener cured of the
operation than of the disease; that patients have often
been cured of the disease without radical operation;
that an immediate opening through the posterior vagi-
nal fornix in the first week of an acute pelvic suppura-
tion will give a large percentage of cures in cases
which under the poultice-and-douche treatment would
terminate fatally. He supported this claim by citing
numerous statistics.
Dr. Sanger, of Leipsic, said that the German gyne-
cologists uphold the following general principles: i.
There must be strict indications for the operation ;
2, the inter\'ention must be as conservative as possi-
ble; 3, the bacteriological, clinical, and anatomical
diagnosis must be our guide in the choice of the in-
tervention in any given case.
Most surgeons discard vaginal hysterectomy and
hystero-salpingo-oophorectoniy, preferring more con-
servative methods and abdominal operation. Hys-
terectomy is not the only thing to be considered in
the treatment of pelvic suppurations.
He then reviewed the special methods of treatment:
Puncture is limited to inveterate cases of encysted
abscesses or single purulent collections in the closed
organs. Success can be expected only when the pus
is sterile.
Incision applies:
{a) To extraperitoneal purulent foci. The pro-
ceeding ought to be limited to real purulent collec-
tions.
ib') To intraperitoneal purulent foci; this opera-
tion may be called simple colpocceliotomy.
The simplest proceeding consists in the incision
of the vagina by means of the thermo-cautery and
ojDcning of the abscess with a dressing forceps. There
is no necessity for irrigations, or for filling the cavity
with gauze immediately after tiie operation.
((■) C'celiotomy is always indicated in purulent col-
lections which through their size amount to real tu-
mors, as well as in suppurating cystic and other
454
MEDICAL RECORD.
[September 26, 1896
neoplasms. . Simple cctliotomy and drainage suffices
in encysted foci, remnants of purulent (and tubercu-
lous) peritonitis, if however the removal of the ap-
pendages or of other suppurated organs is not
demanded.
The difficulties as to the choice of an operation in
connection with the opening of the abdominal cavity,
in suppurated diseases of the appendages, have recently
been enhanced through the increased number of the
proposed operative measures. The speaker then gave
a list of all these operations, of which there are two
main sorts, vaginal and abdominal.
The recognition of the harmful influence of prema-
ture extirpation of ovaries or of complete extirpation
of all the internal generative organs, especially in
younger persons, has led to conser\'ative vaginal and
abdominal operations.
After reviewing at great length all these methods of
operation, their indications, their technique, and their
dangers, the speaker formulated the following conclu-
sions: Advocates of the different operative methods
ought not to claim an absolute superiority for their
own proceeding. Every appropriate treatment may be
justified and in every individual case it is far better
to take into serious consideration the special advan-
tages offered by each one of the methods. Let every
one strive to perfect his own operative methods, while
recognizing at the same time the value of others; the
result will then be improvement and progress.
The Surgical Treatment of Retrodeviations of
the Uterus was the second subject discussed.
Dr. Otto KCstner, of Dorpat, opened the discus-
sion. Although no operation which has ever been
proposed for uterine retroversions, he said, can return
the uterus and adnexa to their normal position, we
should prefer the new position, artificially produced, to
the former retrodeviation; for it gives to the uterus to
the same extent its normal mobility. The formation
of adhesions with neighboring organs is thus pre-
vented, so is the prolapsus.
It is necessary to differentiate the reducible from
the non-reducible retrodeviations; the latter must be
first made movable.
In our procedures for stretching the adhesions we
must not open the abdominal cavity when the adhe-
sions are not very resistant or very large. Massage
or Schultze's method will suffice. If the adhesions
are too numerous or too resistant, we should open tiie
abdomen in order to free the uterus as well as possible.
The opening into the abdomen may be made through
the anterior or posterior cul-de-sac, as well as through
the abdominal walls. No doubt with laparotomy, we
can have a fuller view of the state and size of the
adhesions. Therefore it has great advantages in the
careful treatment of adhesions and of adnexa, which
are always more or less affected. Colpotomy is much
less accurate, and gives less complete results. To
avoid wounding tlie neighboring organs, tlie methods
which have for their aim the fixation of the uterus in
a new position must keep the uterus in good situation
and must not interfere with the healthy functions of
the uterus.
The results obtained by ventro-fixation, vagino-
fixation, abdomino-vesical fixation, and by Alexan-
der's operation show that these operations can keep
the uterus in good position. The same can be said
neither of recent modifications of these methods, nor
of Sanger's retrofixation.
The normal function of the uterus is but slightly, if
at all, disturbed by ventro-fixation, Alexander's oper-
ation, or vesical fixation. It is, on the contrary, in-
juriously affected by vaginal fixation when this extends
to a large surface of the anterior aspect of tlie uterus.
Therefore we should not perform vagino-fixation on
women in the child-bearing period. When patients
cannot conceive, this operation gives very good re-
sults. When the adhesions are large, the Ijest opera-
tion is laparotomy, followed by rupture of the adhe-
sions with Faquelin's cautery, with scissors, or with
the fingers, and ventro-fixation after Olshausen's
method.
The best operation for reducible retrodeviation is
Alexander's, for it gives in every case a nearly or
really normal position to the uterus.
Dr. Pdi.k, of New York, followed with a paper, of
which the following is a summary: Retrodeviations,
especially in a uterus capable of pregnancy, should
not be healed by any operation which fixes the fundus
or body to the abdominal wall or to any contiguous
structure, such as the bladder or vagina.
In such cases uncomplicated retroversions should
be treated by Alexander's operation or by intraperi-
toneal shortening of the round and utero-sacral liga-
ments, operating through the vagina. Retrodeviation
complicated by adhesions should be healed by intra-
peritoneal shortening of the round ligaments, and
when necessary of the utero-.sacral also, operating,
when possible, through the vagina. Alexander's ope-
ration may be applied to the versions after rupture of
the adhesions through a colpotomy, provided the round
ligaments have not adhered to their sheaths, as some-
times happens because of the antecedent perimetric
inHammation.
Retrodeviations in a uterus deprived of its append-
ages should be treated by intraperitoneal shortening
of the round ligaments, and of the utero-sacral also,
when needed.
Retrodeviations after the menopause should be
treated by intraperitoneal shortening of the round lig-
aments, and of the utero-sacral also, the operation
being conducted through the vagina, if possible. If
there are no adhesions and the uterus is not atrophied,
Alexander's operation will suffice.
Whenever they are elongated, so as to form a direct
factor in retrodeviations, the utero-sacral ligaments
should be shortened, the vagina being the best possi-
ble route for the procedure.
The speaker then described the operation for short-
ening the round and utero-sacral ligaments as follows:
(i) The anterior vault of the vagina is opened as in
anterior colpotomy, the vesico-uterine space is entered,
the uterus and appendages are freed from adhesions if
such exist, the uterus is antevertcd, and the fundus is
brought into the vagina. The round ligament with its
peritoneal sheath is encircled w ilh a silk suture, as far
out from the uterus as will permit the easy attachment
of the ]iart encircled to the uterus at the origin of this
ligament. This folds the ligament inward upon
itself, presenting of course two loops; one is always
sutured to the uterus; the other is now sutured to the
round ligament outside the folded section, which sec-
tion in turn is encircled with the third suture. Special
care must be taken to avoid the tube, the suture being
passed as close to the ligament as possible. The
manteuvre is repeated on the opposite side, the uterus
is replaced in the peritoneal cavity, and the wound is
closed with catgut, the peritoneum being sutured first
and then the vaginal wall.
(2 ) The posterior vault of the vagina is opened by
a transverse incision coincident with the utero-vaginal
junction, and extending fully to the cornu of its lat-
eral aspect upon both sides. Douglas' cul-de-sac is
entered and a stout silk suture is passed over the utero-
sacral ligament at about its middle. This is done on
both sides, the ligaments being put on the stretch to
facilitate the procedure. One end of each suture is
now passed through the vaginal wall, upon its lower
side, at the outer ends or angle of the cut, and is then
firmly tied. This draws the cer\-ix upward and back-
ward to the extent of about half the length of each
September 26, 1896]
MEDICAL RECORD.
455
utero-sacral ligament. The wound in the vagina is
closed with catgut, and the sutures holding the utero-
sacral ligaments are left long, the tube being removed at
the end of two weeks. The patient is confined to bed at
least three weeks; no pessar)' is used. .Special care is
to be taken to keep the bowels open and to avoid dis-
tention of the bladder; patients with prominent abdo-
men should subsequently wear an abdominal supporter.
Dr. S. Pozzi, of Paris, said that the clinical con-
ditions known as retroversion and retroflexion do not
form a distinct pathological affection. They are con-
sidered as special affections only through an old tra-
dition, which should to-day be revised.
Retrodisplacement of the uterus, either simple or
with fle.xion, is observed in two entirely different con-
ditions, viz. :
(a) Relaxation of the ligaments, without adhesions,
due to a former perimetro-salpingitis. This is the
movable retrodisplacement.
{/>) Posterior adhesions, especially around the ad-
nexa, following a perimetritis or a peri-oophoro-sal-
pingitis. This is the fixed retrodisplacement and is
by far the most frequent.
For movable retrodisplacements the term mobility
of the uterus should be substituted for those of retro-
version and retroflexion. In point of fact the back-
ward displacement is simply in this case the most
natural position of a uterus which has lost its fixation
and consequently its normal anteversion. But this
abnormal displacement is in itself the cause of slight
symptoms; the principal phenomena of nervous and
reflex origin are independent of the direction of the
displacement and are due to the mobility. They per-
sist when the uterus is momentarily put back in posi-
tion without being kept there. They appear to be due
to a bad equilibrium in the abdominal statics, to a
real pelvic enteroptosis.
All surgical treatment of these cases which aims to
fix the uterus, when replaced, by a limited point of its
surface, will give only temporary results. The con-
stant traction on the point of fixation produces relax-
ation, and is the cause of unsuccessful results which
usually after a variable lapse of time follow Alexan-
der's or similar operations.
The rational treatment of movable retrodisplace-
ments, or rather of mobility of the uterus, is complex
and should provide for the various indications pres-
ent. These are : to cure the metritis, which is very
frequent in such cases, by proper treatment (curet-
tage, amputation of the cervix, etc.) ; to restore the
perineum, often ruptured or relaxed, by a large and
extensive plastic operation; to applv a pessary which
li.xes the cervix by distending the posterior cul-de-sac
as well as a hypogastric bandage which regulates the
intra-abdominal pressure
The treatment of fixed retrodisplacements of the
uterus is that of the lesions which have produced it
and keep it up.
Many fixed retrodisplacements are indolent, and
become tolerated, but morbid symptoms occur if the
uterus is again the seat of metritis. The operative
treatment of the uterus by proper means will be suffi-
cient to cause the accidents to disappear if tiie adnexa
are only slightly or not at all diseased.
In other cases clinical ex^ciiination shows tiiat tlie
lesions predominate in the adnexa and that a niL-lrilis
coexists. Laparotomy is there indicated.
If only slight lesions of the adnexa are found, such
as a sclero-cystic ovaritis without obliteration of the
tubes serving as a starting-point for adhesions, conserv-
ative operations should be performed, such as igni-
puncture and partial resection of the ovary according
to the given case.
The uterus will of itself return to its normal position
after destruction of the adhesions.
There are cases in which the best treatment of a
retrodisplacement is vaginal hysterectomy. These
are cases of old bilateral lesions of the adnexa, com-
plicated by chronic metritis with hypertrophy of the
uterus. In such conditions, extirpation of the adnexa
through the abdomen after destruction of the adhe-
sions, leaves a large and heavy uterus, which will soon
be again retrodisplaced in the posterior vaginal cul-
de-sac. -A complementary abdominal hysteropexy can
of course be performed at the time of operation and
later a cure and involution of the organ can be
brought about by curettage and amputation of the
cervix, and lastly repair of the perineum, if it is re-
laxed and insertion of a pessary. But this practice is
much more complicated and quite as serious as vaginal
hysterectomy.
The Best Method of Closing the Abdomen. — Ur.
Bantock, of London, opened this discussion with an
elaborate paper, of which the following were the con-
clusions:
1. Bacteria do not play any part in the production
of suppuration, but are the result and not the cause
of the conditions under which they are found. Hence
abscess in the wound or in the track of the sutures is
not due to the entrance of "germs'' or fully formed
bacilli, but in the former case to the presence of mat-
ter acting the part of a foreign body, and in the latter
to strangulation of the tissues by too tight constriction
by the suture.
2. In ordinary cases the simple interrupted suture
alone is sufficient for all practical purposes.
3. In very thin or very fat subjects it is desirable
to close the peritoneum separately by continuous su-
ture, while the remainder of the wound may be closed
in one or two stages.
4. For the simple interrupted suture silkworm gut
forms the best material, while for the buried suture
catgut not chromicized will probably be found pre-
ferable.
Dr. La Torre, of Rome, continued the discussion.
Post-operative hernia he defined to be the issue of
viscera through an opening of the abdominal wall ;
more commonly through the musculo-aponeurotic
plane. This accident was very common when the
abdomen was closed by the extraperitoneal method,
but it has become rarer now that we close the abdo-
men after the intraperitoneal plan, or after the extra-
peritoneal method with Durante's modification. Three
principal factors are concerned in a good closing of
the abdomen, viz., the incision, the material of the
suture, and the mode of suturing.
The most important factors are the incision and
suture of the musculo-aponeurotic plane, t.t\, the place
where the tissues are to be cut and sutured.
Hernia is often produced by suturing the aponeu-
roses of the linea alba instead of suturing tlie sub-
stance of the muscle.
When the patients are still in the childbearing age,
the operator should always suture the muscles. It is
better in these cases to cut into the linea alba; then,
before suturing, to cut off the aponeurosis of the linea
alba up to the internal borders of the recti, and to
unite by suture the muscular sheath and the muscle
itself.
With old or sterile patients incision and suture in
the linea alba alone might be recommended, when it
is possible to obtain, during the operation and after-
ward, the conditions necessary to a good cicatriza-
tion.
In case of secondary closing of the abdomen, inci-
sion and suture have always to be made in the sub-
stance of the recti.
The most commonlv used suture materials are silk,
catgut, silver wire, and wormgut. .Although all are
good, silk and catgut are to be preferred.
456
MEDICAL RECORD.
[September 26, 1896
The best mode of suturing -is always in superposed
rows of suture, and suture en surj,-t is to be preferred
to separate stitches; the peritoneum, the aponeurosis
of the linea alba (when this is not cut off), the deeper
layers of the sheath of the recti, the muscles, the
superficial layers of the muscular sheaths, and the
skin with the subcutaneous tissue must be sutured
separately.
Treatment of Eclampsia. — This was the final sub-
ject for discussion. The first paper was by Dr.
Charpentier, of Paris. Kvery albuminuric pregnant
woman, he said, being exposed to eclampsia, and
milk diet giving marvellous results in albuminuria,
we should very carefully examine the urine of pregnant
women, and, when we find albumin in it, even in mi-
nute quantity, we should at once order an exclusive
milk diet. This is par excellence the prophylactic
treatment of eclampsia. When a woman has cedema
without albuminuria, it is advantageous, if not abso-
lutely necessary, to prescribe milk diet. During an
eclamptic attack, if the patient is strong and cyanotic,
we must first bleed her three hundred to five hundred
grams. We may also give inhalations of chloro-
form and set up diuresis by hypodermic injections of.
artificial serum.
If the patient is delicate, if the cyanosis is but
slight, if the fits are not frequently repeated, the chlo-
ralic medication will sufiice.
We must wait till the labor begins spontaneously
and let it go on undisturbed whenever it is possi-
ble. When, the labor having begun spontaneously,
the case does not terminate by itself, on account of
the contractions being too feeble or too slow, we must
deliver the patient by forceps or by turning, followed
by extraction, when the child is living; by cephalo-
tripsy, basiotripsy, or cranioclasis when the child
is dead.
We must wait without performing such operations
till the state of the maternal parts (full dilatation or
at least dilatability of the cervix) permits us to inter-
fere harmlessly, i.e., without violence, consequently
without danger for the mother.
Labor should be induced only in exceptional cases.
Caesarean section and '" accouchement force'' are to
be absolutely rejected as usual methods for the treat-
ment of eclampsia. We must have recourse to these
operations only in case of failure of every other means
and when the mother seems on the point of dying.
Dr. F. Halbertsma, of Utrecht, continued the dis-
cussion. He thought that in the therapeutics of
eclampsia the most important question to decide was
whether, at the termination of the pregnancy or at the
beginning of labor, we must wait or accelerate the
labor.
In the cases mentioned above, the active interfer-
ence of the physician is usually indicated: When the
prognosis seems very serious on account of complete
anuria, or on account of the frequence and intensity
of the convulsions; when nothing shows that the labor
is about to begin; when, the labor having begun, the
particulars of the case lead us to expect it to be diffi-
cult and tedious, as it is for primipara;; when the pa-
tient is aged; when the pregnancy is multiple; or
when the pelvis is narrow.
Dr. Mangiaiiai-li said that prophylaxis is most
important; this consists in a milk diet assisted by the
means capable of disinfecting the intestinal contents,
of increasing diuresis, of improving the functions of
the skin, and of stimulating the action of the heart.
Medical treatment, whether blood-letting or purg-
ing, the use of morphine, chloral, chloroform, vera-
trum viride, or diaphoresis must be essentially symp-
tomatic. It constitutes in every case the only possible
treatment in eclampsia post partum. Blood-letting
followed by subcutaneous of intravenous injections of
physiological solution of chloride of sodium is a
therapeutic method which rests on rational considera-
tions and has clinical facts in its favor.
The prompt evacuation of the uterus constitutes the
most important point in the treatment of eclampsia
occurring during labor.
In case of eclampsia during pregnancy we must in-
duce labor by rupture of the membranes, and admin-
ister morphine, chloral, or veratrum viride in strong
doses; these measures are the more useful the sooner
they are administered after the convulsions have set
in. If the case is serious, the danger imminent, if
in spite of the rupture of the membranes labor does
not progress, or if the neck of the womb is shortened
and softened, forced dilatation will be better than
deep incisions of the cer\-ix. In the cases of the
same category in which conditions exist which render
dilatation or incision particularly difficult, Casarean
section will be justified, especially if the fcetus is at
term and living. Every intenention must be made
under deep chloroform narcosis.
Dr. John W. Bvers, of i;elfa.st, defined eclampsia
as that condition in which convulsions arise suddenly
during pregnancy or labor, or after delivery. He ex-
cluded those cases in which fits occur in a pregnant
epileptic, or when they arise from gross intracranial
disease. While the etiology and pathology of eclamp-
sia are still obscure, he directed attention to a change
of opinion among British observers on two points: i.
The extreme view that the convulsions in all cases
are due to renal disease is being abandoned. 2.
Much greater importance is now attached than for-
merly to the influence of the foetus as a factor in the
causation of the fits.
Taking everything into consideration, the most
probable hypothesis is that the convulsions are due
to the influence on the nervous system of a poison
which arises as a product of ordinary tissue metabo-
lism (elaborated in part by the mother and also by the
foetus), and which in ordinary cases, provided it
does not accumulate in too great an amount and
the eliminating organs are working properly, is got
rid of without any ill etTects. When, however, these
organs have too much to do, as when the muscular
efforts of labor increase the work of the kidney, then
the poison is not excreted and its increased accumula-
tion affects the nerve centres; or the same thing may
occur if the function of the eliminating organs is
interfered with, as in constipation, or when the kidney
is in that condition which Leyden has described as
being peculiar to pregnancy, or when there are changes
in the renal organs and liver in the form of a paren-
chymatous degeneration, produced, it may be, by the
poison in its circulation, through them. Accepting
the above explanation as a working hypothesis, he
considered the treatment of eclampsia under the four
heads :
1. The convulsions should be treated with morphine
(hypodermically). The patient is to be placed on her
side, to prevent the entrance of fluids into the larynx
and lungs (pulmonary oedema being a common cause
of death in eclampsia*. Care should be taken that
she does not injure herself; she should be kept warm,
purged freely, allowed no liquids, and, accordingly as
she is conscious or not. betwee:. the fits, a warm or
vanor bath should be used.
2. Eftorts should be made to eliminate the poison
by purgation, hot baths, keeping the patient warm,
and by the non-administration of liquids.
3. if labor has not set in, the convulsions are to be
treated, but premature uterine action should not be
induced. When labor has begun, and the patient is
in the second stage, chloroform should be adminis-
tered and delivery rapidly completed. In the first
stage, w-itii strict antisepsis, labor may be expedited
September 26, 1896]
MEDICAL RECORD.
457
by the hot douche and by the use of Barnes' or de
Ribes' bag, if the cervix is dilatable. If the cervix
is rigid, this should not be done.
4. In the prophylaxis of eclampsia, rest, milk diet,
purgatives, and warm baths give the best results.
Dr. Theophilus Parvin, of Philadelphia, said that
puerperal eclampsia is in almost all cases caused by
toxffimia. Those instances in which the disease is
apparently reflex in origin may be explained as result-
ing from an increased nervous excitability, consequent
upon blood changes, and without such changes irrita-
tion would not cause convulsions. The bladder filled
with urine, the loaded bowel, pain are not the essen-
tial causes ; they are only exciting causes. The spark
does not cause an explosion if there be no gunpowder.
He regarded that treatment as best which acts upon
the essential cause and at the same time meets symp-
tomatic indications.
He believed that veratrum viride is better than any
other drug yet employed, and that it does affect the
essential cause, as well as to a great degree the symp-
tomatic conditions, for it notably reduces the fre-
quency of the pulse, and convulsions occur only in
very exceptional cases if the pulse be kept at 60 or
less; it increases the activity of the skin; it reduces
the temperature; and it causes increased secretion of
urine. Finally, the recovery of so large a number of
mothers, about ninety-two per cent., when veratrum
viride is employed proves the value of the remedy.
FRExNCH COxNGRESS OF ALIENISTS AND
NEUROLOGISTS.
Held at Nancy, August i-6, iHg6.
Auditory Hallucinations. — Dr. Vali.ox, of Paris,
read a paper with this title, in whicii he expressed the
belief that all hallucinations of hearing were of cere-
bral origin. He made this division of sensorial trou-
les relating to hearing: i, those in which the starting-
point was in the brain — true hallucinations; 2, those
in which the starting-point was peripheral. But all
true hallucinations were cerebral; others were rather
illusions.
Dr. Ballet said a normal perception assumed a
peripheral impression by some sense (hearing, for ex-
ample), conducted to a cortical centre. Little did it
matter in the explanation about the seat of the cortical
auditory centre, but rather what part it played. Of
normal auditory perception there were three forms: i,
brute perception or mere recognition of sound; 2, dis-
criminating auditory perception; 3, verbal auditory
perception. A peripheral auditory trouble might
cause a hallucination, but not in everybody.
Dr. Recjis, of Bordeaux, remarked that the general
view seemed to be that auditory hallucination implied
the intervention of a cortical centre, but according to
his idea the sensory apparatus should be recognized
as the exciting cause. Hallucination was often a cor-
tico-sensorial phenomenon.
Crossed Heredity by Experimentation Dr.
Crocq, Jr., of Brussels, said in this communication
that crosed heredity had been contested of late, prin-
cipally by Andre Samson, who had characterized it as
purely chimerical. VMiile Crocq did not regard it as
constant, nevertheless he thought its existence was
real. Among chickens and pigeons he took two vir-
gin animals of different race, and of twelve of their
young eight were males and partook of the maternal
characteristics, four were females and partook of the
paternal characteristics. This experiment of cross-
breeding with different races of pigeons and different
races of chickens gave similar results whenever the
pair was entirely virgin.
Melancholia, Paralysis : Craniectomy, Evacua-
tion of Cyst, Cure.— Dr. Augu.st Voisin reported
the case of a woman, aged twenty-one, taken three
years before with intense pain in the left temporo-
facial region, gradual development of morbid fears and
suicidal tendency, convulsive attacks, projectile vomit-
ing, and heniiparesis affecting the face and limbs on
the right side. Craniectomy was performed on the
left temporo-parietal region, fifteen by seven centime-
tres. There was pachymeningitis, and in the ascend-
ing frontal and parietal convolutions a cyst was
evacuated, four centimetres in diameter, filled with
serum. FYom the first hour after the operation the ce-
phalalgia, together with the suicidal tendency and pa-
resis, disappeared permanently.
Spasmodic Paraplegia. — Drs. Raymond and A.
SouQUEs, of Paris, reported two cases of progressive
spasmodic paraplegia in sisters, aged nineteen and
fifteen respectively. The disease had started insidi-
ously and without known cause, in the former at the
age of nine, in the latter at the age of twelve. In
the elder sister the spasmodic paraplegia began in the
right leg and went on to implicate in succession the
left leg and upper extremities. By the age of fifteen
she was unable to walk. In the other case only the
legs were as yet affected. The knee reflex was exagger-
ated. Striimpell had made one autopsy in this dis-
ease, and found combined scleroses, implicating the
pyramidal, GoU, and direct cerebellar columns.
Partial Epilepsy in Acromegaly. — Drs. Raymond
and Souques also reported a ca'se of acromegaly of
many years' standing, in a man, aged fifty-four, who in
the last three years had developed Jacksonian epilepsy
limited to the right upper extremity and right side of
the face. They stated that the hypertrophy of the pit-
uitary gland present in acromegaly constituted a cere-
bral tumor capable of exciting from a distance the cor-
tical psvchomotor centres.
Cord Lesions Produced by Microbic Toxins. — Dr.
H. Claude, of Paris, had studied the cord lesions pro-
duced by microbic intoxication in four cases, as fol-
lows: I, a guinea-pig, poisoned gradually by the tox-
ins of the colon bacteria, became paralyzed in one
foot, then in two feet; 2, a dog,*iooisoned by the toxins
of diphtheria, in the course of a month, paresis of the
hind feet; 3, a dog, poisoned by the toxins of tetanus
(two months), posterior monoplegia, then paraplegia,
finally paralysis of all the limbs; 4, a rabbit, poi-
soned by pyocyanic toxin, death without paralysis.
Pathologically he found, besides gross vascular le-
sions, centres of softening and leucocytic infiltration;
also cell alterations, varying with the degree and in-
tensity of the intoxication and the part of the cord
acted upon by the toxins. In the cases of slow intoxi-
cation there were all degrees of cell change in the
cord, and, alongside elements still intact, there were
others entirely degenerated. But cell alterations ex-
isted not alone in animals presenting nervous symp-
toms, but could be demonstrated by the method of
Nissl before these symptoms made their appearance.
Acrocyanose. — Dr. Crocq, Jr., of Brussels, said the
syndrome to which he would apply the term acrocya-
nose was neither Raynaud's di.sease nor the blue oede-
ma of Charcot, although it had some of the features
common to these two affections. He had observed two
typical cases in )'oung hysterical females. The local
cyanosis was constant ; the pain was not intense ; it did
not cause gangrene, nor eruption, nor abolition of sen-
sibility; nor was there, as in Charcot's blue oedema,
either cedema, paralysis, or paresis. All three afTec-
tions had, as a cause, disturbances of nervous centres,
yet it seemed to Crocq that acrocyanosis was more es-
pecially a hvsterical vasomotor phenomenon.
Unusual Duration of General Paralysis, Disap-
pearance of its Special Symptoms, Termination in
Simple Dementia. — Dr. Lapointe said that general
458
MEDICAL RECORD.
[September 26, 1896
paralysis might in some cases be of very long duration,
and its cardinal symptoms disappear, to be replaced by
those of dementia pure and simple. In one instance
cited the duration was tifteen years.
Physical Insensibility. — Dr. Laurent, of Bor-
deaux, related a case illustrating the lack of suscepti-
bility to physical pain in many of the natives of Indo-
China, shown by their self-inflicted mutilation, suicide,
etc.
Lesions of the Cord Cells Consecutive to Section
of Nerves and Anaemia. — Drs. G. Ballet and J)i-
TiL produced by experiments the same changes which
were found in the cells of the cord in peripheral neu-
ritis, their experiments consisting in division of the
sciatic and in causing anaemia of the cord by compres-
sion of the aorta. The latter method showed the
changes to best advantage : After rendering the animal
paraplegic two or three times by repeated compression
of the aorta, the lesions -would be found more delicate
and complex in the nerve cells, the cellule being
rounded; the color granulations disappeared. Here
as well as in section of a peripheral nerve there was
melting of the protoplasmic granulations.
The Semeiology of Tremors. — Two reports were
presented upon this subject — one by Dr. Luciex
Lamacq, the other by Dr. Grasset. Both recognized
the classical division into: i, tremble of repose; 2,
tremble in voluntary movement. Of the former, paral-
ysis agitans was an example ; of the latter, disseminated
sclerosis. According to the number of vibrations one
distinguished: i, slow tremor, three to five oscillations
a second — paralysis agitans, senile tremor; 2, me-
dium, six to seven oscillations — dis.seminated sclero-
sis; 3, rapid or vibratory tremor, eight to nine oscilla-
tions— exophthalmic goitre, some cases of paralysis
agitans. But certain tremors could not be thus clas-
sified, and others were polymorphous. Besides, Pitres
had shown the frequent existence of tremor during the
normal state, affecting different parts, including the
hands, and here showing itself like the tremor of ex-
ophthalmic goitre — rapid oscillations of little ampli-
tude. Grasset stated, in his resume, that the semei-
ological value of tremors was variable, because there
were a number of transition forms among the diverse
types described, for certain forms were as yet imper-
fectly defined. In some cases the trembling was only
a passing manifestation without great importance;
while in others, when constantly present, it was of
great significance.
Tremor and Rhythmic Spasm of Traumatic Origin.
• — Dr. Dei. .MAS related a case of tremor and rhytlimic
spasm with hysterical stigmata in a young man, and
having apparently for cause a trauma five years Ijack.
He was cured in less than three months by hydrother-
apy and bromides.
Physiological Tremor Dr. Pierre Parisot stated
th.it everybody trembled more or less when in normal
health, as he and .Meyer had found by test of the mus-
cles when in a state of relaxation.
Tremor and Suggestion. — Dr. Bernhei.m stated
that hysterical trembH:ig, at least if it were not con-
stant, was always curable by suggestion. This was
also true of hysterical chorea ; but true chorea, that
which was not due to imitation, resisted suggestion,
although the amplitude of the movements could thus
be reduced. Paramyoclonus multiplex responded to
suggestion ; also .some cases of post-hemiplegic tremor.
The trembling of alcoholism, saturnismus, paralysis
agitans, and Basedow's disease was not curable by
suggestion.
Tremor Accompanied by Cracking Sound. — Dr.
Voisix had observed four women in whom a cracking
sound proceeded from the upf>er part of the body,
neck, shoulder, or trunk, loud enough to be heard at a
distance of five or six steps. He assured himself that
the sound did not proceed from the articulations, but
rather from the muscles, in which one could appreci-
ate a tremor. Treatment by suggestion had no effect.
Tremor of the Tongue in Melancholia. — Dr.
Parant said some melancholiacs showed tremor of
the tongue; others did not. When present it was
what he called voluntary titubation when the tongue
was protruded, was seen in melancholia of recent date
and infectious origin, and was a favorable sign in
prognosis.
Dr. Ri'.cis said trembling of the tongue was not
limited to melancholia of infectious origin, but was
also present in infectious delirium, as in acute mania;
and, therefore, could not be pronounced a sign of fa-
vorable prognosis.
Nystagmus by Suggestion. — Drs. Sabrazes and
Caba.nnes had seen three cases of nystagmus in hys-
terics, in two being induced by hypnotic suggestion, in
the other occurring spontaneously. It differed from
the nystagmus of disseminated sclerosis. The oscil-
lations of the eyes were extremely rapid, horizontal,
associated, and exaggerated under strong light.
Commitment of the Insane. — Dr. Pavl Garnier,
in a report on this subject, said that in the pres-
ent state of our knowledge of psychiatry, isolation
(from the general community) remained the best and
most essential measure in most cases in the treatment
of in.sanity. Its efficacy was greater the sooner it
was carried out. The term dangerous could not be
applied in the sense that some should be isolated
and others allowed to be at liberty, for one knew
not at what moment the apparently inoffensive might
become dangerous. Besides, they needed hospital
care, especially if indigent. The progress made in
mental pathology tended to the almost complete sup-
pression of physical restraint in asylums. Moral treat-
ment, it seemed, could not rest on a system of intimi-
dation bv menace or actual punishment. Its principal
value depended upon the word of authority of the doc-
tor and affectionate display of benevolence, which
many insane were still able to appreciate. Provisional
discharge, although having inconveniences for the ad-
ministration, also had certain advantages. The divi-
sion of special institutions into a.sylums for treatment
and into asylums for the incurable presented more in-
conveniences than advantages, and was not in accord
with modern progress. But it was important to dis-
encumber asylums of the feeble and senile, for whom
there should be special hospitals, not necessarily un-
der the law for tlie in.sane. The inmate of an asylum,
when sent out cured, ought not to be abandoned to his
own resources, but siiould be given work and receive
the aid and affectionate oversight of public or private
charity, as it might be required. The remainder of
the conclusions related to the law of 1838. Dr.
Garnier thought there was room for an additional ar-
ticle relating to recurring deliriant alcoholics, of whose
cure one could not be assured and against whom so-
ciety could not effectually defend itself.
The chief dissension from the report related to the
class of cases which should be committed to asylums,
and division into curable and incurable.
Dr. Charpentier mentioned the following among
those not necessary to be confined: Certain cases of
attempted suicide; certain senile dements; lucid epi-
leptics and hysterics; certain idiots: many imbeciles
who were not dangerous; the backward who should be
in educational institutions; many cases falling under
the heads moral insanity, reasoning mania, hallucina-
tory alienation; recurring alcoholic deliriants, who
should be transformed into reasoning beings. Some
of these persons required aid of one form or another,
but need not be committed to insane asylums. He
wished to see the asylums disencumbered of cases not '
properly belonging in them.
September 26, 1896]
MEDICAL RECORD
459
Dr. Taty, of Lyons, believed in division of asylums
into those for the curable and those for the incurable;
and Ur. Marie thought the problem would be solved
by dividing the cases into the acute and the chronic.
About three-fourths of all were not benefited by thera-
peutics.
Dr. Pichenot presented a rare and curious speci-
men of hyperostosis of the cranium in an epileptic fe-
male.
Delirium of Persecution of Double Form. — Dr.
Vai.lon mentioned the fact that the insanity of perse-
cution manifested itself in two forms, as a rule — rea-
soning and hallucinatory; but lately he had seen a
case uniting the two forms. He would call it delirium
of persecution of double form. Out of a large experi-
ence he had seen but one case.
Certain Psychical Troubles, Particularly Trans-
^'ormation of Personality, in the Course of Senile
Dementia Dr. Parisot, of Nancy, said that psychi-
cal troubles independent of all insanity might appear
during the course of senile dementia; and these
troubles, such as the transformation of personality, de-
liriant conceptions, abnormal acts, were due to the re-
vival of past psychical states under the influence of
positive suggestion, spontaneous or provoked. They
showed peculiarities which distinguished them from
insanities.
Senile Dementia and Toxicity of the Urine
Drs. Parisot and Lew, of Nancy, having made some
researches as to the relation between toxicity of the
urine and senile dementia, gave the following brief
lisunu': i. In one case of simple senile dementia (^de-
mentia without delirium) the urinary toxicity had va-
ried in notable proportions, but without influencing
the dementia. 2. In several cases of senile dementia
with maniacal delirium, the appearance of delirium
was always preceded by notable diminution of the
urinary toxicity, a diminution which several times en-
abled them to foretell the delirious attack.
Automatic Speech. — Dr. Berxheim presented a
woman who was suffering from aphasia and parapha-
sia, but who, nevertheless, could sing and recite cor-
rectly her prayer. It seemed, therefore, that auto-
matic speech was retained, while voluntary speech was
much involved. Ordinary speech was attended in
healthy subjects by a series of multiple transmissions
cerebrally, which could not take place in the patient
shown.
Neurasthenia and General Paralysis. — Dr. Regis
said that these two aftections might be associated, and
they might resemble each other. Neurasthenia was to
be distinguished from general paralysis by the fact
that syphilis was a principal factor in general paralv-
sis; also by the relatively greater age of neurasthenia
and the fact that the speech disturbance was more
emotional.
Dr. Charpentier had obser\-ed that when one pupil
was more dilated than the other in general paralysis it
was the right, whereas in healthy subjects it was the left.
Dr. Vallon said he had not obser\'ed this differ-
ence, that the right pupil w^as oftener dilated than the
left in general paralysis.
Case of Clinical Equivalent of Migraine Dr.
Lamacq related the case of a patient who always suf-
fered, the morning following a day of unusually severe
labor or one in which he had experienced a disap-
pointment, from either pain in the right foot or right
hemicrania. In either instance there would be nau-
sea, difficulty in accomplishing mental work. etc.
Sulphate of Duboisine as a Means of Combating
Refusal of Food in General Paralysis. — Dr. Fran-
COTTE had injected once or twice in twenty-four hours
a solution of sulphate of duboisine, 4 to 1,000, as a
means to induce patients with general paralysis to take
food, and had found it successful in four cases.
©littical §cpartincut.
A CASE OF RAYNAUD'S DISKASE.
Bv J. H. H.\UPTM.\N\, M.D..
On March i6, 1893, I was called in the afternoon to
a woman in this city, Mrs. Z , aged forty-seven
years. On my arrival I found the pat'ent sitting
in a chair, suff'ering much pain in her legs and arms.
She was much emaciated, her face was pinched, and
she had all the appearance of one who had been long
suffering. On examining her, I found both feet and
legs very black, the discoloration gradually becoming
less and shading oft" into the natural color at a point
about two inches above the knees. The same condition
was noted in her hands and in her arms up to a point
about three inches above the elbows. Her nose and
ears also had a dark hue. She had been in this con-
dition for over four weeks, the discoloration gradually
extending upward. She had during all this time suf-
fered severe pains, accompanied with sleeplessness
and entire loss of appetite. Her pulse was very feeble,
intermittent, and somewhat thready, and her tempera-
ture was 102.5^ F.
She had been under the care of several physicians,
who had pronounced the case to be one of senile gan-
grene, and had advised immediate amputation. The
family history was negative. Her parents and grand-
parents had died at an advanced age, and none with
any hereditary or nervous disease. The patient her-
self had always worked very hard; she had borne
seven children, all with hard labor, and had had one
abortion, followed with puerperal septicarmia. Other-
wise she had been healthy imtil this disease came
upon her. Her heart was very weak and irregular.
-After careful examination I made a diagnosis of
Raynaud's disease, due to vasomotor contraction. The
main difference between senile gangrene and Ray-
naud's disease, so far as local appearance is con-
cerned, is that in senile gangrene there is a sharper
line of demarcation between the diseased and the
healthy parts, whereas in Raynaud's disease there is a
gradual shading oft' from the dark color into the natu-
ral flesh color.
I went back again that evening and applied electri-
city, using the faradic current, to her legs and arms,
for each extremity twenty minutes, changing the cur-
rent from time to time. In bed, her limbs were ele-
vated and massage was gently employed. That night
she slept four hours, without any narcotic or anodvne
being given. In the lineof drugs I prescribed a nerve
tonic of quinine, iron, arsenic, and strychnine; and
for her weak circulation used digitalis, strophanthus,
and nitroglycerin. Under this treatment and with
nourishing food she quickly rallied.
After one week's treatment as above outlined, the
natural color of her limbs and arms had reappeared as
far as the toes and fingers, and these gradually resumed
their natural color, and in three weeks' time she
walked outdoors. The only parts that were dead were
the first phalanges of all fingers, which later on I am-
putated and which soon healed nicely. She contin-
ued the treatment for several months longer, and has
had no trouble since. She now follows up her occu-
pation of sewing as usual. In the winter she is at
times during the coldest days troubled with slight
tingling and burning in the tips of her fingers, but the
use of the battery always allays this; also rubbing the
fingers will always stop it. I presume that without
the use of occasional electricity and general hygiene,
she might be liable to have another outbreak.
9 West Eleventh Street,
460
MEDICAL RECORD.
[September 26, 1896
A CASE OF ANTITOXIN POISONING.
By L. ROSENBERG, M.D..
NEW YORK.
Lucille J , aged four — previous history good, the
child having been free from all illness up to the ap-
pearance of the present trouble — was taken sick on
Sunday, July sth, with sore throat and a rise of tem-
perature to 101.5° F., per rectum. The heart, lungs,
and kidneys were perfectly normal, and the little pa-
tient was well-nourished and well-developed for her
years. O"". ihe 6th, the appearance of a small mem-
brane on each tonsil warranted a clinical diagnosis of
diphtheria (subsequently verified by culture), and she
was given one injection of two thousand units of anti-
toxin. This was at about i 130 p.m. She slumbered
quietly for about an hour, when the mother (an un-
usually observant and intelligent woman) noted that
the child appeared to become cyanosed. She awoke,
complaining of cold, and was taken with a severe, pro-
longed chill; lapsed into unconsciousness and col-
lapse. Physicians were hastily summoned, and Dr.
Whitman H. White responded. He found the child,
as he believed, /// c.x/rcmis. The temperature per rec-
tum was 109"^ F., verified by myself when I arrived
twenty minutes' later. However, he gave the child
one-one-hundredth grain of strychnine hypodermati-
cally, and also two minims of digitalis fluid extract in
ether. The pulse was scarcely perceptible when I
took charge of the case. The patient was rigid, icily
cold; the pupils were dilated to their utmost; a pro-
fuse perspiration appeared all over the body; a large
quantity of coal-black fa;ces was involuntarily ex-
pelled, resembling meconium but of darker hue and
staining everj'thing with which it came in contact.
I concluded to supplement the other stimulants with
nitroglycerin, one-fiftieth grain of which was injected
under the skin. It was found necessary to repeat this
in twenty minutes. The pulse rallied nicely from
this, but the condition was extremely menacing.
There was more or less rigidity, notably of the mus-
cles of the neck; there was partial opisthotonos; the
surface temperature continued frigid and the skin
clammy. Hot-water bottles were placed all about the
child. Four ounces of strong coffee, with two ounces
of cognac, were thrown into the rectum, hot, and were
retained. This was repeated in an hour. The nitro-
glycerin had to be exhibited freely and frequently, the
heart action being extremely feeble and irregular. In
all, the little patient received one-eighth grain between
3 and 8:30 P.M., when she began to rally. Although
still unconscious, her pulse was slower, full, and regu-
lar; the normal bodily temperature obtained, the pu-
pils w-ere less widely dilated, the temperature was 103'
F. per rectum. Xourishment could not be given; an
enema of whiskey, milk, and egg was not retained.
This condition continued as described until mid-
night, when she came out of the stupor. Attemjits
were then made to nourish her with small doses of
champagne and an infant food, but the .stomach re-
jected everything. The vomit was fluid and inodor-
ous, but contained tiie same dark coloring matter as
the stool before described. The rigidity gave way to
extreme restlessness, the patient writhing about in the
bed, with very short inter\-als, during which opisthoto-
nos would recur. Ten grains of sodium bromide were
given per rectum, without benefit. The extreme ner-
vous perturbation continued.
At II A.M., Tuesday, the temperature was loi' F. ;
the stomach was still rebellious. The child was fully
conscious, but complained of nothing; the restless-
ness was unabated. .A. second rectal injection was
given, containing ten grains each of sodium bromide
and chloral hydrate, and two drachms of whiskey.
The stomach was quieted by one-twelfth grain of mor-
phine, given hypodermatically. From now on the
condition became more tranquil, the child slumbering,
though fitfully. The stomach retained small doses of
fluid nourishment; the temperature fluctuated between
loi" and 102' F. during the day.
Wednesday morning the temperature, pulse, and
general condition were as nearly normal as could be
expected under the circumstances. The membrane
had entirely disappeared. The first urine obtained
(twenty hours after the onset of the collapse) was foul
smelling and strongly alkaline, but free from albumin
or blood. The subsequent history was uneventful,
and at this writing the child is as well as ever. The
small quantity of iron which the child received before
the antitoxin was resorted to was insufficient to give
the stool the deep black color it presented. The dark
color of the vomit is also unexplainable. The condi-
tion of the digestive tract had been normal prior to
the illness. Elsie, an older sister, had been given
three hundred units of antitoxin from the same source,
without any untoward symptoms developing. The in-
jections were made by one of the most experienced
physicians on the staff of the health board.
210 East 0.\e Hl'.ndked a.sd Twelfth Street.
A FISHHOOK REMOVED FROM AN IN-
FANT'S THRO.\T BY DIGITAL MANIPU-
LATION.
By THO.MAS B. HEGE.MAN. .M.D.,
BROOKLYN, N. Y.
Ox August 2ist an infant girl, two years old, was
brought to my office by the mother, who stated that
the child had "swallowed a fishhook."
On examination I found that about one inch of the
catgut to which the hook was attached was protruding
from the mouth. Placing a wine-bottle cork between
the upper and lower molar teeth of the right side, I
found on inspection that the fishhook had passed into
the throat and had been carried to the lower part of
the pharynx, the point being embedded in the mucous
membrane of the lateral wall of the pharynx in the
hyoid space of the left side.
Using the protruding catgut as a guide, the thumb
and index finger of the right hand was passed along
into the phar}-nx. The end of the shank of the fish-
hook could then be felt, but only about one-fourth
inch of the shank could be graspjed by the fingers.
Securing as firm a grasp as possible on this small
lever, I passed the index finger of the left hand deeply
into the pharynx, until the point of the fishhook could
be felt through the mucous membrane.
Realizing that the peculiar nature of the foreign
body made it hazardous to either push or pull, I de-
cided to try rotation. Giving the shank a quick twist
the point of the hook was forced out of the membrane
and caught in the skin of the index finger of my left
hand. Having the hook now between the index fin-
gers, it was an easy matter to withdraw it. There was
very little laceration of tissues, and the operation look
less than three minutes to accomplish. The hook
was of the variety known as a " porgie" hook, about
one and one-fourth inches long, with about six inches
of catgut attached.
The case is interesting because of the nature of the
foreign body. Many strange and curious things have
been swallowed by children, but one does not often
hear of a fishhook as a foreign body in the human
throat. The case is instructive in showing how much
can be accomplished by careful digital manipulation
in removing foreign bodies from the throat.
363 Xewkirk Ave.nue.
September 26, 1896]
MEDICAL RECORD.
461
APPENDICITIS COiMPLICATING PREG-
NANCY.
Bv HOWARD CRUTCHER. JM.D.,
At ten o'clock on the evening of August ist, I was
c;\lled by Dr. Frank H. Waters to see with him a
}oung woman, aged seventeen, unmarried, American,
who presented the following history:
On July 16th she was taken sick with cramps and
pains in the stomacii and bowels. There was some
vomiting and the bowels were constipated. Two days
later (July i8th) a t\vo months' foetus was expelled.
This development was a total surprise to the family,
who at once called a neighboring practitioner to attend
the case, until Dr. Waters could be called from the
city. Dr. Waters and the other attendant held a con-
sultation within a few hours after the expulsion of the
foetus, and decided to curette and pack the uterus.
This was done at once. The girl strongly denied any
criminal procedures, and attributed the mishap to
overe.xertion at the washtub. The condition, however,
did not improve. Abdominal pains, constipation, and
headache continued. The pulse rose quite steadily
from day to day, and it was evident that general sepsis
had developed.
I found the patient slightly delirious at times; the
pulse was 160, with a temperature of 102.5° -P"- ' the
abdomen was not painful to pressure, although it was
much distended. The uterus was e.xplored carefully,
but no traces of degenerated tissue could be detected
at any point. The odor was quite offensive. There
was hardly any discharge from the uterus. On ac-
count of the entire absence of pain, it was evident that
she was already antesthetic from sepsis. The bowels
were discharging a dark, soft mass about every two
hours, and had been very loose for three days. Pre-
viously to this, constipation had been very obstinate.
The urine appeared to be normal in quantity and but
slightly altered in quality.
My belief was that the patient was sutfering from
septic metritis. It was thought that a tubal complica-
tion might account for the peritonitis, although nothing
in the patient's history justified such a belief. The
patient's condition being utterly hopeless as she was,
it was decided that an attempt at relief would be jus-
tifiable.
On account of apparent improvement during the
night, the family insisted upon delay. This action
put off the operation until the morning of August 3d.
Chloroform was given by Dr. Waters. Assisted by
Drs. F. H. Lockwood and A. S. Pease, I opened he
abdomen in the median line three inches below the
navel. On incising the peritoneum there was a hiss-
ing of gas, which, of course, led to the belief that an
intestine had been opened. This was not so. In an
instant there was a torrent of foul pus, which amounted
to more than a gallon. The well-known wall of lymph,
so eloquently described from time to time, had pushed
the intestines and omentum up to within an incn of
tlie umbilicus. At this time the prostration of the pa-
tient was extreme, but irrigation with gallons of hot
saline solution revived her. The abscess cavity was
enormous. Its walls were not broken at any point.
Attached to the right tube and uterine fundus were the
remains of a perforated \ ermiform appendix. It was
strongly attached and no effort was made to remove it.
After the use of many gallons of hot salt water, the
cavity was quickly sponged and a large Mikulicz drain
inserted.
The patient died in three hours, after apparent re-
covery from the shock of operation. Drs. D. H. Gal-
loway, A. S. Pease, and the writer conducted an au-
topsy seven hours after death. Intestinal adhesions.
while recent, were universal. The liver was entirely
adherent. The omentum was a friable mass, occupying
the left lumbar region. The uterus and ovaries, aside
from their recent coverings of lymph, were in appar-
ently good condition, barring the usual congestion of
the uterine tissues. The right Fallopian tube was
normal, save at the point of attachment to the vermi-
form appendix, where a small collection of pus was
found. The vermiform appendix was four inches
long, and gangrenous for an inch where it was adher-
ent to the tube.
In the absence of any other cause for the miscar-
riage, it is evident that the appendicular lesion was
responsible for the trouble. Probably a former attack
of appendicitis had been "cured" by the appendix at-
taching itself to the uterus and tube, where it held in
store a magazine of infection, which, when released by
the normal enlargement of the uterus, dealt the patient
a swift and fatal blow.
103 State Street.
A CASE OF OX.\LIC-ACID POISONING.
By P.\UL W. ERDTMANN, M.D..
NEW VORK.
Mr. L called at my office in great excitement, and
asked me to come with him at once, his wife having
" taken something by mistake." I hurried to his home,
and on arrival found his wife, a woman, thirty-five
years old. She was in bed, vomiting bloody inucus.
The respiration was short and jerky, the pulse small
and irregular, the surface of the body was livid, and
the skin was cold. She complained of severe abdom-
inal pain and burning in the throat. I asked her what
she had taken. She said in a whisper and very
slowly that she had, by mistake, taken a drink from a
bottle in which she kept a solution to clean the boiler
with. She had mistaken the bottle for one containing
lemonade which she had placed next to it. The hus-
band told me it was oxalic acid. I did not scrape the
ceiling, because a drugstore was opposite, to which I
hurried the husband to get lime water.* By this
time the patient was almost completely unconscious
and was cyanosed about the face. She had no con-
vulsions. Vomiting had entirely ceased. I admin-
istered the lime water freely, and then gave mustard
water, which, however, did not cause vomiting. I
then administered apomorphine hypodermically. This
promptly acted. The heart was stimulated all the
time.
After two hours the patient w'as out of immediate
danger and was perfectly conscious. She then told
me she had dissolved an ounce of the acid the day be-
fore in a tumbler of water. She drank the whole
amount. I suspected her of suicidal attempt, which,
however, she emphatically denied.
The patient was also six months pregnant. On ex-
amination I could not hear the foetal heart sounds and
quickening had ceased. I concluded the fcetus was
dead.
Next morning the patient was doing well ; the pulse
was good, the temperature was 102° F. The gastro-
enteritis was quite severe. Examination revealed that
the fcetus was dead.
Next morning I produced premature labor, introduc-
ing a carbolized-sponge tent, and in the evening the
entire ovum, membranes, placenta, and foetus were
discharged at one time. The patient made a complete,
uninterrupted, rapid recovery.
I report this case, as there are but few instances on
record of recoveries after the ingestion of an ounce of
oxalic acid. Some writers have claimed that oxalic
acid is an emmenagogue. In this case no uterine
contractions were produced.
462
MEDICAL RECORD.
[September 26, 1896
A CASE OF MALIGNANT DIPHTHERIA
TREATED BY ANTITOXIN — RAPID RE-
COVERY.
By ARTHUR IRVING BOVER, M.D.,
NEW HAVEN, CONN.
At the present time there seems to be so much doubt
existing in the minds of many of the profession re-
garding the efficacy of antitoxin in the treatment of
diphtheria, that some are no doubt deterred from even
trying it for fear of failure. The case I am about to
relate is one which came up in my own practice very
recently. Saturday, July 25th, about 9:30 p..m., I was
called to see the patient, a girl, eleven years old. I
found her in a semi-comatose condition. Pulse, 120;
respiration, 24; temperature, 104° F. Her father said
that she appeared perfectly well Friday night and par-
took of a hearty supper; she slept \vell until about mid-
night, when she became a little restless, but did not
complain of her throat or manifest any other symptoms
at that time. Indeed, Saturday morning she was
about the house; as the day advanced, however, she
began to act drowsy, and then (about 5 p.m.) for the
first time complained of a sore throat. Her father
looked at her throat and told me that at that time all
he could see was a " small white spot" on one tonsil.
As the child had had tonsillitis before, he did not
attach very grave importance to it; but as she con-
tinued to get worse he sent for me. Upon examina-
tion of her throat I found both tonsils and the phar)-nx
covered by membrane, parts of which had become ne-
crotic. There was no room for doubt as to diagnosis.
At 11:15 P-^'- ^'^'^ cubic centimetres of antitoxin were
injected (New York Board of Health No. 2). At this
time her pulse was 120: respiration, 26: temperature,
104° F.
Sunday, at i:;i5 a..m., another five cubic cen-
timetres were injected. Both these injections were
followed by marked reaction in about ten hours. At
11:15 P.M. there seemed to be a change for the better;
she had a coughing-spell, accompanied by vomiting,
and a sm'all portion of the membrane became detached.
At this time her pulse was 104; respiration, 20; tem-
perature, 101.1° F; and she was conscious and ra-
tional.
Monday, at 10 .\..m., another injection of antitoxin,
this time two cubic centimetres, was given. Pulse,
100; respiration, 20; temjoerature, loi" F. .\t8:i5
P.M. I removed a piece of membrane as large as a fifty-
cent piece, with long forceps. At 10 p.m. there was
a reaction from the antitoxin given in the morning,
and she was somewhat delirious.
Tuesday, at 10:10 a.m., I removed another piece of
membrane with forceps. Pulse, 100; respiration, 20;
temperature, 99" F.
Wednesday, 10:15 a.m., pulse, 100; respiration, 18;
temperature, 98.5' F. She had slept from n p..m.
to 5 A.M., and awoke very much refreshed. The
membrane gradually disappeared. At 8:15 I'.Nr. the
pulse had fallen to 80; respiration, 18: and tempera-
ture, 98.5° F. ; and they have remained so ever since.
The patient gained strength rapidly, and at the
present time of writing, August 5th, she is out of doors,
and her throat is in an entirely normal condition.
Quarantine was raised yesterday.
1 have seen a statement to tiie effect that " bacteriolo-
gical" and "clinical" diphtheria are not closely allied.
AH I can say regarding this is that tiie diagnosis was
proved bevond question by the finding of the Klebs-
Loefifler bacillus, and the case from a clinical stand-
point gave no reason for doubt, as, besides the throat
symptoms, there was marked evidence of systemic in-
fection which the temperature alone would not account
for. No other treatment whatever was resorted to,
with the exception of drachm-doses of brandy in milk
and an antiseptic mouth wash of boric acid in dis-
tilled water.
121 Grand Avenue
A CASE OF COLLAPSE FROM EXCESSIVE
VOMITING SUCCESSFULLY TREATED BY
INTR.WENOUS INFUSION OF SALINE SO-
LUTION.
By C.\RL0S C. booth, M.D.,
VOL'NGSTOWN, OHIO.
Mr. Charles B — • — , aged twenty-six, millman, be-
came suddenly sick with severe pain, accompanied by
general cramps and vomiting of large quantities of
fluid, at 2 P.M., July 28, i8g6, while at work in the
rolling mill. I attended him at 5 p.m., administering
a large hypodermic injection of morphine, and re-
peated the same at 8 p.m. He continued vomiting
large quantities of rice-water-like fluid during the
night, but with less frequency.
On July 29th, although he had received large hypo-
dermic injections all this time at inter\-als of two or
three hours, the vomiting continued.
July 30th, at 9 A..M., he was still vomiting and from
the excessive loss of fluid was rapidly approaching
death. I gave him nitroglycerin and strjxhnine. The
pulse was then 130 to 140; temperature, 96° F. ; the
eyes were sunken, extremities cold, and the man was
vomiting occasionally. At noon Dr. J. Wilson was
called in consultation, and we both agreed that if some-
thing radical was not done, death would surel)' follow,
as the man was rapidly getting worse. At 5 I'.m. the
pulse was 160; temperature, 96^ F. At this hour,
assisted by Drs. Wilson and B. F. Hawn, I infused
two quarts of sterilized normal saline solution, at about
120° F., into his right median basilic vein. The patient
was throwing himself from one side of the bed to the
other, as one dying from hemorrhage. Almo.st imme-
diately he became warmer, fell asleep for a few mo-
ments, and the pulse from a flutter came down to 1 10
per minute, with a full volume. The man expressed
himself as feeling much better and warmer; his ex-
tremities became warm, he perspired a little, and at
once his condition improved in every way.
During the next twenty-four hours he vomited only
three or four times. I continued the nitroglycerin
and strychnine, and on August ist he had a pulse of
96 per minute, normal temperature, desired food, and
is at this time, August 7th, sitting up and feeling quite
himself. There was no secretion of urine from July
28th to 31st, and no movement of the bowels until
August I St, and, in fact, I could obtain none previously
to this time. It is not necessary to detail the minutiae
of the treatment further than this, as we had used about
everything that has ever been suggested for such a
condition. In our opinion, this man would have died
if he had not had the infusion. If occasion presents
itself, I shall not hesitate to recommend and use this
treatment in the above condition, regardless of the age
of my patient.
Vinegar as an Antidote to Carbolic Acid. — Pro-
fessor Carleton (I.u Semuinc Mfilicalc) says that when
applied to a skin or mucous membrane burnt by car-
bolic acid vinegar causes a quick disappearance of the
characteristic whiteness, as well as the anarsthesia
produced by carbolic acid: and prevents the formation
of a slough. It also neutralizes any carbolic acid
that may have been introduced into the stomach. In
cases of poisoning, then, the first thing to do is to make
the patient drink some vinegar mixed with equal parts
of water, and to wash out the stomach. According to
Billroth, soap is an antidote in carbolic-acid poisoning.
September 26, 1896]
MEDICAL RECORD.
463
^hci'apeutlc Hints,
Turpentine is said to be a specific for parotitis.
Antihysteric It is said that one-tenth grain of
aponiorphine given hypoderniatically will break up
and thereafter prevent any attack of hysterics.
Hypodermic Purgative. —
If L'atTeinii; et choral aa gr. viiss.
AquLC rt[ Ixxv.
S. Inject fifteen minims.
— EwALD, Journal de Midecine de Paris.
Antidyspeptic. —
I^ Bism. subnit.,
Magnes. sulphat.,
Cret. prepar. ,
Calc. plios aa lo
M. Div. in cachet No. xl. S. One before each meal in
•dyspepsia accompanied with pains and flatuleney.
■ — Dujardin-Beaumetz.
Antiasthmatic
1} Tinct. opii 4
Ether sulphuric 8
M. S. About fifty drops every twenty minutes in attacks
■of asthma with emphysema.
— Clymer.
Infantile Diarrhoea
If Bism. subgal 3 i.
Sodii bicarb gr. v.
Cret. prep 3 ss.
Creosoti gtt. v.
Syr. cinnam 3 ss.
Aq. dest q.s. ad 3 iv.
M. S. Teaspoonful after each movement.
— Griffin.
Unguentum Refrigerans. —
I{ .Anhydrous lanolin lO
Benzoated lard 20
Rose water 30
Absorbent Powder. —
"Bi Alum, finely pulverized 5
Carbonate of lime, pulverized 4
Starch, pulverized 50
— SlGMUND.
■Cutaneous Irritation of Measles. —
If Lanolini puris ^ i.
Vaselini 3 iij.
01. ricini Tl ij.
Aq. dest 3 v.
Ft. ung. S. Apply as required.
■ — Practitioner.
Toothache. —
B Chloral hydrate,
Camphor,
Carbolic acid.
Glycerin aa 3 iss.
Introduce into tooth cavity a ball of cotton moistened with
this mixture.
Earache
If Chloral hydrate.
Camphor,
Carbolic acid aa gr. xiiss.
Castor oil 3 iv.
Warm the mixture and put a few drops in the ear.
— College and Clinical Recorder.
Epilepsy
If Antipyrin 3 i.
Ammonium bromid 3 iiiss.
Strontium bromid J i.
Solution of potassium arsenite ill xl.
Extract of solanum carolinense 3 xss.
Water q.s. ad § vi.
M. Do.se : A dessertspoonful or more twice daily.
— Gaz. hebd. de Med. et de C/iir., 1896, No. 19.
Chancroid. — Cleanse and dry the parts. Apply sal-
icylic acid so as to cover the ulcer and a narrow zone
of skin beyond. Cover with an adhesive plaster.
Dress every twenty-four hours. On the third day re-
place by an ointment. 'I'hree days after falling of
the eschar reparation is complete. — Hebra.
Bronchitis of the Aged
I? Benzoic acid gr. ivss.
Tannic acid gr. ii^,
M. For one cachet. S. Take four or five such cachets per
diem
— E. Maragliano, Le Progres Mtdical.
Heart Failure in Phthisis.— But one of the most
serviceable means, which has stood me in very good
stead, IS taking advantage of the physiological relation
between the act of swallowing and the act of expecto-
ration. Repeatedly we sue in adults with phthisis the
benefit of sipping hot fluids to ease their morning ex-
pectoration. The experiments of Kronecker and Melt-
zer prove that this result comes about mainly by stim-
ulation of the heart with each act of deglutition. — Dr.
Thomson, before the Academy of Medicine, April 7,
1896.
Infant Feeding — ^Dr. Dillon Brown {American
Medical and Surgical Bulletin, May 9, 1896) says that
the farinaceous foods and the so-called milk foods
are, in his experience, rarely or never indicated, and
are usually harmful. In children with poor digestive
powers, the Liebig foods are often of value; but
they never can be and it never has been claimed that
they are substitutes for milk, and are only to be used as
a valuable addition, in certain cases, to properly han-
dled and properly modified cow's milk.
Tjrphoid. — Dr. Henshaw [Bos/on Medical and Sur-
gical Journal, May 14, 1896) commences an article as
follows: "Within the last few years, more than fifteen
hundred remedies have been suggested for the treat-
ment and cure of typhoid fever. All sorts and kinds
of foods have been advocated as of special value in
the diet; hydrotherapy and antipyretics have been ad-
vised for the reduction of the fever; attention has
been called to the value of intestinal antisepsis;
while the special symptoms arising during the course
of the disease have been relieved, experimentally at
least, by almost every resource of the pharmacopceia.
These methods, however, have not proved invariably
efficient in modifying the course or severity of the dis-
ease."
Foreign Bodies in Ears. — Dr. Belt ( Virginia Med-
ical Semi-Montl/ly, X-grW 24, i8g6) gives this important
admonition to the general practitioner: The physician
is frequently called upon to remove foreign bodies
from the ear — such as insects, grains of wheat, corn,
beans, slate pencils, etc. Sweet oil or glycerin will
usually kill or quiet an insect, after which it can be
removed as any other foreign body — that is, by means
of a syringe and warm water. Never use a probe, ear-'
spoon, or forceps in these cases, as great injury may
be done while contending with a struggling child.
Foreign bodies sometimes remain in the ears for years
without doing injury, so there is no need of haste, ex-
citement, or forcible methods in dealing with them.
Chills in Typhoid Fever. — Dr. Osier, in the i'ni-
versity Medical Magazine, November. 1895, says chill
may occur — First, at the onset of the disease, as seen in
thirteen cases out of a total of seventy-nine treated at
the Johns Hopkins Hospital during the sixth year.
Second, at the onset of the relapse, due to an irregular
or a disturbed elimination of the poison, a large vol-
ume of which is thrown into the blood in a short time.
Third, as a result of treatment, antipyretics being
464
MEDICAL RECORD.
[September 26, 1896
particularly .prone to produce chill, and this phenom-
enon may occur after the injection of sterile cultures
of bacilli and after the external application of guaia-
col. Fourth, with the onset of complications, such as
pneumonia, pleurisy, acute otitis, suppuration in the
mesenteric veins, pyamic abscesses of the kidney,
perforation of the ileum or appendix, or an acute peri-
ostitis. It may occur with thrombosis of the femoral
or saphenous veins, and it may precede acute and
fatal hyperpyrexia. Fifth, during convalescence in
severe and protracted cases. In such cases there may
be no local symptoms to account for the chills, and,
though alarming, they may gradually subside, with
complete recovery. They may possibly be septic.
Sixth, chills may be due to concurrent malaria.
While attributed, as a rule, to malaria, chills in the
course of typhoid fever are very rarely due to this
cause.
Nervine Tonic and Sedative —
I^ .'XsaftfticLv I i.
Acidi arseniosi gr. ss.
.Strj'chnins; sulph gr. ss.
Ext. sumbul 3iss.
Ferri subcarb Bij.
Quininx valerian 3i.
M. Make capsules No. x.\iv. .S. One capsule after each
meal.
— Dr-. Browx, Va. Med. Scmi-Motithly.
Enuresis in Children Dr. Harold Williams
{Boston Medical and Surgica/ Journal) gives statistics
of sixty-two cases: twenty-eight in boys, thirty-four in
girls, of ages from two to fifteen. In thirteen cases
definite causes of reflex irritation were discovered,
with prompt cure of the enuresis in twelve cases.
These causes were: Adherent prepuce, four cases;
vulvo-vaginitis with gonococci, one case: oxyuris ver-
micularis, five cases; chronic ileo-colitis, one case;
prolapse of the rectum, one case. Ana-mia and a
neurotic temperament and history were present in
most of the cases. Forty-nine cases remained un-
explained.
Causes of Migraine Dr. Marcus, of Pyrmont, has
suffered from periodic headaches for forty years and
thinks they are due to changes in the atmospheric
pressure. He finds that the advent of his own attacks
and of those of others are always coincident with a
variation in the pressure, which is not always accompa-
nied with a change in weather, but is confirmed next
day by the official weather bulletin. Dr. Marcus asks
physicians who live in localities where the atmo-
spheric pressure is more stable to investigate the mat-
ter and possibly find .some relief for chronic sufferers.
— Thcrapeutische Wochcnschrijt, March 39th.
Local Anesthesia in Labor — Dr. T. H. Weagly
{Times and Re,^isla; October 5, 1895) has obtained
excellent results in cases of rigidit)' of the cervix by
local ana;sthetics applied to the parts by a spray appa-
ratus. He claims that the following solution will
•expedite and soothe the first stage of lalior, and even
when the occiput has entered deeply into the pelvis
the pain accompanying the expulsion of the head may
be reduced to a minimum by spraying the vagina!
surface of the perineum and outlet.
B Phenolized cocaine solution (3 per cent.). . . 51.
Trinitrin solution (2 per cent.) HI x.
Sulphate of strychnine gr. J^.
Listerine 3 i.
M.
Fevers. — Dr. Da Costa, in the American Jourtial of
the Medical Sciences, June, 1896, says: "The treatment
of the prolonged simple continued fevers is purely
symptomatic. Quinine has no effect on them, nor
have the ordinan,- antipyretics more than a temporary
infiuence. Phenacetin and salol do most good, partic-
ularly in cases with headache. They are best given
in small doses, a grain or two, frequently repeated
until their effect is manifest. Better still, when it
can be efficiently carried out, is t.'ie cold-bath treat-
ment, not only to lower temperature but for its revul-
sive and alterative influence. I regret that in the
extremely long cases first mentioned circumstances
prevented it from being thoroughly carried out. Pur-
gatives, unless contraindit ated by weakness, always
form part of judicious treatment."
Syphilitic Brain Disease. — i. In syphilis of the
brain, especially of the meninges, severe headache is
an early, often predominating, symptom. In our case
the patient did not suffer from headache of any conse-
quence till partial paralysis had developed, nor was
his headache at any time more severe at night, as is
often the case in specific disease. 2. The course of
syphilitic brain disease is subject to great variations
in the intensity of the symptoms: sometimes from day
to day, or week to week, symptoms come and go and
do not show the steady development observed in the
case under question. 3. .Specific meningo-encephali-
tis yields readily to energetic specific treatment, espe-
cially when applied early. Our patient grew steadily
worse under a thorough course of specific treatment:
nor were there any other signs of syphilis of the ner-
vous system, as is so often the case, present to sup-
port the diagnosis of syphilis. — Drs. Stieglitz, Gers-
TER, LiLiENTH.M., American Journal of the Medical
Sciences, May, 1896.
OUorr csp 0 n d cncc,
OUR LONDON LETTER.
(From our Special Correspondent.)
GENERAL MEDICAL COUNCIL — CANDIDATES — RlitlRINt;
.MEMBERS — COLCHE.STER MEDICAL SOCIETY^DEFENCE
UNION '• balderdash" AS INTEPRETED BY BRU-
DENELL CARTER AND VICTOR HORSLEV — INDIRECT
REPRESENTATION REVIVED ^ DANGEROUS TRADES
REPORT — PETROLEUM REPORT — SANITARY CONGRESS
— ARMY VACANCIES.
London, September 4. 1896.
The medical council, though not sitting, is monopo-
lizing the attention of many medical politicians.
First, the coming election of direct representatives
gives rise to discussion of the claims of the candidates,
and fresh names are continually being suggested. I
should think some of the gentlemen whose names have
been mentioned by their friends or others would have
preferred to keep the proposal out of print. I shall
not call them candidates until they declare themselves
such, .\mong those who ha\e done so. Dr. Rentoul will
be remembered as the man who defeated the niidwives
bill by his indomitable courage and energy, and at no
little pecuniary sacrifice. This is certainly no little
claim. .\s one of the retiring members. Sir M'. Fos-
ter, is an Irishman, some of our delightful Hibernian
colleagues have suggested that the occasion should be
seized for doing justice to Ireland by sending two of
her sons to replace him: and this Hibernicism has
actually drawn a refutation from a sober writer, who
thinks it is time England should be considered at the
election of three members for England. The qualifi-
cations for the office do not seem to concern many, and
so we see such claims as these put forward, as well as
others which have equally little bearing on the duties
of councillors.
At Carlisle the British Medical .Association assumed
to thank Mr. Wheelhouse and Sir \V. Foster for their
services, and an effort was made to beg them to con-
September 26, 1896]
MEDICAL RECORD.
465
tinue. This is in accordance with their election at
first, which was managed by the committee of the as-
sociation, of which these two gentlemen were members
at the time. It is the fashion within the inner circle of
the association to e.xtol the work of these two members
in the council, and to hold them up as model direct rep-
resentatives. Outside we smile at the advertisements
that proceed from within, and admit that they were
direct representatives of the inner circle. When it is
asked what they have done, an answer is seldom given,
though occasionally we are told they voted for an in-
crease in the number of direct representatives. Really,
a great deal too much has been made of their so-called
services, and now it has been proposed to get up a
testimonial to them for doing the duty they sought so
ardently. I hope no one will be hoodwinked into sub-
scribing. They secured the position by electioneer-
ing tactics of the lowest order, and if they have voted
as directed by the clique who manoeuvred the election,
let their retirement close the disgraceful page of the
histor}'.
The Colchester Medical Society has nominated Drs.
Rentoul, Drage, and George Brown as candidates.
Some other societies are proposing candidates, or,
rather, selecting those they intend to support. The
attempt of the British Association through the Lan-
cashire and Yorkshire branch is thus being followed,
but that attempt has led to an unpleasant dispute as to
whether its nomination was in order. I am afraid
there is something in the objection' raised to the pro-
ceeding, but it will not invalidate the election, being
only a resolution of a small meeting to support certain
candidates — a meeting held for another purpose, viz.,
to hear an address by Prof. Victor Horsley. I am
sorry he should have been mi.xed up in this move on
behalf of those he supports. He is president of the
Medical Defence Union, which in its brief career has
done more for the interests of the profession than the
General Medical Council in its thirty-seven years of
talking and passing recommendations. Mr. Horsley 's
surgical fame has long since reached you, but you may
not be aware that he has developed equal skill and
energy in the task he has undertaken as president of
the union. I hope he will retain that office and work
it as he has done hitherto. The decision of the Brit-
ish Association to take up medical defence does not
necessitate any particular plan. I am half-disposed to
believe the safest for the time being would be to vote
funds for ever)' case undertaken by the union, up to a
fixed limit in the year or for each case. This would
give the union a free hand, and Mr. Horsley and those
working with him would be encouraged to continue to
give their great experience and talent to the work they
have done so well, and for which they only need fur-
ther funds.
Mr. Horsley has also come out as an acute dialec-
tician. I told you Mr. Brudenell Carter, a keen
controversialist and experienced Journalist, had writ-
ten to The Lanat a defence of the Medical Council
from the criticisms to which it was subjected at Car-
lisle. Mr. Horsley read a paper there, as did the can-
didates he supports. They treated the defects of the
council from different points of view, and Mr. Carter
called their statements "balderdash," which he subse-
quently pronounced to be "a good old English word,
meaning a confused statement.'' Mr. Horsley is equal
to the occasion, and quotes authority to show that
though in early Scandinavian it meant so, it gradually
came to be applied to the sayings and arguments of
persons who talked nonsense, and its present-day
synonyms, according to the great authority of Roget,
are " nonsense, jargon, gibberish, jabber, babble, ho-
cuspocus, fustian, rant, bombast, rigmarole, twaddle,
fudge, trash;" and, he adds, it also appears that bal-
derdash means, further, "a tale told by an idiot, full
of sound and fury, signifying nothing." These are
hard words, Mr. Horsley thinks, though after Mr. Car-
ter's " graceful explanation" he is happy to know that
they were not intended to apply to the criticisms of
the council made at Carlisle. This is the lively part
of the little discussion Mr. Carter provoked. There
is plenty more and of a serious kind, demonstrating
that Mr. Horsley knows what he is talking about, and
that his trenchant criticisms of the council are founded
on a basis which has not been shaken.
In the discussion at Carlisle on the subject, tliemost
interesting point was the revival by one speaker (Dr.
Muir) of the question of indirect representation as
preferable to direct. How should more influence be
obtained ? Instead of more direct representatives to
enlarge the council, he held that every diplomate of a
corporation or university ought to have a vote in the
choice of a representative of such body on the council.
Some dissentients to this were present, as might be
expected, but it is clear that such a reform would be
popular and effective. It was advocated with no little
energy some years ago, and the association made a
great blunder in opposing to it direct representatives
in the hope of controlling the elections.
A year ago the home secretary appointed a commit-
tee to inquire into dangerous trades. After inspecting
one hundred and thirty-four works and examining one
hundred and fifty-three witnesses, the committee has
presented an interim report, in which a number of rec-
ommendations and suggestions are offered, with a
view of protecting the health of workpeople without
pressing too heavily on employers or adding to the
difficulties of keen competition. Most of the recom-
mendations are already in use in the best-regulated
works, where employers regard their workpeople with
interest, and it could, therefore, be no hardship to
make them compulsory on any who may have no
thought for the health and welfare of those who con-
tribute to their own prosperity. The dangers to life
and health in various occupations may, perhaps, be
minimized by judicious legislation, and careful in-
quiries such as this are the best preparation for par-
liamentary action.
The select committee appointed to inquire into the
laws relating to the keeping, selling, using, and con-
veying of petroleum and other inflammable liquids,
being unable to conclude their inquiries in the parlia-
mentary session, reported the evidence they had taken
and recommended the house to reappoint a committee
next session. This will probably be done. Mean-
time, it may be observed that there were great differ-
ences of opinion among the witnesses examined, espe-
cially as to the existence of a safety-flash point for
paraffin. The alternative of looking to the construc-
tion of the lamps presents itself. I suppose that we
must await ne.xt session's committee for further inves-
tigation and legislation, but as there are safety lamps
in the market prudent people will decline to purchase
others.
On Wednesday the Duke of Cambridge opened the
congress of the Sanitary Institute at Newcastle-on-
Tyne, and judging from the proceedings of the two
days that have elapsed, the meeting promises to be
successful.
Competition in the army medical ser\'ice is dead.
At the last examination, as I reported, only thirteen
were passed, and for them twenty-five vacancies
waited. But a further need has occurred from resig-
nations, and there are twent)'-two places waiting for
qualified candidates; but none of these are coming for-
ward. The " combatant officers" have killed compe-
tition, and will yet feel the want of skilled surgeons.
Obesity. — Duboisine is said to cause persistent loss
of flesh.
466
MEDICAL RECORD.
[September 26, 1896
A PROPOSED
CONGRESS
GISTS.
OF LEPROLO-
To THE Editor of the Medical Record.
Sir: Dr. Goldschmidt, late of Madeira, now at Paris,
in a letter to me, last December, proposed that a con-
gress of leprologists should be held, for the suppres-
sion and prevention of leprosy. In a letter I wrote
to Dr. Hansen, I referred to this proposition and sug-
gested the formation of an international committee,
one delegate from each government, to be permanently
active, to meet once a year, and to take cognizance of
all questions and problems relating to leprosy all over
the world. I also suggested the collection of a fund
in every country, for the use of this committee, to sup-
port asylums where such help is wanted, and to send
specialists wherever they are needed. Dr. Hansen at
once received these overtures with favor, and submitted
them to his chief, who in turn communicated them to
the Norwegian government. In his answer to me, Dr.
Hansen said that it was the desire of the Norwegian
physicians that the seat of the first leprosy congress
should be Bergen, Norway, and that the Norwegian
government was willing to issue the call for the first
leprosy congress, provided it had assurances of sym-
pathy from other governments. I at once applied to
President Cleveland, to Queen Victoria, to the Ger-
man Emperor, to President Diaz of Mexico, to Lord
Aberdeen of Canada, to the Japanese and Chinese gov-
ernments, and to all the republics of South America.
I also submitted this scheme to the American Derma-
tological Association, to the American Public Health
Association (of Canada, the United States, and Mex-
ico), and to Miss Clara Barton, the president of the
American Red Cross Society. It is to be communi-
cated also to the Pope, through a hierarchical channel.
It is desired that every influence that may exist, of
any kind, be brought to bear upon the different gov-
ernments, so that they may consent to appoint official
delegates. Of course, leprologists in their private
capacity, or as representatives of associations, will be
invited and are expected to attend. The committee
formed by the delegates will be exclusively concerned
with the promulgation and application of laws suita-
ble to the suppresssion and prevention of leprosy in
each country, leaving the discussion of questions of
etiology, bacteriology, cure, etc., to the specialists.
This is the plan as it stands now, and as it was resub-
mitted by me to Dr. (Goldschmidt. Dr. Goldschmidt,
in his reply, has suggested that Moscow be the seat of
the congress, as the international congress is to meet
there next year. This is open to the following objec-
tions: 1st, If the leprosy congress is held in Moscow,
along with the regular international congress, it will
of necessity fall into position of secondary influence,
and will be, in fact, a section of the general congress;
2d, Hansen is entitled to claim the first leprosy con-
gress, he being the discoverer of the lepra bacillus;
•jd, the Norwegian government, having been the first
to express a willingness to issue the call (which should
be issued by a government, not by individuals), is en-
titled to the honor; 4th, if the congress is now taken
to Moscow, after the Norwegian physicians have ex-
pressed a desire to have it in Nonvay before even Mos-
cow was suggested, the Norwegian physicians will cer-
tainly take offence. A leprosy congress without
Hansen cannot well be imagined.
Will you kindly publish this letter, and ask the le-
prologists of .America to communicate to the provisional
committee of the congress as it exists — Dr. G. Armauer
Hansen, Bergen, Norway; Dr. Jules Goldschmidt, 4
Rue Daunau, Paris, France: Dr. Albert S. Ashmead,
210 West Fourth Street, New York — their own ideas
about this great scheme, and to offer such suggestions
as may help to advance it? May we hope, also, that
you will use the influence of your paper to make the
first leprosy congress a success ?
Albert S. Ashmead, M.D.
THE APPENDICITIS CONTROVERSY.
To THE Editor of the Medical Record.
Sir: Readers of the Medical Record who have
been following the interesting discussion on appen-
dicitis which Dr. MacArtney's article has elicited have
at times felt that the personal element has been very
manifest in most of the letters. It is unfortunate that
calm discussion has been invaded by satire and often
by sneers, which do not conduce to convincing argu-
mentation nor show proper respect for the opinions
of others. Dogmatic assertion on the one hand and
ridicule on both are not calculated to allow a proper
estimate to be made, or to favor the acceptance of obser-
vations that should be weighed in the balance of sober
deliberations. Certainly all are entitled to express
without fear or favor honest opinions and convictions
gathered from personal experience. Very many read-
ers of current medical literature are country general
practitioners, who have not the advantages of hospi-
tal practice. There are bright and keen intellects
among this large army of patient, hard-working men,
yet how many keep in touch with the advances in
thought and practice that master minds are develop-
ing along the lines of evolution in medical science in
the centres of learning and research?
Are not aseptic and antiseptic principles defied by
the methods universally in vogue everywhere in the
management of all kinds of wounds — not excepting
the puerperal uterus? The men who are constantly
combating these "old ruts" and gallantly fighting
against prejudice, ignorance, and often laziness are the
very teachers to whom I, as a general practitioner, am
looking for light in the darkness.
Is it not dangerous for us to accept and practise —
to say nothing of advocating — plans of treatment which
do not lower mortality and give incomplete results and
tedious convalescence? ^^'e should have the courage
of our convictions. All seekers after truth want to
know, and should adopt, the best plans of treatment
in appendicitis — the safest, shortest, and positively
curative methods; those which ensure not simply a
recovery ( ?) but a cure.
What we want is the cumulative evidence of, say,
a thousand cases treated in and out of hospital by sur-
geons and physician.s, their complete histories, em-
bodying all the points that have a bearing upon their
cases in any particular, before and for years subse-
quent to treatment; the sequels, complications, ac-
counts of autopsies, and pathological reports. All
theories based upon individual impressions from
treatment should be eliminated, such as that opium
favors adhesions or that colon irrigations absolve the
sins of the bacillus coli communis. Perhaps then
some rational and more uniform lines will be gener-
ally accepted as bases in treatment than seem to be
followed at present.
I have had six cases that were reported in the
Buffalo Alcdical Journal for February, i8g6 ; also a few
since, but I will speak here only of these six. My
first case, that of a boy of six years, was treated against
my judgment by the opium plan. I had but recently
located, coming from a general hospital, and was un-
known, while my ani/rhvs were men of established
reputation and experience, who independently diag-
nosed the case as one of peritonitis and advised the
opium treatment. The boy died in a few days of un-
mistakable septic peritonitis.
September 26, 1896]
MEDICAL RECORD.
467
My second case was that of a man of fift}', who gave
a histon- of a number of previous attacks. Surgical
aid was deferred for about forty hours, and when the
abdomen was opened the appendix had perforated in
three places and was gangrenous, and diffuse perito-
nitis existed without any evidence of recent adhesions
limiting the infective process. The man died. My
third case was tha* of a young man, who also had had
previous attacks; he was promptly operated on, and
although the appendi.x was severed by perforation from
a concretion and a large abscess was present without
any adhesions, and pelvic peritonitis existed, yet the
man recovered satisfactorily. The remaining cases —
in two of which there had been several attacks — were
treated medicallv. One was on the eve of being ope-
rated on, when the abscess discharged through the rec-
tum. These cases tenninated in recovery from the
attacks, but the patients were not cured, as all com-
plained for over a year afterward of pain and discom-
fort in the right iliac region on exertion.
Only the operated case made a satisfactory recovery,
and is to-day free from the dreaded ventral hernia.
I am not particularly proud of this as e.xemplifying
medical treatment. I have added this experience of
my own to confirm a conviction indelibly impressed on
my mind — that operation done early is free from danger
and gives a complete and speedy recovery as compared
with medical treatment, which encompasses the patient
with greater dangers. No one can say the cure is
absolute, for often the system is left to struggle
against a septic infecting focus and there is always a
dynamite mine ready to explode at an inconvenient
season. It is questionable whether opium favors the
formation of adhesions or that, if it does, relapses are
therefore less frequent; on the contrary, constricting
bands favor relapse, and the patient has a false hope
of cure. S. W. S. Toms, M.D.
Bellport, L. I.
Tn THE Editor of the Medical Record.
Sir: It is to be regretted that some of the readers
of my former reply to Dr. MacArtney discovered any
"keen sarcasm" therein, for it was my intention to
take only a plain part in a plain discussion, which
had for its object the determination of a scientific
point. Dr. MacArtney is voicing the opinion of
many responsible practitioners when he defends a cer-
tain medical treatment of appendicitis which has been
so successful in his hands that it deser\'es the respect-
ful attention of the whole profession — physicians and
surgeons alike. The testimony on appendicitis ques-
tions is about all in, and it is simply for the settling
of borderland questions that I desire to speak from
the experience of a surgeon. Those of us who are
physicians and those of us who are surgeons have no
other object in practice than to do the very best thing
for the patient who places his life in our hands — and
we all comprehend the responsibility that is involved.
Dr. Mac.\rtney asks si.x questions, which I wish to an-
swer seriatim:
(i) " \\'hat is the best treatment for outlying cases?''
By outlying cases I understand him to mean the cases
of appendicitis among the poor, among those who are
too ill to travel, and among those who are not tract-
able. In such cases there has been no better treat-
ment described than the opium treatment as shown in
Dr. MacArtney's statistics.
(2) "What proportion would recover if treated
medically?" This question cannot be answered bv
physicians, because an infected appendix containing a
concretion or a stricture dam may recover from so
many attacks, and in the hands of so many physicians,
that years may elapse before the case can be properly
quoted in statistics. The question cannot be answered
by surgeons, because the cases that get to the surgeon
are not apt to include the very mild ones. It can be
answered pretty well by the pathologists, however, and
in the second edition of my book an analysis is made
of the pathological findings in one hundred consecu-
tive appendicitis cases in which the specimens were
examined, showing that the medical death rate in that
particular series of cases would have been about
twenty-eight per cent, from entrapped concretions,
stricture dams, strangulating adhesion bands, tubercu-
losis, and other causes not amenable to medical treat-
ment. The surgical death rate in that particular
group of cases was two per cent. In a series of one
hundred consecutive cases of half the severity of this
series, the medical death rate could be placed at four-
teen per cent, and the surgical death rate at one per
cent.
(3) "What proportion would relapse?" Relapse
would be looked for in several classes of cases, as, for
instance, those with entrapped concretions, obstructed
solitary arteries, stricture dams, tuberculous foci, and
thick-walled abscesses; and these include in fact about
all of the appendicitis cases that are now going about
the country since their recovery without operation.
(4) " What proportion of these cases if operated
upon under existing conditions, would recover?" By
existing conditions Dr. MacArtney means inability to
receive skilled surgical attendance. I should say
that the death rate at the hands of " occasional opera-
tors" would probably be as large as the death rate
under medical treatment ; perhaps larger. If a sur-
geon possessing by nature nice surgical instincts, and
having manual dexterity, gives himself the benefit of
a thorough special education before taking up abdom-
inal work, he will probably save eighty out of his first
one hundred laparotomy cases; death rate, twenty
per cent. In his second hundred laparotomies he may
get down to ten per cent, death rate, in his third hun-
dred to five per cent., and in his fourth hundred to
one or two per cent. The little bits of things which
go to make up this difference in his percentages will
be too small to receive attention by the " occasional
operator.'' They are like the trifling margins of profit
which roll up fortunes for large business houses and
leave small houses in the lurch. When patients can
have the services of the occasional operator only, sur-
gery should be saved for a last resort instead of being
tried as a pretty and safe method of treatment.
(5) "What proportion would relapse after surgical
treatment?" Relapse would be looked for in cases in
which the operator feared to remove the appendix
when he evacuated an appendix abscess, and in cases
in which a stump of appendix was left at the time of
operation.
(6) " How shall we select the operative from the
non-operative cases?" By looking at the appendix.
There will never be any other way.
Time was when appendix questions were specula-
tive and based on clinical exjjerience. Now that we
have exact knowledge of the pathology of appendicitis,
the questions have become moral ones only, and each
physician who has made a study of this known pa-
thology is guided by his conscience in the disposition
of his cases. Robert T. Morris, M.D.
49 W^EST Thirty-Ninth Street.
Cutaneous Classification. — John Hunter divided
skin diseases into three classes: those which sulphur
would cure, those which mercury would cure, and those
which the devil could not cure.
Thirty Days' Credit Tiie doctors of Stanford,
Ky., have issued a circular giving notice that here-
after their hills must be paid every thirty days in cash
or negotiable notes.
468
MEDICAL RECORD.
[September 26, 1896
Medical Jtems.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending September 19, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-pox
Cases.
Deaths.
161
115
.50
10
31
3
3
3
31
I
126
21
0
0
Duration of Life among Physicians. — Dr. Salz-
mann, of Essling, Germany, has made researches on
this subject among the archives of the German prov-
inces: In the sixteenth century the mean duration of
life was thirty-six years and five months; in the seven-
teenth century, forty-five years and eight months; in
the eighteenth centur}-, forty-nine years and eight
months; and in the present centur\-, fifty-six years
and seven months. These results are encouraging,
and show that the favorable increase in the duration
of life is due to the progress of preventive medicine
and to the diminution of typhoid and small-pox. —
Progres Medical.
The Antiseptic Treatment of Typhoid Fever.— It
is not to abort typhoid fever, as Dr. Osier apparently
believes, that the antiseptic treatment is employed by
the large majority of physicians who have faith in it,
but because it inhibits the activity of intestinal germs
concerned in fermentation and putrefactive processes
and perhaps facilitate the spread of the necrotic pro-
cess induced by the specific organism. To claim that
antiseptics are of no value in typhoid fever because,
as Dr. Osier states, they are a failure in cholera, is
just as reasonable as would be the assertion that they
must be efficacious because quinine, an antiseptic,
cures malarial fever. There are few measures or
means at the command of the physician that fulfil all
the indications, and he who adopts a fad to the exclu-
sion of all other effort, be it in the line of antisepsis
or hydrotherapy, fails in his duty toward his typhoid-
fever patients. — Pittsluox Medical Re'rieiu.
The Blood in General Paralysis In an article on
this subject in the June number of the American Jour-
nal of the Medical Sciences, Dr. Capps draws the fol-
lowing very interesting conclusions: In general paral-
vsis, the haemoglobin and red corpuscles are always
diminished; the specific gravity falls slightly below
normal ; most cases show a slight leucocytosis ; there is
a decrease in the lymphocytes, along with an increase
in the large mononuclear cells. In convulsions and
apoplectiform attacks, the red corpuscles and haemoglo-
bin are usually increased at the time of a convulsion;
both are usually diminished during an apoplectic at-
tack of long duration ; the specific gravity is variable;
there is a leucocytosis; the degree of leucocytosis va-
ries directly with the length and severity of the attack;
in production of a leucocytosis the large mononuclear
cells are increased relatively more than any other va-
riety. The fact that after convulsions and apoplectic
attacks in general paralysis there is not only an in-
crease in the number of white cells, but a change in
their character, as shown by the differential count and
that at times abnormal cells appear, is an argument
against the theory that leucocytosis is merely a change
in the distribution of the white corpuscles.
While the Medical Record is fUased to receive all new publi-
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©viginal :Avticlc5.
A NEW CONTRIVANCE FOR INTESTINAL
END-TO-ENb ANASTOMOSIS.
By J. FR.^NK, M.D.,
SIRGEON TO ST, RLIZADETh'S HOSPITAL, CHICAGO.
The numerous devices which have been introduced
in the past few years for the perfection of operations
upon tlie intestinal tract tend to show the great
activity wliich is displayed in the surgical world in
this important subject. As in medicine, in which
countless drugs are recommended for one disease, the
general conclusion drawn is that almost anything will
do, so in this operation each man has his own device,
the use of which is followed by a series of successes
as well as of failures.
To point out the faults of the different devices in
use is not the object of this paper, nor do I wish to
convey the idea that what I arn about to describe is
perfect in every respect; but I will submit the result
of my labors for criticism.
An ideal intestinal-anastomosis operation should
embrace the following factors:
I. Quickness of operative procedure, as patients
demanding this kind of surgical work are generallv
-Petalcilied Bone Collar.
.'/, inside view; B^ outside view; natural
size.
in a state of severe shock, and every minute saved is
to their benefit.
II. Accurate adaptation of the severed or injured
intestinal ends, with enough ju.xtaposition to insure
sufficient surface for adhesive purposes.
To obtain this result, enough experimental work
has been carried on by various investigators to con-
vince even the most skeptical that with the introduc-
tion of some foreign substance which will temporarily
hold the parts together, the surgeon's labors are
greatly decreased and the patient's chances of recov-
ery vastly increased. This leads us to the subject of
material, and without going over the entire field of
what each and every one has used, I will begin with
a description of my contrivance, in the construction
of which I have aimed at three cardinal points:
I. Material which can be safely left in the intesti-
nal canal.
II. Time saving.
III. Simplicity of application.
The apparatus consists of two decalcified bone col-
lars (Fig. i) with six needle-hole perforations at the
apex or shoulder of each collar, and one piece of
ordinary pure gum-rubber tubing seven-eighths of
an inch in length and five-sixteenths of an inch in
diameter, the kind used for drainage. It is prepared
for use in the following manner: a collar is slipped
over a piece of rubber tubing of the dimension stated
until the apex is brought to a level with the end
of the rubber tubing, when an ordinary medium-sized
curved needle, threaded with No. 8 braided silk,
is carried through each opening and tied; this, as
can readily be seen, fastens the collar to the tube
(Figs. 2 and 3) ; the other collar is next fitted snugly to
the one already fastened, and is then in a like manner
sewed to the other end of the tube. The apparatus is
Fig. 2. — Bone Collar
Sewed t o Rubber
Tubing.
Fig. 3. — Inside View of
Collar with Rubber
Tubing Sewed on.
Fig. 4. — Decalcified
Bone Collars Sewed
to Rubber Tubing
Ready for Use.
now ready for insertion (Fig. 4). The rubber tubing
to which the collars have been sewed, being hollow,
serves -subsequently for the passage of the intestinal
contents after being placed in situ.
It will be observed that the bases of the collars,
which are formed into a broadened rim, are being
held firmly in apposition throughout their entire cir-
cumference. Now the intestinal ends are brought
over each collar and crowded between the line of
junction of the two; of necessity the latter are forced
apart, and the rubber tube is put upon the stretch,
affording an adequate amount of pressure to cause a
necrosis of the interposed intestines. The collars
dissolving in due course of time, but a small piece of
rubber tubing is left in the intestinal canal to pass olT
with the ffeces.
The following description of how the collars are
prepared was kindly furnished by Messrs. Schorse &
Co., of Milwaukee, Wis.
The collars are carved out of sound, very compact
bone, which is obtained from the lower hind feet of a
four-year-old ox. The collars are now subjected to
the decalcifying fluid, which consists of a one-per-
cent, solution of absolute hydrochloric acid. From
this fluid the collars are removed in six hours and
placed under a stream of
cold water for half an
hour to remove the salts
which have farmed.
They are then placed in
a fresh decalcifying fluid
of the same strength and
the process is repeated
until they are completely
deprived of their calca-
reous constituents, and
they are washed with cold
distilled water, so that all
traces of acids and phosphates are removed and the
collars have acquired an almost transparent appear-
ance. Now they are jiractically dehydrated by treat-
ment with pure cologne spirits, and finally immersed
in absolute alcohol, which renders them sufficiently
tenacious for their purpose.
Having described the apparatus, its mode of prepa-
FiG. 5. — Longitudinal Section. WW,
collar; i>, rubber tubing, lo mm. in
dianteter; C, cavity in collar; 7 .!/.)/,
inside diameter of rubber tubing ; zo
MM ^ length and width of collar.
47°
MEDICAL RECORD.
[October 3, 1896
ration and construction, the experimental work upon
dogs is next to be explained.
A few general remarks relative to the management
of work upon lower animals may not be out of place.
As nearly as was possible, the same aseptic and
antiseptic precautions were obseried with regard to
the hands, instruments, field of operation, and dress-
ings as modern surgery
teaches us to observe in a
laparotomy upon the hu-
man subject. The dogs
that were fed upon fluids
prior to the operation
gave less trouble at the
time and thereafter than
dogs otherwise fed. A
dose of castor oil given
the evening before the
oi^eration always cleanses
the intestinal tract, and
the dogs seem to do better
after this.
The General T e c h -
nique.- — A median inci-
sion from three to four
inches in length is made
either above or below the
umbilicus; the small in-
testine is drawn out
through the wound, and
the part to be excised is
gently freed of its contents
by drawing it between the
thumb and index finger,
when an intestinal clamp
is placed at each end of
the portion to be cut away,
care being taken not to
cut too closely to the
clamp, for if this is done there will not be enough
gut to bring over the collars, which will necessitate the
removal of the clamp farther back. The main mes-
enteric branch supplying the excised portion is first
ligated with a No. 8 silk suture. From two to five
inches of the gut may be resected, according to the
fancy of the operator.
Upon severing the intestine, it will be observed
that there is an eversion of the edge of the bowel and
also a contraction, producing a circular constriction at
the end of the intestine; this can be easily overcome
by inserting a finger into the lumen of the gut and
retaining it there for a minute or two, thus prochicing
a temporary paralysis and allowing a much easier ma-
nipulation of the parts; this stretching of the gut must
be gently performed, otherwise the peritoneal covering
will split longitudinally. A straight or curved needle
threaded with No. 8 silk is used for inserting Dr.
Murphy's puckering string (Fig. 6), a description of
which can be found in tlie New York Mkdic.m. Rec-
ord, vol. xlii., p. 673, 1892, to fasten the intestine
about the rubber tube after the former has been slipped
over the collars. The puckering string is similarly in-
serted into the other intestinal end, and the bone col-
lars, having been previously prepared as described, are
taken out of the absolute alcoliol in which tliey were
placed immediately after being sewed to the rubber
tubing. The operator slips an intestinal end over one of
the collars to the line of junction, at the same time gen-
tly spreading the collars apart to facilitate the easy ac-
cess of the gut. .\n assistant takes charge of the ends of
the puckering string, and when the gut has been brought
over the collar he makes one knot and draws down
until his puckering ligature strikes the rubber tub-
ing, which he will perceive by the resistance of-
FlG. 6. — Murphy's Running Thread.
drawing of the puckering ligature on account of its
resiliency, but, to make absolutely sure that the tube
is patulous, the end of a forceps or sterilized nail
may be passed through the lumen ; if this is found per-
vious the assistant finishes the tying of the puckering
string. The other intestinal end is then slipped ove>'
the remaining collar and also tied. Of course at this
stage nothing can be inserted by which to determine
that the tube is not shut off, but, after having tied one
side, the assistant will positively know when he strikes
the tube. The ligature is cut off short and the clamps
are immediately removed, when the operated portion
of the bowel will be slowly distended with gas. .An
interrupted or continuous Lembert suture should be
taken around the border with an intestinal needle,
threaded with Xo. 2 silk, which makes the work more
secure.
The rent in the mesentery may or may not be sewed.
In those cases that were sewed catgut was used; any
bleeding vessels should be tied with catgut. The in-
testine is returned into the abdominal cavity as nearly
as possible in a straight line, the site covered with
omentum, and the abdominal wound closed in the
ordinary manner. The wound is powdered with iodo-
form and a collodion dressing applied: gauze and
cotton are placed over this, and then the bandage.
Experiments. — FxrERiMExr II. — May 16, 1896:
black Newfoundland bitch ; weight, fifty pounds. End-
to-end anastomosis with wooden model (the bone col-
lars not being ready). Time of operation twenty-
eight minutes. No Lembert sutures were taken, as they
were not necessary. The dog was playful after opera-
tion.
May 20th, four days after operation, the bowels
moved primarily.
May 2 2d, six days after date of operation, the
wooden model passed with a bowel movement. The
tube was patulous.
May 23d, seven days after operation, the abdominal
wound was entirely united and the dog was well and
very playful, and continued in this manner up to May
30th, when it was observed that the animal acted
rather sickly. She died June ist, fifteen days after
the operation.
Fost-mortem: Perfect iniion at site of operation.
Uelow this protruded a sharp spiculum of bone; im-
mediately below this was found a mass of hay and hair
matted together. The protrusion of bone was caused
by a spur in the gut below the site of operation. The
cause of death was purulent peritonitis.
ExrERiMENT IV.— May 30, 1896; male Newfound-
land ; weight, seventy pounds. End-to-end anastomosis
with decalcified bone collars. After the collars were
in situ, a continuous Lembert suture was taken, al-
though there was no gaping, but it was deemed ad-
visal)!e to do this, because the bone collars were not
quite hard enough.
June 5th, six days after date of operation, the bowels
moved and in the fa_cal mass the rubber tube was
found (Fig. 7), which had held the
bone collars togetiier. .About the
tube were the puckering strings
and at each end of it were the
sutures which were used to fasten
the collars to the tube; no trace
of the collars could be discovered.
The dog is well and playful to
this date, September 14, 1896.
Time of operation twenty-five minutes.
Experiment V. — June 7, 1896; black Newfound-
land: weight, forty-five pounds; end-to-end anasto-
mosis. .\fter collars were placed /// situ a continuous
Lembert suture was taken, as the bone collars were
still not sufficiently hardened
Fig. 7. — Rubber Tubing
showing Puckering
Thread in Centre and
Sutures at End»i after
Bone Collars had l)us-
solved. Experiment
No. 4.
fered; the tube will not generally permit a too tight June 12th, five days after operation, the bowels
October 3, 1896]
MEDICAL RECORD.
471
moved for the third time, and in the faecal mass the
rubber tube and puckering sutures were found.
June 13th, five live pups were born to patient and
a dead one.
June 14th, three more pups arrived, making nine in
all. The stitches were removed too earlv and nvelve
Fii.. 8. — Perfect Union Fifteen Days after Operation. Lembert .Suture Pre-
senting at Inner Surface of Intestine. Experiment No. 6.
inches of intestine protruded through an opening in
the lower angle of the abdominal incision. The pro-
truded gut was inflamed and adherent to the gauze
dressing. It was gently freed from the gauze by
means of lukewarm sterilized water and replaced into
the abdominal cavity, and the lower end of the inci-
sion again united.
June 1 7th, the dog had made a complete recovery, and
is alive and well to this date, September ist. She has
a large hernia at the lower site of incision. Time of
operation, twenty -four minutes.
Experiment VI. — Juneg, 1896; male; weight, fifty-
five pounds. End-to-end anastomosis with decalcified
bone collars.
June isth, six days after date of operation, rubber
tubing with puckering strings passed in fa;cal mass.
June 17th, dog was well and lively.
Post-mortem: June 24th, fifteen days after opera-
tion, to see the condition of affairs at site of operation.
Union was perfect. There was adherent to the perito-
neum at the site of incision an omental mass, free from
Km,. 4. — Ccrfcct Union Twenty-three Hours after Operation. Decalcified
Bone Collar Still in Place. Experiment No. 8.
intestine but including a portion of the pancreas.
The site of the operation was eight inches from the
stomach. One end of the Lembert suture presented
internally (Eig. 8). There was a slight narrowing
of the lumen of the bowel at the site of operation, due
to the inflammatory condition of the surrounding omen-
tal mass. The mucous membrane was smooth, espe-
cially opposite the mesentery.
Experiment VIII.— June 17, 1896; Newfoundland,
female; weight, forty-eight pounds. Dog was killed
twenty-three hours after the operation to obtain a speci-
men of site at an early period. The abdominal inci-
sion was united. The site of operation was covered by
plastic omental adhesions. No pus, no peritonitis,
and no adhesions to abdominal parietes. The site of
operation and the adjoining five inches of gut on each
side were excised, a fountain syringe was attached to
one end, and the stream passed through very readily;
the distal end was then clamped and the gut filled to
its entire capacity without leakage occurring. The
collars were in the same position as at the time of
operation and were fairly hard. The mucous mem-
brane in the vicinity of the collars was reddened to a
slight extent (Figs. 9 and 10).
Experiment IX. — June 20, 1896; female: weight,
forty-one pounds. Time of operation, twenty minutes.
Dog playful after operation.
June 2 1 St, bowels moved.
June 23d, three days after operation, one undis-
solved collar and the rubber tube, as well as a part of
the remaining collar, passed with the bowel movement.
June 24th, four days after operation, dog was killed to
OUARlfil
POSIT/ON
Fig. 10.— Twenty-three Hours after Operation. Showing Line of Union
Externally. Experiment No. 8.
obtain specimen (Fig. ii). The abdominal wound
was entirely healed; no suppuration nor peritonitis;
intestines empty ; slight redness about the site of opera-
tion, to which was adherent, slightly, part of the omen-
tum and intestine. The intestine at the time of oper-
ation was returned to the abdominal cavity in a straight
line, but at the post-mortem there was found a bend
at the operated portion. Water passed through the gut
freely, and was also retained after one end of the in-
testine had been closed. When the spur (bend) was
straightened, part of the Lembert suture presented
itself at the mesentery; there was a thickened ring
about the circumference of the united intestines; the
mucosa was not inflamed. An intussusception, three
and one-half inches in length, was found fifteen inches
below the seat of operation, through which water
passed readily.
Experiment X. — June 26, 1896; female; weight,
forty - five pounds. Time, twenty - one minutes.
Chromicized catgut, corresponding in size to a No. 8
silk, was used for the continuous Lembert.
June 28th, fifty-six hours after operation, the dog died.
The post-mortem was held immediately after, with the
following facts noted: General peritonitis. One col-
lar was partly dissolved, the other only softened.
When water was passed through the operated portion
leakage occurred at several points through the needle
jserforations of the Lembert suture. The mucosa was
472
MEDICAL RECORD.
[October 3, 1896
inflamed and thickened two inches above and below the
seat of operation. This dog, after the operation, was
placed on carpet which had been used by a dog that
died of perionitis. This may explain the infection.
ExPERi.MEXT XI. — June 26, 1896; female; weight,
fifty-five pounds; time, fourteen minutes. No. 2 silk
used for Lembert sutures.
June 2gtli and 30th, bowels moved.
July I St, five days after operation, bowels moved
again, and in the hardened fa;cal mass the tube and one
partly dissolved collar was found. The dog was play-
ful and seemed to be well. Immediately after the tube
ihad passed the dog was killed.
Result of post-mortem : No peritonitis. Adhesions
to the surrounding intestines and omentum had formed.
The resected portion of gut adhered to itself so
as to form a loop. Water passed through it freely;
under great pressure of stream the adhesions gave
way, and there occurred a small leak at the line of
union. The Lembert suture presented internally (Fig.
13).
Experiment XIII. — June 30, 1896; female; weight,
fifty pounds. In this experiment no Lembert suture
w-as taken. Time, three minutes.
Post-mortem: General peritonitis, resulting from
forty-five pounds. Interrupted No. 2 Lembert sutures
taken. Time, seven minutes for insertion of collars
and eighteen minutes for entire operation. Dog acted
Fig. II. — Four Days after Operation. Showing Elevation at Scat of Opera-
tion Internally. Experiment No. 9.
non-union. The edges of gut had slipped out from
between the collars, the latter not having sufficiently
hardened.
ExPKRi.MENT XVL — July 22, 1896 ; No. 2 colitinuous
Lembert suture taken; time, twenty -two minutes.
July 26th, four days after operation, the dog died.
Post-mortem : Perfect union. Cause of death, intus-
susceptions, of which two were found. One was twenty-
four inches in length, being twenty inches from the
anus; at the proximal end of this intussusception
one undissolved collar was found. The other intus-
susception was found nearer to the rectum. Under
high pressure water passed through both intussuscep-
tions and reduced them. In one the intussuscipiens
was gangrenous.
Experiment XVIII. — August i, 1896; female;
weight, thirty-five pounds; time, nine minutes for in-
serting the collars and twenty-five minutes for entire
operation. The tube was passed on the sixthday. In-
terrupted Lembert sutures were taken with No. 2 silk.
September loth, killed to obtain specimen. Dog
was in fine condition. No adhesions to line of inci-
sion. Union perfect. Omentum slightly adherent to
intestine opposite mesentery. Seat of operation,
thirteen inches from rectum.
Experi.mentXIX. — .\ugust i, 1896; female; weight,
Fig. 12. — Perfect Union Five Jjays aflui Optraliun. Lembert Suture Pre-
senting at Inner Surface of Intestine. Experiment No. ii.
well, but was killed after forty-eight hours to obtain a
specimen.
Post-mortem: Beginning peritonitis; collars were
undissolved and brittle, but softer than at the lime of
insertion. Site of operation ununited. The edges of
gut were cut off by the collars throughout the entire
circumference.
ExPERi.MENT XX. — August 8, 1896, male; weight,
seventy pounds. Operated by my assistant. Dr. Syl-
van Kunz. Four interrupted Lembert sutures taken.
Tube was passed the sixth day.
September loth, forty-one days after operation, the
dog was killed to obtain a specimen. There were no
adhesions to the abdominal incision. The line of union
in the gut was perfect, and a small strand of omentum
was adherent to it. The resected portion of gut and the
two adjacent inches on each side were excised. Upon
passing tiie finger through the bowel a slight constric-
tion was felt at a point corresponding to the line of
Fig. 13.
-Thirty-three Days after Operation, a, Line of Union ; d. Omentum.
Experiment No. 20.
union. Upon laying the gut open, a perfectly smooth-
ened mucosa presented (Fig. 13), the line of union
being barely perceptible.
October 3, 1896]
MEDICAL RECORD.
47:
Summary of Experiments. — Of the thirteen dogs
operated upon, nine nu\de complete recoveries. One
dog (Experiment \'ni.) was killed after twenty-three
hours to obtain an early specimen: from the ap-
pearances at the post-mortem the dog would in all
probability have lived. In Experiment X. the dog
died of general peritonitis, probably infected from
carpet upon which he was placed immediately after
the operation. In Experiment XIII. the intestines
slipped from the collars, owing to their extreme soft-
ness, resulting after three days in the death of the ani-
mal from general peritonitis. In Experiment X^'I. the
cause of death was gangrene of the intussuscipiens.
In the next series of experiments I hope to obtain bet-
ter results, as I have greatly profited from those just
completed.
In conclusion, I beg to state that although I have
not yet been able to try the collars on a human
subject, I am convinced beyond a doubt that they
will prove successful. The small piece of rubber
tubing which is left to pass off' will certainly not
produce any obstruction, nor is it at all apt to ul-
cerate through the bowel. In regard to the result-
ing constriction of the lumen of the bowel, I am sat-
isfied that it is no greater than that following the
use of any other contrivance. Although the experi-
ments are not very great in number, I am anxious
to have them reported, so as to give any one who may
see fit an opportunity to try the decalcified bone col-
lars. It is my intention to add to. this article from
time to time. The series of experiments upon chole-
cystenterostomy and gastro-enterostomy will be pub-
lished separately. I am greatly indebted to my stu-
dent, Mr. Leon Feingold, of the College of Physicians
and Surgeons of this city, for his faithful attention and
assistance throughout my experimental work.
The longitudinal section (Fig. 5) was kindly fur-
nished bv Prof. Herman Haustein, of this citv.
THE TRE.\TMEXT OF PNEUMOXI.A..'
P.v B.\SIL M. T.WI.OR, M.D.,
GREENSBURG, KY.
B.-vcTERiOLOGiSTS in the last ten or twelve years have
shown that acute lobar pneumonia is an acute specific
disease due to a specitic micro-organism, the diplo-
coccus pneumonia. They have demonstrated its
presence in the exudation in the lungs of patients who
have died with acute pneumonia and in the character-
istic brick-dust sputum of patients sick with the dis-
ease. Clinical experience and research have failed to
prove that pneumonia, though caused by a specific
organism, is a contagious disease. There are, how-
ever, reports of epidemics in countries of dense popu-
lation and especially in barracks where a good many
are crowded together. There is no evidence that one
soldier took it from another, but that they were all
subject to the same influence. The germ is widely
spread, as pneumonia is known throughout the world.
Every disease produced by a specific micro-organ-
ism must have that special micro-organism present
and that special micro-organism must reproduce the
disease when introduced into the system of persons or
of animals who are not immune. The sheep, dog,
rabbit, and the field mouse are not immune, and when
the bacillus is introduced into the lung by injection
they die in a few days from a typical lobar pneumo-
nia. Experiments have shown that when the bacillus
was injected into the blood of the peritoneal cavity
thuy did not develop pneumonia, but either recovered
or died speedily from septictemia: but when large
' Read before the (Ireen River Medical Society, at Campbells-
ville, Ky.. July 3. iSg6.
injections of the cultures were made directly into the
lungs they died from acute lobar pneumonia.
Many, however, deny that this diplococcus pneumo-
nia is the cause of pneumonia because this germ has
been found in the saliva of healthy persons. Many
a tubercle bacillus has been swallowed, inhaled, and
carried around in the secretions of healthy persons
who did not contract tuberculosis, but no one in his
right mind will dispute the fact that tuberculosis is
produced by nothing but the tubercle bacillus, and
that people die every day with tuberculosis. It is out
of place here to discuss at length why all people who
possess somewhere about them a specific germ do not
develop the disease produced by that germ. I merely
give this introduction to this paper to show that I
think that pneumonia is produced by a specific germ
and that that germ is necessary for the production of
pneumonia.
Taking it for granted, then, that acute lobar pneu-
monia is produced by the bacillus crouposas pneumo-
nife, it is a specific and self-limiting disease. It runs
its course like all other specific diseases not having
a specific remedy, uninfluenced so far as curing or
aborting it is concerned, by any means at our hands.
There are cases, however, that run a very short course
and seem to be aborted in their incipiency; but such
cases I think are either not pneumonia, or the micro-
organism is not developed properly, or is overcome by
some antitoxin in the person affected, or the condition
of the lung is not such that the organ offers a favor-
able place for its development at that time. I do not
hold to the opinion that any specific, self-limiting
disease can be aborted by internal medication.
Having, therefore, a specific disease produced by a
specific organism that causes inflammation of the lung
and by its special action produces a toxin oftentimes
so fatal to both e.xtremes of life — and the adult also is
by no means immune — the only scientific and "the
way" to treat such a disease is by an antitoxin that
will at once destroy the vitality and development of
the bacillus and counteract the effects of the toxin
upon the patient. We are now just in the dawn of
this scientific principle — orrhotherapy. We will all
welcome the day when each specific toxin will at once
be met with a suitable antitoxin. Not until then will
the physician be armed with the sword of a " sure
cure." Remedies, then, at our hands are only uncer-
tain aids to nature.
Of the ways of treatment as suggested by dift'erent
writers and the remedies in the materia medica there
are many. I suppose every- physician has his own
favorite prescription that he gives to every patient
upon his first visit, whether it be in the first or last
stage.
What is indicated in one stage is, perhaps, contra-
indicated in another. The strong and robust demand
a different treatment throughout from that required by
the weak and nervous. Pneumonia, therefore, is a
disease for which there is no routine treatment appli-
cable to every case, and the physician who fails to
realize this falls far short of his duty to his patient
and to himself, and such a physician fails oftentimes
to do good and when he does no good he will do harm.
We must individualize and not generalize. The phy-
sician who prescribes solely from experience has his
face turned from professional advancement, and will
sooner or later be a source of danger to his patients.
In the treatment of pneumonia there are many
things to consider. We must consider the age of the
patient, the stage of the disease when first seen, the
condition of the patient, whether robust and plethoric
or weak and an.tmic, and the surroundings of the
patient. We must look after the pain, the shock, the
temperature, the stimulation or heart depressants,
sleep, and the nourishment.
474
MEDICAL RECORD.
[October 3, 1896
In pneumonia, near the surface of the lung, there is
always pleurisy, and this is the cause of the pain.
Severe pain is capable of killing of itself and always
to a certain degree causes shock. Shock, of course,
gives the patient a feebler power of resistance. We
have many remedies to control pain — opium or its
alkaloids in some form, heat or cold applied locally,
chloral hydrate, counter-irritants, and the coal-tar
preparations.
Morphine stands at the head of the list. It controls
the pain, gives the patient rest, and produces quiet
and refreshing sleep, prevents shock, stimulates the
breathing and heart, prevents vasomotor disturbances
in the circulation and thus in a degree keeps some
blood from the already overloaded heart and lungs.
Quieting the nervous patients, it prevents a higher de-
gree of fever, from which they suffer more than the
healthy and robust in a disease of equal severity.
Some may object to it on account of its tendency to
check the secretions and thus overload the system
with waste products. In doses sufficient to quiet pain
and give the patient rest, I have seen no such bad
effects from it, and its good efYects are so many and so
noticeable, and so far overbalance its evil effects, that
such objections should without hesitation be over-
looked. By giving rest and sleep and preventing
shock, it many times tides the patient safely over what
might have been a fatal period had he been allowed to
suffer. Chloral hydrate is of doubtful utility and
should be used with caution. When there is no pain
and not mucli depression of the arterial tension, and
the patient is restless and nervous, chloral might be
given in doses sufficient to quiet. I have had very lit-
tle experience witli hydrotherapy, and, in view of the
position that I took in tiie beginning of my paper, I
consider it of doubtful utility, available only to relieve
pain and as an antip\rctic. Water has no virtue suffi-
cient to cut short or modify the course of the disease.
Routine hydrotherapy is capable of doing harm. The
treatment of inflammation as laid down in our te.xt-
books of surgery is to apply cold or heat in some way.
As pneumonia is due to micro-organism and is a self-
limiting disease, water cannot ])romise anything.
A pleurisy might be benefited by the ice bag or coil,
but in pjeuro-pneumonia it should be used with cau-
tion and its effects carefully watched. In tlic ner\-ous
patients who are suffering from a severe attack, and in
whom there is decided shock evidenced by cold extremi-
ties and rapid breathing and feeble pulse, cold applica-
tions on any part of the body will only make matters
worse by increasing the congestion of internal organs
and exposing the ])atient to greater shock. Such cases
need a dose of morphine and strychnine and hot ap-
plications to the body and extremities, which help
to relieve the pressure on internal organs already
overloaded with blood. Cold applications are to be
limited, I think, to those of robust constitution and
with a pneumonia near the surface. Cold applica-
tions must be used with caution and must never chill
the patient. Their field of usefulness must neces-
sarily be limited. They can be used to no advan-
tage whatever in any except the first stage and we
rarely ever see a patient in the first stage in time
to apply them to an advantage. A\'hen the lobe
is about filled with exudation, cold water has no
place. Selecting, then, a s\iitable case in the first
stage of the disea.se, cold applications for a day or
two only may be of some benefit to the patient, but
after the first stage tepid sponging to allay fever and
restlessness and to promote the action of the skin is, I
think, the only field for hydrotherapy in pneumonia.
The function of the bowels and kidneys must be
watched with a never-tiring care. These are the
sewer pipes of the system, and if they are hindered in
their action our patient may die and we charge it to
the pneumonia. Each case is a law to itself. Rou-
tine practice does not guide us here. If there is a
diarrhcea, its cause must be looked into and removed,
and the diarrhoea checked. It may be from .some pill
that the patient has taken to arouse his, as he thought,
torpid liver; it may be from an attack of indigestion
preceding the attack of pneumonia: it may be a case
of chronic diarrhiea; it may be the beginning of an
attack of typhoid fever; it may be from an ulcer or
two in the colon; it may be a vicarious diarrhcea re-
lieving the system of waste products caused by the
checking of the function of the skin or kidneys. We
must look into the cause and then treat the case ac-
cordingly. It is dangerous to check the diarrha-a and
leave the function of the skin or kidneys completely
checked or embarrassed. Remove the cause and then
check the diarrhna.
On the other hand, if there is constipation, relieve
it by giving some mild cathartic. The bowels ought
to move once or twice in the twenty-four hours. It is
a common practice among physicians to give a dose of
calomel at the first visit, whether the case be one of
fractured femur or of tyjahoid fever. I am glad to say
that I am not a mercurial fanatic. If the patient has
a torpid liver in the first stage, give him a mild calo-
mel purge; but if his liver is acting correctly, keep
your calomel in your saddlebags or take it yourself.
If you want to mo\e his bowels, give him a good
saline cathartic. This will relieve to some extent the
congested lung and will not weaken the patient nor
make him sick at his stomach as will a dose of calomel.
If the patient demands it, keep his bowels loose with
Rochelle or Kpsom salts.
\\'e must inquire carefully into the action of the
kidneys and learn if possible if Bright's disease
exists. If we overlook this important duty, the kid-
neys might be suddenly overwhelmed by the poison
in the system and our patient die before we realized
what is the matter. Forewarned is forearmed. If
you would discharge your whole duty toward your
patient and anxious friends, be ever upon the alert,
and you will never have the remorse of conscience
that tells you that one death is charged to your care-
lessness and ignorance. The sum total, then, is to
keep the bowels, skin, and kidneys constantly per-
forming their whole duty. The temjx-'rature of the
patient should demand our careful attention and at no
time be allowed to remain very high. A temperature
of 101 F. does not demand much in the way of anti-
pyretics. Nothing is more dangerous and uncomfort-
able to a patient than a prolonged high temperature.
Many medicines are recommended as antipyretics
— quinine in large doses, the coal-tar preparations (of
which there are .several), aconite, and sponging with
cold or tepid water. I have no use for quinine as an
antipyretic. Of course if there is malaria, quinine
should be given in doses large enough to destroy the
Plasmodium. In every case in which it is practicable a
blood examination ought to be made to determine its
presence or absence. In the first stage quinine in
small doses often repeated may be of some service. Of
the coal-tar preparations antifebrin is my favorite. It
acts belter and is not so depressing as the others. I
give it in from three to five grain do.ses every three
liours, or just as often as is necessary for the reduction
of the temperature. Sponging with tepid water, often
repeated, is of value.
The cough demands careful attention, for, although
only a symptom, it may be very distressing. The
sputum is always tenacious and hard to be expelled.
I'he tenacious sputum should not be allowed to collect
in the air passages any more than can be helped by
remedies at our hands. F.xpectorants should be given
freely until the cough is no trouble to the patient.
The mixture that I prefer is composed of ipecac in
October
1896]
MEDICAL RECORD.
475
small doses, carbonate of ammonium and potassium
in from five- to ten-grain doses in syrup of wild cherry,
and tolu or brandy every two or three hours, according
to the demands of the case. The ipecac promotes
expectoration and the carbonate of potassium keeps
the tenacious sputum almost liquefied. It thus loses
its tenacious character and the patient keeps his air
passages pretty free from it with very little exertion.
The carbonate of ammonia acts as a heart and respi-
ratory stimulant and stimulant expectorant.
Delafield, in Pepper's " Practice of Medicine," vol.
ii., recommends for the treatment of the exudation
digitalin and aconitine and, if the pulse demands it,
whiskey. This treatment is applicable to only a cer-
tain class of patients. I have had no experience with
this treatment. Venesection is recommended in those
who are plethoric and with a full bounding pulse.
When performed carefully and in a selected case, it is
useful in the first stage. I have never employed this
plan of treatment.
The emplo3'ment of stimulants requires good, sound
judgment in regard to the time to use them and the
amount to use. Many patients do not require stimu-
lants in the first stage. If the temperature is kept
low and the patient free from pain, he will not need
much stimulation until later in the disease. We must
judge by the failing pulse. I never give stimulants
until I find them indicated. I condemn the indis-
criminate use of them — that is, to give stimulants
because your patient is sick and you think he must
have medicine in some form. When the pulse is
rapid and weak I give brandy or whiskey, from one to
four tablespoonfuls every three hours, according to the
demands of the case. Its effects should be carefully
watched, and if the patient show signs of irritation
from it it should be withdrawn or lessened in quan-
tity. Just enough should be given to meet the de-
mands of the case and no more nor less. It is useless
to give an excess, because it throws more work on the
excretory organs. I will call special attention to
strychnine as a heart and nerve stimulant. Very often
it will be all the stimulant that is required throughout
the case. It stimulates the heart, gives the patient
more strength, and prepares his system to meet the
shock of the disease. I give it as a rule throughout
the attack. It acts better hypodermically. It ought
to be given in one-thirtieth to one-sixtieth grain doses
every three hours during the day.
Sleep is as important as medicine. If my pa-
tient can do so, I generally allow him to sleep
most of the night undisturbed. Patients in any dis-
ease who are aroused every hour during the night to
take a dose of medicine will gain very little rest, and
if we are not careful they will die from the loss of
sleep if not from the disease. I combine my medi-
cines as much as possible. I put heart tonics and
diuretics in the same dose and let them be given with
the antipyretics, and thus avoid so many different
hours. If the case is not desperate, I allow the patient
to have a little nourishment and a few doses of medi-
cine through the night, but these only when he awakes
himself. A good night's rest will do as much good in
many cases as all the drugs in a store. If the patient
is kept easy and the temperature low, he will as a rule
sleep most of the night. Of course, when the case is
desperate and the heart is rapidly failing, medicine
must be given regardless of sleep.
The patient should at all stages of the disease be
well nourished. His diet should be liquid and easily
digested. Milk is the best food when it can be well
borne. Beef tea, soups, and koumys may be given
with benefit. The diet should be composed of several
different articles. If one article alone is given, the
patient gets tired of it and his stomach is irritated by
its presence. Eggnog is useful both as a stimulant
and a food, and it is usually relished by all patients.
When the stomach is irritable and nothing can be re-
tained, the white of an egg shaken up in a glass of
lemonade will nourish the patient and stop the vomit-
ing. Thus no valuable ground will be lost.
I will not speak of the complications and sequelse
here. They must be treated according to the require-
ments of the case, whether it be medical or surgical.
I have given you my method of treatment, which has
at my hands proven very satisfactory. All we can do
now is to make the best of what we have at our hands
and to wait with eagerness the coming of a specific an-
titoxin with which to meet so fatal a toxin.
July 3, 1896.
SYPHILITIC DISEASE OF THE SPINE.
I'.v f.. IlAKf<ISO\ METTI.EK, A.M.. M.D.,
CHICAGO, ILL.
Our knowledge of spinal syphilis is limited; it is less
than our knowledge of cerebral syphilis. Neverthe-
less, a sharp distinction should always be made, when
possible, between syphilitic disease and other affec-
tions of the cord that may resemble syphilis. The
former is, as a rule, amenable to treatment, and in its
early stages affords a hopeful prognosis; the latter
less often so. It should always be remembered that
while spinal syphilis has its own pathology and symp-
tomatolog)', there are many affections of the spine — as,
for instance, the various scleroses and degenerations
— which are not strictly syphilitic diseases, though
often following syphilis. This is notably the case
with posterior spinal sclerosis. In the former, the le-
sions are purely syphilitic, being produced and main-
tained by the direct action of the specific toxic element
in the blood. In these cases antisyphilitic treatment,
that controls the syphilitic infection, exerts a direct
and curative force upon the syphilitic lesions. In
the latter, however, the lesions are more in the na-
ture of sequela% tiie remains after the storm has passed.
They are mostly of the degenerative sort, and, there-
fore, are not permanently benefited, though occasion-
ally slightly so, by antisyphilitic treatment.
The diagnosis of spinal syphilis can be made at the
present stage of our knowledge only from the history
of the case and by the exclusion of all other diseases
of the cord. Certain gross svphilitic lesions — such as
meningeal inflammations (about which, however, there
is much controversy) and tumors of the spinal canal
and cord proper — are easily recognized and their na-
ture readily comprehended when associated with a his-
tory of specific disease. There are those who deny
that meningitis and myelitis are ever directly due to
syphilitic infection. They also hold that the continu-
ous or tract scleroses and many of the chronic inflam-
mations are not distinctly syphilitic. There is hardly
a spinal-cord degeneration that has not occurred in a
syphilitic patient some time or other, but these same
degenerations have been found in non-syphilitics as
well. Hence it is still an open question just what is
syphilis of the spine and what is not. The relation-
ship between syphilis and the spinal-cord degenera-
tions is not yet clearly wrought out, and I will, there-
fore, not consider these degenerations at present under
the head of spinal syphilis.
There are certain manifestations of spinal syphilis
that so simulate other affections of the cord, and are
in themselves so indefinite and irregular, as to render
a diagnosis a matter of extreme nicety. In such cases
a course of antisyphilitic treatment has sometimes to
be resorted to before any diagnosis can be made. The
more we can avoid, however, such indirect empirical
methods of making diagnoses and the more we can de-
pend upon the direct manifestations of the disease, the
4/6
MEDICAL RECORD.
[October 3, 1896
better it will be for the patient and the more credita-
ble to the science of medicine.
Syphilitic disease of the spine begins within a
short time after infection ; it progresses slowly, and
exhibits a remarkable tendency to improvement as a
result of vigorous antisyphilitic treatment. Erb, of
Heidelberg, states that its frequency in proportion to
posterior spinal sclerosis is as one to ten. Muchin, of
Charkow, believes, on the other hand, that it is far
more frequent than Erb supposes.
Huebner, writing for Ziemssen's '" Cyclopcedia of
the Practice of Medicine," enumerates four general
forms of spinal syphilis:
First, neoplasms of syphilitic origin, including sin-
gle tumors and small multiple and disseminated forma-
tions on the spinal membranes.
Second, syphilitic callus; there being found post
mortem a circumscribed induration of the cellular tis-
sue about the cord, generally with adhesions of the
dura mater.
Third, simple softening of the cord. This Steenberg
describes, though Huebner doubts whether it should
be considered a distinct syphilitic lesion. He also
doubts the existence of a pure syphilitic myelitis.
Fourth, cases in which symptoms of acute ascending
paralysis (Landry's paralvsis) occur without discover-
able post-mortem findings.
After giving a report of a case whicli manifested
symptoms to classify it with Huebner's fourth series.
Wood ("Nervous Syphilis") states that he doubts
wiiether these cases ought to be regarded as syphilitic
at all. Certainly his own case, of which it was diffi-
cult to obtain a complete autopsy, resembled one of
peripheral neuritis as much as anything else. The
cases of Huebner and Kussmaul were not examined for
lesions of the peripheral nerves, so that the fourth
class, as a form of spinal syphilis, has scarcely been
established.
In the production of the second and third classes of
Huebner, syphilitic infiltration and gummatous forma-
tions play an important role; so that the softening of
the cord and the development of callus should be re-
garded in the light of secondary effects rather than
as direct syphilitic lesions of the cord.
This leaves only the first class to be considered.
Sypiulitic neoplasms are generally connected with the
spinal membranes. They may grow inward upon the
cord and produce destruction of the medullary ele-
ments and even chronic inflammation and softening;
or they may extend outward and cause agglutination
of all the spinal membranes, pressure of the nerve
roots, and even disease of the osseous vertebras.
There are probably, therefore, two forms of spinal
syphilis or gummatous disease of the spine — that in
which the membranes are cliiefiy the site of the dis-
ease (Wood), and that in which there is an infiltration
of the cord from its own vessels (Rumpf ).
When examining a case of suspected spinal syphi-
lis, it is necessary to remember that the lesion may be
meningeal, producing symptoms similar to those of
non-specific spinal meningitis: and that, on the other
hand, it may consist of an infiltration of the medullary
substance itself, giving rise to symptoms indicative of
destruction of the sensory motor tracts. When the
gummatous disease is meningeal, the earliest symp-
toms will be those of pain or parai^sthesia and spasm
or paresis, due to compression and irritation of the
anterior and posterior nerve roots. Of course, the
sensory symptoms will be referred by the patient to
the peripheral terminations of the nerves whose roots
are undergoing irritation. The principal difference
between gummatous disease of the meninges and sim-
ple non-specific subacute or chronic meningitis, is that
the symptoms of the former are apt to be more sharply
defined or localized than those of the latter. The rea-
son for this is obvious, since the former lesion is more
in the nature of a tumor with comparatively well-de-
fined limits.
According to Erb, the symptoms of syphilitic dis-
ease of the spinal cord closely resemble those of mye-
litis transversa dorsalis; but the two are, neverthe-
less, distinguishable by a number of typical signs.
The walk, posture, and motion are quite characteristic,
and simulate those of spastic paralysis. The tendon
reflexes are apt to be marked, witiioul much muscular
tension.
The pains, when present, are usually sharp and cut-
ting, and when the lesion is located in the dorsal or
lumbar region they assume the girdle form. Not un-
frequently they resemble the lightning pains of tabes
dorsalis. Rarely are they dull, aching, and continu-
ous. tJften there is no pain at all. On account of
the usual meningitis accompanying the gummatous
deposit, there is more or less local tenderness of the
spine on pressure. Wood states that in several in-
stances this local tenderness was attributable to in-
volvement of the vertebral periosteum and vertebra.
All the various sensations common to local meningitis
are characteristic of this form of spinal syphilis, such
as numbness, formication of the extremities, " pins-and-
needles" sensation, and other bizarre parasthesiae down
to the ultimate condition of complete anasthesia.
There is always distinguishable impaired sensibility,
but severe pain is not generally felt, according to the
observations of Erb. Atrophy is not present. There
is little or no involvement of the head and cerebral
nerves. Rarely are the muscles of the eye implicated.
There is nothing abnormal psychically.
The motor symptoms are the same as those of local-
ized non-specific irritative meningitis, such as rigidity
of the neck and limbs, tremors, exaggeration of the re-
flexes, severe cramps excited by movement. Later on,
complete paralysis supervenes. If the palsy increases
rapidly after long-continued disturbance of sensation,
it is almost pathognomonic of syphilitic disease, ac-
cording to Wood. The sphincters are generally in-
cluded in the final symptoms. Bedsores and other
trophic troubles occur, often with elevated temperature
and general septica-mia.
In a case of syphiloma of the cord and cauda equina,
reported by Osier, death occurred from diffuse central
myelitis. There were pains in the legs, particularly
in the left, wiiich underwent rapid wasting and pre-
sented vasomotor changes. There were pains in the
arms, especially the right, without wasting. There was
absence of control of the bladder and rectum for two
months before death. There were bedsores and arthri-
tis in the knees and ankles. Toward the close of life
high fever wilii delirium came on. There was a gumma
in the anlero-lateral columns of the cervical cord, op-
posite tiie right fourth anterior nerve root. Gummata
also involved the third, fourth, and fifth anterior sacral
nerve roots, and the .second and third posterior sacral
roots on the leftside. Many of the symptoms in this
case were due to the accompanying lesions resulting
from the presence of the syphilitic new formations. A
differential diagnosis in such ca.ses, though extremely
difficult, is important if at all possible. The treatment
of simple spinal syphilis, before the advent of the re-
sulting inflammation and degeneration, is a relatively
easy matter: but when extensive destruction of the
nervous elements has already set in, the prognosis is
that nmch more unfavorable.
In syphilitic disease of the upper cord there may
be diplopia, amblyopia, and pupillary irregularity.
Tinnitus aurium occurred in a case reported by Weber.
The symptoms of the second form of spinal syphilis,
namely, syphilitic infiltration of the cord, are usually
slower in their onset and vary according to the locii-
tion of the lesion. As the latter is more or less dif-
October 3, 1896]
MEDICAL RECORD.
477
fused, so will the symptoms be more or less indefinite.
Tliey will range all the way from hypercesthesia to an-
aesthesia, from spasm to paralysis. Spastic paraplegia
without much pain is highly indicative. Sometimes
the symptoms closely resemble those of locomotor
ata.xia. True syphilis of the cord does not follow the
course of the sensory and motor tracts as do the various
systematic scleroses and subsequent degenerations.
The symptoms are, therefore, much more mixed and
indefinite.
The diagnosis of spinal syphilis is best made by the
exclusion of other spinal affections and by remember-
ing that any one of these other affections, associated
with a history of syphilis and presenting more or less
unusual manifestations, is very apt to be syphilitic in
origin. If a case of apparent locomotor ataxia, for
instance, shows an absence of the usual fulgurating
pains or the presence of the patellar reflex, spinal
syphilis rather than posterior spinal sclerosis should
at once be thought of.
The prognosis of spinal syphilis should always be
guarded, even though great improvement is obtained
sometimes by appropriate medication. Occasionally
absolute cures have been made. More often, however,
the delicate constituents of the cord have been irrepar-
ably damaged when the case first comes under observa-
tion, and then only a prevention of further injury can
be hoped for.
The treatment usually resolves itself into the ad-
ministration of mercury and the iodides. The object
is to neutralize at once the syphilitic poison, to sustain
the vitality of the cellular structures, and to remove as
quickly as possible any gummatous enlargements that
may be exerting a deleterious pressure. Each case
is a law unto itself, but in all cases bold, heroic treat-
ment is usually needed to check at once all further
damage of the nervous elements. Hot and cold spinal
douches, suspension, massage, all have their applica-
bility in the appropriate cases. The indications are
the same as in any of the various forms of organic dis-
ease of the spine. Spinal syphilis should be managed
just as any other disease of the cord and its mem-
branes, plus the administration, heroically and for a
long period of time, of the requisite antisyphilitic
remedies.
4544 Lake Avem-e.
INFANTILE SCORBUTUS.'
l;v H. M. McCLAX.VlI.VN, A.M., M.D.,
OMAHA, NEB.,
TROFESSOR OF DISEASES OF CHILDREN, OMAHA MEDICAL COLLEGE.
A VERY large number of diseases of infants have their
origin in errors of diet. The paramount question
during the first year of life is proper care and nutri-
tion. A well-born baby of rich possibilities may, on
an imperfect food, become stunted and anaemic and
permanently deformed. The correct and complete
nourishment of the infant is essential to perfect devel-
opment. During this period of life growth is rapid,
cell proliferation abundant and of low resisting power:
hence the lack of supply of correct nutritive material
soon manifests itself, not only in impaired nutrition,
but in actual organic disease as well. Primarily, mal-
nutrition may come about in two ways: bv lack of
some element or elements of food or by improper di-
gestion or imperfect assimilation of ingested food.
Both causes may and usually do operate conjointly.
From an important group of diseases having their ori-
gin in want of perfect food supply, I select for your
consideration one, namely, infantile scorbutus.
The credit of giving this disease a distinct place in
' Read before the Nebraska State Medical Society, at Lincoln,
May 20, 1896.
nosology belongs to W. B. Cheadle, of London, who
described three cases in the London Lancet in 1878
as true scurvy. Previously to this, isolated cases had
been noted in Germany by Moeller, Bohn, Hirsch-
sprung, and Senator as examples of acute rickets, and
one case in 1873 by Ingeler as infantile scun^. The
first case recorded in England was in 1876, by Mr. T.
Smith, and called by him hemorrhagic periostitis.
Similar cases were described in 188 1 by Dr. Gee,
under the name of periosteal cachexia. In 1883 Dr.
Barlow in the Medico-Chirurgical Transactions, vol.
Ixvi., gave the history of eleven cases under his care
and twenty cases from other sources. He also gave
very fully the morbid anatomy of infantile scorbutus.
As a result the disease is called by his name bv a
number of writers. Osier of this country^ among them.
Etiology. — A search of the literature of this subject
reveals the following: The disease is never seen in the
infant nursed at its mother's breast and probably never
in the infant fed on fresh cow's milk. In the cases re-
ported by Cheadle, the greater number of patients were
fed on farinaceous foods; some on desiccated patent
foods, a number on condensed milk, and several on
pancreatized milk. In most of these cases the infant
had no fresh food : a few were given a small amount
only. Of the cases reported by American writers, I
find a few in which the infant had received a small
ainount of breast milk, but usually it had been weaned,
and the diet in the most of the cases was some patent
food or condensed milk. .\n interesting question is
this: Can sterilized or pasteurized milk cause this
disease? Upon this subject I find a difference of
opinion. Cheadle, Ashby and Wright in England,
and Osier in this country, say that it can. Professor
Rotch, of Boston, and Professor Northrup, of New
York, say there is no evidence to prove that it can.
All writers agree that the real cause of scur\y is a
lack of fresh food. Cheadle believes this lack of
freshness to be due to the want of organic acids. The
following English writers on children — Ashby and
Wright, Carmichael, Eustace Smith, Goodhart, Don-
kin, and Angel Money — all speak of scur\'y as a com-
plication of rachitis, and call it scurvy rickets. It is
no doubt true that rachitis is much more prevalent in
England than in this country and consequently that
the two diseases are frequently associated. Of the
cases collected by Northrup, scarcely one-half pre-
sented any symptoms of rickets. Professor Rotch
states ■■ that his own individual experience has been
derived from fifty or si.xty cases, and that not more
than a dozen presented any symptoms whatever of
rickets." Now, as there are many cases of rickets pre-
senting no evidence of scurvy, and, in this country at
least, many cases of scurvy presenting no evidence of
rickets, it is clearly a misnomer to call the disease
scur\'y rickets. Both are diseases of nutrition : both
have for their cause improper food, and they are often
associated, but each has its distinct clinical course.
An infant reared on food lacking in fats and proteids
will likely develop rickets. Now, let the food lack in
freshness as well, and scurv'y may manifest itself. On
the other hand, a food abundant in fats and proteids
will not cause rickets, lut may, from lack of fresh-
ness, cause scun-y with absolutely no evidence of
rickets. The two diseases are. therefore, often asso-
ciated because of food defects, but they do not bear
to each other the relation of cause and efiect. Age is
an important etiological factor, the age limits being
at one extreme four months and at the other three
years, almost all cases occurring between the ages
of six and eighteen months, just the period when
infants are kept on an exclusive diet. We might
reasonably expect to find the disease among in-
fants deprived of fresh air, sunshine, and whole-
some environment. Frequently this is the case, but
478
MEDICAL RECORD.
[October 3, 1896
let it be remembered that a number of cases have been
reported from the homes of the wealthy, where the in-
fant has had ever}' comfort that money could procure,
everything needed for health except proper food.
These are usually cases in which the infant has been
reared on some patent food.
The clinical course of the disease is quite uniform.
The precursory symptoms, lasting from four to si.x
weeks, are as follows: anamia, often associated with
an earthy complexion ; general and progressive mus-
cular weakness; mental hebetude, the child being
easily irritated: gastro-intestinal disturbances, usu-
ally diarrhoea, more rarely constipation, loss of ap-
petite, and frequently vomiting of food. Thus far
there is nothing significant except perverted nutri-
tion. Among the symptoms especially peculiar to
scurvy are "pain on handling and excessive tender-
ness, especially on moving the limbs;" when ap-
proached the child cries from fear of being touched;
swelling of one, or more rarely of both thighs; more
rarely still, swelling of one or both arms. The swell-
ing is fusiform in shape.
Purpura is noted in a number of cases; hemorrhages
into the subcutaneous connective tissues, frequently
about the eyes; in some cases hemorrhages from the
bowels; in a few cases ha;maturia. The condition
of the mouth is peculiarly significant. When teeth
are present the gums are swollen and purple: fre-
quently they become ulcerated and bleed freely, so
that the breath becomes fetid. In some cases there
is enormous tumefaction of the gums, to such an ex-
tent that they protrude from between the lips. Before
the eruption of teeth the swelling of the gums is slight
and there are frequently ecchymotic patches in the
mouth. The surface over the swollen extremities is
not hot, or feverish, as in inflammatory swellings. It
will be noted that all of these essential symptoms
have their origin in hemorrhage. The subperiosteal
hemorrhage causes the swelling of the extremities and
is usually greater in amount just above the epiphysis.
This is the most prominent anatomical change. '" The
diagnosis is to be made from acute rheumatism, pur-
pura hemorrhagica, rickets, syphilis, and spinal paral-
ysis" (from Professor Rotch). In rheumatism the
pain and swelling are about the joints; in .scorbutus in
the shafts of the bones. Rheumaii.sm comes on acutely
with fever and hot skin ; scorbutus after weeks of fail-
ing health, with little fever. Purpura ha;morrhagica is
often seen in cases of scorbutus, and no doubt, as Pro-
fessor Northrup says, many cases of scorbutus have gone
astray under that name; but in purpura the osseous
symptoms and the swollen gums together with the his-
tor\- of the case should lead to a correct diagnosis. In
spinal paralysis the pain passes away after the initial
symptoms, and tenderness, so markedly prominent in
scorbutus, is absent. The onset of spinal paralysis is
almost always acute without premonitory symptoms.
In rickets the onset is slow, but the enlargement is in
the ends of the bones. Pain on handling is very
rarely noted in rickets. When scorbutus develops in
a rickety child, we have, in addition to the ordinary
symptoms, the fusiform swelling of the extremities
and the stomatitis. Hereditary syphilis usually mani-
fests itself by the third month; scorbutus almost never
before the sixth month. In syphilis the na.sal symp-
toms, mucous patches, and skin eruptions are usually
distinctive. The prognosis, when the disease is prop-
erly treated, is good. Cheadle has seen but one fatal
case out of nearly {\ity. The most important fact con-
cerning the disease is that when its true nature is rec-
ognized, it promptly yields to treatment, but for want
of proper treatment many cases have gone on to a
fatal termination in spite of all drug treatment.
Pathology. — The essential character of scurvy con-
sists in perverted nutrition. Owing to the lack of
some element of food the processes of secondary as-
similation are perverted and the mysterious harmony ex-
isting between the blood and tissues is deranged. No
blood changes, either microscopical or chemical, have
thus far been discovered. .\ careful post-mortem ex-
amination by Professor Northrup revealed numerous
hemorrhages beneath the periosteum of the shaft of the
femur, dark, disorganized blood in the stomach, infil-
trations of blood in the cellular tissues; no inflamma-
tory changes in either the periosteum or bone were
disclosed by microscopical examination, and no evi-
dence of suppuration. In one post-mortem reported
by Cheadle, in addition to the subperiosteal hemor-
rhage there was free blood in the air vesicles, this
being the immediate cause of death. In the post-
mortems reported by Barlow, the subperiosteal hem-
orrhage was the most important fact stated. No
mention is made of the pathology of scorbutus by
either Whitehead, Green, or Ziegler, and but brief
mention of the disease in adults by Delafield and
Pnidden. The subject of treatment will be mentioned
in the report of the following case recently under my
care :
Infant, male, born November 30. 1894. During the
first four weeks of life it nursed at its mother's breast,
but, the supply of milk failing, it was put on a diet of
modified cow's milk. On June 7, 1895, when six
months old, it was taken with acute entero-colitis,
recovering in a few days. July 17th it had the second
attack. During this period it was still on modified
cow's milk, but on the latter date was placed on an
exclusive diet of a dry patent food. There was no
further diarrha;a, but, on the contrary, marked consti-
pation. During the month of .August the infant grad-
ually failed in strength, and, owing to absorption of
subcutaneous fat, the skin lay in loose folds. It grad-
ually became more pale and anamic, cross and fret-
ful, sleeping only for short periods of time. About
September 1st I again saw the baby. The mother
said it would cry when taken up, but would lie for hours
upon the bed when undisturbed. It now had two teeth ;
its mouth was sore and the gums were red and swol-
len. .September 29th I again saw the child. It still
cried when touched or when approached ; the right
leg kept motionless; the thigh was evidently swol-
len and very tender to the touch. 'I'he sore mouth
ix;rsisted in spite of treatment by chlorate of potas-
sium and other mouth washes. The gums were now
so swollen as almost to cover the two teeth and
bled when touched. It now became apparent that
this was something more than marasmus. The true
scorbutic nature of the case finally dawned upon me,
and on October ist I placed the infant on a mixture
of milk, cream, and sugar of milk, giving it three
ounces every two hours; also the expressed juice of
half a pound of rare steak each day and the juice of
one large orange daily. I gave it castor oil daily, as
the bowels were still constipated. The only medicine
given was a simple elixir of pepsin. Three days after
the beginning of this treatment the infant was mark-
edly improved. In ten days it could be taken up
without any evidence of pain. The swelling of the
thigh rapidly subsided. By Novemijer ist, thirty
days after the beginning of treatment, the little pa-
tient had almost entirely regained his health and
strength, excepting that he did not attempt to walk
until eighteen months of age. This patient lived on
sterilized milk for five months, when the bowel trouble
commenced, and then on an exclusive diet of desic-
cated food for two and a half months, when well-
marked scurvy symptoms developed. There were ab-
solutely no symptoms of rickets in this case. I be-
lieve the symptoms and treatment proved beyond
doubt that this was a case of true infantile scor-
butus.
October 3, 1896]
MEDICAL RECORD.
479
OXYGEN IN THK TREATMENT OF ACUTE
CAPILLARY BRONCHITIS.
liv JUllN L. CORISH, M.D.,
BROOKLYN, N. Y.
Acute capillary bronchitis in the newly born is a dis-
ease which is more common than might be supposed.
Many if not nearly all cases of acute broncho-pneu-
monia take their origin from an attack of acute capil-
lary bronchitis. By some authors these conditions are
treated as if they were different stages of the same dis-
ease. It is absolutely essential that the catarrhal con-
dition of the capillary tubes should be recognized as
a distinct and separate order, and though it may fur-
nish the conditions for a subsequent attack of broncho-
pneumonia, yet it can be treated separately, success-
fully, and practically. The catarrhal condition may
arise from change of temperature, exposure, or intro-
duction of no.xioiis gases, or it may be secondary to a
primary acute catarrhal rhinitis and pharyngitis. An-
other cause is found to be the imperfect closure of the
foramen ovale. In the latter class the acute capillar}-
bronchitis is secondary to the engorgement of the
capillaries with semi-venous blood. The symptoms
present all the characteristics of the class of diseases
in which there is not sufficient accommodation for
obtaining a normal amount of respiratory air — viz.,
cedema glottidis, croupous laryngitis, the second stage
of pneumonia, etc. — except that we have the capillarv
rales in abundance at the beginning of the catarrhal
affection. The dyspncea is noticeable from the be-
ginning and increases rapidly. The number of respi-
rations rises to 60, 70, or even 80 per minute. The
temperature may run up half a degree in the early
stage, only to fall to a subnormal condition toward tiie
end. The pulse, at first rapid and throbbing, finally
becomes thread-like. Dulness on percussion, such
as is present in broncho-pneumonia, cannot be ob-
tained at any time during the attack. In this disease
the pathology is easily understood. To be brief, the
lining membrane of the lobules becomes engorged with
blood and a mucous secretion is thrown out. This
collects in the capillary tubes and forms a barricade,
so to speak, by means of which inspired air is pre-
vented from penetrating into the lobules. The resid-
ual air in the lobules becomes absorbed by the blood
and a vacuum is created. The lobules, being unsup-
ported by the pressure internally, collapse, a result
known as atelectasis.
The physiological results of the obstruction are the
collapse of the lobules; the inability of the blood to
extract sufficient oxygen for the bodily requirements;
the efforts of the different sets of direct and accessory
inspiratory muscles to overcome this condition; the
resulting general cyanosis; the indifference with which
the child regards the partaking of nourishment, its
whole time being occupied in its efforts to obtain air;
the gradual exhaustion from want of nourishment and
overexertion of muscles; and, finally, the easy death
from asphyxiation. How have we treated these con-
ditions when they have been met? Have w'e treated
them symptomatically ? Yes. We have been taught
to keep the alimentary canal freely oiJen. We have
given our great standliy, the ammonium salts, as a stim-
ulant and expectorant, and whiskey, also, as a cardiac
stimulant. The cliild bears the ammonia very well in
this class of cases. We have used counterirritants to
the chest wall, ^^'e have ordered the breast to be con-
tinued, but the child is unable to perform the function
of suction and enforced respiratory eft'orts at the same
time. When there is temporary relief the child obtains
an oversufiiciency of food, which results in the usual
vomiting, followed by passages of undigested or de-
cayed cheese and by various sequelrr. Then these ad-
ditional symptoms must be promptly met. The child
relapses into its cyanotic condition, but this time to a
greater degree. The physician sees that his cardiac
stimulants are having but little effect ; the expectorant
preparations are of scarcely any avail ; all hope of a
favorable prognosis has passed.
The following case is an example of one continu-
ally met with by the experienced physician in his
private practice. On January 5, 1896, I was called
to attend a child, whom I delivered three days pre-
viously. There were no malformations, and from
careful examination I was satisfied of the perfect
closure of the foramen ovale. During the evening an
acute capillary bronchitis had set in, following an
acute catarrhal rhinitis which had existed for twenty-
four hours previously. The temperature of the lying-
in room varied at times, ranging from 68° to 82° F.
The rectal temperature of the child was 99" F. ; respi-
ration, 60; and pulse, 150, strong and full. I cleared
the nasal passages and ordered one-fourth grain of
ammonium carbonate, together with five drops of spir-
itus frumenti, every hour.
January 6th, 8 a.m. — Respiration, 72, bronchial and
shallow. The child refused nourishment. The tem-
perature was 97.8° F. Limbs cold. A general cyano-
sis had set in; the capillary tubes were filled with
mucus, and an acute conjunctivitis in the left eye was
also noticed. At 9 p.m. I met Dr. Brandt, of Brook-
lyn, in consultation. We came to the conclusion that
the treament already adopted should be continued and
that the doses should be increased. Accordingly, we
gave one-half grain of ammonium carbonate and ten
drops of spiritus frumenti every hour. Toward morn-
ing there was some improvement in the frequency of
the respiration and the cyanosis was less marked.
The pulse dropped to 140, stronger; respiration, 50;
temperature, 98° F. The stools became greenish and
of a mucous character, to correct which a warm enema
of boric-acid solution was used occasionally.
January 7th, 8 a.m. — Respirations, 76; cyanosis
very marked. The ala; of the nose were dilating, in
unison with the other respiratory movements. Ab-
dominal breathing marked. Temperature, 97.6° F. ;
pulse, 160, thread-like. The ammonium carbonate
was increased to one grain every half-hour, which dose
the child stood well, with but slight vomiting of mu-
cus. The child had refused to nurse for the past
twenty-four hours. Beef extract and whey, to which
sweet butter and milk sugar had been added, were in-
jected into the bowels as nourishment.
The case became so desperate that at 3 p.m. I ob-
tained a cylinder of oxygen compound, one hundred
and eighty-five pounds pressure. A mouthpiece to be
attached to the wash bottle was constructed of an ice
bag, cut in such a manner that it could be tightly
placed over the vault of the cranium and beneath the
chin. Into this was inserted the outlet tube of the
wash bottle, fastened with ordinary rubber elastic
bands. This rudely constructed affair was placed over
the child's face, the child lying in the dorsal position
on a table, with the head extended well back. The
oxygen mixture was at first applied under a slight
pressure. The respirations decreased in rapidity, they
became deeper, and in a short time the color of the in-
tegument changed from a blackish blue to a normal
flush. Then the child cried, something it had not
done for forty-eight hours previously. The adminis-
tration of the mixture was discontinued at the end of
three minutes. The respirations liad dropped to 42 ;
pulse, 140, full and regular; and the temperature rose
to normal. At the end of an hour the respirations rose
to 70, cyanosis returning. The oxygen mixture was re-
applied, with results similar to those obtained in the
former trial, except that the time was shortened to two
and one-half minutes. All through the night the mix-
48o
MEDICAL RECORD.
[October 3, 1896
ture was given, with increasing inten-als between appli-
cations, but with the pressure gradually increased up
to one-half an atmosphere. It was observed by the
mother, and called to my attention, that immediately
after the inhalation of the gas the child cried and took
to the breast like a starved youngster, something it
had had no time to do previously, as it was too busy
with the more important object of obtaining air.
From this time on, only the natural nourishment was
necessary.
On Januar)- 8th the total number of applications
giyen was four, after each of which the child nourished
naturally. Bismuth and irrigation allayed the intes-
tinal indigestion. The last application of the gas was
given at 3 p.m., and it was at this point that the child
was anaesthetized by the oxygen, owing to the enor-
mous absorption. The pressure used was one-half an
atmosphere, sustained for three minutes. (For what
followed, see article in the Medical Rkcord of Sep-
tember 12, 1896.)
Auscultation of the lungs immediately afterward
showed total absence of capillary obstruction, tliere
being present only a few scattering bronchial rales,
which from that time grew fainter in character and on
January iith finally disappeared. On January 9th,
the day after the o.xygen was discontinued, the con-
junctivitis of the left eye assumed a purulent char-
acter. The right eye has not been affected up to this
date (February 24th I, except by an acute catarrhal con-
junctivitis. An important question for the oculist to
consider is: Did the application of the o.xygen retard
the appearance of the purulent inflammation of the
right eye and render the left eye immune.'
What difficulties are encountered in this disease,
and how shall we meet them satisfactorily? The ob-
struction of the mucus in the tubes must be removed.
The child cannot accomplish tliis, being unable to
inspire sufficiently deep. A pressure of one-half an
additional atmosphere will accomplish this. The o.xy-
gen, restoring the capillary engorgement to a normal
character, will prevent the formation of additional
mucous secretion. The collapse of the lobules cannot
be remedied by any means brought to bear through the
general circulation, but it can by means of the pres-
sure applied. The heart action, which is in a very
feeble condition, must be sustained i)y stimulants in-
ternally administered, liut oxygen, as is well known,
by restoring tlie capillary circulation to its most favor-
able condition for normal movements, acts indirectly,
but with no less a degree, certainly as powerful, as a
cardiac stimulant. The fact that the child refuses
nourishment is evidently not because it has no desire
in that direction, but it is hampered very greatly in its
demand for air by the generally accompanying acute
rhinitis, and also by the additional obstruction which
the nipple necessarily accomplishes in addition.
As to the final treatment adopted in this case, what
physiological results were obtained.' The oxygen,
being introduced into the system in greater abun-
dance, combated the cyanosis by relieviiig the reflex
vasomotor irritation. The production of secretion
becomes thereby lessened. The secretion already in
the tubes was forced deeper into the lobules. The
collapsed condition of the lobules was remedied by the
increased pressure, they being distended to their
greatest capacity, and gradually, a normal condition
being re-established, this latter action being purely
mechanical. After the first application of the oxygen
mixture, the child is in a state similar to that of one who
has passed through its first night of an attack of false
croup. It will go back to its former condition, or
nearly so, because we have given only sufficient to
maintain the balance of supply and demand for an
hour or so.
Some one asks, Will you have to apply oxygen every
time the child becomes cyanosed? Yes. After the
child has received sufficient to enable it to nurse, push
your treatment. Reapply the gas under increased
pressure and expand the lungs to their extreme capac-
ity. The atelectatic condition disappears and the
lungs are better able to do normal work. If the oxy-
gen is applied with still further pressure and the child
allowed to inhale this alone, for a jjeriod of from two
to three minutes, the system becomes thoroughly satu-
rated, the breathing ceases, but the pulse is still sus-
tained normally and there is a temperature of 99 ' F.
The integument assumes a rosy hue and voluntary mus-
cular movements cease. This state will last from five
to seven minutes, during which time the child will re-
cover a great part of the energy wasted in the diseased
condition. When the superabundant oxvgen stored up
in the system has been used up in the bodily require-
ments, the respiratory movements will begin again as
in the newly born. If it were only required to com-
bat the cyanosis, I believe this could be done suffi-
ciently well, temporarily, by inflation of the large in-
testine with the oxygen mixture. But the keynote to
the treatment of acute capillar)- bronchitis is to ex-
pand the lungs to their fullest extent by pressure from
within; to alter the character of the circulating fluid
by giving oxygen ; and to allow the respiratory muscles
sufficient time to recuperate — all of which can be ac-
complished sinuilianeously by the administration of
the o.xygen mixture under pressure.
February 24, 1896.
THE CARK OF IHK BRFAST I\ LACTA-
TION.'
Hy CHARLES KOSEWATER, .M.D.,
I'KOKESSOR OF OUSTETKICS, CREICHTON .MEDICAL COLLEGE, OMAHA, NEH.
It may seem strange to some of you that I should
bring before this society for its consideration a sub-
ject which, by many, is relegated to the domain of the
nurse. But this is the very trouble with our medical
societies. We spend hours, yes, whole sessions in the
discussion of such subjects as laparotomy, hysterec-
tomy, ectopic pregnancy, ovariotomy, or some wonder-
ful but rare operation which perhaps not more than
one out of a hundred of us is ever called upon to per-
form or even to consider; yet the subject of the care of
the brea.st in lactation hardly ever occupies the atten-
tion of the members of our profession at their meet-
ings. I dare say, however, that ninety-nine out of
every hundred physicians are called upon almost daily
for advice and counsel upon this subject, and upon
that advice depends the happiness of an anxious
mother and the welfare of a new-born babe, not to
consider the comfort of an entire household. Many
an infant dies during its first year on account of hav-
ing been deprived of its natural food, when by careful
and persistent attention at the right time the mother's
Ijreast might have been put and kept in proper con-
dition to supply the food nature intended it should.
In the consideration of this subject the first ques-
tion which naturally arises is: Does a healthy breast
require any preparation for its utilization in nursing?
Can we by some means or other aid tiie mother so
that she will be belter able to nurse her child? Is
there anything which we can do during the latter
months of pregnancy to improve the condition of the
mother and her breast with special reference to the
performance of the function of lactation ?
I would answer, " Yes — in a large number of cases
we can." In some cases, however, our ser^•ices are
unnecessary and undesirable. Just as many women
can go through childbirth naturally and without any
' Read before the Omaha Medical Society, on June 9, 1896.
October 3, 1896]
MEDICAL RECORD.
481
assistance without impairing their physical integrity
or vitality, so can many nurse their children without
any preparation or care directed toward the breast.
This being the case, it is important for us to know
when our services must come into requisition. What
local or constitutional conditions might require cor-
rection by us to make the woman suitable as a nurse
for her child?
It is hardly necessary to state that malignant tu-
mors of the breast preclude nursing. It is in fact a
great raritv for malignant tumors of the breast to de-
velop during pregnancy, or for pregnancy to occur
coincident with such tumors.
The presence of benign tumors of the breast does
not necessarily contraindicate its use in nursing, for,
while it is a fact that in a large number of such cases
the tumors so affect the glandular structures of the
breast that their secretion is impaired either in quality
or in quantity, yet there have occasionally been cases
in which the mammary gland itself was not affected in
the least and its secretion continued to be fit for the
child and of sufficient quantity. Hence in such in-
stances each case must be considered individually,
and no general rule can be laid down e.xcept perhaps
that the mere presence of a benign tumor of the
breast need not preclude nursing when the milk secre-
tion is normal.
The condition of the nipple should next occupy our
attention. When the nipple is fiat so that the most
arduous attempts to draw it out with a clay pipe,
breast pump, or some similar instrument fail, lactation
is of course out of the question. In many cases,
however, in which the nipples appeared flat and useless,
and the patients e\en claimed that other members
of their family had been prevented from nursing-
children on account of similar disability, I have suc-
ceeded in making the breast quite serviceable by in-
sisting on persistence in the efiforts at drawing the
nipple out by means of a clay pipe, these efforts being
begun usually during the last month of pregnancy. If
the nipple cannot be drawn out at all, the patient will
be unable to nurse her child.
If the breast is flabby and secretes no milk, or only
a very inferior article, it is far better to furnish the
child other means of nourishment.
If the patient is suffering from serious constitu-
tional disease, such as tuberculosis, intense anremia,
or recent syphilis, it is better for her not to nurse her
child. So also when she is suffering from some seri-
ous nervous disease, such as epilepsy, hysteria, etc.
In acute febrile diseases, as a rule, the breast ceases
to secrete and lactation must of course be interrupted.
Sometimes the interruption is only temporary, even
though it may be of considerable duration, as in a
case of puerperal fever which I attended several years
ago, in which after convalescence was established, the
secretion of milk returned and the child was again
nursed by its mother after it had been nursed by its
aunt for seven weeks.
Many nurses and even some physicians advise the
use of astringent lotions, such as a solution of alum in
whiskey and water to be applied to the nipples during
the last month of pregnancy, so as to harden them and
dull their sensibility. I have seen some cases in which
this method of procedure seemed to me to result in
greater tenderness and dryness of the nipples and
finally in the development of fissures, so that I am
not in the habit of advising it. It has been my prac-
tice to advise that the nipples be rubbed occasionally
with vaseline or cold cream to render the skin soft
and pliable. When the breasts through their turgid-
ity become very tender, and especially when through
clogging of the milk ducts a condition known as
caked breast develops, gentle massage together with
the application of a snug breast binder, which sup-
ports the breast and prevents it from hanging down,
will be a great source of relief.
If the patient has a history of having lost children
previously through not having had sufficient good
milk for them, she should be put on a tonic toward
the end of pregnancy — some preparation especially
adapted to improve her general health. Just what
preparation should be used in each individual case
will depend upon the circumstances.
How soon after childbirth should a mother nurse
her child? This depends upon the mother's physical
condition and the severity of the labor through which
she has just passed. As a rule, a woman may be al-
lowed to nurse her child as soon as she has obtained
her first good rest after childbirth. If she has gone
through a severe labor, complicated perhaps by severe
hemorrhage, it is well to give her plenty of rest, at
least twelve hours before putting the child to the
breast. Before the child is put to the breast the nip-
ple should be carefully washed, and the child's mouth
also. If the nursing is accompanied by severe local
pain about the nipple without there being any excori-
ation or fissure noticeable, then application of a weak
solution of nitrate of silver (five to ten per cent.) to
the nipple after nursing will so toughen the cutaneous
surface and dull the sensitiveness of the parts that the
next nursing will be less painful. Sometimes the
temporary use of a nipple shield will tide the patient
over this period of greatest tenderness, but often chil-
dren will not nurse through such a shield. Persist-
ence in the efforts directed in this channel will,
however, as a rule, be crowned by success, but some-
times leads to maceration of the epithelial covering of
the nipple. This condition, which is extremely pain-
ful, may also develop when the child is allowed to
nurse too often and too long. The feeding of infants
at the breast should occur at regular intervals, not
oftener than every two or three hours during the day-
time and once or twice during the night.
In -cases in which the nipples become very sore
and tender I usually succeed in overcoming the diffi-
culty by applying a powder of tannic acid or bis-
muth after the child has nursed and the nipples have
been washed. And right here comes another factor
largely responsible for the sore breast — the macerated
nipple, I mean — that is, the constant moistening of the
nipples from the milk oozing out. This can be obvi-
ated if the patient will wear some absorbent covering,
such as cotton batting, over the nipples at times when
she is not nursing the child. The parts should be
kept dry between the nursings.
In some cases by the time the physician is called,
a fissure has developed at the root of the nip-
ple, causing the patient excruciating pain whenever
her child nurses, and so exhausting her strength as
frequently to lead to high fever and great prostration.
And yet a very little treatment is needed to success-
fully overcome this difficulty. After cleansing the
parts thoroughly I usually cauterize the fissure with
nitrate of silver in stick, then neutralize and wash off
the superlluity of caustic with a solution of common
salt and apply tannic acid dry on the nipple when a
state of maceration of the nipple exists, or a glycerole
of tannin when the epidermis seems to be too dry.
In these cases it is also well for the patient to rest
the sore breast for from eight to twelve hours at a
time. Usually one cauterizing, such as the above, will
suffice.
If, however, infection has already occurred from the
fissure, a mastitis may develop, ushered in by a chill
or succession of chills, followed by fever, pain in
the entire breast and extending up into the axilla,
hardening and tenderness of the breast, with usually
some alteration of the milk secretion. The latter may
be either entirely checked or greatly diminished and
48:
MEDICAL RECORD.
[October 3, 1896
deteriorated, but, no matter how this is, the breast
should in such instances be put to rest completely by
prompt cessation of nursing. Laxatives and quinine
should be given and a firm breast binder applied.
Cold applications may be applied with advantage in
such cases when suppuration is threatened, but as
soon as it is an established fact moist heat should be
substituted for the cold, and as soon as pus can be
reached it should be let out through a free incision,
made in a direction radiating from the nipple and at
as low a point on the breast as is consistent w ith easy
access to the pus. From this on, the case should be
treated on surgical principles, drainage being neces-
sary in some cases, while curetting and firm packing
with antiseptic dressings are necessary in others.
When it is desirable to dry up the secretion of the
breast the use of an atropine ointment (one grain to
the ounce) or belladonna ointment (fifteen grains to
the ounce) has been strongly recommended, but in
many if not all cases the simple application of a
snug binder together with cessation of the use of the
breast is all that is necessary. The breast, not being
used, gradually stops secreting milk. It is well in
these cases also to give Epsom salts or some other
cathartic to carry off the superfluous liquid by other
channels.
ARE SANATORIUMS FOR CONSUMPTIVES A
DANGER TO THE NEIGHBORHOOD?
By S. a. KNOPF. M.D. (Paris a.nd Bell. N. Y.),
NEW VORK,
FORMER ASSISTANT TO PROFESSOR DETTWEILER, FALKENSTEIN SA.MATORIl-M,
GERMANY.
After the publication of my French thesis on sanato-
riums for consumptives,' in which I endeavored to
make a strong plea for such special institutions as one
of the best means of curing and preventing pulmonary
tuberculosis, I was surprised to hear several of my
medical brethren, some of them of high standing, e.x-
press their disapproval of housing a large number of
tuberculous patients in one institution. A few even
thought my ideas almost dangerous. The laity in
Europe were, of course, still more pronounced in their
prejudices, opposing the establishment of sanatoriums
for consumptives on the ground that their pro.ximity
would prove a source of infection.
To set such fears at rest, I published an article in
the Revue tie la Tii/icnii/ose for December, 1895, enti-
tled " Les Sanatoria de I'hthisiques, sont ils un Danger
pour le Voisinage.'" Since my return to the United
States I have learned that the same prejudices exist
here, which, I am sorry to say, are often shared or
even advanced by medical men. To convince them
of the absolute harmlessness of the vicinity of a prop-
erly conducted sanatorium for consumptives is the ob-
ject of this article.
In my communication to the Rcriie de la Tuheicii-
lose, I mentioned some of the most surprising views
expressed by medical and civil authorities, and cited
one or two instances which, as they illustrate the case
in point, will perhaps bear repeating.
For years it had been the object of some philanthro-
pists in Frankfort-on-the-Main, who have in their
vicinity that excellent institution for consumptives in
Falkenstein, to open a similar one for the poorer
classes. At last their wishes were realized, a build-
ing was procured, and things were in running order.
Professor Dettweiler had kindly consented to act as
physician-in-chief, and a house physician had been
appointed. But an aristocratic lady, living a few
miles from there, objected to her new neighbors. As
' ■■ I.es Sanatoria. Traitement et Prophylaxie de la Phtisie Pul-
monaire." Par le Docteur S. A. Knopf, Paris, 1895 ; George
Carre, editeur.
she did not wish to leave her elegant country resi-
dence, she offered to buy the house which had been
made a sanatorium for far more than it was worth, on
condition that the patients should be moved much far-
ther away. The offer was accepted, and to-day the
poor consumptives of Frankfort have at Ruppertshain
a large, handsome, comfortable structure, better located
and three times as large as the original one. But it is
far from the home of the baroness.
Near Vienna existed a place which had been
known for years as a health resort for consumptives
and persons suffering from similar troubles. Thanks
to the efforts of a distinguished professor and special-
ist in phthiseo-therapeutics and the funds given by a
wealthy philanthropist, it had been decided to found a
sanatorium for poor consumptives, under the direction
of this professor, in the resort mentioned. But the
authorities of the community raised such an outcry at
the prospect of having this institution in the midst of
them, fearing it would drive away the class of wealthy
patients who had come there for so long, that the pro-
fessor, not wishing to go where his sanatorium would
not be welcome, chose another locality.
They thought they had done a wise thing; but soon
the wealthy patients, thinking that the new place must
possess superior advantages to have been chosen by
so celebrated a specialist for his institution, began to
flock thither; and the old resort, so favored for years,
found itself quite deserted.
Here in the United States one will find the authori-
ties of small communities opposing the establishment
of a sanatorium for tuberculous patients, but no objec-
tion would be made to a home for consumptives, espe-
cially if under church su]x;r\ision. Most of these in-
stitutions are the work of the Episcopal Church. I
cannot speak too highly of the laudable efforts of these
noble men and women to provide a place of rest for
poor consumptives, but I have recently visited a few
of these " homes," and I must confess that they seem
to me a dangerous experiment. There is never a house
physician; the visiting physician comes but rarely,
and then only to see the most urgent cases. The di-
rection is in the hands of the brother or sister superior
or matron. What results in regard to prophylaxis and
treatment can be obtained under such conditions? To
me it seems an illusion to think that any notable good
can be accomplished in such a " home" without a phy-
sician. Consumption is a curable disease, and there-
fore tuberculous patients should be treated and not
kept. The excellent results obtained in sanatoriums
for consumptives are due to the constant medical su-
jjervision and the jiersonal training of the patient.
The physician presides at the table, directs the rest
cure in the open air, the breathing exercises and
graduated walks, the hydrotherapeulic applications,
and the many other curative and preventive measures,
the ensemble of which constitutes the real treatment of
pulmonary tuberculosis.
To watch that there may never be any relaxation in
regard to the care w ith the expectoration requires more
than the gentle rule of a sister superior. Still, such
" homes" seem to be welcome in communities where
sanatoriums are shunned, although one is really safer
from infection in a properly conducted sanatorium for
consumptives than anywhere else.
The most important factors in imparting the disease
are the expectoration, the saliva, and other secretions.
In a prop)erly conducted sanatorium ))atients never ex-
pectorate except in a receptacle provided for the pur-
pose, a spittoon or pocket flask. Those in bed and
too weak to make use of the spittoon are provided
with moist rags, which are burned immediately after
use. The expectoration and other secretions are de-
stroyed before they have a chance to dry and do harm.
Napkins and table utensils are boiled or disinfected
October 3, 1896]
MEDICAL RECORD.
483
after each meal. Besides this, a scrupulous cleanli-
ness is observed in all rooms, and the furniture is so
arranged that a thorough disinfection may be easily
carried out.
Repeated microscopical and bacteriological exami-
nations of the dust taken from the rooms of such sana-
toriums have proved it to be practically free from
bacilli. At Saranac Lake, the great American sanato-
rium, none of the twenty to twenty-five attendants have
ever developed tuberculosis. The contraction of the
disease by physicians, nurses, or employees is almost
unknown in these institutions.
But the effect of such sanatoriums upon their sur-
roundings is not a matter of conjecture or of opinion.
We can bring experience and statistics to our help.
In Goerbersdorf, the largest and oldest sanatorium for
consumptives in the world, through which some two
thousand patients pass every year, the mortality from
tuberculosis among the people of the neighboring vil-
lage has decreased in a wonderful degree since the
establishment of the institution. Not only has the
sanatorium done no harm to the surrounding popula-
tion, but it has done good, through the example set
before the village people by the patients and the sani-
tary regulations, which direct all attention to the de-
struction of the bacillus. To uphold these statements
I will repeat from my thesis the official statistics of the
village of Goerbersdorf for a hundred years:
Deaths from Phthisis Pulmonalis.
In the Medical Record of December 28, 1895, Dr.
Irwin H. Hance, formerly assistant to Dr. Trudeau,
published the account of an interesting series of ex-
periments with dust taken from various sources (hos-
pitals, sanatoriums, etc.), showing how free from dan-
ger one is where the proper precautions are taken in
regard to the expectoration, and how little reason there
is to fear the proximity of a sanatorium for consump-
tives.
At this year's meeting of the American Climato-
logical Association, Dr. Edward (). Otis, of Boston,
read a very instructive paper, entitled " The Sanato-
rium or Closed Treatment of Phthisis." ' In it he
speaks of the fears that sanatoriums may be a source
of contagion as misconceptions, and considers such
properly conducted establishments one of the best
means of curing pulmonary tuberculosis and of com-
bating the spread of the disease. Well-conducted
sanatoriums for consumptives are not centres of in-
fection ; but, on the contrary, places where the tuber-
culous patient is the most free from the danger of
autoinfection, and where there is the least chance of
his communicating his malady to others.
349 West Fiftv-Kighth Street.
179O-I799 14
1800-1809 5
1810-1S19 g
1820-1829 9
1830-1839 8
1 840-1 849 6
1850-1859 7
1860-1869 4
1870-1879 5
l8So-i88g 5
After the Establishment of the
Sanatorium.
1877-1879 17.0 per 100.
I880-1882 14.6
1883-1885 6.0
1886-1888 5.0
1889-189I 13.9
1S92-1894 15. 1
These statistics become still more valuable when
one considers that the population of Goerbersdorf has
doubled in the last twenty-five years.
Recently Dr. Nahm has compiled the statistics of
the village of Falkenstein. Here also the mortality
from pulmonary tuberculosis has been reduced from
18.9 per cent, before the establishment of the sanato-
rium, to 1 1.9 per cent, after it was opened. I will
give the statistics of Falkenstein in full, as they were
published by Dr. Nahm:'
Deaths from Phthisis Pulmonalis.
Before the Establishment of the
Sanatorium.
1856-1858 17.2 per 100.
1859-1861 7.7
1862-1864 22.6
1865-1S67 14.0
186S-1S70 16.7
I87I-1873 21.0
1874-1876 33.3
It is the duty of the profession to enlighten the
public and the civic authorities on the question of
such institutions. F.urope has many advocates of the
establishment of sanatoriums for consumptives. Fore-
most among them are Grancher and Letulle, of Paris;
Leyden, of Berlin; Schrbtter, of Vienna; von Ziems-
sen, of Munich ; and Weber, of London.
In the LTnited States the pioneer work in this line
has been done by Bowditch, of Boston, and Trudeau,
of Saranac Lake. They both have visited the sanato-
riums abroad, especially the one at Falkenstein, and
were much impressed with the beneficial results ob-
tained by the hygienic and dietetic treatment in these
"closed" establishments.
Last year, Dr. (juy Hinsdale, of Philadelphia, read
a most interesting article at the meeting of the Ameri-
can Climatological Association, entitled " Recent
Measures for the Prevention and Treatment of Tuber-
culosis," ' wherein he set forth the necessity of sanato-
riums, especially for the poorer classes.
' Miinchener medicinische \\'ochenschrifl, No. 40, 1S95.
''Medical News, August 24, 1895.
progress lof |]t%eclicHX s«ctcnce.
Laryngeal Irritation. —
^ Alcohol (40 per cent. ) 3 v.
Menthol gr. viij.
Cocaine hydrochlorate gr- 'j-
Acid benzoic gr. xv.
M. S. Use as a gargle or spray, by adding ten to twenty
drops to half a glass of warm borated water.
— Za Riforma Aledica.
Diffuse Bronchitis in Children. — Dr. Renault be-
lieves that a simple and harmless method consists in
giving a bath at 100.4" F. for seven to eight minutes
every three or four hours, until the temperature taken
three hours after the last bath has reached 102.2° F.
After a third or fourth bath the fever falls without
rising, and the disease becomes a slight bronchitis,
without even becoming capillary. Quinine sulphate
is given as a general tonic. — JoKnial des Piaticicris,
1896, No. 13, p. 205.
Osteomyelitis and Immunizing Experiments. —
Dr. Canon [Dditsche Zcitsc/irift fi'ir Chirurgic, xlii.,
No. I) draws the following conclusions from a series
of experiments: (i) The presence of streptococci in
osteomyelitic processes is to be regarded as danger-
ous. (2) Staphylococcus osteomyelitis is by far the
most frequent. (3) Osteomyelitis is to be considered
as a staphylococcus pyctmia of the developing period
of life. (4) It is possible to immunize animals
against a staphylococcus infection by the aid of blood
serum from persons just recovering from a staphy-
lococcus disease.
Kidney Wounds. — Dr. I'rimble {Maryland Medi-
cal Journal) says: i. All kidney injuries are to be
considered as serious until proved otherwise. Never
sit quietly by waiting for symptoms to develop in
order that a diagnosis may be made. When in doubt,
explore the kidney; the danger to the patient is not
increased by an aseptic operation. 2. In all kidney
wounds and wounds in the region of the kidney, the
kidney should be examined through a large incision.
In serious wounds of the kidney immediate operation
is the only thing that will save the patient. The
lumbar incision, when it will answer all the require-
ments of the case, is to be preferred to a laparotomy.
' New York .Medical Journal, June 13. 1S96.
484
MEDICAL RECORD.
[October 3, 1896
Chorea. — Dr. E. De Renzi {Gazctta degli Ospitali
e ilt-lle C/iriichc-, 1896, No. 29) has made use of eserine,
antipyrin, salol, and ether spray along the vertebral
column, but he places his confidence in only three
remedies: (i) Absolute rest, the patient being placed
in a dark room and avoiding all external excitation
whatever. [2) The ascending electrical current along
the spinal cord — the best results with a gentle current
progressively increased. (3) Arsenic in large doses,
commencing with twenty drops of Fowler's solution
each day for- children and double this amount for
adults. The medicine should be continued after the
chorea ceases, for the disease readily returns. The
nutrition of the patient must be maintained, and good
food and g)'mnastics are useful.
Time of Rupturing the Amniotic Sac in Labor.
- — I. In multipara:-, rupture when os is fully dilated.
2. In primipara-, delay until the soft parts are also
dilated. 3. In cases of face and breech presentation,
delay in rupturing the sac is best. 4. When the pel-
vis is small and the fcetus large, delay rupturing. 5.
In premature labor, with a dead fcetus, rupture early.
6. Rupture the sac early when the membranes are un-
usually thick, tough, and unyielding. 7. When speedy
delivery is demanded, rupture early and dilate with
the fingers. 8. Rupture the sac when an excessive
amount of amniotic fluid retards labor. 9. \Mien
version is necessary, and can be accomplished by bi-
manual manipulation, perform this operation before
rupturing. 10. Remember that a dry labor is always
to be deprecated; hence do not rupture at all, unless
for good reasons and the case demands it. — Atlanta
Medical and Surgical Joitrnal.
Necessary Pocket Instruments. — An aseptic pocket
case is a scientific absurdity. A good surgical knife,
a stout pair of scissors, a sufficiently large and strong
anatomical forceps, a large probe with a button at one
end and an eye at the other, and possibly a piece of
silk and a needle, are all the instruments that are
really necessary. These may be carried in a neat
canvas "' folder'' and the whole contained in a leather
pocketbook. The instruments may be sterilized in a
match flame and should be dipped in water while hot.
The needle and silk may be boiled in a teaspoon over
a match flame. Hemorrhage, even from quite a large
vessel, may be checked by a silk suture. This device
will nearly always take the place of the artery for-
ceps.— Intertiational Journal of Surgery , June, 1896.
Urinary Examinations — Dr. Lichty {Medical News)
holds that 1. .V crjntinued low specific gravity must
be looked upon with grave suspicion, until it can be
proved beyond doubt that the kidneys are normal. 2.
In nephritis, especially of the chronic interstitial
type, it may happen that at times during the greater
part of the disease the urine may contain no albumin
that can be detected. 3. Casts may be present in the
urine when it is impossible to detect any albumin by
the usual tests. 4. Casts are very easily destroyed in
the urine by bacteria during the process of fermenta-
tion, and unless the examination is made within an
hour or two after the urine is passed, the failure to
find casts does not prove the non-existence of ne-
phritis. The urine should be more frequently exam-
ined, especially after sickness.
Pneumonia — Dr. Scully (Journal of the American
Me Jioil Association, June 6, 1896) says: "Do not give
alcohol in any form during any stage of the disease.
I firmly believe that the use of alcohol has been the
chief cause of the high mortality in recent years. Let
the fever alone. The danger is not from the fever but
rather the heart, and inasmuch as all of the recent
antipyretics act as heart depressants, we should be
very cautious in their use in pneumonia. Stimulate
your heart if necessary with digitalis, using a good
reliable fluid extract, strychnine, or nitroglycerin.
O.xygen should always be thought of when there is a
tendency toward cyanosis. I have seen such excellent
results follow its administration that I unhesitatingly
say: Use oxygen in cyanosis and use it freely. I
have never taken very kindly to cold packs or com-
presses, and have resorted to their use only in a few-
cases. Still in those cases where I have used the cold
compresses I was pleased with the result. Poultices
are disagreeable things at best, and only tend to worry
and fatigue the patient."
Treatment of Red Nose Dr. Lassar {Dermatologi-
sche Zeitsc/irift) recommends scarification after various
methods of exfoliation have failed. Fifteen to twenty
per cent, resorcin paste is his favorite agent for pro-
ducing the exfoliation. .\ superior method to scarifi-
cation is acupuncture, done with forty points mounted
on a solid disc one centimetre in diameter, worked by
an electro-motor and stamping machine like that used
in filling teeth; this method leaves only fine scars,
and thousands of pricks very light and of desired
depth may be made in a few- moments. Consecutive
treatment is rarely necessary. In rhinopliyma, which
Dr. Lassar considers as an adenocystic fibroma with-
out epithelial proliferation, he removes the hypertro-
phied tissue by ablation or decortication, covering the
surface with Thiersch grafts, or leaving it under iodo-
form collodion, which in many cases serves as well.
Relapse in Pneumonia. — Dr. Ruge describes the
peculiarities of relapse in croupous pneumonia: he
bases his remarks on a study of two cases under his
observation, and seven reported by others. Between
the two attacks there is an afebrile period of from
four to fifteen days. During this time the subjective
sensations are those of convalescence. The physical
signs disappear, at least partially. The duration of
the relapse varies from four to eight days. L'sually
the same part of the lung is affected as in the first
attack. Ruge showed by an analysis of eighteen
cases that such cases differ from wandering pneumo-
nia, as this latter is of longer duration. Transition
forms no doubt occur. The frequency of relapse in
pneumonia is stated by various authors as from 0.18
to 0.45 per cent. — Charite Annalen, 1895, p. 184.
Charcoal Dr. Robert B. Wild, after a careful lab-
oratory study of this drug, finds that the present anti-
septic drugs are both more cleanly and more effectual
and are not likely to be superseded by charcoal. In-
ternally it has been used when there is undue decom-
position of the contents of the alimentary canal, as in
dilatation of the stomach, certain forms of intestinal
indigestion, when the alimentary canal contains ab-
normal toxic substances, and in certain specific dis-
eases presenting local lesions of the alimentary canal.
The idea is gaining ground that the serious symptoms
in these cases are due not so much to living organ-
isms as to the formation of toxic substances. Charcoal
is deserving of further trial from its action by o.xidiz-
ing the chemical substances formed during abnormal
decomposition, or the various toxins produced by
pathogenic organisms. It is possible that the oxgyen
in the charcoal may modify the metabolic processes
of the pathogenic organisms themselves and render
them or their products less virulent. The power of
this drug to remove alkaloids from solution is worth
considering. It may prevent auto-intoxication from
the alimentary canal, and may act as a laxative or
remove mucus from the walls of the alimentary canal.
It may be administered in doses of from two to six tea-
spoonfuls daily. — The Medical Chronicle, 1896, Xo. 6.
J
October 3, 1896]
MEDICAL RECORD.
485
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, October 3, 1896.
SCIENCE AND MEDICINE.
At the opening session of the British Association
for the Advancement of Science, in Liverpool on Sep-
tember 1 6th, the president, Sir Joseph Lister, de-
livered an impressive address upon the mutual rela-
tions of scientific research and practical medicine.'
The healing art in all its branches is becoming, he
said, more and more based on science as distinguished
from empiricism, and he proposed to depart from the
usual custom of the presidents of the association of
reviewing the progress of science during the year just
passed, and to confine himself to the instancing of a
few of the most noteworthy illustrations of this scien-
tific basis of medicine and surgery. After a brief ref-
erence to the Roentgen rays, in the practical applica-
tion of which he believed medicine had made but a
beginning, he turned to the subject of anaesthesia, of
which this is the jubilee year.
"That priceless blessing to mankind," he said,
"came froni America. It had, indeed, been fore-
shadowed in the first year of this century by Humphry
Davy, . . . but it was not till, on September 30, 1846,
Dr. W. T. G. Morton, of Boston, after a series of ex-
periments upon himself and the lower animals, ex-
tracted a tooth painlessly from a patient whom he had
caused to inhale the vapor of sulphuric ether, that the
idea was fully realized. He soon afterward publicly
exhibited his method at the Massachusetts General
Hospital, and after that event the great discovery
spread rapidly over the civilized world." The first
operation in England under ether was performed by
Robert Liston, in University College Hospital, and
it was a complete success. Sir Joseph Lister witnessed
this operation, and soon afterward saw the same sur-
geon amputate the thigh as painlessly by aid of
chloroform, which was being advocated as a substitute
for ether by Dr. (afterward Sir) James Y. Simpson.
Concerning the respective merits of these two an-
aesthetic agents, the speaker thought that, when prop-
erly and carefully administered, chloroform was, on
the average, safer than ether.
The next illustration of the debt practical medicine
owes to science was taken from the work of Pasteur on
fermentation. Cagniard-Latour, in France, and
Schwann, in Germany, had independently discovered
the yeast plant and had attributed the phenomena of
' Science, .September 25, i8g6.
alcoholic fermentation to the growth of this micro-or-
ganism, but these views had been discredited by Lie-
big. Pasteur, however, proved that these earlier in-
vestigators were right, and he went further and showed
that lactic acid and all other true fermentations are
caused by micro-organisms. He also disproved the
doctrine of spontaneous generation, which had been
dislodged from various positions which it once oc-
cupied among creatures visible to the naked eye, and
had taken its last refuge where the objects of study
were of such minuteness that their habits and history
were correspondingly difficult to trace.
But the most interesting portion of the address — most
interesting to medical men, at least — was that in which
Sir Joseph Lister spoke of his own great work and of
the marvellous change it had wrought in modern sur-
gical practice. He had been often asked to speak on
his share in this matter before a public audience, but
had hitherto refused to do so, chiefly because he felt
an invincible repugnance to what might seem to savor
of self-advertisement. But the latter objection now
no longer existed, he said, since advancing years had
warned him to rest from active labor. He had long
been impressed with the greatness of the evil of putre-
faction in surgery, for the inflammation preventing
primary union was, he had become convinced, due
essentially to decomposition of blood within the
wound. He had done his best to mitigate this by
scrupulous cleanliness and the use of various deodor-
ant lotions, but to prevent it altogether appeared
hopeless in face of Liebig's doctrine that its primary
cause was the atmospheric oxygen. " When Pasteur
had shown that putrefaction was a fermentation caused
by the growth of microbes, and that these could not
arise tie novo in the decomposable substance, the prob-
lem assumed a more hopeful aspect. If the wound
could be treated with some substance which, without
doing too serious mischief to the human tissues, would
kill the microbes already contained in it and prevent
the future access of others in the living state, putre-
faction might be prevented, however freely the air with
its oxygen might enter."
He had heard of carbolic acid as having a remark-
able deodorizing effect upon sewage, and determined
to try it in compound fractures. He applied it un-
diluted to the wound and " had the joy of seeing these
formidable injuries follow the same safe and tranquil
course as simple fractures, in which the skin remains
unbroken." But there was another and unexpected
result of this application. Portions of tissue which
had been killed by the violence of the injury were no
longer thrown ofT as sloughs, but were absorbed and
replaced by living tissue. This suggested the use of
animal ligatures with all its manifest advantages. It
was soon found that diluted carbolic acid would do
as well as the pure acid, and gradually the truth was
borne in upon him that the elaborate precautions
against the access to the wound of the living atmos-
pheric dust, which lead to the early employment of
the carbolic spray, were unnecessary. Experiments
showed that the blood was able to dispose of the at-
tenuated forms of microbes existing in the air, and
that it was only the grosser forms of septic mischief
486
MEDICAL RECORD.
[October 3, 1896
that surgeons had to dread. He had hinted, at the
London Congress, in 1881, that it might eventually be
found possible to disregard altogether the atmospheric
dust, and nine years later, at the Berlin Congress, he
brought forward what he believed to be absolute de-
monstration of the harmlessness of the atmospheric
dust in surgical operations. "This conclusion has
been justified by subsequent experience; the irritation
of the wound by antiseptic irrigation and washing may
therefore now be avoided, and nature left quite undis-
turbed to carry out her best methods of repair, while
the surgeon may conduct his operations as simply as
in former days, provided always that, deeply impressed
with the tremendous importance of his object, and in-
spiring the same conviction in all his assistants, he
vigilantly maintains from first to last, with care that,
once learnt, becomes instinctive, but for the want of
which nothing else can compensate, the use of the
simple means which will suffice to exclude from the
wound the coarser forms of septic impurity." In
speaking of the various antiseptic materials which
have been employed and their modes of application,
he reiterated his well-known belief that carbolic acid,
by virtue of its powerful affinity for the epidermis and
oily matters associated with it, and also its great
penetrating power, is still the best agent at our dis-
posal for purifying the skin around the wound.
Leaving surgery, the speaker directed the attention
of his hearers to the microbic theory of disease. He
did not believe that we could look forward with any-
thing like confidence to being able to see the materies
morbi oi every infectious disease, for it is not improb-
able that the micro-organisms of some diseases are too
minute ever to become visible to man, even by the aid
of the most powerful microscope; but he affirmed
that it can no longer be doubted that such parasites are
really the causes of all this class of diseases. Once
the cause of a disease has been ascertained, the in-
dications for treatment are obvious, even though they
cannot for various reasons be at once met. Sir Joseph
reviewed the progress which had been made in this
direction and made a profession of faith in the prin-
ciples of orrhotherapy. Concerning the antitoxin
treatment of diphtheria in particular, he said that
there are certain cases of so malignant- a character
from the first that no treatment will probably ever be
able to cope with them, but it seems probable that,
taking all cases together, Behring's hope that the
mortality may be reduced to five per cent, will be fully
realized when the public becomes alive to the para-
mount importance of having the treatment commenced
at the outset of the disease.
Finally Sir Joseph Lister instanced the discovery
by Metchnikoff of the protection against pathogenic
. micro-organisms afforded by the white corpuscles of
the blood. He believed phagocytosis to be " the main
defensive means possessed by the living body against
the invasion of its microscopic foes," for, while the
power of the system to produce antitoxic substances
to conteract the poisons of the microbes is doubtless of
great importance, it is inoperative in those cases in
which animals enjoy a natural immunity against cer-
tain diseases. Here the sole defensive agency seems,
he said, to be phagocytosis. This theory of phagocy-
tosis was ingeniously appropriated by the speaker to
explain the fact, which had been discovered in his own
field of antiseptic surgery, that the dust of the atmos-
phere might safely be disregarded in operations. It
also seemed to afford a clear explanation of the heal-
ing of wounds by first intention under circumstances
before incomprehensible. "This primary union was
sometimes seen to take place in wounds treated with
water dressing, that is to say, a piece of wet lint
covered with a layer of oiled silk to keep it moist.
This, though clean when applied, was invariably put-
rid within twenty-four hours. The layer of blood
between the cut surfaces was thus exposed at the out-
let of the wound to a most potent septic focus. How
was it prevented from putrefying, as it would have
done under such influence if, instead of being between
divided living tissues, it had been between plates of
glass or other indifferent material ? Pasteur's obser-
vations pushed the question a step further. It now
was : How are the bacteria of putrefaction kept from
propagating in the decomposable film? Metchnikofl's
phagocytosis supplied the answer. The blood be-
tween the lips of the wound became rapidly peopled
with phagocytes, which kept guard against the putre-
factive microbes and seized them as they endeavored
to enter." But if phagocytosis could guard the system
against septic microbes in so concentrated a form, it
could hardly fail to prevent infection by the attenu-
ated forms existent in the air.
THE KNEIPP CRANKS.
That portion of the community accustomed to view
even novelties from a common-sense standpoint was
more than surprised at the permission recently granted
the followers of a notorious quack to walk bare-footed
on the lawns of Central Park. It was looked upon
quite naturally as a dangerous precedent for any set
of cranks that might desire to foist absurd notions
upon any community on the plea of equal rights and
individual liberty. It is quite true that only a
secluded portion of the park was delivered to them at
certain restricted times, but the principle of recogni-
tion of the claims of these self-styled health mission-
aries was as effectually demonstrated as if every
public square were placed at the disposal of their
nonsensical antics. It was the sacrifice of the rights
and privileges of a majority to the tastes, inclinations,
and accepted notions of a few, and clearly, from the
latter view, controverted the proper use of the parks as
expressed in their charters. The true motive of the
barefoots, although reasonably suspected, was not until
recently openly manifested. It was simply to use the
public parks as advertisements for their so-called new
cure. The president of the Brooklyn branch now
boldly declares the real wishes of his laudably earnest
disciples: "We want a large, free, open space to de-
monstrate to all the world that the Kneipp treatment
is a cure and not merely a diversion for cranks." It
must naturally be admitted that it is very much more
difficult to prove the former proposition than to com-
October 3, 1896]
MEDICAL RECORD.
487
bat the latter. If the present frightful death rate of
the diseases claimed to be curable by this method
can in any way be lowered, why not give these won-
der workers an opportunity to be seen and heard?
That would appear to be the only way out of the
present difficulty of finally settling the now moment-
ous question. The mission becomingly borrows an
odor of sanctity from the head and front of its
humble and modest projector. Faithful disciples,
let your light shine by all means, and when the
figurative bushel is thrown away with the shoe may
you, while knuckling to this work, continue to glisten
with the cleansing invigoration of the morning dew
and blend your unconfined exhalations with the grassy
scent of breezy lawns.
PRURIGO.
The question of prurigo was considered of sufficient
importance to occupy an entire evening at the recent
international congress of dermatologists in London.
The discussion, which was participated in by E. Bes-
nier. White, Payne, McCall Anderson, Unna, and va-
rious others, is summed up by Sabouraud as follows :
Prurigo has no proper lesion. The lesions which are
seen are polymorphous. Only one of its symptoms, a
functional one, is constant — pruritus. Scratching is
the important factor in the objective lesion, which va-
ries according to the tegumentary reaction (urticaria,
lichen, etc.) of the individual and the secondary infec-
tion. At the base of prurigo there is a nervous lesion,
the cause of the itching, the result of chronic intoxica-
tion, usually of autointoxication of visceral origin. Sa-
bouraud thinks the discussion decided the triumph of
the French doctrine (Besnier, Brocq, Jacquet) over
that of Vienna (Hebra).
'Bnvs of ttxc "mizeU.
A Case of Trichinosis was reported to the health
authorities of Paterson, N. J., a few days ago.
The Plague has broken out in Bombay and other
parts of the presidency. Over one hundred deaths
have been reported as due to this disease.
Dr. James E. Newcomb has been appointed lec-
turer on physiology at the Teachers' College in this
city.
An Epidemic of Whooping-Cough is at present
giving trouble to the officers of the Colored Orphan
-Asylum. There have been about forty cases during
the past two weeks.
Diphtheria prevails in Salem, Mass., and several of
the schools have been closed in consequence. There
are at present about thirty cases known to the health
authorities.
Utah State Medical Society The second annual
meeting of this society will be held in the council
chamber, city and county building, at Salt Lake City,
Tuesday and Wednesday, October 6th and 7th.
The New York State Medical Association will
hold its thirteenth annual meeting at the Mott Me-
morial Hall in this city on October 13, 14, and 15,
1896.
A Monument to Pasteur is to be erected in Munich.
A committee consisting of Professors Pettenkofer,
Ziemssen, and Buchner has been organized to solicit
subscriptions for this object.
A Chapel for Bellevue Hospital Miss Annie
Leary has built a chapel in the grounds of Bellevue
Hospital for the Roman Catholic patients, as a me-
morial to her brother, Mr. Arthur Leary. It will be
dedicated this fall.
The Bicycle as a Therapeutic Agent.— The wheel
has joined the ranks of aperient waters, infant foods,
and other indispensable aids to health and long life,
if we may judge from an exhibit in a Broadway
window. In the window is a bicycle, and below the
bicycle is the certificate of an honored member of the
profession in a neighboring city, whose reputation as
a therapeutist ought to be very valuable to the manu-
facturers of the bicycle ridden and approved by him.
Civil Service Examinations On Monday, Octo-
ber 5, 1896, the New York City civil service boards
will hold a competitive examination at their office
(new criminal court building), for the position of
house physician at Bellevue Hospital. This position
requires a knowledge of the treatment of the insane,
and pays a salary of Si, 200 per annum. Applicants
must be citizens of the United States and residents of
New York State. There will also be an examination
for the positions of druggist and assistant druggist,
on Tuesday, October 6th, at 10 a.m. The candidates
must be residents of the State of New York. Appli-
cations should be made to William Briscoe, secretary.
Jenner Centenary in Chili — Upon the invitation
of the Medical Society of Santiago, all the scientific
associations of Chili united on May 14th in celebrat-
ing the centenar}' of the discovery of vaccination.
An entire number of the Rcvista Mcdica ,k Chile is
devoted to a report of this celebration, which was held
in the hall of the National Conservatory of Music, in
Santiago. Orations were delivered by Drs. A. Ossego
Luco, R. Davila Boza, E. Rodriguez Cerda, Lucio
Cordova, Adolfo Murillo, and Luis tfgarte Valenzuela,
and a poem in honor of Jenner was recited by Dr.
Carlos A. Gutie'rrez.
A Boon to Canadian Druggists An Eclectic
Medical School of Milwaukee, with a branch office in
Chicago, is sending circulars to pharmacists in
Canada, offering them a medical diploma with the
degree of M.D. for a small sum. The regular price,
the letter says, is $35.00 and the diplomas, are "good,
lawful, and valid in Wisconsin, Kansas, Idaho,
Wyoming, Michigan, and Indiana," but as they confer
no right to practise in Canada the price for them in
the Dominion is reduced to §10.00, C. O. D. We
were informed by a Milwaukee correspondent that
this disgrace to Wisconsin was to be clo.sed, but it
seems that the State still protects the diploma mill.
488
MEDICAL RECORD.
[October 3, 1896
Frau Klafsky, a prima donna well known in this
country, died recently in Hamburg as a result, it is al-
leged, of a needless trephining operation. She was
suffering from severe headache, and a diagnosis was
made of tumor of the brain. The skull was trephined,
no tumor was found, but the patient died.
Yellow Fever in Cuba shows no sign of abatement,
the new recruits constantly arriving in the island from
Spain furnishing fresh fuel for the epidemic. The
disease is confined almost wholly to the Spanish sol-
diers, only six of the forty-one deaths in Havana dur-
ing the past week having occurred among civilians.
Of the one hundred and five new cases reported during
the same period, eighty-seven were among the newly
arrived soldiers.
Impure Water in Chicago. — An Associated Press
telegram of recent date reports that the public schools
may be closed on the order of Commissioner of Health
Kerr, because the water supply afTorded them by the
board of education, without filters, is impure. A heavy
rain carried out to the pipes of the various cribs of the
city all of the filth of the sewers, and this has been
brought back to the school children in the drinking-
water which is furnished them in the school buildings.
St. Luke's Hospital Censured. — A man who was
being transferred from St. Luke's to the Harlem, one
day last week, died shortly after being placed in the
ambulance. At the inquest held by Coroner Dobbs
the coroner's physician. Dr. Schultze, testified that in
his opinion the man would not have died had it not
been for the attempt to transfer him. The coroner's
jury brought in a verdict that death was due to alco-
holism and delirium tremens, and censured the hospi-
tal for negligence.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the Medical
Corps of the United States navy for the week ending
September 26, 1896: September 23d. — Passed Assist-
ant Surgeon G. A. Lung detached from the Vermont
and ordered to the naval hospital, Chelsea, Mass. ;
Passed Assistant Surgeon H. D. Wilson detached
from the Chelsea, Mass., hospital, and ordered to the
Bac/te ; Passed Assistant Surgeon G. H. Barber
ordered to the Naval Academy ; Assistant Surgeon M.
K. Johnson detached from the Bache and ordered to
the Nno York ; Assistant Surgeon F. C. Cook ordered
to the Vermont.
Jefferson Medical College. — It is given out that
the trustees of Jeft'erson Medical College have secured
additional property, to the extent of twenty by one
hundred and forty-eight feet, at the southwest corner
of Tenth and Sansoni streets, adjacent to the present
college building. The plans contemplate the tearing
down of tlifi present building and the erection of a
handsome structure in its place. Before this is done,
however, it is hoped to have the new hospital building
at the corner of Tenth and Walnut Streets completed.
When this is accomplished, it is possible that the pres-
ent hospital on Sansom Street will be fitted up for col-
lege purposes, to be used while the new college build-
ing is in process of construction.
A Case of Leprosy in Montreal. — At a coroner's
inquest held recently on the body of a Chinaman who
died in Montreal, it was found that death was caused
by leprosy.
The Late Sister Irene. — At a special meeting of
the New York Foundling Hospital, held September
15, 1896, the following minute was adopted:
" The medical board desires to pay tribute to the
memory of Sister M. Irene FitzGibbon, late superior
of this institution. Several members of the board
have served for more than twenty years, and have
witnessed the growth of this work, its transferrence to
larger buildings, and its full development. They rec-
ognize the fact that the one person who organized, who
procured friends and funds, who planned and built
the one great foundling hospital of America was Sis-
ter M. Irene. Whatever other forces and agencies
were assisting, it has been obvious to all that the cen-
tral figure, the persuasive, tactful genius, the sweet-
souled woman who led to this success was she to whom
to-day the medical board pays this parting tribute.
" Whereas, The medical board, in the death of Sis-
ter M. Irene, the sister superior of the hospital, has
lost the first executive officer and a long-tried friend,
therefore be it
" Resolved, That the board causes to be spread upon
the minutes of its records these resolutions of appreci-
ation and sorrow, incorporating the words:
"'This board has lost the best friend any hospital
board ever had.'
" Resolved, further, that the sympathy of the board
be extended to the reverend mother superior and the
sisterhood of the Sisters of Charity; also that a copy
of the.se resolutions be forwarded them and be pub-
lished in the current medical periodicals.
[Signed] "J. Lew^is Smith, M.D.
"J. O'DwvER, M.D.
"George F. C^rev, M.D.
"President of the Medical Board:'
Obituary Notes Sir John Eric Erichsen, the
well-known F^nglish surgeon, died on September 23d,
at Folkestone, England, from apople.xy. He was born
in 1818, and was educated at University College, Lon-
don. He was a fellow and ex-president of the Royal
College of Surgeons, a fellow of the Royal Society,
and of the American Surgical Association, and a mem-
ber of various other learned and scientific societies.
At the time of his death he was emeritus professor of
surgery and consulting surgeon to L^niversity Hospi-
tal. He was surgeon-extraordinary to the Queen. —
Dk. Charles Milxe, of this city, was found dead in
his bed, on September 28th, by a servant who went to
awaken him. The cause of death was heart disease.
He was fifty-six years old, and was a graduate of the
University Medical College in 1873. — Dr. John C.
Sackville was killed at Washington, Pa., on Septem-
ber 23d, by being struck by an express train. He was
bom in England in 18 14, and was educated at Oxford.
He served as surgeon with the English army in India,
and also with the United States army during the Mex-
ican war.
October 3, 1896]
MEDICAL RECORD.
489
A Victim of the Faith Cure. — The discriminating
coroner of Scranton, J'a., has declined to issue a per-
mit for the burial of a child who died of diphtheria
while under the care of local Christian Scientists.
Gloucester County (N. J.) Medical Society. — The
fall session of the Gloucester County Medical Society
was held at Woodbury, N. J., on September 24th. A
number of papers were read and a luncheon was
partaken of.
Bogus Diplomas. — A man was recently arrested in
Germany for selling university degrees. He had
stolen the seals of the University of Berlin and had
made and sold at least two hundred and fifty bogus
diplomas before he was caught. About one hundred
of these diplomas were sold in the Scandinavian coun-
tries, fifty in England, and twenty-three in Germany.
Against Vivisection. — At a meeting of the Ameri-
can Humane Association held at Cleveland on
September 24th, a resolution was unanimously passed
recommending the general adoption throughout the
United States of laws regulating the practice of vivi-
section. The members were urged to use their per-
sonal efforts to secure the enactment of the necessarj-
legislation in the different States.
Canadian Medical Association. — At the recent
meeting of this association the following officers were
elected: Fresident, Dr. V. H. Moore, Brockville, Ont. :
Vke-Presiikiits, Dr. Peter Conroy, Charlottetown ; J.
F. Black, Halifax; Thomas Walker, St. John; J. M.
Beausoleil, Montreal; \\\ ^^'. Dickson, Pembroke; R.
S. Thornton, Deloraine ; E. H. C. Rouleau, Calgary ;
E. B. C. Hannington, Victoria; General Secretary, Dr.
F. \. G. Starr, Toronto; Treasurer, Dr. H. B. Small,
Ottawa. The next meeting in 1897 will be held in
Montreal, in conjunction with the meeting of the
British Medical Association.
Vital Statistics of Philadelphia.— For the week
ending September 19th, there occurred in the city of
Philadelphia 427 deaths; 42 more than during the
preceding week and 61 more than during the corre-
sponding period of the previous year. Of the whole
number 158 occurred in children under five 3'ears of
age. The principal causes of death were as follows:
Pneumonia, 37; pulmonary tuberculosis, 36 ; cholera
infantum, 26; diseases of the heart, 22; carcinoma,
and inflammation of the brain and membranes, each
19; apople.xy, 17; diphtheria, 16, marasmus, 14;
nephritis, 13; old age, 12; typhoid fever, 10. There
were reported during the week 57 cases of typhoid
fever, 46 of diphtheria, and 10 of scarlet fever.
A Munificent Bequest — By the will of the late
Enoch Pratt, a banker and philanthropist of Balti-
more, a sum of money estimated to be upward of two
million dollars is bequeathed to the Sheppard
.\syluni, with the stipulation that the name of the cor-
poration be changed to the Sheppard and Enoch Pratt
Hospital. It is intended that the income derived
from the fund shall be used to complete the present
buildings and grounds and then to erect an additional
building with a capacity of two hundred beds. After
this has been done the fund is to be devoted to the
care of the indigent insane " free of cost, by the most
approved methods known to medical science."
Philadelphia County Medical Society. — At a
stated meeting of the Philadelphia County Medical
Society, held on September 23d, Dr. E. E. Montgomery
read a paper on the "Treatment of Retrodisplacements
of the Uterus." He contended that the displacement
itself is generally not of so much significance as the
accompanying complication, and that no procedure
which does not take cognizance of the latter condition
will prove a satisfactory method of treatment. The
following recommendations were made: In recent
cases, when the uterus is freely movable, the use of a
medicated tampon or of a pessary. In recent cases,
when a plastic exudate is present, together with ad-
hesions, and suppurative salpingitis can be excluded,
the employment of massage, supplemented by the
medicated tampon, and restoration of the mobility of
the uterus, followed by the introduction of a pessary.
In chronic cases, when the uterus is movable, the
practice of curettage followed by suture of the round
ligaments in front of the uterus through anterior col-
porrhaphy. When ovarian or tubal disease exists as
a complication, the practice of curettage, followed
by abdoniinal incision, treatment of the diseased ap-
pendage, and fixation of the uterus to the abdominal
wall. If adhesions are present, without serious tubal
or ovarian disease, the practice of curettage in con-
junction with shortening of the utero-sacral ligaments,
after separation of the adhesions, through the posterior
vaginal incision. Dr. John M. Fisher exhibited a
specimen of multiple fibroids of the uterus, in the re-
moval of which a cyst situated in the broad ligament
caused some doubt as to whether it was the bladder.
Pathological Society of Philadelphia. — At a
stated meeting of the Pathological Society of Phila-
delphia, on September 24th, the following presentations
were made : Dr. J. A. Scott, " Carcinoma of the Pan-
creas, with Secondary Growth in the Liver;" Dr. D.
Riesman, " Atheroma of the Vessels in a Case of
Diabetes Mellitus in a Girl Thirteen Years Old;"
Dr. A. A. Eshner, '" Multiple Aneurisms of the Aorta,
with General and Extensive Atheroma of the Entire
Vascular System, Death Resulting from Rupture into
the .\bdominal Cavity; Typhoid Ulceration, Involv-
ing both Large and Small Intestine, from a Case Ter-
minating Fatally during a Relapse;" Dr. .\. E.
Taylor, '"Malarial Hamatozoa ; Thrombosis of the
Pulmonary Artery in a Child;" Dr. T. S. Westcott,
"Urethral Calculi from a Case Terminating Fatally
as a Result of Cerebral Hemorrhage;" Dr. F. A.
Packard, " Tuberculous Laryngitis, with Abscess on
the Trachea, and Slight Involvement of the Lungs;"
Dr. C. J. Garitee, " Heart and Kidneys from a Case
of Verrucose Endocarditis and Parenchymatous Ne-
phritis;" Dr. J. D. Steele, "Contracted Gall Bladder,
with Gall Stones;" Dr. Joseph Sailer, "Perforated
Aortic Leaflet from a Case of General Septicsemia ;"
Dr. A. Hand, "Meningocele, with Congenital Absence
of One Kidnev and Ureter."
490
MEDICAL RECORD.
[October 3, 1896
^evinvs and Notices.
Medical and Surgical Report of the Presbyte-
RLAN Hospital in the City of New York. Vol-
ume I., Januarj-, 1896. Edited by Andrew J. .McCosh,
M.D., and Walter B. James, M.L).
Besides the usual statistical report, there are records of clin-
ical histories by the various members of the staff, and a
chapter on the preparation of dressings, sutures, sponges,
etc., compiled by Miss E. S. Anthony.
The Multum in Parvo Reference and Dose Book.
By C. Henri Leonard, M.A., M.D., Professor of the
Medical and Surgical Diseases of Women, Detroit College
of Medicine. Detroit: The Illustrated Medical Journal
Company. 1 896.
This is a new edition of Leonard's dose book, printed on
thin paper and bound in flexible leather with round corners,
making it easy to be carried in the pocket. The book not
only gives the doses of all drugs used in rational medicine,
but also contains numerous tables of solubilities, poisons and
their antidotes, urinary tests, incompatibilities of drugs, etc.
The American Academy of Railway Surgeons. Re-
port of the Second Annual Meeting, Held at Chicago, 111.,
September 25, 26, and 27, 1895. Edited by R. Harvey
Reed, M.D., Columbus, O. Chicago: American Medi-
cal Association Press. 1896.
This edition of the transactions of the American Academy
of Railway Surgeons is a neat little volume of over two hun-
dred pages, well printed and well edited. The papers vary
considerably in merit, but all of them bear witness to the in-
terest of the writers in their work, an interest which augurs
well for the future of this important branch of surgical em-
ployment.
A Short Course of Experiments in General Che.m-
isTRV, with Notes on Qualitative Analysis. By
Charles R. Sanger, A.M., Ph.D., Eliot Professor of
Chemistry in W'ashington L'niversity. St. Louis: Pub-
lished by the Author. 1896.
The author has endeavored to present in this course a series
of experiments teaching practically as well as theoretically
as much chemistry as it is possible to teach in the limited
time which can be devoted to it in one year at a medical
school. No attempt is made to teach the subject from a
purely medical standpoint, for, as the author vcr\- wisely
says, a good theoretical and practical foundation is necessary
before taking up the special subject of medical chemistry.
Atlas of the Diseases of the Skin. By H. Rad-
cliffe Crocker, M.D., F.R.C.P., Physician to the
Department for Diseases of the .Skin, University College
Hospital ; formerly Physician to the East London Hospi-
tal for Children ; E.xamincr in Medicine at Apothecaries'
Hall, London. Edinburgh and London: Young J. Pent-
land. New York : Macmillan & Co.
Fasciculus XVL of this series of illustrations from original
drawings, with descriptive letterpress, has just come to hand,
completing the work, whose many excellent features have from
time to time been referred to in these columns. The' first
plate, representing impetigo contagiosa gyTata, strikes
one at first as being overdrawn in the definition of ery-them-
atous outline of the areola. That the situation of lesions
upon the back, as here portrayed, is unusual goes without
saying, but, as it is well known that the affection may extend
over the entire body, even to parts which cannot be easily
reached by the hands, the diagnosis need not be questioned
on that account.
Excellent plates of mycosis fungoides and pemphigus
are presented, and those portraying the various nail and tongue
affections are most instructive.
Acanthosis nigricans, myxotdema. and one-sided lentigo
are among the rarer affections reproduced. On the whole,
this la.st fasciculus is in a way the crowning number of the
series.
Dr. Crocker deserves the highest commendation for pre-
senting so excellent a work, and the publishers should be
complimented upon the manner in which they have brought
it out.
Manu.al of Midwife "y. For the Use of Students and
Practitioners. By W . E. Fothergill, M.A., B.Sc,
M.B., CM., Buchanan Scholar in Midwifery, L'niver.sity
of Edinburgh ; Late House Physician to the Simpson Me-
morial and Royal Maternity Hospitals, and Gynecological
Wards, Royal Infirmary, Edinburgh; Neil Arnott Prize-
man in Physiological Physics; Scottish L'niversities Ex-
tension Lecturer; Honorary Surgeon to the Chorlton-on-
Medlock Dispensary, Manchester. New York: The
Macmillan Company. 1896.
This is a very concise yet complete gfuide for the student
and young practitioner. It is of convenient size, well
printed, and well illustrated. While it claims to be "a book
for Edinburgh men by an Edinburgh man." we can see no
reason why its teachings could not be profitably followed by
students elsewhere, since the science of which it treats is uni-
versal in its application. The author follows the usual plan
of beginning with the anatomy and physiology of the female
reproductive organs, then taking up pregnancy, normal and
pathological ; labor, normal and abnormal ; obstetrical opera-
tions; the puerperium; and closing with a brief chapter on
the hygiene of infancy. The author's style is easy and com-
prehensible, so that the reader has only to occupy himself
with the subject matter and is not distracted, as in so many
works by medical writers, by efforts to interpret the English.
The affectation of the printer in employing two letters in
place of a diphthong is not to be commended.
Practical Points in .Nursini;: For Nurses in Private
Practice, with an Appendix Containing Rules for Feeding
the Sick; Recipes for Invalid Foods and Beverages;
Weights and Measures ; Dose List ; and a Full Glossary
of >Iedical Terms and Nursing Treatment. By Emily
A. M. Stonev, Graduate of the Training School for
Nurses, Lawrence, Mass. ; Superintendent of Training
School for Nurses, Carney Hospital, .South Boston, Mass.
Illustrated with 73 Engravings in the Text and 9 Colored
and Half-tone I'lates. Philadelphia: W. B. Saunders.
1896.
The title of this book indicates clearly the nature of its
contents. It is intended to serve as a guide to the nurse in
her private work. The writer expresses herself clearly and
intelligibly, and the descriptions are supplemented by numer-
ous instructive illustrations.
Svste.m of Surgery. Edited by Frederic S. Dennis,
M. D. , Professor of the Principles and Practice of Surgery,
Bellevue Hospital Medical College ; ^'isiting Surgeon to
the Bellevue and St. \'incent Hospitals; Consulting Sur-
geon to the Harlem Hospital and Montefiore Home, etc.
Assisted by John S. Billings, M.D.. LL.D.. D.C.L.,
Deputy Surgeon-General. L'. S. A. Volume I\'. New
York and Philadelphia : Lea Brothers & Co. 1 896.
This final volume of Dr. Dennis" excellent work is fully
equal in interest of subject matter, authority of the writers,
and beauty of illustrations and typography to any of those
which have preceded it. The first article is on "' Tumors,"
by the editor, and following this come " Hernia," by W. T.
Bull and W. B. Coley; " Surgery of the Alimentary Canal
from the Pharynx to the lleo-c*cal \'alve." by M. H. Rich-
ardson and Farrar Cobb; "Appendicitis," by Frank Hart-
ley; "Surgical Treatment of Appendicitis," by Charles
McBurney; "Surgery of the Alimentary Canal from the
Ileo-ciccal Valve to the .'\nus," by Lewis S. Pilcher; " Sur-
gery of the Liver and Biliary Passages, " by Robert Abbe;
" Surgical Disorders and Diseases of the Uterus," by Wil-
liam M. Polk ; • ' Surgical Diseases of the Ovaries and Tubes, "
by Joseph Taber Johnson; " Minor Gynecological Surgery,"
by Henry C. Coe ; ".Symphyseotomy," by William T. Lusk;
"Surgery of the Thyroid Gland," by Roben F. Weir;
"Surgical Peculiarities of the Negro," by Rudolph Matas;
" Di.seases of the Female Breast," by Frederic S. Den-
nis; and " The L'se of the Roentgen Rays in Surgery," by
W. W. Keen. The volume is concluded by an index to the
present volume and a general index to the entire work. The
latter has been most carelessly made and is absurdly incom-
plete, with the result that what would otherwise ha\e been
a valuable work of reference is rendered utterly useless as
such. .As a text-book, to be read and studied by the stu-
dent and young practitioner whose time is unlimited, the work
can be commended.
October 3, 1896]
MEDICAL RECORD.
491
The Medical and Surgical Uses of ELEcrRicri'\.
By A. D. Rockwell, A.M., M.U. Illustrated with
200 engravings. New Edition. New York : William
Wood and Company. 1 896.
For twenty years and more the work of Beard and Rockwell
has been the leading authority in this country on the subject
which it treats. They were the pioneers in the field of
electro-therapeutics, and enunciated ideas and methods which
have stood the test of time. The present work by Dr. Rock-
well is the offspring of the former, and, as he states in the
preface, has been thoroughly revised and mostly rewritten,
the old stereotyped plates having all been destroyed. The
illustrations have been newly drawn and many new ones
added, so that the author again offers to the profession a
treatise in every way complete and modernized. Electricity
in medicine has assumed proportions and an importance
which cannot be ignored. When the author of this treatise
and his associate, the late Dr. Beard, first began their inves-
tigations, the subject of electro-therapeutics was little known.
For years it gained ground slowly, but within the last decade
it has felt somewhat the great strides made by electricity in
its commercial aspect. Instruments of precision and greatly
improved apparatus have rapidly developed. Schools of in-
struction have been established, and he who is still ignorant
of the possibilities of electricity in medicine and ignores its
claims has failed as a physician to keep abreast the current
of the times. The influence of electrization over nutrition,
the central idea of the work, and which the authors were the
first to enunciate and develop, has received wide recognition
and is indeed the basis of its medical use. The chapter on
Ohm's law alone will well repay the reader. It is the basis
of all electrical measurement, indispensable to the worker in
electricity, and so clearly discussed and illustrated as to
make this abstruse but most important subject plain to the
dullest comprehension.
Among the chapters new or entirely rewritten are those
devoted to the Roentgen rays in diagnosis and to static elec-
tricity, in which the aid of Dr. S. H. Monell, of Brooklyn, is
acknowledged. The work plainly sets forth all the funda-
mental principles of electricity in its relation to disease, is
clear in detail, and cannot fail to aid greatly all who are in-
terested in this department of medical science.
A System of Medicine. By Many Writers. Edited by
Th(JMas Clifford Allbutt, M.A., M.D., LL.D.,
F.R.C.P., F.R.,S., F.L.S., F.S.A., Regius Professor of
Physic in the University of Cambridge, etc. Volume I.
New York: The Macmillan Company. 1896.
The first article in this volume, after the editor's introduc-
tion, is by Dr. John S. Billings, and two other articles,
namely, "Massage," by Dr. J. K. Mitchell, of Philadelphia,
and the bacteriological section of ■' Relapsing Fever," by Dr.
Westbrook, of Minneapolis, are from the pens of Americans.
The other contributors are British, some of them well known
by their writings to the profession in this country, others
with a local reputation doubtless, but whose names are not
yet familiar in America. The first half of the volume is
taken up with a number of short essays on miscellaneous sub-
jects, entitled " Prolegomena." Among these one on the
".Medical Geography of Great Britain " is of local interest
only, and another on " Nursing" seems as out of place in a
work of this sort as would be a collection of cooking-recipes
or a chapter on the compounding of prescriptions. The ar-
ticle, which is by Miss Hughes, of Bolton, is an excellent one,
however, and if it could be detached from the rest of the vol-
ume and sfimewhat amplified would serve as an excellent
book to put in the hands of an amateur called upon to nurse
a .serious illness. The best of these " Prolegomena," at
least tho.se which have interested us the most, are " Inflam-
mation, " by .-^dami ; ' ' Fever, " by Burdon-.Sanderson : ' ' The
Laws of Inheritance in Disease," by Hutchinson ; and " Prin-
ciples of Drug Therapeutics," by Leech. The second divi-
sion of the volume is devoted to a consideration of fevers.
The principle of subdiTOion of labor has been carried here to
a rather extreme degree, several of the articles having been
divided among two or more writers, and one, that on " Chol-
era .Asiatica. " being the product of the combined labors of
no less than five authors, two of whom treat of the etiology-,
two more of the bacteriology', and one of the symptoms,
pathology, and treatment. This is a refinement of special-
ism that might, we think, have been avoided w ith advantage.
As a whole, however, the work is one that can but com-
mend itself as a faithful exponent of British medicine, and one
that gives promise of deserving a success equal to that of
" Reynolds' System of Medicine." of which it will now
doubtless take the place.
A Ve.st-Pmcket Medical Dictionary. Embracing
those Terms and .Abbreviations which are Commonly
Found in the Medical Literature of the Day, but Excluding
the Names of Drugs and of Many Special ."Vnatoniical
Terms. By Albert H. Blck, M.D. New York:
William ^\'ood and Company. 1 896.
Notwithstanding the appearance of a new medical dic-
tionary every year or two for the past decade, there has been
up to the present none in existence which met the needs of the
physician and especially the student. Of lexicons in one or
several large volumes there is an ample choice, but they can be
consulted only in the librar)-, and even then the labor of taking
a hea\y book from the shelf, and the interruption to reading
caused thereby, are often enough to deter one from looking up a
half-understood word. Furthermore many busy practitioners
have little time for quiet study in the librar)% but must read their
books and journals while riding to their patients, and to such
persons a ponderous lexicon reposing on the bookshelf is no
more useful than if it were printed in Chinese characters. But
it is the student in the classroom who especially feels the need
of a dictionary which he can have always with him, and to
which he can turn whenever an unfamiliar word strikes his ear.
To these, the busy practitioner and the student, this little
book will come as a welcome friend. It is really of vest-
pocket size, being but two and a half inches wide by three
and a half long, and about one-half inch in thickness, yet it
contains the definition and pronunciation of over five thou-
sand words. We are aware that there are other professedly
pocket dictionaries which contain a much greater number of
words, one indeed which bases its claim to the preferences
of purchasers on the stated number of words it contains.
Of course, the value of such a work, which does not pre-
tend to contain all the terms known to medicine, must de-
pend entirely upon the intelligent judgment of the author
as to what words shall be admitted and what excluded. A
careful examination of the lexicon has caused us to admire
the rare discrimination shown by Dr. Buck in this task.
Obsolete terms and the creations of some ambitious word
coiner, which would never be encountered in a lifetime of
study of contemporaneous literature, have been rigidly e.x-
cluded, but of the new terms and the old ones still current
we have failed to find scarcely one in a most thorough
search. In this careful discrimination and selection the book
possesses great advantages over similar works which base
their claims upon the large number of words they contain.
There is quality in Dr. Buck's book rather than quantity.
.■\lthough the book contains such a large number of words
in such small compass, the type is of good size and can be
read with ease without the least strain of the eyes. It is
substantially bound in flexible leather cov-ers.
Oxygen in the Treatment of Suppurating Sur-
faces.— Dr. VV. Peyre Porcher writes in the North
Carolina Aledical Journal concerning the use of oxygen
in the treatment of old wounds and suppurating sur-
faces of all kinds, as practised by Dr. Stoker. He
says that he saw old sores of thirty years' duration,
ulcers extending from knee to heel, a burn 10x8
inches on the back, all in rapid progress of healing
simply by continued exposure to oxygen gas, pure or
diluted; ear polpys dried up and dropped off and
atrophic rhinitis was materially improved. There
were no hard indurations in the cicatrices of these old
ulcers, but the surface was smooth and apparently full
of blood-vessels. Cultures from the wounds were
regularly taken and the progress toward healing noted.
At the recent meeting of the British Lar\ngological
.Association, cases of atrophic rhinitis and purulent
middle-ear disease were shown which had greatly
improved under the application of oxygen. Mr. Len-
nox Browne and several members reported cases in
which the treatment had been used with success.
492
MEDICAL RECORD.
[October 3, 1896
AMERICAN
Society Reports.
DERMATOLOGICAL
TION.
ASSOCIA-
Twentieth Annual Meeting, Held at the Hot Springs
of Virginia, September 8, g, and lO, l8g6.
The attendance was small, chiefly owing to the fact
that many members were absent in Europe, where they
had been attracted by the International Dermatologi-
cal Congress.
President's Address Dr. A. R. Robinsox, of Xew
York, delivered an address of welcome, in which he
first spoke in glowing terms of the character and abil-
ity of the only active member the association has ever
lost by death, Dr. Edward Wigglesworth, of Boston.
The field which the dermatologist cultivates the
speaker looked upon as a most important and e.\ten-
sive one, and still the specialist in this branch does
not yet hold the position he should in the eyes of the
general profession. One reason of this is the attitude
of most medical schools in this country in not looking
upon the study of cutaneous diseases as a natural and
necessary part of the college curriculum. Medical
education, he said, has not yet reached a common-
sense basis. The school has no right to pronounce a
man capable of treating diseases of which it has given
him no knowledge. Classes are habitually too large
for proper clinical instruction. The physician gradu-
ated without the ability to diagnosticate and properly
treat diseases of the skin is not justified in accepting
a fee from a patient with a disease of this nature, if a
properly qualified physician is within reach. The
English custom of granting one degree for graduates
in medicine and another for graduates in surgery, if
adopted here would, the speaker held, be a step in the
right direction. Attention was called to the many un-
necessar)' operations which result from the family
physician calling in a surgeon instead of a dermatolo-
gist in doubtful cases, in wiiich the diagnosis lies
between sarcoma, lupus, tuberculosis, and syphilis.
Instances were quoted to show how slight and often
overlooked eruptions pointed to the true condition,
and would, if recognized, save the patient from the
knife. To obtain proper recognition by the schools,
the general practitioners, and hospital authorities, so
that teaching and practising in public as well as pri-
vate may become what it should be, the dermatologist
ought to be more aggressive toward notorious offenders,
and show by his works the great importance of this
special branch to humanity. Papers representing
original research should be published only in journals
devoted to the special branch, so that the dermatolo-
gist could keep track of the subjects; while those in-
tended to instruct the general practitioner or to ac-
quaint him with the fact that the writer is devoting
his time to dermatology, can be printed in journals
devoted to general medicine. The speaker opposed
strongly the reading or publication of papers, the sole
purpose of which was to advertise the writer. Ad-
mission to the association should be a goal for every
true worker in dermatology, to be gained by hard la-
bor. One who writes for notoriety is not likely to
bring much credit upon the association, one of whose
objects is to guard the dignitv of dermatology'.
Paget's Disease of the Nipple. — Dr. G. T. Jack-
son, of New York, read a paper upon this subject, and
described a case occurring in a woman, aged fifty-two
years. After a dermatitis about the nipple, a tumor
developed within the substance of the breast, which
Dr. Curtis amputated with good results: but subse-
quently a similar tumor formed in the opposite
gland. Dr. VA\\ who made the microscopical e.\ami-
nation, reported that the growth was not cancerous.
Dr. Jackson advocated early amputation in Paget's
disease as soon as possible after a positive diagnosis
had been made, since cancer is so prone to develop.
Dr. Fordvce thought the pathologist's report indi-
cated that a fibrous growth was present in the gland
before the eczema-like disease occurred about the nip-
ple, while te.xt-books teach that the disease always
begins in the epidermic cells and extends secondarily
along the galactiferous ducts.
Dr. Kowex agreed with this criticism.
Dr. DuHRixr, said at first there was an jnflamniation
of the skin about tlie nipple, clinically identical with
eczema. Five years later an entirely different clinical
picture was presented. Epithelioma masked the ec-
zema. He had suggested the name " eczematoid epi-
thelioma," since the vast majority of cases became
cancerous.
Dr. White thought the case described could not be
regarded strictly as one of Paget's disease. If im-
provement does not take place in the latter disease
from ordinary remedies, it is proper to advise excision.
Dr. Robinsox said he failed to see that any connec-
tion had been shown between the alTection of the
breast and the nipple changes. There might have
been fibroma in accidental combination with dermati-
tis. He had seen cases diagnosticated as Paget's
disease, in which without operation recovery took place.
Dr. J.^cksox said, in closing, that the clinical ap-
pearances had been typical, and he thought any one
present would have made this diagnosis.
A Pathological and Clinical Classification of the
Diseases of the Skin. — Dr. I,. A. Dihrixg, of Phila-
delphia, read a paper with this title. He presented a
table, showing the diseases arranged and grouped ac-
cording to the views advanced. Nine classes were
given: i, .Ana-mias; 2, congestions; 3, inflammations;
4, hemorrhages; 5, neuroses; 6, hypertrophies: 7,
atrophies; 8, new growths; 9, diseases of the appen-
dages of the skin. The last class was divided into
diseases of the (a) sweat glands; (/') sebaceous
glands; (<■) the liair and follicles; (</) the nails. The
structures composing the appendages of the skin, es-
pecially the follicles, hair, and nails, were subject to
such varied forms of disease that it was eminently
jjroper and useful to lump them together. The classi-
fication was based on the pathology, histopathology, and
anatomy of the skin, note being also taken of the chief
primary lesions of disease, as well as of the other
prominent clinical features, with a view to aiding the
clinician in recognizing the various diseases of the
skin.
Dr. White did not think it an improvement on Dr.
Duhring's previous classification. He found many
affections placed under one head which might as well
be placed elsewhere, and the last class appeared to be
an ^^ omnium gatlieriim.''' In the present state of knowl-
edge, the etiological element can scarcely be ignored.
It seemed to him more important than the anatomical.
Pityriasis rubra and dermatitis exfoliativa, he said,
were considered as separate affections.
^'arious criticisms were afterward made.
Dr. Morrow said an etiological classification was
the ideal one, and it seemed a step backward to en-
tirely ignore the etiological element. Finding the
various tineas in different classes would tend to con-
fuse the students. Morphota and scleroderma-a, classed
as atrophies, he thought, were recognized by all to be
primarily hypertrophies.
Dr. Ai.len said a satisfactory- classification seemed
an almost impossible task, and still he thought it a
reproach that the association had to rely upon an
alphabetical list. He thought Dr. Duhring had at-
tempted a necessary work, and hoped he would persist
in his effort to improve it.
October 3, 1896]
MEDICAL RECORD.
493
Dr. RoB[NiON thought the classification would not
be as useful to the reader or the teacher as Dr. Duhr-
ing's original one. It was quite complicated. An
etiological classification was at the present lime im-
possible, and probably always would be, because many
agents are capable of presenting widely differing
pathological processes. The general arrangement
seemed correct, showing much serious study, but still
presented many objectionable features.
Dr. Dchrixg, in closing, said that he had given
much thought to the matter, and during the past
twenty-five years had laid out a half-dozen classifica-
tions on different lines. While a few diseases behave
well under an etiological classification, the larger
number cannot be so classified. It becomes too con-
fusing for the student. The class of diseases of the
appendages of the skin have been introduced to give
a place for the convenient grouping of a number of
diseases. In forming a classification it is not well to
depart too far from old lines. The speaker felt sure
that he could show a form of pityriasis rubra which
would not be considered the same as dermatitis e.\fo-
liativa.
A Peculiar Affection of the Mucous Membrane
of the Lips and Mouth. — Dr. J. A. Fordvce, of New
York, read a paper entitled as above, in which he re-
ported a case of a peculiar mottling of the lips and
mucous surface of the cheeks, more noticeable when
the parts were put upon the stretch. The condition had
existed for two years without subjective symptoms, but
the patches had gradually increased in area. The mi-
croscope showed a degeneration of the protoplasm of
the epithelial cells. The muciparous glands were not
involved. . The specimen and colored drawings were
shown.
Dr. MoRJiow said it was an interesting point that
the same condition had been found in several mem-
bers of the patient's family. The nature could be de-
termined only by the microscope.
Dr. White had seen superficial changes suggestive
of the case reported.
Dr. Bowen thought there might be a plugging of
the glands by the process described, which would ac-
count for the yellowish or whitish bodies seen beneath
the surface. He had seen bulla followed by atrophy
and attended with the formation of bodies similar to
those by plugging up of glandular structures.
Dr. Allen thought the condition a very common
one, but the cases he had obser\-ed had not sought
treatment. At times it constitutes almost a deformity.
A Favus-Like Eruption of the Oral Mucous
Membrane Caused by Aspergillus Nigrescens. —
Dr. Winfield, of Brooklyn, gave the history of a case
which had been referred to him by Dr. Browning, who
had had it under observation for some weeks. A small
ulcer had first appeared on the middle line of the roof
of the mouth, about half way between the incisors and
the soft palate. It was supposed at first to be an or-
dinary' canker sore, giving discomfort only when bread-
crusts or other hard substances pressed against it.
The patch increased slowly in size, and others formed
ii. the neighborhood. Two weeks after its first appear-
ance the patient consulted Dr. Browning, and, as the
patch continued to enlarge, a course of antisyphilitics
was given, but without good eft'ect. It was then sus-
pected that the infiammation was due to a local para-
site, and bichloride and other parasiticides were em-
ployed, without avail. A drawing was shown, re-
vealing a lumpy patch extending from just behind the
incisors to within one-fourth of an inch of the soft pal-
ate. Cup-shaped elevations on the soft palate ap-
peared on either side of the middle line. A firmly
attached membrane, giving rise to hemorrhage when
forcibly removed, covered the areas. The color of the
recent deposit suggested the sulphur-colored scutula of
favus; where it had remained undisturbed it was
darker. A few minute ulcers were scattered over the
larger patch. With low power the growth was recog-
nized under the microscope as a fungus differing from
the achorion. The mycelium network was composed
of delicate fibres, bearing perpendicular fructifying
hyphcE. Scattered over the field were a number of
fruit receptacles and a few spores. The manner of
fructifying showed that the fungus did not belong to
the oidium, but to the ascomycetous genus. Cultures
showed it to be aspergillus nigrescens which had
caused the inflammation. Upon applying twenty-five-
per-cent. ethereal solution of '' pyrozone," improve-
ment was immediately noticed. The pseudo-mem-
brane disappeared and new patches ceased forming.
After seven weeks' treatment the patient was well.
Literature has failed to show a similar case, although
many instances were recorded in which aspergillus
has been found in the human ear. The spores were
supposed to ha\e been implanted in the mouth through
the medium of cheese, strong and mouldy varieties of
which the patient was very fond of eating.
What Effect do Diet and Alcohol Have upon the
Causation and Course of the Eczematous Affections
and Psoriasis? — Dr. J. C. White, of Boston, opened
the discussion on this subject. He said that little new
in this line had been brought out at the recent congress
in London, the president of which had expressed his
continued belief that leprosy was due to a certain ar-
ticle of diet. Some recent discussions have shown
that observations of the past have been so inexact that
no trustworthy conclusions can be drawn from them.
The importance of the bearing of diet upon eczema
has been shown to be greatly overestimated. It has
also been denied that the existence of eczema proves
the coexistence of gout. Improper selection of food,
its improper preparation, and the use of food contain-
ing toxic properties are all harmful. In certain no-
madic tribes the diet is largely animal ; among certain
religious sects it is almost exclusively vegetable;
while it is only recently that certain inland people
have had fish as a common article of diet. In spite of
these opportunities, the therapeutic test has rarely been
applied on an extensive scale. Articles of food which
increase the cutaneous circulation or excite the ner-
vous system, and so e.xaggerate a pruritus, certainly
have a bearing upon eczema. The diet in this dis-
ease should be the same as in all other inflammatorj-
processes. As he does not recognize any connection
between eczema and any so-called diathesis, he would
deny the efficacy of systems of diet based upon the
existence of such diathesis. He recognized both a
direct and an indirect influence on the maintenance of
the disease by alcohol, but did not regard it as an im-
portant factor in its causation. Personally he be-
lieved that diet and alcohol had no influence on the
causation and course of psoriasis in general, but in
exceptional tj-pes they have a temporar}- importance.
The successful treatment of these two diseases is still
a matter of empirical experimentation.
Dr. Fordvce said eczema was a general term, in-
cluding many dift'erent conditions. Our etiological
knowledge is so meagre that it is difficult to express
definite views upon the influence of diet and alcohol
on these affections. A study of the natural historj- of
psoriasis would, perhaps, explain the divergent views
regarding this supposed influence. In the early pro-
gressing stage the development of psoriasis may be
influenced by alcohol and, perhaps, by diet. In the
stage of decline the disease can be influenced by al-
most any drug or any food.
Dr. Jackson believed alcohol aggravated eczema
and psoriasis. Perhaps we shall soon have to allow
the influence of micro-organisms in eczema. I'he
more simple the diet the sooner the cure. He had
494
MEDICAL RECORD.
[October 3, 1896
seen cases treated by Ur. Fox with all kinds of exclu-
sive diets, and had been unable to observe any de-
cided effect from any of them. Simplicity is of prime
importance.
Dr. Duhring said that in so broad a subject only cer-
tain points could be touched upon. We must distin-
guish between food as a cause and food as an injurious
factor in disease. He would seriously question food
being the cause of eczema, but it may possess a direct
injurious influence. In many cases it decidedly ag-
gravates an eczema already existing. As to alcohol,
he did not believe it exerted much influence in causa-
tion, but all would admit that it was injurious. It was
far from being such a potent factor as is food.
Dr. Dyer said he had repeatedly watched cases of
recurrent infantile eczema, notably that attacking the
face. Whenever he investigated the dietary he usually
found it faulty. Without internal medication and with
indifferent applications, a cure was usually effected by
regulating the food.
Dr. Morrow said that in Honolulu these two dis-
eases were the ones habitually seen, and the diet was al-
most exclusively vegetable. A certain proportion of
subjects of infantile eczema suffer from malassimila-
tion. Some of the elder children are allowed coffee,
vegetables, meat, and a piece of bacon to suck. By cor-
recting these faulty conditions, an eczema will show
marked improvement. In dispensary practice he gave
no instructions as to diet, knowing that they would
not be observed. Private patients did better, mainly
for this reason, .\lcohol injured in eczema, just as it
does in syphilis, because of the influence on the circu-
lation. We must recognize the influence of alcohol in
favoring relapses in psoriasis.
Dr. .-Vllen said his hospital experience accorded
with that of Dr. Morrow, in that relapses occurred
promptly and in a severe form in those who drank
spirits as soon as they were discharged. tlhildren
with eczema of the face were generally found to have
some error of diet, and the disea.se seemed aggravated
by it.
Dr. Robinson said if one lived upon mutton for a
number of weeks the molecidar constitution would
differ from that after an equal period on a mixed diet.
This point was brought forward by Huxley twenty or
thirty years ago. The diseases of children are of two
classes, toxic and parasitic. There is no direct toxic
agent, but the ground is made favorable for the devel-
opment of such organisms as reach the surface di-
rectly. In fermentative forms of indigestion toxins
are formed, and in this way a toxic eczema may be-
come established. He especially condemned sweets,
and particularly the cheap candies these subjects are
often found to a sume. Correction of the intestinal
disturbance ai^ne almost invariably leads to a disap-
pearance of eczematous eruptions, but more slowly
than if local applications are also made, especially if
they are such as are unfavorable to the development of
parasitic organisms. Urate of sodium has been found
upon the skin surface in gout, and he could recall an
instance in which internal treatmc-iit directed against
the gouty condition pronqnly removed an eczema,
which other treatment had failed to influence. In
psoriasis he thought food had little influence. He de-
pended upon establishing an alkaline state of the sys-
tem; as long as the urine remains acid, he is unable
to successfully treat such ca.ses. If the diet is prop-
erly regulated, less alkaline medication is required.
Dr. White, in closing, said we had not as yet any
positive knowledge that eczema was a specific parasitic
disease. .\t present that claim was a mere theory. It
must not be forgotten that eczema was most frequent in
the early months of infancy, while the food was of the
simplest nature. Up to the tenth year the complexity
of the food was constantly increasing, and still ecze-
mas became less frequent. He would be inclined to
draw more serious conclusions from Dr. Dyer's re-
marks if regulation of diet had been followed by the
results without any local treatment.
Dr. DiHRiNC; said that food influences the nutrition
of the skin in eczema in a 'notable degree, and hence
must be regarded as an important factor in the history
of eczLMua.
Symmetrical Morphoea. — Dr. P. A. Morrow, of
New \'ork, reported a case of symmetrical morphcea
attended with formation of bullae and ulceration.
The striking features of the case were the number and
size of the plaques, their symmetrical distribution,
the occurrence of bulla', and the extensive breaking
down and ulceration of the affected tissues.
He was consulted in regard to it first by Dr. A. H.
Crane, of Waterbury, Conn., who had been called in on
the suspicion that it was a case of leprosy, and sub-
sequently Dr. Rodger had brought the patient to his of-
fice. He was a man sixty-five years old, whose health
had been good with the exception of attacks of rheuma-
tism. One year ago he began to experience stiffness
in the riglit thigh and ob.served that the skin in this
region was changed in color, and felt stiff, hard, and
unyielding. Soon after this while jiatches appeared
on tile left thigh and later below both knees. In
January last similar patches appeared on the lower
portion of the abdomen, about the hips, sides of the
trunk, and on the back between the shoulders. The
patches below- the knees became painful and ulcerated,
and did not heal for six months. In May (1896) the
upper and middle region of tlie right thigh was occupied
by a large irregular plaque covering almost the entire
anterior and outer surfaces. It was made up of smaller
plaques which had become c(jnfluent, their lines of
coalescence being distinguishable. Over the opposite
thigh the plaques are symmetrically disposed, but not
confluent. Band-like patches are seen above Pou-
part's ligament, extending upward and outward on
either side. On the lateral and posterior aspects of
the trunk are svmnietrical patches; on the right leg the
ulcerative process has extended into and above the
popliteal space. The patches are round, oval, or of
irregidar contour. The color is lardaceous white,
the older ones ha\ing a yellowish or parchment color-
ation. Each patch is surrounded by a clearly defined
lilac border. The skin over the patch cannot be
pinched up, there is complete absence of hair, and the
secretions are entirely sujjpressed over the affected
areas. There is lancinating pricking pain in the ul-
cerated surfaces, and a hypersensitiveness to cold is
complained of. In .August there was marked improve-
ment, the ulcerations being healed. Here and tiiere
over the cicatrix .small excoriations and ulcerations
formed from time to time, due to the rupture of bullae
the size of large peas, of a gray color, giving exit to
an amber-colored fluid. The occurrence of bulls has
been a constant feature for two months.
'IVeatment consisted in giving thyroid extract
tablets, fifteen to twenty-five grains daily, along with
large doses of iodide of potassium, forty to forty-
five grains t. i. d. — replaced after the second visit by
salicylate of sodium and Merck's thyroidin in the
same dose as the extract. There has been progressive
improvement. Many patches are in process of invo-
lution. The skin is softer, more supple, and the pa-
tient seems in a fair wav to recover.
Mycosis Fungoides and Sarcomatosis Cutis. — Dr.
J. T. BowEN, of Boston, read a pa])er on this subject.
There is often very great difficulty in differentiating
these two types of disease. The reader possessed a
series of photographs illustrating this point. A study
of his cases and of others which had been re-
ported would make it probable that there are transi-
tional forms between the two affections, as has been
J
October 3, 1896]
MEDICAL RECORD.
495
suggested by Kaposi. A histological study of the
papules, which resemble the prurigo of Hebra showed
a structure exactly corresponding with the true prurigo
papule.
Dr. White asked how large these nodules were, and
whether the speaker referred to large papules or the
secondary large nodules occasionally developed in
prurigo.
Dr. Bowex said that he referred to tlie true prurigo
papules.
Dr. White thought we must regard the fugitive
character of these lesions as common to both mycosis
and sarcoma. There was a great difference in the
maximum size of lesions in the two affections, but it
was only a matter of degree. A nodule the size of a
pigeon's egg would disappear rapidly in one case, and
one the size of a goose egg w'ould disappear rapidly
in true mycosis fungoides. How far this indicated any
common nature he was unable to say.
Dr. Duhrin'g preferred the term granuloma fun-
goides. The diagnosis was simple in most instances
when the disease had become fully developed. It was
quite different from sarcoma. There was much confu-
sion in the histological condition, and he was not
prepared to distinguish clearly between the two. The
inflammatory element was more marked in granuloma
fungoides.
Dr. Fordvce said there was nothing very distinc-
tive in the pathological anatomy of mycosis fungoides
and certain forms of sarcomatosis.' Certain forms of
spindle-cell sarcoma could be differentiated with the
microscope.
Dr. Robixsox did not think that the disappearance
of the tumors should exclude the term sarcoma, which
really meant only a new growth in the proper sense of
the term. He had seen epitheliomatous tumors dis-
appear without treatment, proving that thev were not
simple new growths. He did not think that certain
cases of mycosis fungoides could be dift'erentiated from
multiple sarcoma, certainly not by pathological find-
ings alone.
Dr. Bowex, in closing, said the term granuloma
fungoides was objectionable, because it had not been
shown to be an infectious granuloma. The term mv-
cosis fungoides seemed the least objectionable.
Xanthoma Diabeticorum was the title of a paper
next read by Dr. Rorixson, of New York, in the
course of which he described the case of a woman, who
had never been jaundiced herself and had never had a
relative thus affected. During the past ten years,
however, she had suffered from gall stones. The erup-
tion first showed itself in 189 1, especially upon the
anterior surfaces of the forearms and about the elbows,
with a few scattered spots upon the knees. With the
exception of those about the elbows, they all disap-
peared. In the present attack about one hundred and
fifty lesions made their appearance upon the right arm,
and about the same number upon the left; but in the
latter there were none over the fingers or joints.
About fifty lesions are present upon each leg, from the
calf to the middle-thigh region. The face and eyelids
are free. The size ranges from that of a pin's point
to a pin's head. The color is yellowish, with a tinge of
red. On pressure the former is intensified. The urine
showed no sugar, but the report of the examiner was
that it appeared "glycosuric.'' It contained twent\'
per cent, by bulk of albumin and a few granular
casts. A photograph of the patient was shown.
In the discussion Dr. Dihrixc said he had recently
seen a similar case, in which the diagnosis was diffi-
cult because of the smallness of the lesions, which
disappeared under antidiabetic treatment.
Dr. Morrow said that sugar was not always found
in these cases. In some undoubted cases of this erup-
tion, it could be discovered at onetime and not at an-
other. It might be found only after the morning meal.
Interstitial nephritis is common, but he had never
known it to precede the glycosuria.
Dr. Fordvce reported a similar case, seen in Dr.
Elliot's clinic.
Dr. Allen said that if the urine was persistently
examined in Dr. Robinson's case, he would expect
sugar to be found eventually. He had seen instances
of intermittent glycosuria.
Dr. White said that while the old F^nglish works
laid much stress upon the association of xanthoma and
jaundice it was in reality seldom observed. English
physicians had told him that the combination was also
in their experience exceptional.
Dr. Allex said that he had obser\'ed an instance
of most intense and long-lasting jaundice in the most
extensive case of xanthelasma about the lids he had
ever seen. The man died. The only post-mortem
examination permitted was a small incision over the
liver. A small piece of the latter, which was much
enlarged, was taken, but was lost in the laboratory.
Its surface was mottled and xanthoma was strongly
suspected from its gross appearance.
Dr. Ronixsox thought it remarkable that while
diabetes was comparatively frequent, xanthoma was
rare. When he reported his first case it was the tenth
on record, and till now but tsventy-nine have been
recorded. The patient had a parenchymatous nephri-
tis, but the speaker had never observed sugar in this
condition.
Some Glycosuric Dermatoses. — Dr. Charles W.
Ai.LEX, of New York, read a paper with this title.
The writer considered that while many different der-
matoses depended upon glycosuria and disappeared
when sugar was no longer present in the urine, the
number of dermatological conditions which could be
looked upon as peculiar to the disease diabetes was
so limited that a class of diabetides could scarcely be
said to exist.
Some unusual cutaneous eruptions occurring in
subjects of diabetes were described, such as multiple
areas of cutaneous gangrene, and states suggesting
acne varioliformis and acne cachecticorum, with pig-
ment spots and exaggerated hairy growths correspond-
ing to the areas affected.
Dr. White said, in opening the discussion, that
the writer had failed to mention that form of derma-
tosis which he regarded as characteristic, viz., the
very acute eczema about the genitals, occurring espe-
cially in stout women. He also referred to an acute
evanescent form of erythematous eczema, like that
seen in association with oedema of the lower extremi-
ties. The skin furnishes a good nidus for the devel-
opment of the furunculus coccus without the existence
of a so-called diathesis.
Dr. Duhrixg had not tound glycosuria in such
frequent connection with furunculosis as some
had.
Dr. Fordvce asked if the patient with xanthoma
and discolored skin had presented symptoms of Hodg-
kin's disease.
Dr. Allex said he had found no evidence of such
a condition.
Dr. Morrow said these eruptive troubles had been
explained on the assumption that they were due to
the local contact of saccharine urine, favoring fun-
gous and parasitic growths. Others besides Dr. U'hite
had mentioned eruptions on parts remote from the
genital region where there was no contact with sac-
charine urine. Sugar in the blood modifies its chem-
ical properties and its power of maintaining nutrition
of the tissues. It had been asserted that sugar was
excreted by the cutaneous glands, producing irritation.
Many eniptions could be explained by the foreign
substance in the blood, just as in drug eruptions.
496
MEDICAL RECORD.
[October 3, 1896
Dr. White spoke of grocers' itch, clue to handling
brown sugar.
Dr. Duhring thought the clermaiitis due to the
mite found in such sugar.
Dk. Dver thought it a trade eczema due to the irri-
tation of the sugar itself.
Dr. White said e.xperiments with the sugar mites
had given negative results.
Dr. WixFiELD had obser\'ed that sugar workers who
kept their hands out of the sugar water were exempt.
Dr. Allen, in closing, said he had omitted to read
that portion of his paper which touched upon the gen-
ital pruritus and dermatitis. He had not meant to
imply liiat he always found sugar in furunculosis, but
he always made it a point to examine for it. He
agreed with Dr. Morrow that local contact of urine
was the cause of eruptions about the genitals, but at a
distance excretion by the skin would explain tlie irri-
tation. Vergely had found two and a quarter grams
of sugar in one hundred and ninety cubic centimetres
of fluid collected from an ulcer on an oedematous limb
showing such excretion.
Hypertrophic Rosacea (Pachydermatosisi, Re-
sembling Tubercular Leprosy, Cured with Thyroid
Extract. — Dr. Dvek, of New Orleans, reported a case
of this nature. The patient, aged sixty years, was
suspected, from his appearance and from the fact of
his living in a community where leprosy is endemic,
of being a subject of this disease. The nodose ap-
pearance of the face was much that of the leonine
countenance of tubercular lepros)', but the limitation of
the affection to the face and to die dorsum of the hands
furnished the first points which determined the exclu-
sion of that disease from the diagnosis. The skin of
the face was much thickened in rugrt, in mostly paral-
lel lines, crossing each other at intervals of an inch or
less apart, producing a tessellated appearance. There
was extensive scaling and almost constant itching.
The color was dull red. There were no tubercles nor
telangiectases. The patient drank beer sparingly. The
infiltration and thickening in regular nodosities sug-
gested the name pachydermatosis. No treatment had
inriuenced the condition, and after two months or more
the reporter concluded that this case was identical with
one depicted in the atlas of the St. Louis Hospital as
hypertrophic rosacea, the early histors' being that of a
progressive rosacea which had been neglected. Thy-
roid extract in five-grain doses three times daily was
now ordered and for local use resorcin, 3 i. ; rose water,
"iv. ; lanolin, ad ; vi. After two months of almost
constant treatment there was decided improvement, the
skin being soft and normal to the touch and the color
being greatly improved both in face and liands. In
July the patient was discharged cured after some three
months of thyroid medication. Photographs showing
the condition before and after were presented for in-
spection.
Dr. White said the report did not recall to his
mind any ordinary case of pachydermia he had seen.
He asked if there were other evidences, as my.xoedema.
Dr. Dver replied in the negative.
IJR. DfHRixG said the term pachdyermia seemed
appropriate, but he did not see how the diagnosis
hypertrophic rosacea could be made.
Iodoform Dermatitis.— Dr. Fordyce, of New York,
showed two water-color sketches of an unusual form of
iodoform dermatitis occurring in a man with pulmo-
nary tuberculosis and following the application of the
drug to a contused finger. It consisted of large patches
of grouped tubercles, papules, papulo-vesicles, pustules,
and elevated erythematous spots, involving the hands,
forearms, neck, and face. A colored drawing of an
eruption resulting from the internal use of iodide of
potassium was shown, in which almost identical re-
gions were involved.
Multiple Papillomatous Tumors. — Dr. Fordyce
then exhibited se\eral colored drawings illustrating
an unusual form of granuloma, occurring on the an-
terior surface of the leg, the popliteal spaces, the penis,
the scrotum, and over the sacrum. The tumors devel-
oped on an eczematous surface and presented many of
the features of mycosis fungoides.
Dr. Fordyce also showed colored drawings of cases
of symmetrical keratosis of the cheeks, tinea barbae,
psoriasis of the palms, atrophy of the skin following
involution of molluscum fibrosum tumors, congenital
na;vus of the eyelids, epithelioma of the scalp with
papillary outgrowth, epithelioma of the auricle, myco-
sis fungoides in the stage of tumor development, lupus
eiythematosus of the cheek after frostbite, and a case
of erythema multiforme of the arms, of toxic origin.
Photographs of pityriasis rubra (of Hebra). ichthyo-
sis, navus papillaris, molluscum fibrosum, and of
complete alopecia resulting from early syphilis were
shown, together with a number of photomicrographs of
pathological conditions.
The Relation of Dermatitis Herpetiformis to
Erythema Multiforme and to Pemphigus. — Dr. L.
A. DuHRiNc;, of Pliiladelphia, read a communication
on this subject, of which the following were the con-
clusions: (i) Dermatitis herpetiformis is in most in-
stances a disease with well-defined and tolerably
constant clinical features. (2) In most instances it
is more closely allied to erythema multiforme than to
any other disease. (3) The bullous variety of derma-
titis herpetiformis possesses features which resemble
those of pemphigus vulgaris, from which latter disease,
however, it differs in the peculiar inflammatory char-
acter of the cutaneous lesions, as well as in the ten-
dency to polymorphism, in the irregular evolution of
the lesions, and in its course.
Dr. Fordyce said we had been \mable to classify
recurring eruptions of multiform type frequently leav-
ing pigmentations until we recognized this separate
and distinct type of dermatitis herpetiformis, now gen-
erally accepted.
Dr. j.'^CKSON had been in accord with the writer's
views. He believed many cases reported as pemphi-
gus belonged to this class.
Dr. Whii e thought the term multiformis far better,
because of the great multiformity of the lesions and
because of the variations assumed by the disease in
different recurrences in the same individual. The
term '" herpetic" seemed a misnomer. No case he had
seen presented an area which he would mistake for an
expression of the lesions which characterize herpes,
nor did we see the self-limitation of the lesions as in
herpes. Many cases, too, have no suggestion even of
herpes. He could not agree with the reader that in-
dividual cases could be so easily distinguished from
pemphigus. In obser\'ing a case over a considerable
period, we should always be able to make the diag-
nosis.
Dr. Allen said the paper had cleared up one or
two points about which there had been doubt as to
Dr. Duhring's exact views. He had believed and
expressed himself in writings that multiformis was
the preferable term, since three or four primary lesions
may appear together and none of them closely re-
semble herpes, and he had further suggested the gen-
eral adoption of the designation " Duhring's disease,"
which would do away with all controversy as to the
name. He knew of no reason why we should speak
of lesions following certain nerves rather than lym-
phatics or blood-vessels.
Dr. Rgbi.nso.x said that if the term dermatitis was
to be used at all he was strongly in favor of using it in
the connection in which Dr. Duhring had employed it.
Dermatitis multiformis means nothing at all. He
was astonished that Dr. Duhring should use the argu-
October 3, 1S96]
MEDICAL RECORD.
497
ment of the neurotic nature of the affection, as tiiougii
it were an accepted view. It was an instance of
choosing the name of a symptom for tlie name of a dis-
ease. He believed it most certainly a parasitic disease
or a toxic disease manifesting itself through the blood-
vessels or the nervous system.
Dr. Dl'hring, in closing, said he thought the causes
varied. He could not state just what the causes al-
ways were. The name was important and he thought
the "herpetiformis" more exact. Herpetiformity was
an essential of tiie disease, but it did not mean that it
resembled herpes or zoster. The original meaning
was a creeping disease. Herpetiform expressed a
broader meaning than herpetic. He admitted a rela-
tionship of pemphigus in symptoms and probably also
in etiology. He had only said the cutaneous nerves
were implicated, not that the eruption followed their
course. Implication of the cutaneous nerves gives
rise to the peculiar evidence described under the term
" herpetiform."
Impetigo Contagiosa Universalis. — Dr. C. W.
Allex, of New York, read this paper. He based his
remarks upon the case of a young girl whose vesiculo-
bullous eruption, extending over alomst the entire
body, was shown in photographs presented. The le-
sions had begun to appear as vesicles upon the arm very
shortly after vaccination, and from then until the pa-
tient was cured some nine months later had continued
to crop out in various regions as bulla extending at the
periphery or drj-ing down with formation of crusts, with
smaller blebs or vesicles in their neighborhood. She
w'as first seen four months after the disease began.
There were infiltrated and pigmented areas where the
lesions had existed. The disease bore a resemblance
to pemphigus, and the same condition is called epi-
demic pemphigus or pemphigus contagiosus when a
number of cases coexist. The diagnosis was based
upon the benignity of the process, the non-effect of
arsenic and internal medication, the origin in vacci-
nation, and certain lesions upon the chin which were
clinically identical with those of ordinary impetigo
contagiosa. Cure was finally effected under the use
of ichthyol in collodion as an occlusive dressing.
Dr. Dyer said he had been interested in the paper
because it called to his mind a series of similar cases
after extensive vaccination in New Orleans. In the
first case he supposed the condition to be true derma-
titis herpetiformis. The photographs exhibited are
identical with those of his own case, excepting that in
the latter the bulla became hemorrhagic. The urine
contained a large percentage of albumin. During
two years there were recurrences of a true impetig-
inous type. He had seen three other cases, in only
one of which the urine was free from albumin. Judg-
ing from Dr. Duhring's paper, perhaps after all the cor-
rect diagnosis was dermatitis herpetiformis.
Dr. White asked if there were any similar cases in
the patient's immediate surroundings.
Dr. Allen said there had occurred an almost iden-
tical case, as he had been told, in the same part of the
city, and he had subseciuently seen a number of im-
petigo cases near by and was told it was very common.
Dr. White said that cases in which there are widely
distributed staphylococt i present features very differ-
ent from those here described. He thought it un-
fortunate that no examination had been made to es-
tablish the presence of the staphylococcus, about which
so much had been said.
Dr. Dchrixc; said no proof had been brought for-
ward of contagion or of the existence of micro-organ-
isms which militated against the diagnosis. From
the piiotographs alone he would be inclined to make
the diagnosis between pemphigus and dermatitis her-
petiformis. In children the latter was milder than in
adults, but there was a special tendency to bleb forma-
tion. He was strongly inclined to e.xclude impetigo
contagiosa.
Dr. Allex said, in closing, that he believed the
bullous form of impetigo existed and that his was an
example of such cases. There might be bullous le-
sions, but none such were present in this instance.
The origin in vaccination, starting in the immediate
neighborhood of the crusts, was a strong point in
favor of impetigo. There was nothing in the distribu-
tion or in the appearance which could be described as
" herpetiform," unless one spoke of the creeping under-
mining of epidermis in this sense. The element of
contagion was lacking, but if we admit the possibility
of accidental inoculation along with vaccination it
seems not so important. The communication from
one surface of the body to another by scratching, etc.,
was almost as good proof of its communicable nature
as though transfer to a second person had been shown
in the history.
He would ask Dr. Duhring if he regarded vaccina-
tion as an important etiological factor in dermatitis
herpetiformis.
Dr. Duhrixg said he did not.
Election of Officers. — Dr. James C. White was
elected Presidctit ; Dr. Louis A. Duhring, Vice-Presi-
ileiit ; Dr. John T. Bowen, Secretary and Treasurer.
The next meeting will be held in Washington, D. C.,.
in connection with the congress of American phy-
sicians and surgeons.
AMERICAN PUBLIC HEALTH ASSOCIA-
TION.
Twen/y-Piiiirth Annual Meeting, Held in Buffalo, N^.
1'., Septefnber i^, 16, IJ, and 18, j8g6.
First Day — Tuesday, Sepieiuher Jjtli.
The association assembled in Ellicott Square, and its-
deliberations were presided over by Dr. Eduardo Li-
ce'.aga, of Mexico, president of the superior board of-
health of that city.
Dr. Stephen Smith, of New York, the first presi-
dent of the association, w^as introduced and made a>
few- remarks with reference to the progress the associa-
tion has made from its beginning.
Dr. Erxe.st WExbE, commissioner of health of
Buffalo, cordially welcomed the association in behalf
of the local committee of arrangements.
Report of the Committee on Car Sanitation. —
This was read by Dr. C. Prob.st, in the absence of
Dr. G. p. Coxx, of Concord, chairman. The report
states that any one who takes an interest in car sanita-
tion will soon become convinced that there is some-
thing lacking in the manner in which cars are
cleansed and kept in condition for the travelling pub-
lic. Ignorant and untrained help may and does de-
stroy a great deal that should be cared for, and thus
the expenses of this department are far beyond what is
actually necessary.
Observations on the Cleaning of Railroad Pas-
senger Cars. — By Dr. Domingo Orvananos, of the
City of Mexico. To afford any security against con-
tagion or infection from railroad cars, it is necessary
that the cleansing operations shall be carried out sev-
eral times a day. To attain these objects, the author
thinks passenger cars ought to be constructed in a
manner very different from the pre.sent one. The bed
clothing, including the blankets and curtains, should
be changed daily, as well as the mattresses.
Possibilities of Contagion from Venereal Diseases
in Railway Cars — This paper was read by I)k-
ToM.AS Noriega, of the State of Chiapas, Mexico, in
which he cited the case of a married man, thirty years
498
MEDICAL RECORD.
[October 3. 1896
of age, who arose from his berth in a Pullman car and,
as was his custom, washed his face in the lavatory.
Two days thereafter he felt the first symptoms of puru-
lent ophthalmia, for which he consulted a physician.
The patient \\as treated energetically, but in spite of
all efforts the right eye was lost. Other similar cases
were reported.
Dr. Frederick Moxtizameert, of Montreal, gen-
eral superintendent of the quarantines of the Domin-
ion of C'anada, presented the report of the committee
on steamboat and steamship sanitation.
Infectiousness of Milk. — Dr. James Kennedy,
of Des Moines, la., read a paper on this subject.
Cow's milk alone was considered, since no other kind
of milk is used by many infants and adults, and since
it is the almost universal and, under proper conditions,
the best substitute for human milk in the feeding of
children. In Berlin, in giving the certificates of death
of children under one year, the fact must be stated as
to whether the child was fed from the breast or brought
up artificially. In ten thousand deaths thus reported,
it was found that two-thirds, or seventy-six hundred
and forty-six infants, were artificially fed. The author
emphasized the importance of a sanitary inspection in
addition to, if not to the exclusion of, the mere com-
mercial examination.
Report of the Committee on Animal Diseases and
Animal Food. — This was read by the chairman. Dr.
D. E. Salmon, of Washington, D. C. Animal dis-
eases are now more intelligently managed by sanitary
officers than ever before, and the meat-inspection ser-
vice has been steadily extended and perfected. Out-
breaks of anthrax among the domesticated animals
are apparently becoming more frequent. The con-
tagion once introduced into a pasture remains indefi-
nitely. A disease so fatal to man and beast should be
promptly repressed whenever it makes its appearance,
and precautions should be observed to prevent infec-
tion of new territory.
Pathogeny, Etiology, and Prophylaxis of Ty-
phus.— Dr. Francisco de P. Bernaldez, of Mexico,
contributed a paper on this subject. This disease
arises from a microbe not as yet discovered. Through-
out all the districts which are called the hot country
in the Mexican republic, the infection of typhus does
not exist, while in the temperate regions at a higher
elevation it occurs in endemic form.
Report of the Committee on Nomenclature and
Forms of Statistics. — liy Dr. Samiel W. Ahbott, of
Wakefield, Mass., chairman. The report dealt with
the need of a uniform system of classification and
nomenclature. Before advising the general acceptance
of any one svstem for general use, the committee rec-
ommended that the association collect and compare
the .systems now in u.se and employed by the different
national, State, and municipal authorities in this coun-
try, in order that these may also be compared with the
sy.stems in use in other countries, so that a general
system can be recommended for adoption throughout
the States and countries within the bounds of the as-
sociation.
The Nomenclature of Diseases and Forms of
Statistics. — Dr. KnrAKDo I,kka<;a, the president,
read a paper on this subject. The board of health of
Mexico City had, from the year 1879 up to the year
1887, classified the diseases resulting in death in a
certain number of groups. In the year 1888 he, as
president of the board, proposed the adoption of the
provisional nomenclature adopted by the Royal Col-
lege of Surgeons of London. This nomenclature was
adopted because it was the one then followed by al-
most all the English-speaking nations, and so the
Mexican tables of mortality might be compared with
those of such nations.
On the Need of Uniformity in the Meaning of
the Term Stillborn. — By Dr. Jesus E. Monjaras,
of San Luis Potosi, Mexico. The laws of different
countries were cited by the author, after which he pro-
posed the following: (i) That there shall be included
under the term stillborn all children of more than six
months of intra-uterine life that are born dead. (2)
That there be added to the nomenclature of the causes
of death the term that shall represent all children that
die within seventy-two hours after birth wiliiout known
cause, and that they be designated by the term "died
at birth without known cause." (3) That the commit-
tee on nomenclature of diseases and forms of statistics
be authorized to recommend this modification of the
existing nomenclature in all the countries of the
American continent. (4) That these modifications
once adopted in said continent, the same would doubt-
less be accepted in Europe and elsewhere.
Dengue. — A paper on this subject was read by Dr.
Henry D. Hori.heck, of Ciiarleston, S. C. The dis-
ease was defined, after which the author said the ob-
ject of the paper was to put on record a brief account
of a widespread outbreak of this malady which oc-
curred in Charleston in 1895. During its prevalence
from July until November, it is estimated that fifty
thousand of the inhabitants were afflicted with the dis-
ease. Men and women seventy years of age and in-
fants had it, and yet the malady was not prevalent a
few miles away from them. Notwithstanding the sud-
denness of the onset and severity of the attack, death
is rare.
Municipal Responsibility for Healthy School-
houses — Mrs. Ellen H. Richards, of ]5oston, con-
tributed a paper on this subject. Local agitation of
this question might do some good, but to the author it
seemed as if the time liad come for some concerted ac-
tion, comjielling city authorities to keep schoolhouses
in good condition. A most efficient way would be to
bring to bear the power of the law, and to insist that
such buildings as are flagrant violations of the law
shall be closed, as private buildings would be.
Addresses were delivered by the mayor of Buffalo
and the Rev. Tho.mas Slicer, both of whom spoke of
the benefits of sanitation.
Presidential Address.— The president. Dr. Liceaca,
then delivered his address. He first thanked the mem-
bers for the distinguished honor conferred upon him,
after which he said that the preservation of health, the
prolongation of life, and the physical improvement of
the human race were the ideal principles that ought
to be kept in view. Coming to the question of ej)!-
demics, he stated that they can be suppressed at their
inception by isolating the first patients and disinfect-
ing the objects which they have contaminated, whether
these objects be the clothes they have used, the furni-
ture found in their res])ective rooms, or the rooms in
which they were kept during the disease. Isolation in
cases of diphtheria must be absolute and complete. A
proposition which demanded special study was the
technique of disinfection. Lastly, the speaker cited
examples to show the advisability of organizing a
committee to study the periods during which each
contagious disease is transmissible, and the time dur-
ing which every patient who has suffered from such
disease is dangerous to the communitv.
SfiOiid J) ay — Wednesday, September J 6th.
Report of the Committee on the Disposal of Gar-
bage and Refuse. — This was presented by Mr. Ki-
DOLPH Hering, C.E., of New York City, chairman,
and was followed by a paper entitled "Disposal of the
Garbage and Waste of the Household," by Coi.. W. F.
Morse, of the same city. In considering the matter
of the final disposition of garbage, the author said
that no record of methods could be complete unless
October 3, 1896]
MEDICAL RECORD.
499
those means were considered by which the waste of the
family was destroyed in the home where it was j re-
duced. An apparatus in the form of a carbonizer for
the disposal of garbage was described.
A Plea for the Domestic Disposal of Garbage
Dr. N. E. W'ordin, of Bridgeport, Conn., read a paper
-with this title. Fire is the best destroyer. It leaves
■no filth and no germs behind. The different methods
of disposing of garbage were tabulated as follows: i.
The most wasteful — sea disposal. 2. The most offen-
sive— hog feeding or fertilization. 3. The most eco-
nomical to operate — reduction. 4. The most sanitary
and complete — cremation. Reduction and cremation
■were the only methods worthy of consideration for any
•city.
Dr. William S. Tremaine, of Buffalo, explained the
results of practical e.xperiments with one of the gar-
bage crematories in Bufialo. This crematory success-
fully disposes of garbage and excrement without oc-
casioning any odor.
Report of the Committee on Transportation and
Disposal of the Dead. — By the chairman, 1)k. Charles
O. Probst, of Columbus, O. The committee is of
the opinion that it is quite possible to so prepare,
with promptitude and but little expense, a body dead
of infectious diseases as to make it transportable
without any danger of transmitting infection ; and it is
the duty of the association to develop the simplest
methods by which this desirable end can be obtained,
in order that the sentiment of respect for the dead
niav be maintained without any danger to the living.
If, however, all dead bodies are to be allowed trans-
portation, it will be necessary to provide that the
preparation of bodies dead of contagious disease shall
in each instance be under the direct supervision of
the health authorities.
The Quick or the Dead — Dr. Benjajiin Lee, of
Philadelphia, read a paper with this caption. Health
authorities should be very slow in relaxing any of the
precautions and restrictions at present in force attend-
ing the transportation of those dead of contagious dis-
eases. He thinks the true solution to the question of
transportation is to be found in the cremation of all
bodies dead of contagious diseases.
On Measures for the Prevention of Blindness. —
By Dr. Augustine Chacox, of the City of Mexico.
Statistics, cited by the author, prove that a great deal
more than half of the cases of blindness might very
probably have been avoided, if proper measures had
been taken in time. The two diseases of the eyes
which cause the loss of sight in the largest number of
patients were atrophy of the optic nerve and purulent
ophthalmia. These two diseases were considered at
length. Special attention ought also to be given to
hygiene of the sight in schools.
Miasmatic Fevers in the State of Sonora. — Dr.
Alberto G. Noriega, of Mexico, read a paper on this
subject. The author spoke of the origin, treatment,
and some of the peculiarities of the symptomatic char-
acteristics of fevers of miasmatic origin in the State of
Sonora. He proposed the following prophylactic meas-
ures: I. The planting of thick woods around the town-
ship, with the idea of suppressing the paludic miasma
where the trees grow. 2. The houses ought to be
built on the highest places, in order to keep them as
far as possible out of the reach of the gases from the
pools and marshes. 3. The front of the houses must
not face the direction of tiie dominant wind, and the
houses themselves ought not to be in the way of the
winds coming from the pools. 4. To avoid the water-
ing of the floors, in order to maintain the interior of
the houses as dry as possible. 5. The workmen in the
fields must not commence their work until the sun is
well up, and they must retire from the fields before the
sun sets.
Summary of Sanitary Legislation in the State
of Mexico. — This paper was read by Dr. M. Alvarez,
of Mexico. The author said that the philosophy of
sanitary legislatiort rested on three bases: i. Those
which attempt to endow the individual with good
health. 2. Those which take precautions against dis-
eases of all kinds. 3. Those which require the partial
sacrifice of individual liberty in favor of the general
community. The author then entered exhaustively
into a consideration of drinking-waters, vaccination,
and vaccination laws, paying particular attention to the
obligatory-vaccination Liw of Mexico.
Obiter Dicta Concerning Sanitary Organization. —
Dr. a. Walter Suiter, of Herkimer, N. Y., read this
paper. He said a system of health administration
without effective organization was like a ship without
a rudder, subject to the mercy of every pestilential
storm. Dr. Suiter made a strong plea for an arrange-
ment so systematized that sanitary direction may be
administered in the most practical and advantageous
manner without conflict of authority. The public
should be educated to a point of proper appreciation
of the importance of the service required.
Some Thoughts Relative to Sanitary Legislation.
— Dr. U. O. B. Wixgate, of Milwaukee, Wis., read a
paper with this title. The author believes that laws
pertaining to sanitation should differ very material Iv
from other laws, inasmuch as they voice a scientific
fact, and if applicable in one locality they should be
also applicable in all localities. Attention was di-
rected to the great need of a system of statistics, not
only pertaining to births and deaths, but to sickness
or the prevalence especially of contagious and prevent-
able diseases. A strong plea was made for a depart-
ment of public I'lcalth at AVashington.
The Sanitary Administration of Unincorporated
Districts. — In a paper with this title, I)r. Henry
Mitchell, of Trenton, N. J., presented the following
propositions: 1. By law provide that in each township,
or other local political division outside of municipali-
ties, the sanitary authority should be exercised by one
official. 2. The local health officers should be se-
lected under civil service rules, and their term of
office should be five years. 3. The examination of ap-
plicants for the office of township health officer should
be conducted by the State board of health. 4. The
appointment of the health officer in each township
should be made by the governing body of the district,
from an eligible list to be furnished by the State board
of health. 5. No healtli officer should be removed
except for cause, and vacancies should be filled for the
unexpired term in the manner provided for original
appointments. 6. Local health officers should be re-
quired to conduct all of their official operations in
accordance with rules and regulations approved by the
State board of health, and they should also make
weekly reports of their doings to said board and annu-
ally to the local governing body. 7. The local health
officer should be paid for his services by the local gov-
erning body. 8. All suits for the violation of any
local sanitary rule, regulation, or ordinance should be
brought at the instance of the local health officers, and
they should be prosecuted by the district attorney or
prosecutor for the county; but no such suit should be
begun until the necessity for its being instituted has
first been agreed to by the State board of health.
Report of the International Committee on the
Prevention of the Spread of Yellow Fever Dr.
Felix Form kn 10, of .\ew Orleans, read this re]xirt
which embodied the following recommendations of
the committee: i. Extreme measures of local sanita-
tion in yellow fever foci. Modification of the soil,
improvement of harbors, etc., by all means known
to sanitary engineering. 2. Putting in perfect sani-
tary condition all home seaports and towns most ex-
500
MEDICAL RECORD.
[October 3, 1S96
posed to infection. 3. A rigid and efficient system
of quarantine against the introduction of the disease.
4. Abolishing forever the abominable system of inter-
ment and disinterment practised in Spanish-American
countries. 5. Wherever practicable, yellow-fever hos-
pitals should be established beyond or above yellow
fever foci. When this cannot be done, these hospitals
should be established at a distance from centres of
population in a desirable locality and perfectly iso-
lated. 6. Compulsory cremation of all bodies of per-
sons who have died of that disease, and incineration of
all infected material.
The Study of Yellow Fever from a Medico-
Geographical Point of View. — Dr. Liceaga said
that this was the fourth paper he had presented on this
subject, and his object was to enable the association
to realize the true situation of the Mexican republic as
regards yellow fever. With the aid of facts, he dis-
proved the erroneous idea which for so many years
had e.xisted, that it was a country in which this disease
was always found throughout the entire extent of its
territory.
A Contribution to the Study of Yellow Fever in
Relation to Epidemics in Cordova Dk. G. Mex-
DizAiiAL, of Orizaba, Mexico, followed with this paper.
The author presented a resume of the number, inten-
sity, duration, and mortality of each of the epidemics
of yellow fever which had desolatcil during three cen-
turies the above-mentioned citv. Tiiis city, besides
its climate and soil, its constant humidity, its proxim-
ity to Vera Cruz, and many other causes which favor
the propagation of the morbific germs, has a great
scarcity of potable water of the requisite purity. It is
the duty of the municipal authorities to improve the
hygienic conditions of the people of this city, to pro-
vide them with potable water, to make the soil sterile
to the germs of the disease, and thus forever close the
doors against this desolating plague.
Isolation Hospitals. — Dk. John L. Leal, of Pater-
son, N, J., read a paper, in which he spoke of the util-
ity of isolation hospitals in the restriction of preventa-
ble diseases, and illustrated his remarks by views and
plans of the Paterson Isolation Hospital.
Third Day — Tlnirsilii\\ September ijf/i.
Pollution of Water Supplies. — Major Chari.es
Smart, surgeon of tiie United States army, Washington,
D. C, chairman, read the report of the committee on the
pollution of water supplies, in which he referred to
the bacteriological convention held in New^ York City
and the work accomplished by it, and said that when
a description of the standard methods recommended
by this convention is in the hands of the bacteriolo-
gists of this country, the committee will then be in a
condition to define its lines of action for effecting an
organization for co-operative work, as suggested at
Montreal.
Dr. Peter H. Brvce, of Toronto, chairman, pre-
sented the report of the committee on river conser\'-
ancy boards of supervision. The committee was not
as yet prepared with such data regarding individual
cases of pollution to present practical suggestions
with reference to such a board for any particular
stream, but desired, by laboring in conjunction with
the committee on pollution of streams and with various
engineering associations to collect material which
might give to the committee's report in another year
some practical value.
Dr. Charles N. Hewitt, of Red Wing, Minn., as
chairman, presented the report of the committee on
protective inoculations in infectious diseases.
The Serum-Diagnosis Test for Typhoid Fever. —
By Dr. W. JoHNsrox, of Montreal. The author de-
monstrated a modification of N'ldal's method of serum
diagnosis in this disease. He considered the test verj-
reliable from a diagnostic point of view and thought it
would prove of considerable value for public-health
work, and that it would lead physicians to report their
cases more frequently and promptly.
Prophylaxis of Typhoid Fever was the title of a
paper by Dr. Johx K. Woodbridi;e, of Cleveland, O.
Typhoid fever was characterized as a water-borne
disease, and every attack was considered the child of
a previous one and was /r/md /ireie evidence that the
victim had eaten or drunk unsterilized human excre-
ment or some of the products thereof. The govern-
ment of the I'nited States, he said, will not have dis-
charged its whole duty to the people, will not have
attained the zenith of its greatness, until through a de-
partment of public health, aided by wise legislation, it
has taken every possible precaution not only to protect
the health and foster the highest physical development
of its citizens, but to guard well the purity of the air
they breathe, the food they eat, and the water they
drink.
Dr. I". C. KuniNsoN, of Brunswick, Me., read a
paper in which he spoke of the practical use of formic
aldehyde as a disinfectant.
Dr. E. a. De ScHWEiNrrz, of- Washington, D. C,
demonstrated and exhibited a convenient lamp for
generating fonnaldehyde gas: while Dr. J. J. Kin-
vouN, of Washington, D. C., followed with a prelimi-
nary note on the use of formaldehyde for room and
car disinfection. His results so far obtained from its
use were very gratifying. Dr. Ivinyoun also exhibited
and described an apparatus of his own design for
generating this gas.
Malaria. — Two papers were then read, one on the
prophylaxis of paludism, by Dr. A. R. Erdozai.v, of
Mexico, and the otiier on jOTludism in the State of
Morelos and its prophylaxis by sanitary measures, b\'
Dr. a. CiAvino, of Mexico.
Public Health in Tabasco. — Dr. Juax Mt ld.son.
of Mexico, read a paper on public health in 'I'abasco.
He presented the following conclusions: i. The san-
itary condition of Tabasco in general is good. 2.
Paludism is the principal disease, but it is satisfac-
torily treated. 3. Yellow fever is not endemic: it
occurs in isolated cases, being generally imported and
not finding a good soil for its propagation. 4. Isola-
tion and other hygienic measures have successfully
prevented propagation of the disease. 5. Natives are
not so easily attacked by yellow fever as foreigners
are, and people accustomed to the climate who have
lived there for many years also acquire this immunity.
6. The climatological conditions notably modify the
clinical history of certain diseases, among which for-
cibly calling our attention is the benign course of sep-
tica-niia.
Prevention of Diphtheria. — Dr. T- J- Kixvoin,
of Washington. D. C, chairman, presented the report
of the committee on the cause and the prevention of
diphtheria. The committee recommends the follow-
ing:
1. That there should be uniform rules and regula-
tions adopted by all the States and provinces for the
prevention and control of diphtheria. The several
governments should assume the responsibility and act
in unison in preventing the spread of the disease from
one country to another and assume authorit}' over
inteqjrovincial and interstate communication.
2. That it should be the duty of the health authori-
ties to provide facilities for determining the diagnosis
in all .suspected cases by the establishment of inexpen-
sive laboratories for each health jurisdiction : to
agree upon a system and means of transmission of
material for diagnosis through the mails.
3. -Compulsory notification of all suspected cases
and the abolition of the terms croup and membranous
October
3<
1896]
MEDICAL RECORD.
501
croup, unless diphtheria has been excluded by culture
and microscopic examination.
4. Compulsory isolation of all cases, domiciliary or
in hospital, until the recovered cases show the absence
of the diphtheria bacillus.
5. That the medical inspection of schools should
be inaugurated under the direction and supervision of
the health authorities, by making daily inspections of
all school children in the larger cities for the detec-
tion of infectious diseases. (The plan advocated by
Dr. S. H. Durgin, of Boston, at the last meeting of the
association, was highly commended.)
6. School buildings, books, etc., should be subjected
to a reliable method of disinfection at least once a
month, and oftener if suspected of being infected.
7. The early treatment of those ill with diphtheria
with antitoxin, the administration of preventive doses
to those who have been exposed to infection and have
the bacilli in their throats.
8. Prompt and effective methods of disinfection of
infected articles and apartments, to be carried out
under the supervision of the health authorities.
Diphtheria in Chihuahua. — Dr. M. Marquez, of
Mexico, contributed a paper with this title. He said
that diphtheria was one of the infecto-contagiojs dis-
eases which was most observed in Chihuahua, and in
such a degree that it sometimes caused a panic among
families. The author formulated twenty-four rules to
be carried out to prevent the spread of the disease.
Bacteriological Diagnosis as Governing the Ad-
mission and Discharge of Patients in Diphtheria
Hospitals. — By Dr. E. B. Shuttleworth, of To-
ronto. The isolation hospital at Toronto was estab-
lished in 1891, and up to June 30th last, there were
admitted one thousand six hundred and ninety pa-
tients said to be suffering from the disease. Diagno-
sis by bacteriological methods was begun in February,
1895, and since July of that year the discharge of
patients had also been governed by this means of
investigation. The statistics for this period covered
five hundred and. sixty-five cases, and when compared
with those for the preceding time, afforded an oppor-
tunity for ascertaining the practical value of bacteri-
ology when applied to the purposes indicated.
Dr. Charles N. Hewitt, of Minnesota, presented
the report of the committee on causes and prevention
of infant mortality.
The Mortality of Children, Its Causes, and
Means of Diminishing It. — Dr. S. Garciadiego, of
Mexico, followed with a contribution on this subject.
The speaker classified the causes of mortality of chil-
dren under three heads — crime, carelessness, and
ignorance. The author believes that the mortality
among children can be diminished by the institution
of lying-in hospitals or obstetrical departments, by
which means it has been proved that infanticide nearly
disappears, and also by establishing orphanages and
homes for foundlings under the care of the government,
and of religious people. In each of these asylums a
limited number of children should be allowed in order
to be properly cared for and attended to. For the
feeding of infants in these institutions, the mother's
milk should be replaced by that of the goat, or other
nearly as proper as the former, using the utmost care
in the cleaning of bottles. Mothers who abandon their
children should be severely punished.
Dr. Fei.ix Fermexto, of New Orleans, presented
the report of the committee on the use of alcoholic
drinks, which was substantially that presented last
year at the Denver meeting.
The Bicycle in Its Sanitary Aspect Dr. Albert
L. GiHox, of New York, read a jaaper on this subject.
The author criticised the posture and saddles used by
riders of the bicycle, .\fter presenting arguments for
and against the bicycle, he ventured the prediction
that a light three or four wheeled vehicle, propelled
by some easily managed motor, inexpensive enough to
be generally available, would be the means of progres-
sion for pleasure purposes in the future, covering long
distances without fatigue, permitting sight seeing and
outdoor exposure without labor, and adding the charm
of companionship and participated enjoyment, while
the rational instrument of exercise for exercise's sake
alone would ever be a pair of sturdy human legs.
Dr. H. L. Chase, of Brookline, Mass., read a paper
on public bathing-establishments and gave a descrip-
tion of the new public bath in Brookline; while Dr.
\V. H. ToL.^LAN, of New York, gave an illustrated lec-
ture on public baths.
Dr. Carlos Santa Marl\, of Durango, Mexico,
read a paper on the part that public instruction should
play in the way of precaution against contagious dis-
eases. It was a plea for the general teaching of the
elements of hygiene in the public schools.
Foii)-th Day — Friday, September j8/h.
At this session the following papers were read:
" Report of Committee on the Relation of Forestry to
Public Health," by Prof. R. C. Kedzie, of Lansing,
Mich.; " Report of Committee on Transportation of
Diseased Tissues by Mail," by Dr. Henry Mitchell,
of Trenton, N. J. ; '" On Statistics of Vaccination and
Mortality from Small-pox in the City of Mexico," by
Dr. Jose Ramirez, of IMexico.
Dr. a. N. Bell, of Brooklyn, N. Y., read a paper
on drunkenness, which he considered as a vice, and
said that it should be so treated.
Protection of the Innocent from Gonorrhoea. —
Dr. F. C. Valentine, of New York City, read a paper
on this subject. He said that if justification were
needed for the discussion of this matter, it could be
found in the statistics of the German empire for 1894.
These show that of the women who died of uterine or
ovarian diseases, eighty per cent, were killed by gonor-
rhoea. They further show that of children hopelessly
blind, eighty per cent, went into a life of darkness from
gonorrhoea. Gonorrhceal patients should be educated
in incontrovertible facts, the physician ever choosing
terms within the range of their intelligence.
Several other papers on the programme were read,
some of them by title.
Election of Officers. — The following officers were
elected for the ensuing year: Pfesident, Dr. H. B.
Horlbeck, of Charleston, S. C. ; First Vice-Fresidtiit,
Dr. Peter H. Bryce, of Toronto; Second Vice-Presi-
dent, Dr. Ernest Wende, of Buffalo; Treasurer, Dr.
Henry D. Holton, of Brattleboro, Vt. ; Secretary, Dr.
Irving A. Watson, of Concord, N. H.
Place of next meeting, Philadelphia, 1897.
Masturbation and Spermatorrhoea I do not be-
lieve it safe for a physician to prescribe fornication.
It is not safe nor curative, apart from the moral aspect
of the matter. It has always struck me also as pretty
small business, for a man to purposely select a wife
to relieve him of the results of a w^eak will and vicious
sensual indulgence. If marriage comes in the natural
course of events, as it often does, so much the better.
But to select a wife as a remedial agent for masturba-
tion is unjust to the woman and a confession of moral
and mental feebleness. Man is distinguished from
the brute by his self-control. Let him bear the fact
in mind and raise him.self by a determined effort of
the will. Pure thoughts and chaste associations,
vigorous physical exericse, and a resolute effort to act
a manly part will always be successful. — Dr. Charles
L. Dana, Text-Book of Nen-ous Diseases, p. 460.
;02
MEDICAL RECORD.
[October 3, 1896
Cardialgia of Hysteria and Neurasthenia — Tinc-
ture of piscidia erythrina in daily dose of twenty
drops. — Deutsche med. Wocli.
Clinical Thermometers should always be cleansed
with antiseptic care after using. This is neglected by
many physicians, even after use in the mouths of pa-
tients ill with infectious diseases.
Dyspepsia. —
I{ Acidi hydrochlor. dil 3 ss.
Tinct. nucis vom 3 ij.
Liq. potass, arsen gtt. Ixxij.
Ess. of pepsin q. s. ad 3 vi.
M. S. Two teaspoonfuls in water after meals.
Amenorrhoea. —
'S, Aloes pulv.,
Ferri sulphat. e.tsic. .
Terebinth, alb aa gr. xv.
M. et ft. capsul. No. xvi. S. One capsule an hour after
each meal.
Much better effects are obtained from the iron by
giving one hour after meals instead of immediately
after. — Dr. Parviss.
Seasickness. —
I^ Cocain. hydrochlor.,
Hxt. opii 5a gr. iss.
Powd. niarshmallow root q. s.
Mix and divide into pills No. x. S. One pill every second
hour.
Hyperidrosis of the Feet. —
1{ Liquor, ferri chloridi § i.
Glycerini 3 iiss.
Olei bergamotta; 3 v.
M. S. Apply topically with a brush.
— Dr. Lec.oux, Deiitsdie mcil. Jl'or/i.
Chronic Pyelitis when Pain is Present. —
U Venice turpentine,
Powdered camphor aa 3 iss.
Extract of opium gr. v.
Extract of aconite root gr. iij.
Mix and make into tnenty pills. One pill to be taken every
eight hours, and at the same time a small glassful of infusion of
uva ursi. slightly sweetened.
- — Dr. a. Robin, Progres Medical.
Epilepsy. —
I^ Codeina; 3 i.
Potass, bromid 31).
Infus. adonidis vernalis 3 iv.
M. Dose; From half a tea.spoonful to a teaspoonful thrice
daily.
— Gaz. hcbd. de Med. ct de Chir., 1896, No. 17.
Nettle Rash.—
I^ Sugar of lead gr. xv.
Dil. hydrocyanic acid 3 iv.
.\lcohol 3 viiss.
Distilled water q. s. ad ; ij.
M. S. To be applied on cotton wool.
— Di(hlin Journal of Medical Sciences.
Broncho-Pneumonia in Children —
^ Sodii benzoatis gr. viij.
.Vmmonii acetatis gr. xxiv.
.Spiritus vini (cognac) 3 ij.
iiistune acacia?,
Syrupi simplicis aa 3 iss.
.S From one-half to one fluid drachm every two hours.
— Dr. M.^rfan, Bct. Intcntat.
Ichthyol Varnish. —
U Ichthyol 25 parts.
Carbolic acid 2 J^ "
Starch 50
Water ■Zi%, "
Dissolve the ichthyol and carbolic acid in water with heat,
then aild the starch.
— Unna.
Influenza. — Creosote, fifteen to sevent\-tive minims
dail}-.- -I^Ki.iN".
Lympho-Sarcoma. — Full doses of arsenic. — -Schle-
SINGER.
Lupus Erythematosus. — Continuous large doses of
arsenic up to the point of systemic poisoning effects,
— Hutchinson.
Pemphigus. — Treat locally as a burn. In acute
pemphigus, sulphate of quinine. If patient is robust,
blood-letting. In chronic pemphigus, tonics. — Cham-
bard.
Hydrotherapy has proven successful. — Hebra.
Pruritus Ani has become a frequent affection among
bicyclists. Wash frequently with alcoholic lotions;
change linen often. In severe forms apply a solution
of caustic potash. — Stafford Taylor.
Chlorosis. — In true idiopathic chlorosis, when iron
is ineffectual, sulphur will produce a marked amelio-
ration. After using sulphur, iron can again be re-
sorted to, and it becomes very beneficial. — I)r. Shultz,
London Medical Times.
Coil ;dones and uterine chloasmata are improved by:
1$ Aq. oxygenat 20-40 gm.
Vaseline 20
Lanolin 10 "
Pruritus Vulvae. — After local bath apply:
I{ Ex. cannabis ind 2 parts,
Pulv. zinci oxid 6 '*
Potass, brom 10 "
Glycerite of starch 30 "
Haematemesis. —
li Pulv. plumbi acetatis 0.20 cgm.
.Morph. hydrochlorat o. ID "
Pulv. sacch. alb 5. gm.
AL et ft. cht. div. No. x. S. One every two hours.
— Bamberger,
" L " Line Favorite for Burns —
I^ Lanolin I part.
Lard 2 parts.
Lime water 3
— Allen.
Borosalicylic Cream. —
R Borosalicylate of sodium 20 g[ni.
Glycerole of arnica 40 "
Lanolin '. . . . iS "
.•American vaseline 22 "
— Bernegau.
Hemorrhage after Tooth Extraction. — Ferrijjyrin
(a combination of untipyrin, si.\t\-four per cent., and
chloride of iron, thirty-six per cent.j not only stops
bleeding, but diminishes the pain when ap|)lied by
means of a pledget of cotton. — Frohma.v.
Guaiacol as an analgesic should be mi.xed with an
equal part of glycerin, and covered with impermeable
tissue to prevent evaporation. To secure antithermic
results, it must be used pure or in a vehicle capable
of being absorbed by the skin..^FERkAND.
A New Thermometer without visible scale until
tlie tube is cf)vered witii an outer case has been pre-
sented by Dr. Mercier to the Zurich Medical Society.
It is intended for use in cases of inquisitive patients
when it is thouglit best that they should be kept igno-
rant of their thermic condition.
Prolonged Gestation. — Reckoning from the cessa-
tion of the last menses, the first feeling of life, and
the objective signs. Dr. Szaszy reports a case in which
gestation lasted three hundred and thirty days. The
child was normally developed, and forty-nine centi-
metres long. — Gyogyassat, 1894. No. 39.
October 3, 1896]
MEDICAL RECORD.
503
OPoi;triespDuclcuce.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE WATER FAMINE ENDS SANITARY INSIITUTE
OFFICERS OF HEALTH PORT SANITARY AUTHORITIES
— LAWSON TAIT ON VIVISECTION MRS. TAIT ON
THE MATERNAL EXPRESSION ARMY SUR'JEONS.
LuNl)i>N, September li, l8g6.
A RAINY week has put an end to the so-called water
famine, which I have previously mentioned. It is to
be hoped that the company will not be allowed to es-
cape its responsibilities, for this is the third time in
1895-96 that it has failed in its duties. When the
contract to supply is broken, surely payment should
not be expected; and in the case of such a necessity
as water, a serious failure should entail forfeiture of
the monopoly. A representative of the Times has
rather taken the part of the company, and harped on
the wastefulness of the locality and the necessity of
cisterns. He does not seem to know that household
cisterns have long been tabooed by sanitarians, and
talks of fifteen gallons daily per head as a sufficient
supply. New York, which has, I believe, between
eighty and ninety gallons, would demur to his esti-
mate. \N'hy, it takes thirty to forty gallons for a com-
fortable bath. The F.ast London Company has failed
again and again. There is no need of delay for in-
quiry. The time for action has come, and their mo-
nopoly should be ended. The water question must
come before Parliament again.
The Congress of the Sanitary Listitute, of which I
reported the opening by the Duke of Cambridge, was
fairly successful. Milk supply, water supply, the
grievances of sanitary officers, the need for a minister
of health, and various similar subjects were discussed.
Drs. Waldo and Walsh urged that medical officers of
health should devote all their time to the duties of the
office. Professor Corfield held that compulsory vac-
cination ought to be strictly enforced, in order to pre-
vent the spread of the most dreadful infection the
world has seen. Earl Percy, the new president, said
he always thought after one fine it would be better to
send a recalcitrant to prison, which would show
whether his objection was really cotiscientious. Dr.
Newton also spoke on this subject, liovine tuberculo-
sis was treated by Mr. W. Hunting, ex-president of
the Royal College of Veterinary Surgeons, who ably
argued that it was absurd to try to protect the public
by inspecting meat and milk while doing nothing to
control the source of infection in the animals from
which the meat and milk are obtained.
The conference of oflicers of health was presided
over by Dr. A. Hill, who pointed out that diplitheria
is increasing in this country, and that this is the more
important, inasmuch as tiie proportion of this disease
to small-pox, measles, scarlet fever, whooping-cough,
and typhoid is also increasing.
The conference of port sanitary authorities was pre-
sided over by the chairman of the port of London au-
thority, who pleaded for a wider recognition of the
work of those who were keeping the front door of the
coiuitry against the importation of infectious diseases.
.Mr. Lawson Tait has long been numbered among
llie opponents of experiments on animals with a view
of applying the results to surgery. Sucii a course, he
considers, would lead to serious error. He has now-
cast in his lot more decidedly with the antivivi-section-
ists. Their magazine. The Aiiimal's Friend, for Au-
gust, opened with an article by Mr. Tait, entitled " Why
I Oppose Vivisection." He says Syrne and I''ergus.son,
who differed whenever they could, were right when
they asserted that surgery had in no way been advanced
by experiments on animals. He then observes that
the opinions first enunciated by these eminent sur-
geons, and entirely shared by himself, " have since
their time slowly percolated through the profession and
will some day soon be completely recognized by the
whole body officially." The last word scarcely adds
to the value of the assertion, as we have no official in-
terpreter of the whole body ; and whether the '" some
day" will be "soon" is open to question. Then comes
the statement that the governing infiuence of the Koyal
Society has been the biological school, and of late
years this may be admitted; as may, perhaps, the ac-
companying statement that hospital physicians and
surgeons covet the F.R.S. less than formerly. Mr.
Tait goes on: "This, however, has still to be said, as
it might have been said any time this last twenty years,
that any one holding the \iews I do on the subject of
experiments on animals might as well stand for the
presidentship of the United States as for the fellow-
ship of the Royal Society — and of this no secret is
made." The introduction of this personal allusion
will bring a grim smile to the faces of some of his
enemies, who may exclaim, " Iii7ic illm lacrymie ;'^ but
Mr. Tait cares for nothing of the kind, and is not
likely to mince his words. This he shows a little fur-
ther, when, having quoted Sir Edwin Arnold's speech
from the British jMeJieul Joiiniai, he adds: "The edi-
tor of this journal is a Mr. Abraham Hart, a Hebrew
with a past, and his rancor on the subject . . . and
his animosity toward tliose who support tlie movement
in any way, has been most remarkable, even among
those of his race who are noted . . . for their support
and their practice of vivisectional research." This
fling would, perhaps, have been as well reserved for
the ethical meeting at Carlisle.
Passing by all hard words, which will have no more
effect on his opponents than on himself, I find little
in Mr. Tait's contribution to 7'/ie Animal's Friend,
until he mentions his position on ectopic gestation and
his views concerning the uncalled-for experiments of
a German vivisector. Certainly here Mr. Tait speaks
to the point. But his opponents will draw a distinc-
tion between the use and abuse of experimentation.
He says he does not take up the sentiment of the
question. This point, however, is illustrated by his
wife in a subsequent article in the same magazine.
Mrs. Tait gives some interesting reminiscences of her
sensations and of her cats. She also professes to rec-
ognize a " peculiar look impressed by maternity upon
the female of all animals." This "special expression
is common to us and the lower animals," says Mrs.
Tait, and she sees it in the Madonnas of A. del Sarto
and of other painters, as well as in the cold marble of
the wolf suckling Romulus and Remus, at Florence.
I cannot emulate Mrs. Tait as a judge of physiog-
nomy, but have, I fancy, quite as kindly feelings
toward animals. Put I draw the line where perhaps
she would, too. A lady living near me treats a cat to
fresh sole and other expensive articles of diet daily.
That, too, when human children starving do not touch
her sympathy. Truly, human beings are strange
creatures !
I hear that between sixty and seventy army medical
officers, having completed their six years' foreign ser-
vice, are now entitled to be relieved. With the dearth
of doctors at home and only half the number of candi-
dates for the vacancies, the officials will be puzzled
to make proper provision. It is not the first time such
a deadlock has been brought about by the stupidity of
military prejudice. The Admiralty and Norse Guards
Gazette, which refiects the follies of so-called comba-
tants, has lately pretended that the army surgeons are
too bru.sque to be favorites. The discovery is worthy
of the combatant who " seldom drinks and never
504
MEDICAL RECORD.
[October 3, 1896
swears,"' or of the journal that is content to play syco-
phant to snobs.
The contest with clubs ' still goes on with varying
fortune. In some places the profession has triumphed,
but onlv where a united front has been maintained.
THE SECOND INTERNATIONAL CONGRESS
OF GYNECOLOGY AND OBSTETRICS.
To THE Editor of the Medical Recokd.
Sir : The medical profession is, perhaps, the most truly
co-operative international body on earth. Its mem-
bers all work toward one aggregate result and rule of
practice. When, therefore, the full report of the Ge-
neva Congress is published, we shall have the latest
opinion of the best professional minds of the world on
the subjects discussed.
You will already have received the special report of
proceedings. But until the volume of transactions
arrives, it is premature to estimate the scientific result
of the meeting. It must suffice to touch its surface
phases.
"Scientists are all compatriots," said Pean, in his
toast; and this sentiment was realized thoroughly in
the social aspect of the congress, though hardly in the
set meetings. Some of the contretemps here were al-
most farcical. In the first place, there was no discus-
sion. The papers on the set subjects were printed
and distributed in advance, and then rapidly read in
the mother tongue. Nearly all the members, other
than the compatriots of the speaker, would scamper at
the opening of an uncomprehended paper — excepting,
perhaps, our own courteous countrjmen, whose sense
of decorum made them more than attendants upon a
mere national section of an international congress.
Then, the " ten-minute" discussions, so-called, were
also short essays printed and distributed beforehand;
giving, it is true, the author's opinion, but in no sense
debating previously expressed views. The one virile
exception was Pe'an's extempore response to Doyen, of
Rheims, who claimed priority over the giant hysterec-
tomist in describing the vaginal operation. Here the
interest was real, instant, and international, and
reached a climax in the trumpet-like note of wrathful
denial from Pe'an, while his adversary still held the
Hoor. Its significance made it of no import that he
had already exhausted his right to respond. The de-
nial was thoroughly before the jury.
This, with a few similarly interesting episodes,
lightened the tedium of the polyglot monotony. A
president of one tongue would sometimes preside en-
tertainingly, yet disastrously, at the reading of a paper
in another. One gentleman, turning -to illustrate a
point on the blackboard, found himself stranded with
his drawings and his successor well into a new sub-
ject, because the jaresident had fancied his paper con-
cluded. Orators with individual communications on
subjects otiier than the leading ones before the con-
gress were shown to a room apart, where they might
read their papers, to themselves at least, in default of
better audience.
But these trifles, occasioning hardly a ripple of feel-
ing, served only to accent the cordialit)- of the ban-
quet board and to demonstrate that in the social com-
minglings rather than in the amphitheatre was to be
found the worker's heartiest recognition. For here
each great man button-holed each other great man,
and compared grandeur. Consequently, it was man to
man — Frenchman to German, Russian to Italian,
American to Spaniard, though oft in pigeon tongue —
that the real discussions of the congress were held. It
' .\n obvious misprint in my letter on this subject in the
Medical Record, August Sth, may be corrected. The annual
sum was printed ^2.6.f to £'i.bs instead of is. bd. to 3x. td. It
is a case of pence, not pounds — dimes, not dollars.
was this near touch which will enable men to judge of
the reliability of the views and statistics of all these
familiar names and now familiar faces, when the edit-
ed transactions come to be perused in the quiet of the
home library. It was this personal contact which al-
lowed the scanning of the statistic makers for truth
and conscience and absence of vainglory — for the zeal
for science more than zeal for self.
The best men should have the shortest lists and the
worst statistics. A zero mortality is easy to a con-
scienceless man bent on personal eclat. A large mor-
tality is necessary to the conser\'ative man w-ho ope-
rates only on desperate cases, and whose ambition is
to see how few instead of how many of the women
coming before him he can put to the knife. This is
why statistics lie. This is why personal knowledge of
the operator interprets his figures.
Whether or not great addition to the scientific store
has been made, the congress from this social point of
view was pre-eminently successful. It showed the
arena to the gladiators; man measured man ; and from
this atmosphere of the leaders in the science of g)'ne-
cology and obstetrics, one must return to the local cli-
entele stimulated to renewed labor, taught the vast
difference between mere well-fed local success and the
honor of contributing even a mite to a world's science.
And humanity profits, although all of the gray heads
of the second may not be present at the third interna-
tional congress.
Eugene Coleman Savidge, M.D.
Paris, September lo, 1896.
2^ccUccil Ztcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending September 26, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Leprosy
Cases.
Deaths.
170
"4
25
10
33
3
3
3
34
0
127
20
I
0
According to the Text-Books. — A bright young
'■ dresser," whose knowledge of anatomical illustra-
tions seems to have e.xceeded his acquaintance with
the operating-table, was asked the other day how he
could distinguish between a vein and an artery in an
operation. " By the color," quickly responded the
youth. ■■ \\'hat is the difference?" asked the surgeon.
" The veins are a beautiful blue, and the • " but
the remainder of his interesting statement could not
be made out owing to the altered condition of the
class. — Medical Press.
Tobacco. — Tobacco, one of the curses of the world,
as pronounced in its malignant influence as dirt; not
so hoar)'-headed with age as filth, but considered more
respectable; only the proverbial peck of dirt, the
amount allotted to each individual, but no limit placed
on the amount of tobacco used; the average chewer
consuming nine hundred pounds of the weed, causing
an expectoration of about forty-five barrels of saliva;
the average smoker consuming sevent\--three thousand
cigars; the smoke ascending from the cigars and pipes
of the world rivalling the fumes of the bottomless pit.
— H. M. Ochiltree, M.D., Kansas Medicaljournal.
Medical Record
A IVeekly yournal of Medicine ami Surgery
Vol. 50, No. 15.
Whole No. 1353.
New York, October 10, 1896.
$5.00 Per Annum.
Single Copies, loc.
©vioiual %x\xt\z^.
PRACTICAL POINTS REGARDING THE SE-
NILE INSANITIES, WITH SPECIAL REF-
ERENCE TO PROPHYLAXIS AND MAN-
AGEMENT.
Bv RALPH LVMAX PARSONS, A.M., M.D.
NEW YORK.
Of all tlie mental aberrations and degeneracies, none
are more worthy of the attention and study of the gen-
eral practitioner of medicine than those which occur
at advanced periods of life; for while under normal
conditions the mental powers should outlast the phys-
ical, remaining unimpaired in their essential qualities
until the end, it is nevertheless true that in many of
the aged the mental faculties fail with or before the
physical; and, furthermore, that many of these fail-
ures might have been prevented, or at least delayed,
if wise counsels had been obtained and followed; and
that no one can be so well fitted to give such counsel
and advice as the family physician, who is in a posi-
tion to see and duly estimate the causes which are
leading to these failures. And wlien, in due time, the
family physician shall be habitually retained as an
adviser of the family in health as well as in disease,
as he should be, and as lawyers are now often em-
ployed to look after the interests of the family prop-
erty when it is neither in litigation nor in danger, the
physician can render still greater ser\ice in warding
off the mental diseases to which the aged are exposed.
.Another reason why this subject deserves the espe-
cial attention of the family physician is that the aged
are more disturbed by removal from cu.stomar)' habits
and surroundings than younger persons, and a proper
and laudable respect for their age and for the ser-
vices of a lifetime demands that their feelings in this
regard should be respected in so far as is compatible
with their best interests; and so that they should re-
main longer under the care of the family physician
than would be advisable or desirable in the case of
younger persons.
We are quite accustomed to expect that mental de-
terioration will take place /rtrZ/i^j-.w with the physical
weaknesses that are inevitable at an advanced age.
And yet we not unfrequently meet with aged persons
who are on the verge of physical dissolution, but
whose mental faculties remain unimpaired in quality,
and as active as at any other period of life when the
body is in a like state of debility from any cause. In
fact, the normal brain which is free from disease, in a
well-constituted body, ought to be the ver}' last of the
organs to fail in its functions. .\nd mental force often
proves itself to be the conser\-ator of the physical
forces. In proof of this, it is sufficient to note the
fact that people who are apparently hopelessly ill and
who are told that their recovery is beyond hope, some-
times stubbornly dissent from that view and actually
do recover: and when there can be no more doubt that
they would have died but for their mental resistance,
than we can doubt that of two drowning men of equal
physical powers one may save himself by his deter-
mination to do so, while the other is lost by his lack
of mental force. And this mental force or its lack
does not depend entirely on the.original quality of the
brain substance itself, but in part, at least, on the sort
of training to which the mental powers have been sub-
jected. If these well-constituted brains are less ac-
tive in later tlmn in earlier years, this can be readily
accounted for by the fact that bodily weaknesses hin-
der and prevent prolonged activity ; and also that
former incentives to activity no longer exist. It is
generally admitted that persons of advanced age are
often of better judgment than the young. Nor is it
correct to assume that every failure of the memory is
an evidence of failure of the mental powers. There
are different sorts of memory, and some of these mav
fail while others persist: those which persist being
the ones in which the person takes the greatest interest,
or which have been oftenest repeated. And then, with
increased years, the number of things to be remem-
bered also increases, and the impressions which have
been the fewest in number will naturally be the first
to fail in the memory. The impressions of earlier life
excited great interest from their comparative fewness
in the past, or they have had many repetitions and so
have induced a cell habit favoring a reproduction of
the impression. Proper names — that is, specific
words which are applied each to one specific person or
thing — are the soonest forgotten of words, for the
simple reason that they are specific, and so of infre-
quent application. It is only an exaggerated or an
essential loss of memory in the aged which should be
considered as involving the integrit)' of the mental
faculties; as when the names of near relatives are for-
gotten, or when the conventionalities of daily life are
no longer remembered. And it is even possible for
the reasoning powers to subsist with the ability to
perform the ordinary duties of daily life, when there
is an entire lack of ability to construct a single intel-
ligible sentence or to recall the names of intimate
friends.
But it must be acknowledged that with the acces-
sion of the physical infirmities and changes incident
to old age — the loss of muscular strength, the loss in
weight, the wrinkling of the skin, the arcj*s senilis,
the trembling of the hands, the emaciation, the failing
appetite, the impairment of digestion and nutrition,
the weakening of the action of the heart, the dimin-
ished tone and resiliency of the vascular system, at-
tended oftentimes by organic changes of the vessels;
the dulling of the special senses, especially of the
hearing; the disturbed sleep at night, or the hebetude
by day — that these, existing in var)'ing degrees, are
often attended or soon followed by important changes
in the mental processes — changes which, although they
cannot yet be fairly considered as pathological in
character, are still an evidence of a weakness that fore-
bodes impending danger. As examples of these men-
tal changes may be mentioned irritability of temper,
imperiousness, disturbance of the emotions without
sufficient cause, or an undue diminution of emotional
excitability, extreme loss of memory, great diminu-
tion of the power of attention, diminished power of
abstract thought, fickleness, or perversity of disposi-
tion.
5o6
MEDICAL RECORD.
[October lo, 1896
When many of these signs and symptoms are mani-
fested in a marked degree, the border line of unmistak-
able mental alienation cannot be far distant. But it
should not be inferred that the border line must of
necessity be passed. Under wise advice and suitable
conditions, the crisis may never be reached ; and the
reason may be conserved, without essential impair-
ment, until the end. \or should it be inferred that
because the border line has unmistakably been passed,
a recovery is impossible on account of the advanced
age of the patient; for, in fact, the aged are nearly or
quite as likely to recover from an acute attack of in-
sanity as those persons who suffer an attack at other
periods of life, when the ratio of persons living at this
period is taken into consideration.
And at this point it is well to note that senility is
not altogether a matter of years. Some persons are
physically and mentally as old at fifty as others are
who are ninety or even a hundred years of age. Some
families have greater vitality than others; and so
their members are likely to live a greater number of
years and to become senile later in life. The age to
which any individual can possibly survive under the
most favorable conditions depends upon the amount
of vitality he has inherited from his ancestors. This
amount can never be increased, although it may be
and often is diminished. And herein lies the indica-
tion for means to delay the approach of premature se-
nility and decay, whether on the phvsical or on the
mental side — the removal of influences which are pre-
judicial and the substitution of those which are ad-
vantageous.
The acute mania of the aged differs so little from
the acute mania of earlier years as to require only a
passing notice, save that the physical resistance lo
prolonged excitement and loss of sleep is sometimes
marvellous. Complete recoveries are not infrequent;
and these may be enduring or may give way to subse-
quent attacks. The maniacal attack is often preceded
by a period of mental depression.
The cases of mild maniacal e.xaltation that are
sometimes observed in the aged usually have their
origin at an earlier period of life, and cannot be con-
sidered as characteristic of senile insanity.
Melancholia in the aged is more insidious in its
onset, and may be either a simple mental depression,
melancholia without delusions; or it may be charac-
terized by insane delusions. In either form suicidal
impulses are common. The simple form of the dis-
ease is of frequent occurrence, and recoveries are
also frequent. It should be noted, however, that such
false ideas, as that some great calamity is impending,
that they are becoming impoverished, that they have
ruined their friends, that their souls are lost, or that
they have committed the unpardonable sin, should not
be ranked as essentially insane delusions — that is, as
delusions which are in themselves diagnostic evi-
dences of insanity. The essential characteristic of
this form of insanity is the emotional depression.
The gloomy ideas are the direct outcome and result of
the depressed emotions, and not their cau.se.
In the delusional form of melancholia, in the aged
no less than in earlier life, the delusions are of an es-
sential character, as that their most devoted friends
have become their malignant enemies, that their food
is being systematically poisoned, that they are to suffer
a violent death, or that their bowels are inhabited by
snakes. Incredible delusions of this sort are indica-
tive of a profound mental degeneration, and recovery
is very much more rare than in the simple form.
If recovery from these acute forms of senile insan-
ity takes place, subsequent attacks are liable to fol-
low, especially if care be not taken to avoid the excit-
ing causes. The same predisposition which was the
basis for the first attack must still persist, and in a
brain already weakened by the previous attack. If re-
cover}' does not take place, the patient usually passes
into a condition of consecutive dementia, from which
recovery is not to be expected.
The typical insanity of the aged is a primary de-
mentia, which differs from the primary dementia of
earlier life in that it is incurable; depending, as it
does, on organic changes in the tissue of the brain.
Primary senile dementia is in many particulars simi-
lar to general paresis, its characteristic condition be-
ing one of weakness.
Oftentimes this form of senile insanity is verj- in-
sidious in its onset. In the earlier stages it may be
very difficult to distinguish the approaches of a de-
mentia which leads ine\itably to a condition of fatu-
it}-, from the mere lack of mental activity which ac-
companies the physical infirmities of the aged while
the reason still remains unimpaired. In this stage of
the disease the demented person often performs acts
which are foolish in the extreme, and which may lead
to serious medico-legal complications. He becomes
penurious, depriving himself of the comforts and nec-
essaries of life, or he disposes of his property with-
out reason or consideration; he makes unwise mar-
riage engagements, or makes improper proposals to
women, or, more likely, he makes indecent assaults on
little girls. The sexual instinct often persists in the
aged dement when the power has become nearly or
quite extinct.
Later on, both body and mind inevitably fail in
strength, especially the mental powers. The dement
then wanders aimlessly about, meddling with whatever
comes within his reach, or he busies himself with
placing and replacing articles without value. He
loses all ideas of the conventionalities of life, of de-
cency, of persons, and of places; he removes his cloth-
ing, urinates in a corner of the room, or he passes his
excrements unconsciously ; or he becomes utterly stu-
pid and apathetic, with, perhaps, alternations of exci-
tability and depression. And from this condition there
is no reprieve until the end.
The causes of the senile insanities, some of which
are coincident with the causes of the other insanities,
maybe conveniently considered under three categories
— those which are so remote as always to have been
practically beyond our control; those which are in ac-
tion at the earlier periods of life; and those which are
in action when senility is already impending.
There can be no question that heredity and congen-
ital influences are important factors in determining
the mental status in any period of life. If these influ-
ences are beyond our control, their consideration may
be an important aid in making our prognosis and in
advising such measures of prophylaxis as may be re-
quired.
The second class of causes is also worthy of consid-
eration, not only with reference to prognosis, but also
because, although somewhat remote, they may still be
controlled or modified if only timely advice be given
and heeded; and it is at least barely possible that
here and there a person may be found who will profit
by advice bearing on the yet remote future. These
causes are, for the most part, such as tend to produce
organic changes in the vessels of the brain or to bring
about a state of exhaustion of the physical or mental
powers — as chronic alcoholism, syphilis, gout, rheu-
matism, venereal excesses, great and ]5rolonged physi-
cal strain, intense and long continued mental applica-
tion, with anxiety or worry; and lack of self-control,
as indulgence in the passions of grief or of anger.
A mere mention of these causes is enough to suggest
the measures of prevention that may be required. On
the other hand, a life of self-control and moderation
in all things is the best possible safeguard against a
premature breakdown in advanced life.
October lo, 1896]
MEDICAL RECORD.
507
The causes, however, which are in operation when
at a somewhat advanced period of life the infirmities
of age begin to make themselves felt are of more im-
mediate importance; because the advice of the physi-
cian is then more likely to be sought and followed.
Some of these causes are the same as those pertaining
to an earlier period of life, and are only of more im-
portance now because the power of resistance has
been diminished. Others are especially pertinent to
the advanced period of life. It will be a matter of
convenience to consider measures of prophylaxis in
connection with each, in turn.
When the physical powers begin somewhat to fail,
with advancing years, giving notice of the greater dis-
abilities that are soon to follow, there is oftentimes a
great disinclination to heed the warnings thus re-
ceived; a tendency to engage in exhausting labors in
competition with those who are still in the prime of
life, and to encounter hardships and exposures which
might have been borne with impunity in earlier years,
but which now involve a strain which is likely to
prove injurious in its results. There seems to be a
sort of pride in appearing not to have lost anything of
pristine vigor. Although it may be evident enough to
others that a moderate pace should now be taken, ad-
vice to this end will usually be required.
But the opposite extreme should also be avoided.
The entire giving up of accustomed physical activities
may be even worse than their continuance. It is often
observed that those who suddenly and entirely cease
from their accustomed work fail more rapidly than do
those who continue their labors, only there should be
a diminution in the amount and hours of physical ac-
tivity, in due accord with the bodilv failing and disa-
bilities.
Although mental work with a well-constituted brain
may usually be continued more fully and later in life
th.in physical work, this should also be diminished
with advancing years; both because the brain then re-
quires more rest and more time for recuperation, and
also because severe mental work is of itself exhaust-
ive of the bodily powers. But here, also, an entire
giving up of mental work may be more injurious than
its full continuance. What is required is a continu-
ance of mental activity with such changes in amount
and quality as are in accord with its diminished pow-
ers of endurance. And these changes in habit, both
mental and physical, should be made not after this
has become compulsory through loss of ability, but
when the first intimations of the coming necessity be-
gin to make themselves observed and felt.
Among the premonitory symptoms and the imme-
diate causes of insanity in persons who are becoming
old, lack of proper and sufficient food and lack of
sufficient sleep are prominent. With advancing
years, a certain degree of insomnia comes on, the
nights are restless, and so the sufferers from insomnia
remain sitting up or wandering about, because they
thus seem to be less uncomfortable than when tossing
about in bed with inability to sleep. When they finally
lie down and fall asleep, their sleep is disturbed and
unrefreshing, and they awaken with or before the early
dawn, having secured only a moiety of the sleep they
really require; or, after an almost restless night, they
fall asleep after dayl)reak, when others are just begin-
ning the occupations of the dav. And thus the vicious
circle is commenced of turning night into day and day
into night, with all its inconveniences and draw-
backs; for the nighttime, with its quietness and free-
dom from causes of disturbance, is a much more
favorable time for normal, restful sleep than the day-
time, with its many causes of disturbance. And yet,
if sleep will not come at night and does come by day,
this is certainly better than no sleep at all. But every
possible means should be employed to break the
vicious cycle and to secure a sufficient amount of rest-
ful sleep during the hours of night. It will often be
found that a short nap taken once or twice during the
day will favor better sleep at night, by relieving the
nervous irritability which tends to prevent sleep.
And then there are many things that the aged sufferer
from insomnia may do to promote sleep. A warm
bath taken just before retiring, with cold applied to
the head, may be an efficient aid. A cold douche to
the feet and legs, or a wet pack to the abdomen, is
sometimes useful. A light supper just before retiring
is usually of advantage.
Babies and brute animals are usually somnolent
when their stomachs are well supplied with food, the
activity of the stomach withdrawing the excess of
blood from the brain, where it is not needed during
sleep. On the other hand, people who are very hun-
gry usually find it difficult to sleep. And, then, a
habit of sleep at a regular time and during proper
hours should be cultivated in case this habit has been
lost. In accomplishing this, the attainment of a fa-
vorable state of mind is of great importance. Sleep
cannot be enforced by a direct exercise of the will.
The very effort of the will to command sleep is enough
to render its attainment nugatory. The mental state
to be encouraged is one of quiescence, one of indiffer-
ence, a feeling that the recumbent posture is a proper
one for rest, and that if the thoughts are disposed to
continue active they may be safely allowed to take
their course without any effort toward control. This
state of mind and thought is next akin to dreams, and
dreaming is next akin to sound sleep. Many mental
methods have been advised and put in practice for the
purpose of securing sleep, the design being to turn the
thoughts from objects of interest to a condition of
monotony; as by mentally repeating well-remembered
phrases or sentences, or by counting. But the state of
indifference, if this can be obtained, is likely to be
the most efficient, as being the least active. The mere
mention of these simple methods will be sufficient to
suggest others equally effective.
Equally important with restful sleep is the taking of
a sufficient amount of nutritious and easily digestible
food at proper intervals; for one of the usual forerun-
ners of a mental breakdown is loss of appetite or ne-
glect in the taking of food. Not that the stomach
should be overburdened with food, for this, too, would
be prejudicial ; but that a sufficient amount of suitable
food for the purposes of nutrition should be taken at
proper intervals. If the nights are restless, a glass of
milk and a biscuit may often be taken with advantage
on awaking in the middle of the night or toward
morning; or a glass of warm milk in the early morn-
ing before rising.
In case an actual attack of insanity should super-
vene, one of the first questions to arise will probably
be whether the patient can be better treated and man-
aged at home and among his own friends or away from
home. The conditions and circumstances vary so
greatly in different cases that each one must practi-
cally be considered by itself. In a general way it may
be said, however, that the acute cases usually do
better under skilled treatment away from their homes
and their intimate acquaintances. And since these
patients have a fair prospect of recovery, they should
be given every advantage that tends to secure this de-
sirable result and without too much regard to their
feelings or wishes in the matter. If it is decided,
however, to treat them at home, their domicile should
be made a private hospital, in so far as may be re-
quired for their successful treatment, or until all rea-
sonable expectation of recovery has passed away.
Especial attention should be given that they get suffi-
cient food and sufficient sleep; and inasmuch as the
melancholies almost always have suicidal propensities.
5o8
MEDICAL RFXORD.
[October lo, 1896
these should always be under efficient supervision. In
case food is persistently refused, resort should be had
to forcible feeding; and there should be no unneces-
sary delay in doing this, for the longer the delay the
more obstinate is the refusal likely to be, while with
delay the physical powers are liable to become too
much impaired to admit of recuperation. But, before
resort is had to forcible feeding- by means of the
■cesophageal or the nasal tube, e\ery possible means
should be employed to induce the patient to take food
with something of volition, by persistent and strong
persuasion, or by an assurance that force will certainly
be used if required. If forced alimentation be re-
quired, the cesophageal tube has the advantage of be-
ing safer and of admitting the use of more solid food,
an advantage in itself if the feeding is to he long con-
tinued. In addition to the means already mentioned
for securing sleep, drug treatment may now be advis-
able; the various well-known hypnotics being em-
ployed in turn, in order to avoid the danger of estab-
lishing a tolerance for any one of them and thus
limiting the means of relief at our disposal. Another
reason for a frequent change in the hypnotic drugs
administered is that, inasmuch as all potent remedies
have their disadvantages, each in some particular way,
as well as their advantages for the specific need, the
disadvantageous action of the remedies will be dis-
tributed and thus reduced to a minimum. Opium is
rarely to be recommended as a hypnotic. It may be
of use, however, in very small doses, as a stimulant in
cases of melancholia.
The wet pack is also sometimes useful, acting as a
revulsive from the head, relieving the dryness of the
skin and at the same time securing a state of bodily
quiescence which is favorable to sleep. The applica-
tion of some form of the electric current, or suitable
massage may also be of advantage. Those little mo-
notonous attentions which are well known to be so
soothing in the care of restless children should not
be forgotten. The mere presence of the nurse as a
bedfellow, with a hand resting on the person of the
patient, may afford a sense of security or relieve a
sense of lonesomeness, and so promote sleep.
It is always to be understood, as a matter of course,
that all concurrent and intercurrent diseases will be
treated in accordance with the requirements of each.
The decision of the question whether the subject of
senile dementia should be treated at home depends
chiefly upon two considerations: First, whether this
can be done without too seriously compromising the
welfare of other members of the family; and sec-
ondlv, whether, all things considered, the patient can
be made as comfortable and as happy as at some
availaljle place elsewhere. But, there may be no
suitable home; there may be neither relatives nor
friends who are willing and competent to under-
take the necessary supervision and care; for, however
kind and w'illing the friends of the patient may be, the
task may involve too great a strain upon their sym-
pathies and on their powers of endurance. Or, as
often happens, the patient may be less tolerant of the
necessary measures of care and restraint at the hands
of relatives than at the hands of others. .Ml these
considerations should be carefully taken into account
by the physician who is called upon to advise. If,
however, these two questions can be answered in the
affirmative, inasmuch as a cure is no longer to be
expected, there can be no doubt that such of these
patients as have a home and devoted friends ought not
to be removed elsewhere for care and treatment.
It often happens that the relatives of the aged de-
ment are quite competent to give all the care and nurs-
ing that mav be needed. If not, suitable nurses should
be employed; and, even for the care of men. female
■nurses are to be preferred, if competent for the per-
formance of the required duties. Or if, as sometimes
happens, kind-hearted neighbors volunteer their ser-
vices as nurses, these untrained volunteers, as well as
the family of the patient, need to be especially in-
structed regarding the nature of the service to be done.
A neglect of this precaution has sometimes led to dis-
astrous results, from a failure in the proper observance
of sanitary measures, when the patient has become
bedridden and can no longer control his evacuations.
And so instruction will usually be needed in regard
to the proper ventilation and cleanliness of the apart-
ment occupied by the patient; the removal of carpets,
curtains, and upholstered furniture; the immediate
removal of all evacuations and other sorts of filth;
.scrupulous cleanliness of the person; the prevention
of bedsores, and so on. In other respects, no special
experience is required for the proper management of
this class of patients.
APPENDICI'J'IS— TO OPERATE OR NOT 'I'O
OPERATE.'
liv l.V.MES H. DUNN. M.O.,
.mi.»;neapolis, mink.,
tropessor of gknito-urinarv and adjunct professor op clinical
surgerv, .medical department, fmversitv of minnesota.
Despite the trite ma.xims tiiat doctors are prone to
disagree, and that many men incline to many minds,
no one, whether layman or practitioner, can fail to be
astounded at the wide and positive divergence of the
opinions which have prevailed and .still do prevail
as to the proper management of the condition stermed
appendicitis.
One may readily recall numerous medical and sur-
gical topics upon the details of which authorities have
been in far from complete accord, but it is perfectly
safe to say that during our generation at least no
equally clear and definite condition has been faced by
two partisan and nearly diametrically opjjosite camps
of advisors, who have often met the views of each
other with almost brutal bluntness if not with appar-
ent contempt. Candor com|X'ls me to admit tliat the
assertions of both medical and surgical jxirtisans ap-
pear more ardent tiian accurate and that one often
meets with cases which exhibit the sad results of an
absurd partisan teaching and preaching of abstract
nonsense rather than modest scientific study of the
cases in hand. On the one hand are cases "cured"
into irreparable intestinal adhesions and complica-
tions by the scouters of surgical treatment, and on the
other hand precipitated into the hereafter by indis-
creet, incipient disciples of the shouters of "always
operate."
I have said one is at first glance ajnaxed at the dia-
metrically opposed views so generally set forth on
what might appear to be, as medical problems go, a
relatively simple and now fairly understood condition,
but further scrutiny shows this problem, like most
great patliologic and therapeutic equations, far from
as simple as tlie disputants seem to indicate. To
label a train of pathologic events as variable as those
comprised in appendicitis with a name and to place
opposite it a specific treatment or operation is but
to incite the hordes of comparative ignorance, inex-
perience, and impracticability to pernicious activity
rather than to invite candid, patient study of phenom-
ena and sensible adaptation of remedies to specific
conditions and surroundings.
You may have listened, as I have, to medical ex-
tremists who report scores, even a hundred consecu-
tive cases of appendicitis cured without operation and
' .\ paper read before the Mississippi \'alley Medic?! Associa-
tion, September i8, 1896.
October lo, 1896]
MEDICAL RECORD.
509
without a death. To most of us this would appear a
very rash statement, even on first thought — one calcu-
lated to impair our confidence in the veracitj' or judg-
ment of the reporter. Yet nothing is easier to under-
stand. These good people only mean to say that all
those cases which they have recognized as appendicitis
have appeared to recover. To such I would reply, we
surgeons may learn one thing from you, namely: that
an astonishing percentage of these cases, and even
most threatening ones, recovers more or less completely
from the acute attack. But you have two lessons to
learn from us; first, you clearly fail to recognize a
small percentage of appendicitis cases, namely: those
fulminant cases of peritonitis, the appendical origin
of w'hich is well known to surgeons experienced in
abdominal work. Second, if you carefully follow your
patients long enough you will find that a large propor-
tion of them are far from being cured ; indeed, some die
suddenly after being cured from one to half a dozen
times; while others become invalids from a great
variety of obscure ailments due to intestinal adhesions
and other sequels of the natural cure, which are some-
times difficult, if not impossible, of subsequent relief.
After a considerable experience with the disease
treated without operation as well as on the operating
and post-mortem table, I must admit that the clearly
overdrawn assertions of these medical e.xtremists as-
tonish me less than those of some of our prominent
surgical teachers. I say tiiis, because the surgeons by
their opportunities of direct observation ought to be,
and in general are, more practically familiar with the
whole course ofthisdisea.se than are medical clinicians.
Turning to the latest surgical monograph at hand,
"A Treatise on Appendicitis," Deaver, 1896, I find,
page 113, '"It is true some cases will eventuallv re-
cover by medical treatment (sixteen to four hundred
according to Ribberts) and a slightly greater number
will apparently recover from an attack."
Now, so long as we advise upon such absurdly ex-
treme views as these, we must appear to give each
other the lie direct, and as between the medical and
surgical enthusiast the patient must take his choice,
while the comic daily editor does the rest. As already
remarked, the views of the surgical extremists are on
the whole the most enlightened, and, hence the greater
harm of their often absurdly overdrawn and rashly
stated dogma.
If the line of a surgeon's personal experience leads
him so overwhelmingly into surgical cases as to justifv
such a doctrine as just quoted, the very positive obser-
vations of the medical brethren, although doubtless
and even clearly containing elements of error, should
receive sufficient respect to admonish more caution
and less dogmatic teaching. Just so long as a surgeon
of eminence holds as a fair statement of the non-ope-
rative treatment that but sixteen out of four hundred
cases may he expected to recover permanentlv, and,
more especially, that but a slightly greater number
will recover from one attack, just so long may we ex-
pect every sound-headed general practitioner to scout,
or at least heavily discount, the opinion of surgeons,
because his personal experience leads him to know
better with absolute certainty, and, having found sur-
gic.l teaching clearly false in this particular, natu-
rally to turn his ear from other facts which surgical
experience could furnish him and of which he ou<rht to
be cognizant in giving wise advice to his patient. So
long as surgeons say to these men, What you observe
to be white is perfectly black, there is no ground for
assimilating facts or for advancement of practice.
If this line of treating the subject drives the experi-
enced general practitioner to a dangerous and obsti-
nate suspicion of surgical treatment, it leaves the
young and inexi:)erienced practitioner, of late with a
much overgrown and rather unhealthy surgical ten-
dency, to face the overdrawn dangers of appendicitis-
with ill-timed, ill-placed, or ill-executed operations
which may easily prove yet more dangerous. My own
experience leads me to know that one great class of
practitioners greatly underestimates the dangers of ap-
pendicitis, while another, becoming almost as numer-
ous, as greatly overestimates it.
Another class of surgeons has tried to quash the
whole discussion of the treatment of appendicitis by a
simple application of logic, thus: Some cases of ap-
pendicitis can only be saved by early operation. No
one may infallibly distinguish these cases from those
which may recover without surgical interference.
Ergo, always operate at once; the diagnosis is made.
Logically, and on paper or in discussion, I find this
position fairly good. The rule is certainly easy and
simple and removes a multitude of difficulties from
the practitioner, but I fear only transfers them to the
patient. In all practical matters of this life one finds
none so fallible as those who strive after and adopt
infallible rules of action. Such individuals err about
as frequently as less positive mortals, and when they
do go astray their blunders are often those of genius,
such as a modest fool could not commit. In practice
such a simple rule finds many and serious objections.
Time forbids a discussion of the proposition directly
and I shall seek a shorter refutation in the general
axiom that any treatment which takes nothing inta
account but a single disease factor, giving no heed ta
the patient himself, his circumstances and surround-
ings, is on its face unworthy of the consideration of
practical scientific men. Circumstances alter cases.
True, if we try each case on its own merits and strive
to operate when, where, and in such manner as the
indications and the circumstances interpreted by keen
observation and toiling skill seem to dictate to be for
the individual's welfare, we shall sometimes fail to
have done the best thing at the right time. But will
the advocates of '" always operate" at once prove anv
nearer infallible.' When they shall have proven so
and have been able to say : " Do as I bid and I can
assure you of recovery," then I shall yield. But till
then I prefer to seek indications — now operate at once,,
now delay; or again not operate at all. Time forbids
boring you with statistics, and besides they are, as
mostly used, the tools of error quite as often as of
truth. Suffice it to say that during the past six years
I have had to do with more than one hundred and fifty
cases of appendicitis and have operated myself upon
about fifty cases. Of those not subjected to operation
many have passed out of sight, but a good number have
been kept track of from one to five years. From such
observations as I have been able to make, I conclude:
First, that a small percentage of cases of appendi-
citis, possibly between five and ten per cent, of acute
attacks, is absolutely fatal unless promptly relieved
by surgery. Here to be very successful the interfer-
ence must usually be undertaken very early, generallv
within forty-eight hours of the onset, or at least of the
onset of the threatening symptoms. The condition is
so dangerous that surroundings and imperfect opera-
tive advantages need not have the influence they must
claim in subjecting a patient in less peril to a pre-
ventive oiaeration. While it is perfectly true that it
is difficult always to recognize the sudden perforative
form, a good and careful clinician may by study of the
onset and the course of the disease during the first few
hours distinguish these cases as accurately as most
other internal diseases. The operative technique
places the least demands upon the operator and the
peril of the patient justifies the less perfect operative
installation of an emergency operation.
Second, in the other ninety or ninety-five per cent,
of cases the emergency is not so great. However, the
patient is in the clutches of a treacherous disease and
5IO
MEDICAL RECORD.
[October lo, 1896
it is always well to mount the guard and prepare for
action. If conditions are in every way the most favor-
able— the best of surgical attendance, the best of hos-
pital advantages — and the patient upon a just and fair
statement of the facts consents, I believe appendec-
tomy is the most certain and complete course. On
the contrary, if operative conditions be not very per-
fect, to rush upon such a patient an operation will not
much improve the general mortalit)' rate and quite
certainly sometimes lessens the individual chances.
1 have many times refused to operate because the
patient was in a most critical state, such that with the
surrounding conditions one would rather trust to the
Tis tnedicatrix natiine than to surgery, and I have been
surprised to find that patients sometimes recover en-
tirely, and at other times reach a more favorable stage
for successful operation.
Third, when as a consultant, or otherwise, one is
called in to a case after the fourth day and up to the
tenth or fifteenth, when the symptoms indicate a local-
ization of the trouble I am particularly inclined to
conservatism, and in this stage, I think, one should
never " always operate," but should always hesitate
and feel the way unless there are pretty clear indica-
tions for interference. A case having progressed to
the fourth day favorably. I.e., without alarming symp-
toms and witii evidences of strict localization, we may
be unable to predict the final outcome, but the chances
are less than one in ten that the patient will fall into
a sudden danger. An abscess may later need to be
opened, but a very large majority will, at least tempo-
rarily, recover or reach a stage where a safer and bet-
ter operation may be performed. The periods of
election for appendectomy are very early or very late,
or between attacks. The' direct dangers are less at
these periods and completer operations may be made
with better closure of the abdominal walls.
Fourth, again in this intermediate stage, great care
and judgment are necessary in the operation in order
to do just the best thing. As a rule, with some excep-
tions, the operation should consist simply in opening
and draining without attempt to remove the appendix
or without breaking down protective adhesions. Here
experience and skill in operating and in the after-
management are very necessary to the best results;
for, while nothing can be simpler than to open and
drain many of these abscesses, in others to do a little
too much, or a trifle too little, will sacrifice the case.
In one we open the pointing abscess with a stroke or
two of the knife; in another we explore with the ut-
most care, find an extra-peritoneal opening which will
really drain the irregular, variously located, perhaps
multilocular collection, and in others it will be best
after this to remove the appendix. For the most part,
however, these are incomplete operations and it may
or may not be necessary to subsequently remove the
appendix, or repair a hernia, or both.
Many of the milder cases of appendicitis appear to
reach their acme by the third or fourth day and grad-
ually to subside during the following week. But it is
not rare for others to show little general improvement
before the end of eight or ten days and yet recover
very completely.
Fifth. But as a rule, if at the end of ten or twelve
days there is not some progressive abatement of the
disease, 1 think we may assume that an abscess exists
which it is in general useless as well as dangerous to
leave to nature and which should be opened without
entering the general cavity.
Sixth. In all relapses, certainly after the second,
it is good advice to operate either after the attack has
subsided or on the first symptom of the relapse. It is
well known that these cases form the most favorable
class for operative interference : first, as regards the
mortality, which ought not to be above two or three
per cent., and second, because the operations may be
completed as a rule without drainage and with the
most perfect closure of the abdominal walls. Next to
operations during the early hours of preliminary acute
attacks, those between the attacks are the simplest
and most definite in technique. Often an operator
with good theoretical training and little experience in
abdominal surgery will find such cases easy, but occa-
sionally they present complications in the way of
intestinal adhesions, sequestered appendix, etc., which
renders the experienced surgeon an easy victor where
the novice would fail or expose the patient to entirely
unnecessary dangers.
Thus, I do not find the indications for operation in
appendicitis or not to operate in a fixed rule based
upon logic, upon the day of the disease, the tempera-
ture range, or any other single rule of thumb; but
upon broad clinical principles, aiming to estimate as
closely as possible the conditions present and to meet
them by such means as the variety and stage of the
disease, the condition of the patient and his circum-
stances may seem to demand. By such a course it is
not possible to avoid occasional errors of operating
too early as well as too late, of doing too much as
well as too little. But I feel sure a good clinician,
guided by a wide knowledge of the pathologic and the
clinical course of the atTection, will be able to feel his
way with as few^ mistakes as the positivist who acts
upon an absurd rule, however laconic, whether that of
" always operate" or " never operate."
I am able to say that of about one hundred cases
not subjected to operation, the direct mortal ily was
less than ten per cent. A considerable number appear
to have made complete recoveries, lasting from a few-
months to i\\& years. Very many are known to have
had relapses; some have been soon lost to view. My
impression is that scarcely half have remained per-
fectly well. In fifty-two cases selected for operation
upon the lines here laid down there were four deaths.
In thirty-eight the appendix was removed and in four-
teen it was not. Some years a score of cases have
been seen without meeting one submitted to operation.
Again, for some months most of the cases have ap-
peared to demand operative interference; at one time
a number of relapsing or chronic cases present; again,
a dozen or more consecutive acute suppurative ones.
Of the fourteen incomplete operations, six have oc-
curred consecutively in the past few months; indeed,
four of them in one month. Hence, in my experience,
appendicitis is not a condition to be dogmatically
treated of by a few sweeping assertions, but one pre-
senting a very var)ing aspect, to adequately meet
which broad judgment, broad clinical knowledge, and
experience are necessary. On the whole, it is far more
a surgical than a medical di.sease. I have more quar-
rel with the prognosis of the surgical extremists than
with their treatment, for, though my experience leads
me to know that the probable mortality of an attack
of ap]5cndicitis is not, in considering a large number
of ca.ses, very greatly above ten or fifteen per cent., the
probabilities of cure are quite otherwise, and I have
no doubt whatever that at least the minority ought
.soon or late to be subjected to surgical treatment.
This absurdly false prognosis leads to great mis-
understanding and inopportune interference. On the
other hand, the quite as inaccurate claims of medical
extremists, that because a patient gets up from an acute
attack he should be regarded as a cure, a living reproof
to surgeons, and a dazzling medical trophy, leads to
quite as disastrous sins of omission. I would have
the medical brethren look for some of the medical
cases which are a shame rather than a glory to medi-
cine and admonish surgical extremists that insisting
upon an absurdly grave prognosis retards rather than
advances sound practice.
October lo, 1896]
MEDICAL RECORD.
5"
PREGNANCY COMPLICATING OPERATIONS
ON THE UTERUS AND ITS APPENDAGES.'
I!V R. ST.WSBURV SUTTON, ^r.U., LL.I).,
riTTSBt."RG, PA.
On March 30, 1891, Dr. Bell, of Butler, Pa., brought
to my private hospital Mrs. S , aged twenty-six
years. She was three and a half months advanced in
her si.\th pregnancy, five of which had terminated in
three living children and two miscarriages. After the
cessation of each of these periods of utero-gestation, a
tumor could be felt to the left of the uterus. Upon
e.\amination, a well-defined cyst w-as distinguishable,
occupying the abdominal cavitw ]5elow and to the
right side of it the pregnant uterus was located.
Upon opening the abdominal cavity, I encountered a
large cyst of the broad ligament on the left side. Its
contents were evacuated and the cyst was enucleated.
After the enucleation, which was tedious and diffi-
cult, there was tolerably free bleeding. The cavity
was irrigated w ith hot water, and the wound was closed
with two rows of buried catgut sutures and a superfi-
cial row of interrupted silkworm-gut sutures. She
was discharged twentv-three days after the operation.
Her pregnancy went on without interruption, and she
was confined at temi, her child living.
Notwithstanding that this patient had aborted in two
subsequent pregnancies, the operation failed to pro-
voke any trouble in this, her si.xth pregnancy.
On February 13, 1893, Mrs. D , aged thirty-four,
widow for ten years, mother of one child, thirteen
years old, was sent to me by Dr. Beatty, of Alleghany,
Pa,, for operation. At her menstrual periods she had
cataleptic seizures, and frequent attacks of severe pain
in the ovarian regions. She was incapacitated for
work, and protracted treatment and all remedies ap-
plied had failed to relieve her. She stated that her
last menstruation had occurred two weeks prior to this
date. A digital vaginal examination revealed a linear
contraction at the juncture of the upper and middle
third of the vagina, which arrested the finger. The
finger was now transferred to the rectum, and by the
aid of the superimposed hand I made the following
diagnosis: Lacerated cervix, subinvolution of the
uterus, chronic salpingitis and ovaritis.
Five days later I made a very short incision in the
median line, and through it removed the ovaries and
tubes. I noted the supposed subinvolution of the
uterus with the fingers, and closed the wound. The
patient recovered promptly, and left the hospital.
About ten months after her discharge from the hospi-
tal, her attending physician informed me that in nine
months less forty-one days after the operation, he had
attended her in confinement. She ga\-e birth to twins,
healthy children.
Occasionally an ectopic and a uterine pregnancy
coexist. The great majority of such cases have, in the
past, ended fatally. In the future, the question of do-
ing abdominal section or an operation for tubal gesta-
tion is much simplified, in this fact, at least, that the
coincident uterine gestation is not a complication
worth serious consideration, and hereafter a diagnosis
in any case of tubal disease or suspected ectopic ges-
tation may be elucidated safely — although uterine
pregnancy exist — by an exploratory incision.
The fact that twin pregnancy, one fietus in the
uterus and one in the tube, has occurred many times;
that such a condition has usually proven fatal; and,
further, since in all recorded cases a correct diagnosis
has been arrived at only four or five times, the ques-
tion of intra-abdominal operation in the presence of
uterine pregnancy is swept of its terrors for the future.
' Read at the meeting of the Mississippi Valley Medical Society,
St. Paul, September 15-1S, 1896.
Intraperitoneal operations made directly on the
pregnant uterus, with the expectation that such opera-
tions will not disturb the progress of the pregnancy,
require a much more critical consideration and greater
caution, for not only is the life of the fcetus involved,
but the life of the mother may verj- easily be sacri-
ficed.
In the myomectomies done thus far on the pregnant
uterus, nearly sixty per cent, of the mothers have been
lost, and enough of the children have been lost to
swell the mortality to more than one hundred per cent.
Unless, therefore, the tumors have but a slight attach-
ment to the pregnant uterus, myomectomy under such
circumstances had best not be done.
In three cases of pregnancy, dangerously compli-
cated by the presence of fibroid tumors in the body of
the uterus, I have done supravaginal hysterectomy, by
Chrobak's method — in each instance sacrificing the
foetus and saving the mother.
It is a remarkable, and yet a natural consequence,
that a uterine myoma is usually stimulated to a very
rapid growth by the process of uterine gestation. I
say a natural consequence, for what difference is there,
histologically, between a pregnant uterus and a myo-
ma.' Practically they are identical.
In one of my cases — all of which are published in
the Transactions of the American Gynecological So-
ciety— the tumor weighed ten pounds. It is a some-
what remarkable fact that in these three cases all the
women were primiparse.
Recently I have seen a fourth case, in which there
has been up to this date no surgical interference.
This patient is also a primipara, and in the sixth
month of gest&.tion. She is so located that she can be
temporized with, in the hope of doing a Ca;sarean sec-
tion and thereby sa\ing both the mother and child.
Believing, as I do, that the existence of myoma in
the uterus of a woman before marriage is a source of
the greatest danger, if marriage is contemplated I hold
that the tumor should in every instance be destroyed,
either by myomectomy, enucleation, hysterectomy,
removal of the ovaries and tubes, or by ligation of the
uterine arteries; and also that it is the duty of the
medical man to advise against marriage until a cure
has been effected.
The Indications for Ventral Fixation of the
Uterus. — The following indications for ventral fixa-
tion of the uterus are given by Dr. G. M. Edebohls in
the Medical News : i. Vaginal fixation of the uterus
does not come within the sphere of legitimate opera-
tions in women liable to future pregnancy, 2, The
indications for ventral fixation of the uterus should be
limited to the utmost degree in women liable to sub-
sequent pregnancy. 3. Ventral fixation is never indi-
cated in uncomplicated retroversion of the uterus. 4.
Inability of an operator to perform shortening of the
round ligaments maybe an indication for ventral fixa-
tion, but not in the case of one claiming to be a spe-
cialist in gynecology. 5. Ventral fixation is indi-
cated, as an adjuvant, in the perfonnance of combined
operations for prolapsus uteri et vaginas. 6. Ventral
fixation is indicated as a closing step in all coelioto-
mies in which the adnexa are removed andthe uterus
is left. 7. \'entral fixation may be indicated, under
exceptional conditions, in cases of adherent retrover-
sion, with tubes ancl ovaries in good condition. 8.
Ventral fixation may be indicated in the most aggra-
vated cases of uncomplicated sharp retroflexion. The
w'riter has not met such a case not amenable to success-
ful treatment by shortening the round ligaments. 9.
Ventral fixation is indicated, under certain condi-
tions, in cases of uterus unicornis.
512
MEDICAL RECORD.
[October lo, 1896
TWO CONTRIBUTIONS TO THE SURGERY
OF THE GALL BLADDER.'
liv J. R. HOLLOWBU.SH, M.D.,
KOCK ISLAND, ILL.,
SLRGEON TO ST. ANTHO.N'v's HOSHTAL.
The rapid development of surgery of the gall bladder
and the frequency of operative procedure for the relief
of disease of this viscus almost preclude the possi-
bility of anything new being said on this subject.
Accuracy and amplification of our knowledge, how-
ever, are only obtained by experience ; therefore, it is
much to be desired that every case bearing upon this
subject should be reported, to the end that an analysis
of a series of cases may be of benefit to the profession.
For this reason the two following cases of gall-bladder
disease, tliat have recently been under my care, are
presented to your notice.
Case I. — Mrs. S , aged fifty-four years, was
brought to me by her family physician, Dr. O. M.
Looker, of Hillsdale, 111. For some four years she
has been complaining of pain and tenderness in the
region of the stomach and liver. This ever-present
soreness was accompanied at intervals by attacks of
severe and almost unbearable j^ain, followed by nau-
sea and vomiting. As time progressed these attacks
increased in frequency and severity. Jaundice, which
at first was present only after an attack of colic, now
became almost constant, and the only rest obtained
was that produced by narcotics. When she was first
seen by me, her appearance vas indicative of great
physical sufferings — debilitated and emaciated in the
extreme, face pinched and anxious and jaundiced in
color — altogetiier not presenting a condition likely to
witiistand a severe operation. Upon examination of
her abdomen, a large, hard, nodular mass was found
occupying the space between the eighth and ninth
costal cartilages and the umbilicus, the entire tumor
tender and painful to the touch. At the lower portion
of this neoplasm was a smaller circumscribed tumor
which could be readily outlined from the remainder.
This portion was exquisitely tender to the slightest
pressure. The ])revious history of tlie case, together
with tlie condition found on examination, left the diag-
nosis between gall stones and malignant trouble of the
pylorus, or both. She gladly accepted tiie proposal of
an operation, in hopes of alleviation of her suffering.
December 21, 1895, under ether an;Lsthesia, an in-
cision in the median line was made and Lire diseased
mass was exposed. The pylorus was found to be the
seat of a large carcinoma, and the left lobe of the liver
was aLso infiltrated with carcinomatous nodules. The
walls of the gall bladder were diseased, thickened, and
friable. The gall stones now could be readily felt,
filling the bladder to its utmost capacity. The viscus
was incised and twenty stones were removed, some
of which are here presented. The incision was closed
by a row of interrupted sutures. The friable condi-
tion of the walls rendered the coaptation of the serous
surfaces very difficult, and some apprehension was felt
that leakage would occur; but, happily, no such acci-
dent followed. The abdominal wound was closed in
the usual manner, and the patient made an uninter-
rupted recovery from the operation, being discharged
from the hospital on the nineteenth day. For some
weeks succeeding the operation she was free from pain
and more comfortable than she had been for years;
but the respite from suffering was cut short, and in a
few days over three months she succumbed to the dis-
ease.
C.\sE II. — Mrs. C , aged forty-six, was referred
to me by her family physician, Dr. Eddy, of Milan,
111. This patient gave a history of six years of inter-
' ICe.nl before the Central District Medical Society of Iowa and
Illinois, at Rock Island, 111., .\pril 9, 1896.
mittent suffering — spasms of hepatic colic, accompa-
nied by temporary icterus, vomiting, and general pros-
tration. These attacks usually confined the patient to
bed for from one to three weeks, the soreness and
tenderness resulting from the acute pain remaining for
some time. The intervals between attacks were gen-
erally comfortable, with the exception of more or less
indigestion. The increasing frequency of the spasms,
their intensity being such as to endanger life from col-
lapse, led her to seek surgical relief from her sufliering.
When she was first seen by me, her general condition
was fair, although she was somewhat weak from her last
attack of colic. Upon examination of the abdomen,
no circumscribed tumor could be felt, as in the case
of Mrs. S . Deep pressure, however, revealed an
undefined swelling. By passing the tips of the fingers
under the free margin of the liver, a hard nodule could
be felt. A diagnosis was made of impacted gall stone.
Under ether, the median incision was made. As soon
as the edges were retracted, the enormously distended
gall bladder came into view, in size some five to six
inches in length, and of the circumference of a man's
wrist. The contents, a mucoid fluid, were drawn off
through a cannula, and the bladder was incised. A
stone weighing sixty-nine grains was removed. The
cystic duct was fountl impacted with a stone, about the
size of a joint of the little finger. Considerable diffi-
culty was exiierienced in crushing and removing it.
The duct was now pervious, but the inflamed and
hardened condition of the walls determined the use of
the Murphy button in making an anastomosis with the
duodenum. This was accordingly done, and the vis-
cera were returned. Considerable bile had escaped,
notwithstanding careful gauze packing; therefore the
peritoneal cavity was thoroughly flushed with hot
water. The abdominal wound was closed with three
tiers of stitches and dressed with aseptic dressings.
The operation lasted two hours, owing to the difficulty
in removing tlie stone from the duct. The patient
bore it well, and made an uneventful recovery. The
stone removed is a hexagonal cube, four sides of
which have been worn smooth by constant rubbing
upon the face of the stone in the duct.
The clinical histories of these two cases are entirely
different. The conditions present upon examination
were equally dissimilar. They emphasized the diag-
nostic points already laid down by writers on this sub-
ject, and especially those given by Mayo Robson, in
his paper on "Surgery of the Gall Bladder,'' read be-
fore the international medical congress in Rome in
1894, He says that in all cases of malignant di.sease
with jaimdice tlie gall bladder formed a perceptible
tumor, while in jaundice dependent upon gall stone
alone no marked tumor was present. In the first case
here reported, the tumor was perceptible to the slight-
est touch; while in Case II. it was only by deep pres-
sure under the liver that a tumor was recognizable,
and that only because of the large size of the stone.
The jaundice in the first case was almost constant,
while in the second it only followed the acute attack
of colic. These two cases illustrate how unjust it is to
both the patient and the physician to allow disease of
the gall bladder to be treated by medical means alone,
until the patient is reduced by years of pain and suffer-
ing to such physical condition that surgical relief is
only a di-niier icssoit. It is safe to say that the irrita-
tion produced by gall stones, either in the bladder or in
the ducts, is an important etiological factor in the pro-
duction of carcinoma of the stomach and liver. When
jaundice has become constant and cachexia has devel-
oped, we have a class of cases very unfavorable for sur-
gical relief. The danger from collapse in the intense
spasms seen in the second case offers sufficient reason
for operative procedure in similar cases. Ulceration
and perforation of the duct are accidents liable to oc-
October lo, 1896]
MEDICAL RECORD.
513
cur when the impaction is so complete as in tliis case.
Erosion of tissue will soon follow the constant pres-
sure here observed. The foregoing cases are not un-
familiar types of gall-bladder disease, and are reported
with the hope that in making up the sum total in these
operations thev may serve some end.
THE TREATMENT OF .\CUTE ABSCESSES.
By EDWAKI) \V. PEET, M.D.,
.\E\V YORK CITV,
.ASSISTANT GVNECOLOt:iST TO ROOSEVELT HOSPITAL, O. P. D.J ASSISTANT
St'KOEON 1U ST. BARTHOLOMEWS CLIMC.
There are many abscesses of larger or smaller size
which follow the infection of the genitals, and the
treatment of which has not been satisfactory to me
until lately. The abscesses to wliich I refer are sup-
purating glands in the inguinal region of both se.\es,
and abscesses of the vulvo-vaginal glands in the fe-
male.
The dissecting out of these glands is not always
practicable, and requires an etherizer and one assis-
tant. The opening of the glands by a free incision,
thoroughly curetting and packing the cavity with iodo-
form gauze, and using a wet or dry dressing, is a long,
slow way to recovery and disables the patient for sev-
eral days. Patients coming to our clinics are of the
working class, and generally are obliged to attend to
their household duties or nominally appear at their
work. If a small incision is made, which allows the
patient to get about, and the abscess is packed with
iodoform gauze, when the ne.xt dressing is done (in
twenty-four or forty -eight hours) the gauze has become
so saturated with the discharge and so adherent to the
line of incision that the drainage is practically nil.
\ more desirable dressing is one which will allow
free drainage and can easily be kept in place. I have
found narrow strips of gutta-percha tissue to answer
this purpose admirably. My routine treatment now
for suppurating vulvo-vaginal glands and inguinal
adenitis is to make a small incision, depending on the
size of the abscess — a larger incision for a larger ab-
scess— to press out as much of the pus as will easily
fiow out, and to pack the cavity comfortably with long
strips of gutta-percha tissue, about one-fourth to one-
half inch in width, slightly twisting and folding the
gutta percha as it is packed into the cavity, and to leave
the end of the packing outside the wound. If the
packing shows a tendency to work itself out, the end
can be tucked within the incision. The opening will
not close as long as the cavity is packed with gutta
percha. For the patient I order ung. hydrarg., fifty
per cent., with the instruction to apply the ointment
liberally over the abscess morning and night, and
cover with a cloth to protect it from the clothing.
When the skin is tender, an ointment of equal parts of
ung. ichthyol, ten per cent., and ung. h3'drarg., ten
per cent., can be used.
The packing is to be kept in twenty-four or, better,
forty-eight hours; then the patient returns and a new
packing is inserted. The patient is told to go about
her regular duties. When she returns for the first-
dressing, it is generally with the report that she has
no pain and can get about very comfortably. On re-
moving the gutta-percha strips, one is struck by the
clean, healthy, granulating appearance of the abscess;
and this seems to have been brought about by the
movements of the surrounding muscles, which keep
the gutta-percha tissue moving about in the abscess
cavity, gently curetting the abscess. The curetting
work is done more satisfactorily if the incision into
the abscess is not too long and the packing is not too
tight. Rarely is it necessary to pack an abscess in
this wav more than two or three times, before the
healthy, rapidly growing granulations are ready to fill
up the cavity. The packing is then discontinued,
though the application of the ointment is kept up.
In using the packing the gutta-percha tissue should
not be twisted too closely, but the cavity should be
comfortably filled with partly twisted and partly folded
strips of tissue. Better results are obtained when the
cavity is not irrigated witli an antiseptic solution be-
fore packing.
This mode of drainage has also been used most sat-
isfactorily in deep infected wounds under strong fascia,
as in the palm of the hand, even though these wounds
are accompanied by a marked cellulitis. The drain-
age in these cases is much better than when iodoform
gauze is used. The infected wound is opened thor-
oughly, packed with strips of gutta-percha tissue, and
the surface -s covered with a compress, kept constantly
wet, of a solution of acetate of aluminum. The ace-
tate of aluminum is made up as follows:
R Pulv. alum 3 V.
Pulv. plumbi acet 3 ,\.kv.
Aqua; destil q.s. ad O iv.
M.
There is a precipitate when this solution is made
up, and the bottle should be shaken before its contents
are used.
The gutta-percha tissue is best prepared by being
cleaned, then folded, and put into a i to i,ooo solu-
tion of HgCl., in which it will keep indefinitely.
When used, a strip of the folded tissue is cut oft', un-
folded, rinsed in plain water, and packed into the
abscess, as above described. The gutta-percha tissue
should not be used with carbolic solutions, as they
destroy it.
Having used this dressing for abscesses for a year
and more in my clinic at Roosevelt Hospital, with
satisfactory results, and not knowing of its being used
before, I suggest it for trial by others of the pro-
fession.
20 West Fortv-Third Street.
(Clinical gcpavtmcnt.
LARYNGEAL PAPILLOMA IX A CHILD-
REPEATED INTUBATION— DEATH.
By F. LOHRSTORFER, M.D.,
CORT HURON, MICH.
T. P , aged three years. Ten months ago the pa-
rents first noticed some difficulty in the child's breath-
ing, but attributed it to asthma. The obstruction
gradually increased and when the child was brought
to me it presented an appearance identical with that
of one suffering from severe diphtheritic stenosis.
The voice was whispering. A laryngoscopic exami-
nation was unsatisfactory on account of the fractious
disposition of the patient, and a like attempt under
chloroform nearly terminated fatally from suffocation.
An intubation tube was at once inserted, with com-
plete relief. Si.x days afterward the tube was re-
moved, when dangerous dyspncea at once supervened.
This, however, soon passed off and in two or three
days the breathing was quite free. The relief lasted
four weeks, when stenosis again returned, worse than
before. An O'Dwyer tube was again inserted. Four
days later as the child was playing in the street it
coughed the tube out and the dyspnoea became at once
urgent. I then introduced a larger tube, which gave
IJerfect relief. The child's condition was normal in
every way except for its loss of voice. This third
tube remained undisturbed for three weeks, when, fear-
ing injury to the larynx, I administered chloroform
and removed it. Instantly on its withdrawal the face
5H
MEDICAL RECORD.
[October lo, 1896
became cyanotic, the pupils dilated, and the most
strenuous efforts of the patient failed to provide air.
Tracheotomy was at once performed and the immedi-
ate danger was over. I had intended an operation for
the radical removal of the obstruction on the follow-
ing day, but in the night the child was suddenly seized
with dyspnoea and died in less than a minute, prob-
ably from some obstruction in the cannula, although
both inner and outer tubes were removed in succes-
sion by the attendants. The autopsy, twelve hours
later, showed a broad-based papilloma entirely encir-
cling the interior of the laryn.x at the level of the
vocal cords and completely blocking the passage.
In spite of the last intubation tube remaining in three
weeks, there was not the slightest trace of irritation of
the larynx or trachea.
CONGENITAL IRREDUCIBLE UMBILICAL
HERNIA— DOUBLE UTERUS.
Bv JA.MES HARVEY RAYMOND, M.D.,
WAILfKf, K. I.,
GOVERNMENT PHYSICIAN FOR THE DISTRICT OF WAILVKt' AND ATTENDING
rHVSICIAN TO MALl'LANI HOSPITAL, WAILfKC, MALT, HAWAIIAN ISLANDS;
FORMERLY INSTKLCTOR IN SIKGICAL I'ATHOLOGV, RL'SH MEDICAL COLLEGE,
CHICAGO.
On June 7, 1895, Dr. Aiken, of Paia, Maui, H. I.,
asked me to consult with him in a case of labor. The
patient was a Portuguese woman, a multipara, aged
twenty-five years; she was apparently well nourished,
and had a history of no previous illness. She had been
pregnant twice before, and each time the foetus was
born dead. The first birth gave no trouble whatever,
but in the second labor was prolonged and a phvsician
had to be called to deliver the placenta.
On the 29th of May the woman called on Dr. Aiken,
informing him that she was pregnant, and asked him
for medicine to produce delivery. From remarks made
by the woman in response to his questioning. Dr.
Aiken suspected that the child was dead; he so in-
formed her and advised a digital examination. Al-
though she concurred in his suspicion, and also stated
that on two previous occasions she had given birth to
a dead child, slie absolutely refused to allow an exam-
ination at that time.
Eight days later the doctor was sent for to attend
the woman and upon examination found a dead ftetus.
The patient refu.sed to have the fatus extracted until
two days later, at which time I was called in. The
face of the patient was blanched and wore an expres-
sion of great fatigue; she was perspiring profusely.
Respirations rapid ; pulse full and collapsing; tem-
perature subnormal; fecal vomiting. The patient was
anajsthetized, and upon digital exam-
ination we soon determined that the
foetus had been dead for some time,
as it was in a stage of advanced de-
composition.
The cervical portion of the uterus
was deflected to the left, as though it
were drawn to tliat side by adhesions,
and an exploration of the interior of
the organ necessitated carr)-ing the
fingers well to the left to find the os.
The OS would not admit more than two fingers, and
to the left of it could be felt a circular depression,
from three to four centimetres in diameter and about
five millimetres in depth, with a smooth rounded edge
and a hard base. The occiput could be felt to the left
side, but it was impossible for the head to present,
owing to the apparent distortion of the uterus.
I hooked my finger into the os and slowly dilated
it, using considerable force, until it would admit the
whole hand, when with comparative ease the head
came away, and the body and placenta were speedily
delivered without difficulty.
The depression felt at the side of the patulous os
was then found to be the os of a separate organ, which
was entirely within the impregnated uterus and large
enough to admit my hand on dilating it with moderate
force. The hand could be passed completely around
the abnormal organ from within the impregnated
uterus, as it was attached only at the os.
The patient survived the anasthetic, but died eight
hours later of septicaemia, the symptoms of which were
manifest upon my arrival.
Unfortunately, we were unable to obtain permission
from the relatives of the deceased to perform an au-
topsy ; therefore our deductions are more or less hypo-
thetical. But, from the observed anatomical condi-
tion, we arrived at the conclusion that the abnormal
uterus was nourished by the same blood-vessels, excited
by the same ner\-es, and consequently enlarged con-
comitantly with the pregnant uterus, and that it caused
the death of the foetus by mechanical pressure.
A MONSTROSITY.
By I. M. IR.VNKENBURGKR, M.D.,
EDITH, COL.
On April 15, 1896, I was called to attend Mrs. A.,
aged forty, mother of three children, the youngest of
whom was five years of age. I found her having
slight labor pains, the membranes having been rup-
tured about half an hour. On palpation the position
was made out as being a breech presentation, head to
the left. Vaginal examination revealed nothing, the
parts still being too high up. I tried turning by ex-
ternal manipulation, but was unable to accomplish
anything, and concluded to let the case alone until
something further developed. The pains were very
slow and irregular, and no
progress was made in the
labor for about ten hours,
when on making a vaginal
examination I could clearly
make out the presenting
Fig. I.
parts. But the puzzling part of the examination was
a mass of something feeling like intestines which
I could detect just inside the os. There had been very
little hemorrhage. I could tell by the sense of touch
that it was not placenta, and I was completely non-
plussed. Labor progressed slowly, and one-half hour
before the child was born I could detect no fcetal-heart
sounds, .\bout twenty-four hours after labor had set
in, my patient had a severe pain, and the mass before
mentioned, foetus, and placenta came away together.
J
October lo, 1896]
MEDICAL RECORD.
515
Fig. I shows the f(ftus as it appeared at time of
birth, before any dissection was made. Dissection
was as follows: Weight of fcetus, six pounds; head
well developed, the bones of the skull being freely
movable, so much so that the head could be pressed
together until one-half the original size. Lungs very
small, but complete. Heart very small, the left ven-
tricle being almost as large as both auricles and the
right ventricle combined. Below the diaphragm there
was absolutely nothing in the abdominal cavity (or
what should have been the abdominal cavity) e.\cept
two small blood-vessels, which ran to the lower ex-
tremities. There was no evidence, either internal or
e-xternal, of any organs of generation or anus, there
being no break at all in the skin. From the umbili-
cus there was suspended a bag or pouch containing
all the abdominal organs, which was the mass I
could feel during Labor. A long tube-like continua-
tion of the oesophagus e.\tended to the stomach, which
was quite large. The rectum was smaller than the
small intestine, and had no opening at all. There
was but one kidne}", and about one-half an inch of
ureter between it and the bladder. The liver, spleen,
and pancreas were normal. The umbilical cord was
but three inches in length, and ran through the pouch.
The left hip was dislocated. Both feet were in a
position of talipes equino-varus.
Fig. I shows the entire continuity of skin between
the legs, and also the dislocated hip. Fig. 2 shows
the talipes, tlie pouch cut open, the intestines and
liver exposed, and the approximation of it to the
placenta.
I present this on account of the peculiar develop-
ment, or rather non-development, especially of the
abdominal organs, all being outside of the abdominal
cavity, and the absence of organs of generation, these
being ordinarily among the first to develop.
Suicide is very common among Russian physicians,
due, it is said, to the hard struggle they have against
the competition of free and heavily endowed dispen-
saries. F'ees are often ridiculously and tragically
low, sometimes, according to The Lana-t, only twenty
kopeks or six cents for an office consultation.
The Fundamental Treatment of Disease is wliat
Malcolm Morris dubs orificial surgery.
REPORT OF A CASK OF RECURRENT BA-
SILAR MENINGITIS, WITH RECOVERY.
Ry llENRV M. KOI.ES, M.I).,
NEW VOKK.
On account of the number of attacks resembling a
meningitis at the base of the brain which this patient
has suffered from, together with the rapid response to
antisyphilitic treatment, and the positive assertions
on his part as to never having been affected with this
specific malady, I deem it of sufficient interest to put
a detailed history of this case on record.
X. Y , twenty-three years of age, medium height,
well nourished, had never suffered from any serious
illness until his seventeenth year, except that when a
baby he had had measles and what was then regarded
as rheumatism. His parents are living and healthy;
neither one gives a history of any protracted illness;
his sisters are living and all are healthy. X was
a proficient scholar at school and at fifteen years of
age left it to enter business; at seventeen years of age
he held the position of clerk in a wholesale establish-
ment, where he spent his spare moments in wrestling
with his companions During one of these bouts he
was thrown violently
against the edge of a
table and rendered un-
conscious. When he
recovered he vomited,
had a severe headache,
and required the assist-
ance of his comrades to
lead him to his home,
where he was confined
to the bed for several
weeks, suffering with se-
vere headache in the
frontal and parietal re-
gions and general weak-
ness. A few months
after recovering from
this attack, while doing some heavy work, he sud-
denly experienced headache severe enough to compel
him to discontinue work and seek his home. On his
way, when a short distance from his place of busi-
ness, he had an attack of vertigo and fell to the
ground. He was taken to a neighboring drug store,
where restoratives were administered. As soon as he
felt sufficiently revived he essayed to rise and walk
away, but he was unable to do so. He was then taken
in an ambulance to Chambers Street Hospital, where
he remained until the next morning, when his anxious
relatives called for him. He w-as confined to his bed
for many weeks; as nearly as he can remember it was
more than two months before he recovered the partial
use of his right arm and leg, which had been para-
lyzed. He thinks that there was a slight facial paral-
ysis but is not certain. He was conscious all of the
time, did not vomit, appetite was fair; he passed urine
regularly, was slightly constipated ; the special senses
were unimpaired. He was able to return to work and
for two years was almost entirely well. He then be-
gan to have attacks of headache, which compelled him
to take to his bed for several weeks at a time, and ren-
dered him unfit for work for several weeks more.
These headaches, which recurred about every six
months, were usually preceded by an attack of vomit-
ing. The location was over the frontal and parietal
regions of the left side. He could not sleep, and his
moaning and shouting were loud and prolonged.
About a year ago he acquired a blennorrhoea and was
referred to me for treatment by one of his friends.
After a protracted siege he finally recovered and en-
joyed comparatively good health for several months.
Six or seven weeks ago I was hurriedly sent for by the
5i6
MEDICAL RECORD.
[October lo, 1896
young man. I found him in bed with one of his ac-
customed attacks ; he was complaining \ erj' much of
pain in the front and left side of the head and was
very restless; the face was flushed, the eyes were in-
jected, the tongue was coated; temperature, 101° F. ;
pulse strong, rapid, and full. He had an attack of
vomiting just previously to the onset of the headache,
■which otherwise was sudden and abrupt; during my
stay he vomited some fluid matter containing mucus
and bile. I prescribed some calomel to relieve the
constipation, bismuth and bromide mixture, together
with absolute rest in bed, ice to the head, and re-
stricted diet. In the course of a few days the symp-
toms subsided and he returned to business; he had
not been there more than a few hours, however, when
he suddenly became faint, and then was attacked by
dizziness and nausea. He required assistance to
reach his home and to be put to bed, where he was
seized by a fit of uncontrollable vomiting, which did
not cease until his entire breakfast had been voided.
I found him about an hour later suifering with head-
ache and nausea; the face was flushed and an.xious;
the pulse was rapid; temperature, 101' F. ; the ex-
tremities were cold ; the breathing was labored and in-
creased in frequency, and the head was drawn back-
•ward and to one side. This attack was similar,
I was told, to all his previous ones and his folks were
not alarmed, but expected it to pass away just as
the others had done before. .\ careful examination
of the heart, lungs, and abdominal organs revealed
nothing abnormal. I refrained from stating to his
relatives that I thought we had to do with a menin-
gitis, not desiring to alarm them, f prescribed .some
phenacetin and bromide of potassium, ice cap to the
head, and enjoined perfect quiet and rest. The con-
dition on the next day was about the same: tem|3era-
ture, 100^ F. ; pulse, no, but weaker than on the pre-
ceding day. Fie complained of a pain in the abdomen
together with the violent throbbing pain in the head,
Avhich rarely left him, and if it did was followed soon
after by one of increased severity. There was also
pain in the back of the neck, but no rigidity. He
preferred to keep his head drawn backward and to one
side; he had slept but little. I combined small doses
of morphine and chloral with bromide of potassium,
which, however, gave but transitory relief.
On the morning of the third day following the at-
tack, in addition to his other trouble, he complained
of pain in his abdomen more severe tlian heretofore,
and constipation ; tiiere was no tympanites, no point
of tenderness, and the administration of an ox-gall
enema was followed b\' a copious stool and entire re-
lief of abdominal pain. Temperature in the evening
was 102° F.; pulse, 120; rigidity of muscles of the neck
was marked and pain quite severe. Pain in the head,
which recurred at intervals, was so severe as to cause
him to moan and even to shout. His tongue was
coated ; the skin was hot and dry.
A hypodermic injection of one-fourtii grain of mor-
phine relieved his pain for several hours and he was
enabled to sleep. His condition remained about the
same for two days, the only improvement, however,
being a partial cessation of the pain in the head. His
appetite was not impaired; he took only fluid nourish-
ment— milk, broths, and eggs. He still continued to
take morphine, bromide, and chloral for pain and
sleeplessness, with ice caps to back and head con-
stantly; besides this, he was put on iodide of potas-
sium in increasing doses. His bowels moved once in
twenty-four hours. The urine was acid and deep am-
ber in color; specific gravity, 1.018. It contained no
albumin, no sugar, no casts. Temperature, 101° F. ;
pulse, 120, weak. The pupils were slightly dilated,
not over sensitive to light; the special senses were
unimpaired.
Fifth day. — Temperature, 102" F. ; pulse, 125.
Slight double exophthalmus became apparent; the pu-
pils were dilated, and there was beginning internal
strabismus of the right eye. The muscles of the back
of the neck were markedly rigid. He took nourishment
regularly and was interested in everything going on
about him. He answered questions readily and cor-
rectly. Morphine and bromide were diminished and
iodide was increased; he was taking one hundred
grains of the latter in twent}'-four hours.
Sixth dav. — He passed a restless night with very
little sleep, and shouted a great deal. The strabismus
was more marked. I'here was slight ptosis; the pu-
pils were dilated; the tongue was dry, rough, and
coated. Temperature, 103 F. Pain was severe. He
tossed about in bed a great deal, and complained of
pain radiating from the shoulder down the ann. He
took nourishment when offered and after an interval
answered questions. Sensation and special senses
were not impaired.
Seventh da\-. — Temperature, 103.5^ F. ; pulse, 125;
respiration labored, sighing; tongue dry and coated;
sordes on teeth and lips; internal strabismus of the
right eye complete; pupils dilated, not responsive to
light. He shouted incessantly and did not reply to
questions so readily as before. Morphine and bro-
mides .seemed to have but little effect. The neck was
rigid and immovable.
Fighth day. — (."ondition wor.se than on preceding day.
Pulse, 140, vibratory, weak; temperature, 103 F. ;
Cheyne-Stokes respiration, sordes on lips and teeth;
carpiiologia. He shouted continually and was mania-
cal. There was beginning strabismus of the left eye
and exophthalmus of botli. He was very restless and
delirious part of the time.
Ninth day. — I considered his case hopeless. Tem-
perature, 103' F. ; pulse, 140, weak, irregular; respira-
tion slow, labored, Cheyne-Stokes. Complete con-
verging strabismus of both eyes, ptosis, pupils widely
dilated, facial ]iaralvsis (left). There was beginning
difficulty of deglutition. He was delirious most of the
time. Alorphine, two grains during twelve hours, to-
gether with bromide and chloral and hyoscyamine,
had very little effect. I'elieving firmly that the end
was approaching and desiring to satisfy the parents as
to the correctness of the diagnosis and method of
treatment, I received their consent to a consultation
«ith Dr. -Alfred Wiener, who was kind enough to see
the patient with me late that evening. .After carefully
going over the case, he found by ophthalmoscopic ex-
amination, in addition to the symptoms enimierated
above, choked discs and a hemorrhage in the retina of
the right side. The conclusion arrived at after the
examination was that the chances for recover)- were
very slight if any, and the parents and friends were
notified of the patient's impending fate. I adminis-
tered fifteen minims of Magendie's solution with atro-
pine, ordered the iodide increased, and at the sugges-
tion of Dr. Wiener pre.scribed some ten-pcr-cent.
oleate of mercurj' to be rubbed in the skin over the
muscles of the neck and the iodide of potassium to be
given in increasing doses.
The next morning I saw but little change in the pa-
tient. He swallowed with more difficulty. Tempera-
ture, 103° F. ; pulse, 130. He took nourishment, was
apathetic and delirious by turns, and answered but few
questions. He received four injections of morphine
and atropine in twenty-four hours, one-half grain each
time, and sixty grains of iodide of potassium four times
daily, together with mercury inunction, alcohol bath,
and ice applications. This treatment was persisted in
for several days.
The looked-for end did not materialize; on the
contrary, he gradually improved after he had been
taking three hundred grains of iodide per day and
October lo, 1896]
MEDICAL RECORD.
517
mercury inunctions for several days. He was grow-
ing more rational, answered questions more readily,
recognized persons and actions at his bedside. The
Cheyne-Stokes respiration gave way to normal; pulse
became stronger and less rapid (100); temperature,
morning 99 F., evening 100'' F. Facial distortion
faded away, mobility of the eyeballs was increased,
and in the course of several weeks he was able to sit
up. Rigidity of muscles of the neck was overcome
completely. Tlie appetite improved, the bowels be-
came regular, and morphine was discontinued. The
point of tolerance for iodide was reached when he
was taking a little more than three hundred grains
d.iily.
Taking this history into consideration, the first thing
that attracts our attention is the hemiplegic attack
from wliich this patient suffered at the commencement
of his illness. Whether this was due to an embolism
or to a thrombosis can hardly be established on fimi
grounds. Taking the early history of rheumatism into
account, the early age at w'hich the apoplectic attack
took place, the mild onset, there being no complete
loss of consciousness, we would be inclined to tliink
of embolism. A careful e.xamination (physical) of the
patient furnishes no source for the production of such
an embolism.
With regard to thrombosis it may be said that
through an early infection of syphilis the arteries may
after all have been in a diseased condition and thus
favorable for such a thrombosis to form.
With regard to attacks of headache, vomiting, and
fever with slight rigidity of muscles of back of'neck,
which this patient suffered from, although I did not
see him at these various times, I do not hesitate to
say that these attacks were undoubtedly due to menin-
geal irritation.
The last attack, which I have carefully recorded
above, demonstrated beyond a doubt that we had here
to deal witli a meningitis which localized itself in the
neighborhood of the interpeduncular space and in the
region of the pons and medulla.
Whether this pathological condition was in the form
of a syphilitic meningitis or of a gummatous intiltration
cannot be positively set down as a fact. I am inclined
to believe that it was in the form of a meningitis, first,
on account of its spreading nature, and second, on ac-
count of the fever which attended the attack.
The rapid response to heroic anti-syphilitic treat-
ment in this case, the gravity of the sj-mptoms being
considered, establishes beyond a doubt that the nature
of the pathological condition existing at the base of
this patient's brain was truly specific in character.
inch from the last knot and clip off the thread. I now
have a cork that can be drawn out at any time, even if
it has been pushed in too far. The thread is always
ready to pull upon, and is clean, neat, and very handy
and inexpensive.
TO DR.'^W
THE CORK
BOTTLE.
OF .V TABLET
tiv D. W. EVANS, .M.I)..
DEM. RAI'IDS, SO. DAK.
Lv taking a look at the small bottles which are used
lo contain hypodermic tablets and having demon-
strated the impracticability of pulling the cork, espe-
cially when one is in a hurry, as one is likely to be
when called upon to use the hypodermic S)ringe, I
have devised a method by which the cork is never
broken, neither is the bottle broken, in the attempt to
remove a refractory cork that one has accidentally
pushed in too far. As most corks are nearly the same
in diameter throughout their entire length, I take a
common sewing-needle and thread it double w ith No. 8
thread, having first tied two knots on the end. I force
the needle through the cork, beginning at the smaller
end and piercing it lengthwise, then knot the thread
again at its point of exit in such a manner that it can-
not be drawn back. Then I tie a knot about one-half
FOREIGN BODIES IN THE MALE URETHRA.
liv H.\RRY C. HAYS, .M.D.,
TOLEDO, OHIO,
ASSISTANT PHVSICIAN, TOLEDO STATE HOSPITAL.
Ot'TSiDE of an institution for the care of insane pa-
tients, foreign bodies in the male urethra are not very
common, aside from the infrequent cases observed in
small boys whose spirit of curiosity and investigation
is worthy a higher aim, and an occasional accident,
self-inflicted or otherwise, to a man while intoxicated.
In most cases it is generally understood to be an in-
dication of a more or less unstable neurotic tempera-
ment, which has as its motive the excitation or
gratification of that sexual passion which is either
perxerted or has been so abused that its normal mani-
festation is impossible.
The following case is interesting, in that it shows
to what extent it may be practised by insane patients
and how long the real trouble may be concealed, even
when the physical suffering and mental distress is
great, if the physician in attendance fails in his
duty of making a careful physical examination, as is
so often the case with this class of patients outside
hospital treatment. John R , aged sixty-five, Ger-
man ; occupation, farmer. Form of mental disease,
chronic melancholia: duration of insanity, several
years. The patient came under my charge from the
care of another physician, who thought he was aware
of the real nature of the trouble existing, respecting
the gen ito-uri nary system, and had pronounced it
hypertrophy of the prostate, but had taken no steps to
relieve the suft'ering, although he had had charge of
the case for over a year. The clinical signs and
symptoms were simply those of great pain and distress
when micturition was attempted, the flow of urine
being slow, interrupted, and at times suddenly stopped
altogethei^ with intense pain in the glans penis. The
necessity existed of passing water very often both day
and night. The symptoms, as a matter of fact, were
typical in all respects of stone in the bladder.
On attempting to pass a sound an obstruction was
met immediately after entering the external meatus.
This first foreign body could be plainly felt by taking
the penis between the thumb and forefinger, and no
great difliculty was experienced in extracting with
a pair of simple artery forceps what proved to be
a piece of rubber tubing or catheter about one inch in
length with a diameter of one-quarter of an inch. It
was covered with a deposit of urinary- salts; but the
lumen of the tube remaining open and lying length-
wise in the urethral canal allowed the urine to pass
through without difliculty.
Passing the sound still farther, a second obstruction
was met and its distal end found to be located at or
near the peno-scrotal junction. This was easily de-
tected on manipulation and seemed to be about three
to three and one-half inches in length. Evidently
either two foreign bodies were lying side by side, or
one was turned upon itself and lying in the long axis
of the urethra, as was the first. On grasping this with
a pair of forceps and attempting its extraction, it was
found that when traction was made the two ends
moved forward at the same time, although only one
seemed to be caught between the blades of the instru-
ment. Finding that the loose end was in danger of
penetrating through the urethral wall into the sur-
5i8
MEDICAL RECORD.
[October lo, 1896
rounding structure, an incision was made to the ure-
thra, the foreign body serving as a guide, and with
a pair of small forceps a large-sized hairpin was
withdrawn. This was also covered with a deposit of
urinary salts and rust, showing that it had been in the
urethra some time.
Introducing the sound finally into the bladder, the
unmistakable and characteristic click was produced
which indicated stone.
The patient was allowed to recover from these two
slight operations, and after getting him into as fair
condition as possible the median operation of lithot-
omy was made, with the result of extracting a stone
weighing four hundred and nine grains. It was of the
mi.\ed or fusible variety of phosphatic calculi, on
breaking up which its nucleus for deposit was found
to be a piece of fine iron wire, coiled upon itself, and
measuring in length when straightened out five and
one-half inches.
This was as far as I thought practicable to pursue
the investigation in this case, but our curiosity was
aroused to the degree of wondering if perchance some-
thing more might not be discovered, either in the
ureters or in the pelvis of one or the other kidney.
The patient, notwithstanding his age, condition,
and length of time of his distress, made an uneventful
recovery. The only thing necessary now is to pass a
sound occasionally, to be assured that he has not
introduced something more into his urethra.
there really seemed to be little chance of union taking
place. The process of healing took fifty days; the
skin and a small amount of the superficial tissue on
the end of the finger dried and separated before union
was complete.
UNION OF A SEVERED FINGER TIP.
By W. V. GAGE, M.D.,
M'COOK, NEFi.
On Monday, February 17 th, the patient, E. W ,
while applying a lubricant to the chain of his bicycle,
had the misfortune to catch the index finger of the
right hand between the chain and the rear sprocket of
the rapidly revolving wheel. The pressure of the
opposing surfaces completely severed the finger at the
root of the nail, cutting through the middle of the last
phalanx. The accident occurred in a bicycle store, a
block from my office, and a few minutes after the
patient was under my care. On examination I found
that there was not sufficient uninjured tissue to make
suitable flaps, and a temporary dressing was applied,
in view of an early operation, w'hen it was my inten-
tion to shorten the bone so that I could utilize the
tissue for flap coverings. About half an hour after
the patient arrived in the office, one of the young men
of the town brought me as a curiosity' the .severed end
of the finger, wrapped in a piece of tissue paper.
The fragment had passed through several hands since
the accident, and had been used as the subject of one
or two practical jokes, before coming into my pos-
session, and was covered, as had been the hand of my
patient, with dirt and oil deposited during the bicycle-
cleaning process. Although realizing that there was
little hope of success, I scrubbed the fragment with
soap and water, and immersed it in a five-per-cent.
carbolic-acid solution; I removed the dressing I had
just placed, and fixed on the end, pushing the matrix
of the nail which remained on the severed end well
under the tissue, and then replaced the dressing.
I did not suture, as I did not wish to cut with the
needle any small artery which might possibly fur-
nish a source of nutriment to the severed end.
Thirty-six hours after the accident I applied two nar-
row strips of adhesive plaster, crossing each other at
right angles over the end of the finger, to guard against
any possible accident from a slight blow, and dressed
with iodoform and five-percent, carbolic-acid dressing.
The end at the time looked white and lifeless, and
TRAUM.ATIC PERITONITIS AND RUPTURE
OF THE BLADDER.
By CARI. C. WARUKN, M.D.
ISHPEMING, MICH.
Joseph C , twenty-three years old, woodsman,
came to the hospital at midnight on April 8, 1896.
He had been drinking heavily all day and had been
unable to urinate since four o'clock in the afternoon.
One hour before admission, during a drunken brawl,
he was twicfe kicked in the abdomen. The patient
complained of great pain in the hypogastrium and was
in a condition of partial collapse.
Examination showed a small ecchymotic area in the
right iliac region, the abdomen much distended and
painful, and the bladder rising above the umbilicus.
Catheterization brought away sixty-four ounces of
bright bloodv urine.
The following morning at seven o'clock the pa-
tient's condition was not improved. Forty-eight
ounces of urine tinged with blood came away by the
catheter, giving the man no relief. Distention and
tympanites were evident. The patient developed a
general peritonitis. Subsequent catheterizations
brought away a normal quantity of urine unmixed
with blood.
On the evening of April 10th only a few drops of
thick dark-colored urine could be obtained. The man
died early on the following morning.
The autopsy showed the abdominal cavity filled
with serum, the intestines distended, agglutinated,
and covered with patches of lymph. A portion of the
ileum lying in close relation to that portion of the
abdominal wall which received the blows was gangre-
nous to the extent of four inches. The kidneys were
normal and both ureters intact. The bladder was
partially filled with clear urine. .\t the fundus of
this organ was found a complete laceration, one and a
half inches in length, running posteriorly. Tiie edges
of the tear were uneven and gangrenous. The organ
was otiierwise in a perfectly healthy condition.
A diagnosis of rupture of the bladder was not offered
without reservations. The quantity of urine drawn
off at regular intervals during the man's sickness
would indicate that the bladder retained its contents
perfectly, and consequently the peritonitis could not
have taken origin from leakage of urine but from the
lesion of the gut alone.
It seems probable that the rupture of the viscus ex-
tended primarily through the mucosa and muscularis
coats, the serous covering remaining intact until a few
hours before death.
Calomel Hypodermically. — The calomel is blended
with sterilized oil, and e\ery precaution observed to
prevent infection with the needle. A long, strong
needle is used and the fluid is injected deeply into
the tissues of the right loin. No suppuration or no-
dosities follow. The maximum dose of calomel by
this plan is five centigrams, about one grain. By
this method the patient is spared the pain and incon-
venience of stomatitis, and, besides, the action of the
drug is more energetic and decisive. — Therafeiitie
Review.
October lo, 1896]
MEDICAL RECORD.
519
POISONIiVG BY CANNABIS INDICA.
liY MARV L. GEISER, M.U.,
'Mf^w Instvximents.
FOkr MADISON, IOWA.
Having read the case of cannabis-indica poisoning
reported in last week's Medical Record, by G. G.
Fischlowitz, M.D., and noticing that not many cases
have been recorded, I will report a case of poisoning
by the same drug, which occurred in my practice Au-
gust 13, 1896. The patient. Miss M. C , aged
fifty-seven, suffering from malarial cachexia, began on
July 6tii to take iriv. of normal liquid cannabis indica
which I had prescribed for migraine. On August
12th I increased the dose from ill v. to nivii. The
first prescription was dispensed by a druggist who has
the reputation of substituting. The patient called
after having a second prescription filled and we exam-
ined it, the patient stating that it did not resemble the
first in color or taste, the first being light colored and
of pleasant flavor. ( It was suspended in simple elixir.)
The first dose was taken about 1 1 145 a.m., August
13th; the patient ate dinner about twelve o'clock and
was taken suddenly and violently ill a few minutes be-
fore I P.M. The first sensation was that of fainting, and
the patient went to the door for fresh air. A feeling
of numbness and tingling of the entire body rapidly
supervened, with much difficultv of breathing. Being
in the neighborhood, I saw her in less than five min-
utes; at that time she was seated in a chair, her ex-
pression being staring and somewhat anxious. The
apnoea grew worse. The patient said she felt para-
lyzed and very weak. Two or three times she seemed
to lose consciousness; at those times the pulse was
very weak. She was able to lie down most of the
time, though at times we were compelled to hold her
up to facilitate respiration. I gave her one-fortieth
grain of strychnine and one-tenth grain of apomor-
phine hypodermatically. Before emesis took place I
gave her a second one-fortieth grain of strychnine.
Emesis now began and she was somewhat relieved.
She was given copious draughts of hot water to thor-
oughly wash out the stomach. Twice after this she sank
and was given each time one-fortieth grain of strych-
nine; the last dose being given about 3 :3o p.m. It
■was about 4:30 p.m. when I thought she was well
enough to be left, though there was still some sighing
respiration. .She did not go to sleep luitil after 8 p.ji.
and spent a rather restless nigiit. .She felt quite weak
for some days and does not yet feel as well as usual.
The apnoia and extreme weakness were the chief
symptoms. The patient experienced none of the feel-
ings which are thought usually to attend poisoning by
cannabis indica. Her mind was clear, except when
for a few moments she was unconscious. The time
did not seem especially long; she felt entirely her.self ;
did not feel dizzy; was able to hear and understand
all that was said to her; answered all questions per-
fectly, though her voice had a faint far-away sound.
Sight seemed to be more affected than any other sense.
The patient said she felt at a distance from us and
also felt at different times as if she were d)ing; these
feelings occurred just as she was losing consciousness.
The urine was not changed.
I believe that if my patient obtained any cannabis
indica in the first mixture it was inert, and in the sec-
ond she received a larger dose than she could bear by
not coming up to it gradually, as I had intended she
should.
Auj<ust 27, 180O.
Rupture of the Kidney. — Dr. C. K. i'oland re-
cently reported a case of rupture of the right kidney
in a young man of nineteen years, who had been
"charged and kneed" by an opponent while playing
football.
GLASS DOUBLE-GURRENT
TUBES.
IRRIGATING
Hv KtiHERT COLEMAN KEMP, M.D.,
NEW VURK,
SURGEON TO THE CHrRCH 1NK1R.M.=.RV AND DISPENSARY.
The glass rectal irrigator is a tube five inches long,
shaped like a rectal bougie. The central tube opens into
the bowel at the tip of the instrument. There are two
openings, about half an inch posterior to the tip, for
the return current, which passes on all sides of the
central tube and flows out of a single collecting tube
below. Above the point of exit for the return current
is an open-
i n g for
clean i n g
the instru-
ment. This
is closed by
a cork.
Some of the
glass tubes
are made
w i t h o u t
this open-
ing, and in
these the central tube
is of large calibre,
being used for the
return current, the in-
gress current enter-
ing laterally. These
are not so readily
cleansed. When the
return current is made
to pass through the
central tube, only a
small amount of water
will pass up the
bowel, as the return
will be nearly im-
mediate. By varying
this and by pinching
the entering and re-
turn tubes, the quan-
tity of water can be
regulated, as de-
scribed in the Miii-
ICAL Record, Decem-
ber 7, 1895. These
glass tubes are made
in two sizes: No.
I, diameter one-half
an inch; No. 2, di-
ameter five-eighths of an inch. They can be
bought of the instrument makers in this city.
The double-current surgical irrigating tube is about
ten inches long, made of tough glass, either straight
or curved. It is in effect a double-current Chamber-
lain tube, and can be used as a simple irrigating tube:
or, on the siphon principle, to wash cavities; or, with
the direct return, to wash large sinuses. The tubes
are made closed, or with the cork opening for cleans-
ing purposes, as in the glass rectal irrigators. The
closed tubes should allow the entering current to pass
out laterally, and the return current to pass through
the centre. The curved tubes have the large enter-
ing tube on the concave side, to act as a handle and
also as a guide to the curve. They are made in two
sizes, No. I and No. 2, the same as the rectal.
44:) P*BK Avenue.
520
MEDICAL RECORD.
[October lo, 1896
^'focjress of ^Xedical J-ciencc.
The Effect of Laparotomy on Tuberculous Peri-
tonitis.— Dr. Gatti [II J'li/niinico, March 28, 1896)
has experimented on clogs, guinea-pigs, and rabbits in
order to determine the value of laparotomy in the
treatment of peritoneal tuberculosis. He concludes
that laparotomy has little etTect when the tuberculosis
is quite initial. The tuberculosis presents no macro-
scopic changes in the first three to five days after
operation, but a small quantity of reddish serum is
thrown out. I'Vom seven days to nearly a month the
tubercle was almost always increased in amount, but
after this diminution and disappearance were noticed.
Cure occurs through a degeneration of the epitheloid
cells, without the intervention of wandering cells, in-
dependently of phagocytosis and without the forma-
tion of fresh connective tissue. Dr. Gatti thinks the
serous lluid which is thrown out the first few days
stimulates the repressive processes after laparotomy ;
this is effected by the serous fluid bathing the tuber-
culous mass, however thick, and having a bactericidal
and attenuating action on the tubercle bacilli.
Hypertrophy of the Prostate. — Dr. Glenn {Soii/Zi-
cni J'ractitioiur, July, 1896J summarizes as follows:
I. Prostatic hypertrophy is a disease of old age, sel-
dom giving trouble under forty-five years of age. 2.
Prostatic hypertrophies are di\ ided in two classes:
those slightly enlarged, with some residual urine, some
interference with the force of the stream and recur-
rent attacks of cystitis; and those very much enlarged,
with decided deformity of the urethra and inability to
urinate voluntarily, the bladder emptying itself only
by the aid of tiie catheter. 3. Subjects with the first
variety should keep up careful and systematic dilatation
with metallic bougies and empty the bladder with the
catheter once daily. The second class should at once
be submitted to surgical treatment for radical cure. 4.
A safe and efficient means of giving relief to urgent
symptoms is by puncture through the perineum, which
may be done without an ana;sthetic or with cocaine. 5.
In operating for radical cure pedunculated middle
lobes should be removed by electric cautery, or ecra-
seur, not with scissors or knife. If not pedunculated
the hypertrophied portion should he gouged out with the
finger after the mucous membrane isthoroughly incised.
Local Treatment of Gout. — Dr. William Murrel
(LniUii) gives the following method, which he has em-
ployed with success: '" I take half an ounce of iodide
of potassium, dissolve it in half a pint of rectified
spirit — methylated spirit is used in hospital practice
— add one ounce of soap liniment, and then one-half
drachm each of oil of cajeput and oil of cloves. A
piece of lint is soaked in this mixture, wrapped roinid
the affected part, co\ered with a jirotective, and ke]it
in place by a bandage. It acts as a powerful counter-
irritant, and the inllammaiion usually subsides in from
twelve to twenty-four hours. In addition, I not un-
commonly give a drachm of colchicum wine with ten
grains of iodide of potassium three times a day.
These large do.ses of colchicmn wine induce bri.sk pur-
gation, sometimes accompanied by \omiting, but they
speedily cut short the attack. This mode of treatment
is especially useful in the case of robu.st, full-bodied
men in active employment, to whom the loss of a day's
work is a serious consideration. In sciatica, lumbago,
and rheumatism affecting one joint the local applica-
tion of a liniment containing haif an ounce of salicy-
late of sodium, half a drachm of oil of cajeput, fifteen
minims of oil of eucalyptus, and half an ounce of soap
liniment in six ounces of rectified spirit affords prompt
relief."
Extirpation of the Rectum by the Kraske
Method. — Dr. Joseph ilacon says that when the can-
cer or stricture is limited to the anus and lower rec-
tum it frequently happens that the diseased portion
can be removed without opening the peritoneal cavity,
and in such cases the danger of the operation is re-
duced to a minimum. Unfortunately cancer of the
rectum, like stricture, usually begins at a point where
the levator ani muscles encircle the rectum, and when
the growth is removed the greater part of the levator
ani muscles and the recto-vesical fascia, together
with the peritoneal covering, is so extensively re-
moved that resuturing of the peritoneum so as to
close the peritoneal cavity is out of the question, and
one must close the abdominal cavity by means of
gauze packing in the pelvic outlet, until after four or
five days, when the peritoneal surface next tlie gauze
will have thrown out a layer of hmph and granulation
tissue, entirely closing off the jK-riioneal cavity from
the external wound. It is important to remember
that the bony incision must be limited above at the
lower border of the third sacral vertebra, otherwise
the third sacral nerve is injured and serious bladder
complications are brought about by the paralysis of
this ner\e. — Inlerslale Medical Journal, April, 1896.
Treatment of Pneumonia in Infants. — Dr. L.
tlmnielt Holt (Air/ikts of J\ilialiiis, xiii.. No. 4)
gives the following method in use at the Babies'
Hospital, New York: Among the children under three
years of age treated at this hospital, one-fourth of the
jmeumonia cases are lobar, three-fourths broncho-
pneumonia. The cases are kept in a ward by them-
selves, with plenty of air space, temperature 70 F.,
and the children are removed once a day to permit a
thorough airing of the ward. To secure proper nutri-
tion, and to avoid digestive disturbance, food is given
considerabl)' diluted, and at regular hours; also abun-
dant water between times, with stimulants. Pepto-
nized milk is used for the youngest infants. Care is
taken to avoid distention of the colon by gas, which
frequently occasions cyanosis or convulsions in in-
fants. Daily irrigation of the colon is practised in
such cases. Drugs are to be avoided and especially ex-
pectorants. .\ntip\Tetics are to be used only when
there is a high temperature, with extreme nervous symp-
toms. Cold sponging, ice to the head, or the cold
pack or bath are freely u.sed, and occasionally phena-
cetin. Counter-irritation by a mustard-and-fiour paste
of the strength of one to six, applied for a few minutes
three times a d.iy, is much more useful than jjoultices.
Inhalations of steam from a croup kettle imder a tent
are emploved systematically in all ca.ses every three
or four hours. The steam is charged with vaporized
creosote, turix'ntine, or benzoin. The inhalation is
continued from ten to twenty minutes, and controls
the cough. For stimulation, from one-half to three
ounces of whiskey are administered every twenty-four
hours well diluted: strychnine in frequent small doses;
sometimes nitroglycerin, or digitalis and ammonia.
An oil-silk jacket should be worn. Prolonged cases
do better when sent away to the country than when
retained in the hospital wards.
Cold Baths in Delirium Tremens We read in La
Frcsse Aleduali\ 1896, No. 4, that cold baths are very
effective in quieting even the most violent attacks of
delirium tremens. The temperature of the water
should be 18 C. The patient is placed in the water
up to his shoulders, and it is poured over his head.
The bath is repeated two or three times the same day.
This treatment lias given surprising results in two
cases in which all other measures were ineffectual. A
few glasses of warm wine were given afterward, fol-
lowed by quiet sleep.
October lo, 1896]
MEDICAL RECORD.
521
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, October 10, 1896.
THE LADIES' HEALTH PROTECTIVE ASSO-
CIATION.
What may be done by earnest women in the way of
health reforms is well illustrated in the account given,
in the New York Medical Times, by Mrs. Ralph Traut-
man, the president of the Ladies' Health Association,
of twelve years of work of that organization. The
reason for the initiatory proceedings is thus signifi-
cantly stated;
" In November, 1884, eleven women, residing on
Beekman Hill, whose houses are beautifully located
on a high bluff overlooking the East River, with
everything desirable to make them healthful, were so
outraged at the continuance of the foul odors which
polluted the atmosphere of the entire neighborhood,
causing them to keep windows closed in the hottest
weather and depriving them of their inalienable right
to pure air, that they resolved to investigate the cause
of this nuisance.
"Accordingly, they made a tour of the neighbor-
hood, in that section of the city known as the Abattoir
District, which runs on First Avenue from Forty-third
to Forty-seventh Street. Their first visit was a reve-
lation, and while they returned to their homes ill from
the inspection and the discovery of the nuisance by
which they had so long been tortured, they decided
that some action must be taken to better the condition.
" The following morning their number was increased
to fifteen, and it was resolved that these women should
form themselves into an organization, to be known as
the Ladies' Health Protective Association."
The first action of the new society was to appear be-
fore the Grand Jury, and procure an indictment against
the nuisance. Notwithstanding the strong political
pull of the proprietor, who was the brother-in-law of a
State senator, a verdict was secured against him, and
he was compelled to employ a large force of men
promptly to remove the foul and reeking nuisance.
The earnestness and impartiality of the association
was a matter of surprise to the then health authori-
ties, and the gentleman who was president of the health
board at that time was forced to admit on the w^itness
stand that he had neither visited nor had a report of
that section for six years!
In close proximity to the manure ground were the
slaughterhouses, and adjoining the latter was a noto-
riously offensive bone-boiling establishment. A di-
rect appeal was made to the legislature for the abol-
ishment of the former establishments. As might have
been anticipated, the measure was defeated; but the
large amount of money it cost the butchers to effect the
object caused them to recognize the facts that the
women were in earnest and were not to be overawed
either by interested parties or by the political backers
of the latter. The men who first came to scoff after-
ward remained to pray, and the result was a confer-
ence and consequent compromise. It was then dis-
covered by the butchers, in consideration of the fact
that the demands of the society were so great, that it
would be cheaper in the end entirely to reconstruct
their slaughtering-pens than to undertake the neces-
sary alterations. Growing out of this determined effort
on the part of the association, abattoirs have been con-
structed which are a credit to the builders and which
in every way fulfil the advanced requirements of sani-
tary science.
The bone-boiling establishment was next dealt with,
and after a valiant fight on the part of the determined
reformers the firm was eventually forced out of busi-
ness.
Duly encouraged by such good results, the associa-
tion took up other matters, which had been more or
less neglected by the authorities having them in
charge. The gas-house nuisance was largely abated,
the sanitary condition of stores, public conveyances,
and public places was insisted upon, and the exposure
of meats in thoroughfares was prohibited, through their
instrumentality, by a special health ordinance.
We are informed in this interesting report that
efforts are now being made to prevent exposure of all
articles of food to the influences of the dust and dirt
on the streets — a very proper and sensible measure,
and one demanding the immediate attention of the
health board and police authorities.
We heartily congratulate the association on the
magnificent showing of good work accomplished along
these and other lines, and trust that it will gain
strength and wisdom in well doing. The great hope
in its future efforts rests on the fact that it is not
afraid of the so-called political bosses, that no special
political pull can result in pigeonholing complaints,
and that its members, being women, are naturally en-
titled to be heard on any subject in which they may
be interested. We only wish it were within the prov-
ince of these earnest and good women to attack the
Hunter's Point stench nuisance, which has vied for
years with the other outrageous abominations in the
immediate vicinity of their headquarters. The mem-
bers of the association could give valuable testimony
at the pending investigation by the State health board.
THE COMMON DISEASES OF THE ANUS.
The " Causes and Treatment of Some of the Com-
moner Affections of the Anus" are discussed by
Dr. D. H. Goodsall, in a recent number of T/ie Practi-
tioner. The common diseases, he says, are abscess,
eczema, fissures, fistuljE, venous pile, ulcers, syph-
ilis, oedematous skin, and cancer.
As to abscess, very few hints as to treatment are
522
MEDICAL RECORD.
[October lo, 1896
really needed, for there is but one way to take care of
such a condition. The abscess cannot be opened too
soon, and the incision which gives the most satisfac-
tory result is the T-shaped, with its horizontal part
parallel to the anus. Abscesses in this part of the
body are generally left too long before being opened,
and when opened the incision is usually far too
small.
Eczema is, perhaps, one of the commonest of the
troubles in this region, and is often associated with
pruritus. It is caused by an absence of cleanliness,
by constipation, by the passage of rectal mucus, by a
discharge from the fistula, and by the discharge from
the wound of the part. The treatment recommended
by Dr. Goodsall is to cleanse the part thoroughly with
olive oil and dry cotton wool, and then a liniment
composed of si.xty grains of powdered zinc oxide, one
drachm of camphor liniment, and si.x drachms of lime-
water liniment is gently rubbed over the surface for
about five minutes. The parts are then covered with
a layer of dry absorbent cotton. Wlien the surface
has become dry, a powder composed of oxide of zinc
and camphor, one drachm of each to an ounce of
starch, is applied. The part should be cleansed every
night and morning, and the powder gently rubbed
over the surface.
Fissure is another of the common and annoying
troubles of this region. It is to be looked for when
the patients complain of a burning, aching, or throb-
bing pain coming on during or within half an hour
after an action of the bowels. The pain may last for
only a few minutes to several hours. Frequently
blood is lost in small amount. On examination, the
part will be found contracted in appearance, and the
patient is unable to force it down. Fissures are gen-
erally found in the middle line dorsajly or anteriorly.
The common advice for the treatment of this condi-
tion is to undertake at once some surgical measure,
such as stretching or cutting. Dr. Goodsall, however,
says that in mild cases the fissure may be cured by
aperients, diet, and cleanliness. When the fissure is
of long standing and there is some internal growth, the
sphincter should be divided and the growth removed.
In some cases of old-standing fissure the-sphincter be-
comes hypertrophied and loses much of its natural
elasticity; the fissure itself becomes somewhat cica-
trized. In these cases the condition may be relieved
by forcibly overstretching, and may be more certainly
cured by complete division of the sphincter on one
side only. Patients wlio will not submit to an
operation will gain some relief by injecting an
ounce of olive oil every night, this to be retained,
if possible.
Venous piles are usually caused by straining or
lifting heavy weights, and often come on suddenly.
They cause pain and also itching and soreness and
tenderness. Local applications of lead and opium,
together with aperients, are usually sufficient to re-
lieve this state, though in many cases a small opera-
tion is necessary.
For chancroidal ulcers, the writer recommends the
application of a ten-per-cent. solution of cocaine, fol-
lowed by the application of sulphate of copper.
THE INHERITANCE OF NEOPLASMS.
Among the questions which have interested medical
men for ages there are few, perhaps, regarding which
there has been more confusion of thought than that
relating to heredity in its various bearings. At some
time and in some form nearly everybody has regarded
tuberculosis as hereditary, yet on occasion many who
may have observed it desolate families have denied
its heredity, for no other reason than that it does not
accord with their conception of a beneficent Creator
that innocent offspring should inherit disease from
parents. Some men of high scientific attainments
have sought to oft'er balm to an anxious public by
proclaiming that cancer cannot be hereditary, since
it is unreasonable that a disease which makes its ap-
pearance many years after birth should in reality date
from intra-uterine life. But science has no regard
for sentiment, and when an abnormality, a lesion,
or a weak organ which furnishes a culture bed for
disease germs is inherited, it simply notes the fact.
It is the facts of the case which scientists would
know.
Dr. Fere, of Paris, recently reported to the Soci^t^
de Biologic a number of observations and experiments
touching upon this question. He has found that the
embryo of the chick between the twentieth and six-
tieth hours may, if implanted under the skin of a
chicken, grow and form a tumor with elements which
had not been differentiated when the graft was made.
.Vfter a time the tumor disappears by absorption. He
says one can conclude from this experiment that em-
bryonic elements remaining in tissues normally devel-
oped are capable of ulterior evolution. Thus, the
theory of the embryonic origin of certain tumors and
the teratologic theory of the heredity of tumors, and
tlieir family connection with diseases to which there
is congenital predisposition, finds interesting sup-
port.
These experiments and others, consisting in inter-
ference with eggs in the brooder, showed that under
nearly similar conditions there was considerable differ-
ence in the effect upon the nature of the tumor in the
one case and upon the development of the chicken in
the other. Fere also relates a few cases of asymmet-
rical development of one side in man, combined with
other stigmata, such as tumors on the defective side of
the body, pointing to a degeneiate type, anil concludes
that the multiplicity of tumors in the same individual,
their heredity, and the dissemblance in their heredity
place them among the characteristics of degeneracy.
Their accord with tcratological deformities in the
family and the individual is favorable to the hypo-
thesis of a common origin of the degeneracies (neuro-
pathies, arthropathies, etc.), with which tumors may
also find themselves associated. F^r^ would apply
the term famillc Urafoplasique to the non-parasitic
group of tumors. In his experiments, he finds that
agents capable of influencing the development of the
embryo are not limited in their action to a retardation
of development or to a production of malformations:
briefly stated, they produce variation, which may be
either exaltation or depression.
i
October lo, 1896]
MEDICAL RECORD.
523
mcius of the 'Wicch.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
October 3, i8g6. September 28th. — Assistant Surgeon
R. G. Brodrick detached from the Franklin and granted
leave for two months. September 30th. — Medical Di-
rector W. K. Van Reypen ordered to duty as mem-
ber of the inspection and survey board, October ist.
Medical Inspector J. C. Wise detached from duty on
the board of inspection and survey and ordered to
museum of hygiene, October ist.
Physician Shoots Druggist — Dr. George S. Henry,
of Duncannon, Pa., was shot and probably wounded
fatally on September 28th by Dr. T. L. Johnston, who
accused the former of immoral relations with the wife
of the latter. Mental aberration is suspected on the
part of Dr. Johnston, who has been a successful practi-
tioner and at the time of the accident was acting presi-
dent of the Duncannon National Bank.
The New President of the New York State
Lunacy Commission, Dr. Peter M. Wise, entered upon
the duties of his office on October ist. He was ap-
pointed by Governor Morton to succeed Dr. Carlos
F. MacDonald, resigned.
Prof. Rudolf Virchow will be seventy-five years
old on the 13th of this month, and it is proposed in
Berlin to celebrate his birthday in a worthy manner.
He was born in Schivelbein, Pomerania, and obtained
his medical degree at the University of Berlin in
1843. He was appointed physician to the Charite'
and Privatdocent to the university just fifty years ago.
The Deadly Chewing-Gum. — A young man who
was scorching for a record on a bicycle track a few
days ago was thrown from his wheel. When picked
up his face was cyanotic and his arms and legs were
twitching convulsively. A physician found a ball of
chewing-gum, the size of a walnut, obstructing the
entrance to the laryn.x. The gum was removed and
the man recovered. In the interest of sesthetics it is
to be hoped that this accident w-ill serve as a warning,
to w'heelmen at least, if not to other men, to desist from
their deforming habit.
Obituary Notes. — Dr. William Remsen Taylor,
of Long Island City, died at the home of his brother
in Middletown, N. J., on October ist, after a long ill-
ness. Dr. Taylor w-as health officer of the city for si.x
years and was a candidate twice for the office of coro-
ner and once for mayor on the Republican ticket.
He was a graduate of the Long Island College Hos-
pital in the class of 1864. -Dr. Charles H. Chalk-
lev, professor of chemistry, to.xicolog)-, and medical
jurisprudence in the University College of Medicine,
Richmond, Va., died on September 13th. He was
born in Powhatan County, Va., August 4, 1859, and
was a graduate of the Medical College of Virginia in
1883. — Sir William James Moore, of London, died
recently at the age of si.xty-eight years. He served in
the Bombay medical service from 1852 to 1888. He
was honorary surgeon to the viceroy of India, and
after his retirement from the service and return to
London was appointed honorary physician to the
Queen. — Dr. Henry Hooper Mitchell died at Elk-
ton, Md., on September 27 th, at the age of seventy-
seven years. He was a graduate of the University of
Pennsylvania and began the practice of his profession
at Elkton immediately after receiving his degree.
The French Congress of Alienists and Neurolo-
gists will meet at Toulouse in 1897. The following
questions are proposed for discussion : i. Differential
diagnosis of general paralysis. 2. Infantile hysteria.
3. The medical service in lunatic asylums.
The Semi-Centennial of the Discovery of Anaes-
thesia is to be celebrated in Boston on October i6th,
in the amphitheatre of the Massachusetts General
Hospital. The following addresses will be made:
"Address of Welcome," by Charles H. Dalton, Esq.,
president of the Massachusetts General Hospital ;
'■ Reminiscences of 1846," by Dr. R. T. Davis, of Fall
River, and Dr. Washington -A.yer, of San Francisco;
" Surgery before Anesthesia," by John Ashhurst, Jr.,
M.D., of Philadelphia; " What Anesthesia has Done
for Surgery," by David W. Cheever, M.D., of Boston;
" Relation of Anesthesia and Obstetrics," by John P.
Reynolds, M.D., of Boston; "The Influence of Anes-
thesia upon Medical Science," by W. H. Welch, M.D.,
of Baltimore; " The Surgery of the Future," by Charles
McBurney, M.D., of New York; "The Birth and
Death of Pain," a poem, by S. Weir Mitchell, M.D.,
of Philadelphia.
Dr. Samuel Fenwick has resigned his post as
visiting physician to the London Hospital, after an
incumbency as physician and assistant physician of
twenty-eight years. He has been appointed to the
consulting staff.
The Ninth Congress of Italian Alienists was held
in Florence from October 5th to 9th.
Fraudulent Testimonials. — The British Medical
Defence Union has taken up a case of the publication
of a bogus testimonial in favor of a drug preparation.
It appears that an American firm sent to English phy-
sicians a pamphlet describing the virtues of a new
drug, and among the testimonials in the pamphlet was
one to which was appended the name of a well-known
physician. He knew nothing about the drug and had
never used it, and naturally objected to the unwar-
ranted use of his name.
Trained Nurses in California. — Many trained
nurses from Philadelphia and Baltimore have recently
been induced to go out to San Diego and other places
in Southern California on the representation that they
could find employment there that would pay them S20
or §2 5 a week. On arriving there, however, they have
found that there was no work for them, and that, even
if there were, they could not obtain any such remuner-
ation for their services, and they have in many cases
had to send to their friends in the East for money to
enable them to return itome. The San Diego Medical
524
MEDICAL RECORD.
[October lo, 1896
Society recently adopted a preamble setting forth
these facts, and a resolution stating, " for the informa-
tion of such as may hereafter be likely to fall victims
to such misrepresentation, that the profession of nurs-
ing is now greatly overstocked, and that at no time
has any demand or such opportunities existed for
trained nurses as represented."
The Medical Service in the British Army is
rapidly deteriorating, owing to the snubbing which its
members constantly receive from the commander-in-
chief of the army and his subordinates among the so-
called combatants. There are at present, it is said,
about forty vacancies and no candidates can be found
to fill them. The pay at some stations does not meet
the medical officer's necessary expenses, but one of
the most galling points in the situation, says the
Medical Press, is the supercilious social attitude, for
the most part, assumed by the combatant officers. The
newly fledged army medical, who is, in nine cases out
of ten, a man of liberal education and decent social
position, finds himself the only medical man on a sta-
tion. He is admitted, not as a right but upon suffer-
ance, to the officers' mess, and is thus at once intro-
duced to the system of arrogant social snobbishness
with which the British army is still cursed, at any rate,
so far as its medical branch is concerned. What won-
der if the medical schools now warn all students
against choosing the army as the scene of their future
career? It will be interesting to observe what impres-
sion the dearth of candidates will have on the heads
of the department.
" The Edinburgh Medical Journal," as we noted
recently, has been bought by a new publisher and is
to have a new editor. The change, however, does not
appear to have given very general satisfaction. The
sale was effected without notice to the editor or to the
two medical societies of which the journal was the
recognized organ. The members of these societies
are now talking of organizing a syndicate among the
physicians of Edinburgh to establish and conduct a
new medical journal.
The Association of German Physicians and Sci-
entists held its si.xty-eightli annual meeting at l''rank-
fort-on-Main, during the week ending September 28th.
Among the general addresses delivered were essays by
Dr. liuchner, of Munich, on " Biolog)' and the Science
of Health;" Dr. Below, of Berlin, on "The Practical
Aims of Military Hygiene;" and Dr. Weigert, of
Frankfort-on-Main, on " New Questions in Pathologi-
cal Anatomy." A discussion on "The Results of
Recent Investigations on the Brain" was participated
in by Flechsig, of Leipzig; Edinger, of Frankfort; and
von Bergmann, of Berlin.
The Government of South Australia is a queer
thing. It recently turned out the medical staff of the
Adelaide Hospital and, being unable to find subservi-
ent tools among the local profession, imported some
London doctors to fill the vacancies. Now it has
again shown its contempt for medical men by appoint-
ing a layman to the office of public vaccinator for the
colony.
The Fourth French Medical Congress will be
held in Montpellier in the spring of 1898, under the
presidency of Professor Berrtheim, of Nancy. The
questions proposed for discussion are: i. "The Clin-
ical Forms of Pulmonary Tuberculosis." 2. " Mi-
crobic Associations and Mixed Infections." 3.
"Therapeutic Use of Organs with Internal Secretion."
A New Uniform for Members of the Hospital
Corps of the Army. — Upon the recommendation of
the surgeon-general of the army. Secretary Lament
has directed a change in the army regulations in refer-
ence to the uniform of members of the hospital corps.
In place of the regulation full-dress uniform of blue
heretofore prescribed, members of the hospital corps
will hereafter receive an allowance for an e.xtra suit
of white duck. Members of the corps are not required
to turn out for parades and inspections of troops, and
therefore it was deemed unnecessary that they be re-
quired to wear the full-dress uniform of the army.
When these men are called upon for duty the service
required of them is of a character that demands cloth-
ing that will be more comfortable and better adapted
to their particular duties than that prescribed for the
enlisted men of the army. A white duck suit in a
hospital ward will not only prove more comfortable
for the wearer, but the appearance will be more in
keeping with the surroundings and the duties to be
performed. — College ami Clinical Record.
Dr. Charles A. Powers, of Denver, Col., while on
a visit to tills cily, was the recipient of many courte-
sies from his numerous friends here. Dr. William T.
Bull tendered him a complimentary dinner on Wednes-
day evening at the New York Club.
Beri-Beri has broken out again in the Richmond Dis-
trict Lunatic Asylum in Dublin, twenty cases of the
disease being at present under treatment there. There
was a similar epidemic in the same institution last
year. The asylum is greatly overcrowded, and a hos-
pital is soon to be erected at Portrane to relieve the
congestion in the wards of the Richmond District
Hospital.
Dr. George L. Peabody. — The many friends of
Dr. Peabody in this city and elsewhere will be
pleased to learn that he is now convalescent after the
operation for appendicitis which was performed at his
country place, Gaspe, Canada, by Dr. Sheppard. He
is at present under the care of Dr. Sheppard at the
Montreal General Hospital.
The Mount Vernon City Hospital was closed four
weeks ago for want of funds, tlie aldcYmen having
refused to make a sufficient monthly appropriation to
meet the necessary running expenses. A man was shot
in the town a few days ago and, as there was no place
where he could be attended to, the coroner. Dr. A. T.
Banning, took him into his own house. He had sub-
sequently to be removed to Yonkers for operation and
died, and now it is claimed that the man's life might
have been saved could he have been operated upon
without being moved such a distance. The murderer
will probably profit by this when he comes to be tried
for the shooting.
October lo, 1896]
MEDICAL RECORD.
525
J»ocietr[ ^e^jorts.
AMERICAN ASSOCIATION OF OBSTETRI-
CIANS AND GYNECOLOGISTS.
Nintli Annual Meeting, Held in Riihmond, I'd..
Septeviber 22, 2j, ami 24, iSg6.
The association met at the Jefferson Hotel, and was
called to order, at 10 a.m., by the president, Dr. Jo-
seph Price, of Philadelphia.
The Cause of Pelvic Disease Dr. John M.
Duff, of Pittsburg, read the first paper, which was
entitled " Pelvic Diseases and Their Principal Causes:
What Should the Laity be Taught Concerning Them ?"
He said thit notwithstanding the fact that some of the
prominent members of the medical profession had, in
talks to the galleries, held the gynecologists up for
ridicule and criticised them severely, he did not think
any apology was due either the profession or the pub-
lic for the character or results of the work of pelvic
surgeons. Those members of the profession who had
been devoting themselves to the care of diseases pe-
culiar to women, had, in the face of revilings and pro-
fessional and public prejudice, worked patiently and
persistently, until they were now obtaining results of
whicli they may well feel proud, results far beyond
what the most sanguine expectations of the hardy pio-
neers of a quarter of a century ago ■ led them to hope
for. They were to-day charged with irrational radi-
calism, with an operative mania, which was gratified
without a proper consideration of the ultimate benefit
to the patient. Entreatingly they were urged to adopt
more consen-ative measures, and thus stop the whole-
sale mutilation which was going on at present, which
it is claimed is neither scientific nor humane. Senti-
ments such as these, endorsed lay men of reputation,
were eagerly taken up by the lay press as sensational
news and advertised by pretenders as an endorsement
of their methods of practice; and thus the laity, in
the opinion of Dr. Duff, is taught false notions re-
garding the nature of pelvic diseases and their treat-
ment. That there is a great amount of mutilation
connected with pelvic surgery, he would not deny;
but that regular pelvic surgeons were guilty of reck-
less despoliation was not, he thought, susceptible of
proof. Pelvic surgeons could scarcely be held ac-
countable for the work of general practitioners; and
for the work of ignorant egotists and pretenders, wlio
with brazen effrontery undertake operations for the
performance of which they are not qualified by char-
acter, experience, or education, the pelvic surgeons
disclaim all responsibility. During the period of the
evolution and upbuilding of pehic surgery, no doubt
much of the work was crude, and perhaps too much
was done by overzealous operators. That at this day,
through mistaken diagnosis, operations are sometimes
needlessly performed, no one would have the hardi-
hood to deny ; but that such cases are as frequent as
some critics say they are, Dr. Duff could not believe.
He said the true pelvic surgeon was governed by no-
isier purposes, by more elevated aims. Conservatism
in its true sense — the saving of life, relief from pain,
the curing of the patient — was his watchword.
Deceptive Similarity of Signs and Symptoms of
Intra-Abdominal Disease, with Cases. — Dk. Wal-
ter }!. Dorsett, of St. Louis, followed with a paper
on this subject. In order to arrive at a conclusion
and to formulate a diagnosis in a given case, be it
medical or surgical, the practitioner must exercise care
and judgment in the consideration of such signs and
symptoms as are presented. Each should be weighed,
and mental annotations taken as to their value indi-
vidually and collectively. Dr. Dorsett directed at-
tention to the importance of the family and personal
history and habits of patients, to the pulse and tem-
perature, the knowledge to be gained by manual ex-
amination, the use of analgesics, etc. Regarding the
exploratory incision, it should not be regarded as an
evidence of ignorance, but as a legitimate means of
diagnosis, and the oft-hand diagnostician or the sur-
geon who never makes mistakes should be looked
upon with at least a grain of suspicion. To illus-
trate his statements, he reported the following case;
Mrs. M , aged twenty-eight, married eight years,^
no pregnancies, was seen by Dr. Dorsett about a week
after having recovered from an attack of malarial fever.
Temperature, 99 "^ F. ; pulse, 90; tongue slightly
coated, and a tendency toward diarrhoea. Com-
plained of general abdominal tenderness. Palpation
of abdomen revealed a slightly more tender spot at
McBurney's point; no swelling or tumefaction could
be felt. A vaginal examination revealed a retrover-
sion with fixation ; no tubal enlargement nor tender-
ness could be made out, and no vaginal discharge.
Diagnosis: Gastro-intestinal irritation, with chronic
inflammation of pelvic contents. Diarrhceal mixture
was prescribed, and patient was told that further at-
tendance would probably not be necessary. Four
days subsequently the temperature was 99.8" F. ;
pulse, 100. Abdominal palpation revealed a dis-
tinctly tender spot with some swelling at McPurney's
point. Patient stated that she had eaten heartily of
Wienerwurst the day before, and had been awakened
during the night by cramps at the navel. Bimanual
examination was again resorted to, with negative re-
sult. Appendicitis was diagnosticated at this visit,
first stage. Drachm doses of salts were prescribed,,
and patient was urged to go to the hospital, but
refused. The next day she was found sitting in
a rocking-chair, and, aside from slight tenderness
over abdomen, was feeling quite comfortable. The
salts had acted freely. Bimanual examination again
gave negative results. Temperature, 99° F. : pulse,
100. Patient was ordered to bed and advised to
keep quiet. At that time she was regarded as better,
and thought to be out of danger, but the following
day the pain became more severe, and the patient
came to the hospital of her own accord. Upon ex-
amination the right iliac fossa was found to be ex-
ceedingly tender and fluctuating. Vaginal examina-
tion revealed nothing aside from what was found at
the previous examination. Temperature, 103° F. ;
pulse, 130. Diagnosis; Ruptured appendiceal ab-
scess. She was ana:sthetized and placed upon the
table, and a section made in the median line. The
large sac was found on the right side filled with fluid
blood and clots, and when washed out a rent of the
posterior layer of the broad ligament was found, which
communicated with another rent in the F'allopian tube.
The appendix was perfectly healthy and was not dis-
turbed. A thorough washing out of the sac was done
and ligation of the tube with a portion of the broad
ligament; a glass drainage tube was introduced. Not-
withstanding the utmost care, the temperature re-
mained high, the pulse became worse, the abdomen be-
came distended, and the patient died on the third day.
I'ost-operative diagnosis: Ruptured tubal pregnancy,
without the usual symptoms. There were no history
of shock, no cessation of menstruation nor any nervous
symptoms of pregnancy, no passage of decidua, no
vaginal discharge of any kind; but in their stead a good
history and train of signs and symptoms of inflamma-
tory disease of the appendix.
The Most Potent Causes of Pelvic Inflammation.
— Dr. RtiFUs B. Hall, of Cincinnati, read this paper.
He claimed that .septic infection following labor or
abortion, or gonorrhoeal infection, was the cause in
almost every instance. He said there would always
526
MEDICAL RECORD.
[October lo, 1896
be some cases of septic infection following labor,
which are in no wise due to infection from the atten-
dant, injury to small pelvic tumors, etc. The reten-
tion of the products of conception in abortion is a very
frequent cause. He advised complete emptying of
the uterus at once after abortion. He believed the
most frequent cause to be gonorrhctal infection con-
veyed to the woman from a latent gonorrhcea of her
husband. Tiie more he saw of the ravages of gonor-
rhoea, the more he was convinced of the fact that phy-
sicians are derelict in their duty to their patients in
the dissemination of knowledge upon this subject.
The teaching of a few years ago that gonorrhoea in the
male could be easily and speedily cured by a little
balsam of copaiba or oil of sandal wood, with mild
astringent injections, and that the patient was well as
soon as the purulent discharge ceased, is false doc-
trine and must be corrected. This must be done by
the family physician. Dr. Hall said that on many
occasions he had been compelled to remove suppu-
rating tubes and ovaries from women who had con-
tracted the disease from husbands who believed them-
selves well when married. He had no hesitation in
.saying that gonorrhcea is more destructive to women
than syphilis, and believed it is the duty of every phy-
sician to impress upon his male patient the fact that
he is not well as soon as the urethral discharge disap-
pears. He was a firm advocate of legislation upon
this subject, believing that every man should have a
certificate from the health officer of freedom from
syphilis and gonorrhoea before he could obtain a mar-
riage license.
Dr. f. Henry Carstens, of Detroit, in discussing
Dr. Dorsett's paper, said that the difficulty attending
diagnosis in some cases was exceedingly great.
The gynecologist should exhaust his diagnostic re-
sources before resorting to abdominal section. The
too frequent opening of the abdomen stimulated in-
competents to do likewise, and as a consequence re-
sults were disastrous, eventually reacting on gynecol-
ogists.
Dr. W. K. J5. Davis, of ISirmingham, Ala., did not
believe that gonorrhoea played so important a part in
the production of pelvic intlammation as had been as-
serted. One's conception of causes of pelvic trouble
depends largely upon the class of ])atients one has.
The cases met witli in dispensary practice are differ-
ent from those encountered in private practice. He
believed that fully fifty per cent, of the cases of pelvic
inflammation are due to puerperal infection, either at
the time of delivery at full term or of premature deliv-
ery. As to tuberculous trouble, more importance is be-
ing attached to it as a cause of pelvic intlammation than
it deserves. Those who did considerable operative
work knew that only a small percentage of cases have
their origin in tuberculosis.
Dr. James MacFadden Gaston, of Atlanta, called
attention to the prophylactic management of cases of
pregnancy prior to the period of confinement. Ex-
treme hygienic precautions might warrant in some in-
stances the use of antiseptic douches prior to labor,
bat there was a great tendency on the part of some
members of the profession to resort to measures which
are regarded as precautionary, and to order douches in
advance of confinement. He believed that this was
altogether out of place, for when there is a normal
condition of things nature should be allowed to take
its course.
Dr. Ernest S. Lewis, of New Orleans, cited a case
illustrating the errors that sometimes arise in the di-
agnosis of abdominal tumors. He operated on a
patient last winter for what he supposed at the time
was a small ovarian tumor, but after the abdomen was
opened it turned out to be a retroverted gravid uterus.
Tubo-Ovarian Cysts. — Dr. Ai iiert Goldspohx, of
Chicago, read a paper on this subject. By tubo-ova-
rian cyst is meant a non-purulent sac whose walls are
composed, in variable proportion, of the walls of the
Fallopian tube and tho.se of some cystic ovarian or
parovarian formation, with the coalescence of two or
more cavities — at least one from each — into one, by
a free communication. The fluid contents of such a
sac may be serous or hemorrhagic, or may partake, in
variable degree, of the qualities and characteristics of
the fluid contained in glandular ovarian cystomas.
The fimbria of the abdominal cstium of the tube may
be distinguished or not upon the inner or on the outer
side of the ovarian portion of the sac, or they may
have coalesced with otjier structures to form some
portion of the walls of the united sac. The ovarian
element in this formation can have originated from a
hydropic Graafian follicle, a cystic corpus luteuni,
from the primordial glandular ducts of f'flueger in the
ovary, or from the parovarian. In order to exclude a
large number of ordinary tubo-ovarian conglomerates,
we need to recognize the following minimum require-
ments in distinguishing a tubo-ovarian cyst: (i) The
participation of the tube, which is easy enough from
its position and connections. (2) To prove the par-
ticipation of the ovary by demonstrating some ovarian
tissues in the wall of the sac. (3) That their cavities
are united by some opening through which the mucous
membrane of the tube is continuous with the lining of
the ovarian cyst or follicle. The following were the
conclusions of the paper: 1. Tubo-ovarian cysts come
to pass in consequence of a plastic inflammatory union
between a I'allopian tube and the adjacent ovary, after
either or both of these organs and the intervening
peritoneum have experienced a non-purulent patho-
logical change of a cystic character, the septum
inter\ening between the two lumina disappearing in
consequence of pressure atrophy from the tension of
liquid confined to one or both sides of it. 2. This
union of a distended tube cavity may occur also with
that of a parovarian cyst (v. Ott) or with that of a
peritoneal p.seudo-cyst (Zedel). 3. In those rarer cases
in which the fimbria; are really found floating in the
interior of the main cyst cavity, we must assume either
the congenital anomaly of an '"ovarian tube,'' as was
seen by Scimeidemahl in a mare, as a vitiiim prima
foniuitioiiis, or that an ovarian cyst or follicle cyst
ruptured, and the abdominal end of the tube dropped
into the rent and was united to its edges by inflamma-
tory action, thus making a joint cyst and tubal cavity.
Mixed Tumors of the Ovary. — Dr. Walter K.
Chase, of iirooklyn, followed with a paper with this
title. Mixed tumors of the ovary ha\e a peculiar in-
terest, for the reason that, if small, they are often diffi-
cult of diagnosis. These tumors of the ovary may be
made up of a variety of cysts, or may be a combina-
tion of cysts and solid growths. The etiology of
tumors as a whole is a matter of great importance,
both in the relation to diagnosis and treatment. The
question of what constitutes a tumor might be consid-
ered with profit. Senn defines a tumor as " a local-
ized increase of tissue proliferation of embry-onic cells
of congenital or post-natal origin." An important
fact concerning true tumors is that they never dis-
appear except by removal or destruction. Benign tu-
mors always remain local, while malignant ones are
disseminated by migration or transportation of their
peculiar cells, and they always originate as benign or
malignant growths. If the tumor matrix is made up
of embryonic cells of the lowest development, there is
greater liability to malignant growth than if from
tissues susceptible to the highest physiological type of
development. Retention cysts of the ovary are not
tumors in a technical sense, and they never attain
large size. Large ovarian cysts are most often cyst-
adenomas and are not developed from Graafian fcflli-
J
October lo, 1896]
MEDICAL RECORD.
52;
cles, but arise from the embryonic structure. It would
seem tiien that the genesis of simple and mixed tumors
is divested of much that is misleading and contra-
dictory and reduced to a rational basis. It also
demonstrates with great clearness that tumors are not
only of local origin, but at their inception are con-
genital.
Movable Kidney : Local and Remote Results —
Dr. a. H. Cordier, of Kansas City, Mo., read a paper
on this subject, in which he drew the following deduc-
tions: I. A movable kidney often produces a dilata-
tion of the stomach with all the accompanying symp-
toms of a disease of that organ. 2. It is a fruitful
source of gall stones, because of the pedicle produc-
ing a partial obstruction of the common duct. 3. The
bending of the ureter often gives rise to a hydrone-
phrosis. This, in turn, is sometimes converted into a
pyonephrosis. 4. It may produce death by a complete
strangulation by a torsion of the vessels and ureter.
5. By dragging on the abdominal aorta and kinking
the vena cava, a condition simulating an aneurism of
these vessels may be produced. 6. Pain of a referred
character to the region of distribution of the spinal
nerves is often induced by a movable kidney's dis-
turbance of the abdominal brain. 7. A general nerve
exhaustion (neurasthenia) is often induced by the in-
terference of this condition with digestion, assimila-
tion, and elimination. 8. Nephrorrhaphy is a safe and
effective surgical procedure. 9. All cases of movable
kidney, if accompanied by symptoms pointing to the
kidney as their source, should be operated on. 10. In
summing up the local and remote results of this now
often recognized condition, the author thinks the cor-
rectness of the deductions has been frequently demon-
strated by the disappearance of each and every
symptom after a restoration and retention of the
kidney in its normal position. 11. Symptoms are not
to be relied upon in making a diagnosis of movable
kidney. The physical examination is the only tnist-
worthy guide.
The Limits of Nephrorrhaphy was the subject of
a paper by IJr. Hugh M. T.aylor, of Richmond, Va.
He conceded the frequency of nephroptosis. Since
he had been sytematically looking for movable kid-
ney, he had found it so frequent in its occurrence that
he no longer regarded the experience of Glenard,
Lindner, Edebohl, and Noble as unique. His opin-
ion was equally fixed that only a small proportion of
the cases met with give rise to symptoms of suffering,
ill-health, or death, and consequently a majority of
cases do not call for nephrorrhaphy. He favored the
classification of nephroptosis under three clinical
heads: i. Patients who have displaced kidney, do not
know it, and suffer no inconvenience whatever from it.
This type he thinks represents by far the largest class.
2. Patients with displaced kidney, who may or may
not know it, who suffer from gastro-enteric discomfort
and perhaps a long train of vague neurotic disturb-
ances. In this type he thinks we find the largest class
calling for operative interference. 3. Patients with
movable kidney who are subjects of occasional or
frequent mild or severe attacks of renal crises. This
last mentioned is, he thinks, the least frequent fyix;
met with, but the urgency of the symptoms more fre-
quently demands operative interference. Nephror-
rhaphy for the relief of gastro-enteric disorder is
limited by our ability to tell to what extent the dis-
order is due to renal ptosis per sc or to enteroptosis,
or to -some one of the many well-known etiological
factors of gastro-enteric disorder. Nephrorrhaphy for
the relief of the condition of Deitl's or renal crises
must be limited by one's success in differentiating
between this condition and that of gall-tract, appen-
dicular, and kidney colic due to nephrolithiasis. He
accepted as logically sustained the conclusion that the
Deitl's or renal crisis is due to a kink or twist of the
ureter with retained urine in the ureter and pelvis
of the kidney. Apart from the violent paroxysms of
pain (the renal crisis), the tendency of ureteral twist
and urinary obstruction to induce hydronephrosis and
in exceptional instances pyonephrosis rendered opera-
tive interference more imperative in this class of cases.
His protest was not against nephrorrhaphy, but against
its abuse. He conceded the value of operative inter-
ference in many selected cases, but deprecated the
tendency toward operative interference merely because
the kidney is movable.
Dr. George Bex Johnston, of Richmond, Va.,
said that some years ago his attention was called to
the subject by encountering several cases of movable
kidney that had been unobserved either by him or by the
physician who preceded him in the treatment of these
cases for obscure nervous and gastro-intestinal dis-
turbances, and when he observed the similarity of
symptoms in the first three cases which he saw he
was obliged to associate those symptoms with the
presence of movable kidney. He prevailed on these
women to be operated upon for movable kidney and
in all three cases the results were most gratifying.
Dr. L. H. DtNxiNG, of Indianapolis, was greatly
interested in the subject, for the reason that about
1880 he resorted to operative procedures for the cure
of floating kidney, and in connection with this work
he sought to determine if possible some of the causes
which led to movable kidney. He emphasized the
importance of differentiating between floating and
movable kidney, the former being always congenital,
the latter acquired to a greater or less extent. He
found by his investigations that the partially fixed
condition of the kidney depended upon three or four
causes, the two principal ones of which were its posi-
tion behind the peritoneum and the fact that it had
an envelope of cellulo-adipose tissue. A little further
investigation showed that the perinephric cellulo-
adipose tissue was composed of two parts, one fixed,
the other movable. The normal kidney had a range
of motion of from one-half to three-quarters of an
inch in its fatty envelope.
Dr. Thomas B. Eastman, of Indianapolis, reported
the case of a woman, twenty-five years of age, who
came to him with the symptoms of appendicitis. She
also had considerable albumin in the urine. Opera-
tion showed that the appendix was firmly adherent to
the kidnev. It required considerable force to liberate
it. As soon as liberated the kidney bounded back
into place as though it were rubber. The appendix
was removed, the albumin in the urine ceased, and
the woman made an uneventful recovery-.
Dr. James MacFadden Gaston, of Atlanta, directed
attention to the possibility of movable kidney being
mistaken for enlarged gall bladder. The gall bladder
was capable of being pushed back into the lumbar
region and carried around in front in just the same
manner as a floating kidney. It behooved gynecolo-
gists to look into this phase of the matter.
Dr. W. E. B. Davis, of Birmingham, had seen a
number of cases of movable kidney, and said that at
the Charleston meeting of the Southern Surgical and
Gynecological Association there was quite a differ-
ence of opinion as to the frequency of the condition.
He believed that movable kidney was a condition
which did not require in all cases operative interfer-
ence. Of the number of cases he had seen he had
only operated on a few.
Dr. I. S. Stone, of Washington, D. C, related the
case of a woman who, after the operation of nephror-
rhaphy had been performed, gained twenty-five
pounds in flesh. In many instances this procedure
brought color back to the cheeks of patients and made
them feel well. He had never seen such gratifying
528
MEDICAL RECORD.
[October lo, 1896
results from any other operation in surgery, except,
perhaps, the reuioval of an ovarian tumor. The pa-
tients made rapid improvement after the operation.
Dr. Joseph Price, of Philadelphia, said his expe-
rience was somewhat limited in operating for movable
kidney. The improvement in the condition of patients
so operated upon was rapid, but there was such a thing
as operating too much upon cases of movable kidney.
Dr. J. Hexrv C.'vrstens, of Detroit, said the line
should be drawn between movable and floating kid-
ney. The trouble which arose from floating kidney
consisted of a twisting of the ureter and consequent
obstruction.
Treatment of Peri-Uterine Septic Diseases — Dr.
W. K. B. Davis, of Birmingham, Ala., read a paper on
this subject. Only recently has the extremely radical
procedure of hysterectomy been practi-sed in this coun-
try for septic diseases of the internal genitals. A
wave which had its origin in Paris at the hands of
Pean, aided by Richelot, Segond, Jacobs, and others,
readied our shores three years ago and has found a
considerable following among our leading oiserators.
The claim is made that there is no use in leaving the
uterus behind after the removal of the apjiendages.
In every operation for septic diseases of the female
generative organs which demands the removal of the
tubes and ovaries, hysterectomy should also be per-
formed, unless there are plain contraindications for-
bidding it. It should be the aim of the surgeon to
preserve everything consistent with thorough surgical
work, and not to sacrifice important organs because it
can be done with only a small mortality. We are
told that the uterus has no function after the removal
of the appendages, but this has not been demonstrated ;
and, on the contrar)-, we know that the sexual life of
the woman is very much better preserved by leaving
the uterus, and that tlie mental effect is also much bet-
ter. .\ slow convalescence, or even a second opera-
tion, is preferable to its removal, unless very much
diseased. It is a reflection on the correctness of the
reports by many most excellent surgeons of complete
recoveries of such a large per cent, of the cases when
the uterus was not removed, to accept the argument
now being used in favor of hysterectomy in all these
cases. As stated by Dr. Davis at the last meeting of
the American Medical .Association, he could not agree
with Dr. Sutton and others that pus in the tubes was
due to gonorrhcea in seventy-five per cent, of cases.
He thought that puerperal infection was the cause of
more than fifty per cent. Tuberculous infection was
rarely the cause, and was not so important as had been
claimed. However, the importance attached to gon-
orrhoea was against the argument for the removal of
the uterus, as the infection from this source was not
deep and could be removed with the curette. Because
some patients were not completely cured by the re-
moval of the appendages was no argument for hyster-
ectomy in every case in which the bilateral operation
was required; for nearly all these could be relieved by
a thorough curettage. Some large uteri would require,
in addition to this, a high amputation of the cervix,
and only a small number would need a hysterectomy.
Vaginal incision for the drainage of pus in the pelvis,
not confined to the tubes, was a most valuable method
of treatment in a well-recognized class of cases, and
had been practised for a long time, with gratifying re-
sults. .\ large number of tiiese cases required no fur-
ther surgery. More recently large pus tubes and
ovarian abscesses had been incised and drained
through the vagina, with permanent recoveries in a
good proportion of cases. The uterus should always
be curetted at the same time. These were the very
cases in which the vaginal operation and hysterectomy
had been recommended so highly by the French sur-
geons. Yet a considerable percentage of these cases
could be relieved by vaginal incision and drainage.
The object of the surgeon should be, not so much
to reduce still further the death rate from the opera-
tion, but to relieve the subjects and preserve as far
as possible organs which had so much to do with the
woman's health and happiness.
Hysterectomy in the Presence of Active Inflam-
mation Dk. L. H. Dunning, of Indianapolis, fol-
lowed with a paper upon " Hysterectomy in Intiamma-
tory Diseases of the Pelvic Organs." The author
discussed only that form of inflammation of the pelvic
organs and tis.sues denominated diffuse pelvic iiiHam-
mation, and drew the following conclusions:
1. We recognize the utilit\' of hysterectomy in a
small percentage of cases of bilateral suppuration of
the tubes and ovaries, in which the uterus is distinctly
.septic, and in cases of septic uteri which cannot be
cured by other means after bilateral salpingo-oophor-
ectomy.
2. We oppose hysterectomy, as a rule, in inflamma-
tory diseases of the pelvic tissues upon the following
grounds; viz.: (<?) The uterus is the central organ of
the reproductive system, and should not, except upon
palpable and urgent cause, be extirpated ; (fi) it is
only in rare cases that the uterus is so far diseased as
to resist the curative effects of appropriate treatment :
((■) the removal of the uterus profoundly atfects the
nervous system and emotional nature of young women
deprived of this organ; {//) we oppose the removal of
the uterus from anatomical reasons; to wit: as a re-
sult, the vagina is shortened; the anatomical relations
of the bladder, sigmoid, and rectum are changed: the
elasticity of the pelvic diaphragm is greatly diminished
or entirely removed, the elastic tissue being largely
replaced by sensitive scar tissues; (tr) in married
women it often disturbs the sexual relations of hus-
band and wife, and is apt to induce mental depres-
sion ; {/) vaginal hysterectomy compels the use of
drainage, because of the necrosis of tissue and suppu-
ration induced.
Shall the Uterus be Left in Situ in Excision of
the Adnexa?— Dk. E. F. Fish, of Milwaukee, Wis.,
read a paper which was an argument in favor of leav-
ing tlie uterus m siin, if sound, after excision of the
appendages. It considered the pathological condi-
tions requiring hysterectomy after salpingo-oophor-
ectomy, as well as the conditions which do not re-
quire it. The author argued against all operations
which leave a degenerated uterus, such as Hegar's,
Tait's, Martin's, and Robinson's, except under ex-
treme conditions, and concluded as follows: I. When-
ever it becomes necessary to excise the uterine ad-
nexa, if the uterus is sound, leave it. 2. Whenever
we excise the tubes and ovaries, and the uterus, though
in a pathological condition, in our judgment will
yield to treatment, leave it. 3. Whenever it is neces-
sary to do an abdominal hystero-salpingo-oophorec-
tomy and the cervix is healthy, do a supravaginal am-
putation, as this leaves the vaginal vault intact. 4.
Whenever it is necessary to do a supravaginal amputa-
tion, suspend the cervix to the stumps of the broad
ligaments or anchor it to the abdominal wall, to pre-
vent' prolapsus vagina;. 5. Whenever it is necessary
to do a general ablation, and the cervix uteri is un-
sound, take the entire organ, because of the danger of
carcinoma. 6. Whenever a subserous or interstitial
myoma can be removed without too great damage to
the uterus, do a myomectomy and leave the organ. 7.
Whenever we excise the appendages and leave the
uterus, ventral fixation is not an unsurgical operative
conclusion.
The author's reasons for leaving the uterus were that
it helps to maintain the woman's sexual integrity: it
relieves the patient of much mental strain, and is a
prophylactic measure to neurasthenia, melancholia.
October lo, 1896]
MEDICAL RECORD.
529
and insanity; it tends to maintain the family ties un-
strained; it obviates the possibility of vaginal hernia,
cystocele, and proctocele, and delays vaginal atrophy ;
and, finally, it holds up and prevents shortening of the
vagina.
Dynamic Ileus. — Dk. J. W. Long, of Richmond,
Va., contributed a paper with this title. Intesliniil
obstruction had been variously classified, but I)i.
Long regarded the classification adopted by Murphy
as the simplest and the most rational: 1. Adynamic
ileus, always the result of intestinal paralysis, due to
varying causes, may be clearly illustrated by such
cases as those following injury to the spinal cord and
paralysis due to ]3eritonitis. 2. Dynamic ileus. This
variety formed the subject of the paper, and was dis-
cussed in detail. 3. Mechanical ileus embraced such
common lesions as strangulated hernia, intussuscep-
tion, fecal impaction, etc. The speaker reported the
following case:
Mrs. C , twenty-one years old, married three
years, but never pregnant; was rather below the me-
dium size and height. In temperament she was of the
spoiled-child type, not hysterical but rebellious. It
was with great difficulty that she could be induced to
have anv local treatment or even to take medicine.s.
After admission to hospital her obstreperous disposi-
tion required all the tact and firmness of a sagacious
nurse. Early in April of this year the patient had
malarii, followed by delayed menstruation, pelveo-
abdominal pain, and obstinate constipation. The
malaria and menstrual disturbance yielded promptly
to treatment, but the abdominal pain continued, and
gradually the ileus symptoms became more and more
pronounced. After exhausting every other measure to
move the bowels, vhe patient was put under the influ-
ence of chloroform, and by means of a Ricketts tube
a quantity of fecal matter was washed away. Not-
withstanding, there was no improvement, the nausea
and vomiting recurred oftener and were more distress-
ing, the pain and tenderness became worse, and a
marked degree of tympany suiservened. When she
was brought to the hospital there had been no move-
ment of the bowels for four weeks, excepting what was
washed away with the colon tube while the patient
was ana;sthetized. The history justified the diagno-
sis of intestinal obstruction, while the urgent symp-
toms demanded an immediate operation. The abdo-
men was opened bv a median incision. No mechanical
obstruction could be found, although a careful search
was made along the whole length of the intestine.
The bowel was moderately distended with gas and
congested. A singular feature, however, was that at
three points — two in the ileum and one in the sigmoid
fle.Kure — the canal w'as constricted sutficiently to con-
stitute obstruction. In the ileum one of the constric-
tions was about fifteen inches from its lower end and
si.t inches long; the other was nearer the jejunum
and about four inches long. The lumen was not en-
tirely closed at either point, but was greatly reduced,
being less than half the normal size; while the diam-
eter of the remaining portions of the bowel was in-
creased, on account of the distention with gas. No
peristalsis was observed, but the contracted portions
could be dilated by "milking" the intestinal contents
along. In the sigmoid the limitations of the con-
tracted portion were not so sharply defined, but the
lesion was just as evident. The walls were thickened
and the c.libre much diminished. Incidentally a
small ovarian cyst on the right side was discovered
and removed. -\s the intestine had been handled a
good deal, the abdomen was flushed with normal salt
solution. The incision was closed with two tiers of
sutures — silk for the peritoneum and interrupted sil-
ver wire for the remaining lavers. The recovery was
most satisfactory in every way. The bowels responded
to the usual laxatives and enemas on the second day,
and from the first to last there was not a hitch in her
convalescence. The patient left the hospital in four
weeks, and three weeks thereafter took a trip to Ala-
bama. There could be discovered no evidence of lead
or ptoniain poisoning.
Spontaneous Rupture of the Uterus during Labor
at Term. — Dr. B. M. Hypes, of St. Louis, read a
paper on this subject. Mrs. O , aged thirty-one,
of German parentage, general health good; had had
one child four years ago. Labor pains began Sep-
tember 16, 1895, at 10 P.M., at full term. The family
physician was called, and found labor in progress, ver-
tex presentation, with normal condition of mother and
child. The p.iins were slight and progress was slow.
At 2 .A..M., September 17th, he gave a dose of morphine
and went home. At 9 a.m., upon his return, he found
the patient comfortable, with occasional slight labor
pains. He left the house, with injunction to call him
when signs of labor became pronounced. Patient re-
mained quiet during the day. Suddenly, at 3 p.m.,
she was seized with violent vomiting, followed by the
most excruciating pains in her abdomen, associated
with rolling and tossing in bed, gasping for breath,
faint feelings, pallid face, and rapid exhaustion: in
short, the usual symptoms of abdominal shock. The
family physician was at once sent for, and upon his
arrival, at 4 p.m., found her in complete collapse, with
convulsive seizures. The symptoms, w ith vaginal and
abdominal examination, revealed to him this dreadful
condition: The presenting part receded, the womb
empty, and the child plainly felt in the abdominal
cavit}'. The patient had suffered spontaneous rupture
of the uterus. The physician at once sent for surgical
aid; Ijut by the time the surgeon, I)r. Meisenbach, ar-
rived, the patient was moribund. Still, with the hope
of saving the child, laparotomy was hastily performed;
and the child, which had escaped entirely into the
abdominal cavity, was extracted from a mass of blood
and amniotic fluid. It had ceased to live, and con-
tinued efforts at resuscitation failed to cause it to
breathe. The child was fully developed, male,
weighed six pounds, and was eighteen inches long.
The uterus, when removed from the body, presented
the following condition : A rupture through the fundus
superiorly, extending from half an inch from the en-
trance of one tube to an equal distance from the en-
trance of the other; the walls at the place of rupture
were comparatively thin. The placenta was located at
the middle third of the uterus, anteriorly and to the
right, where the walls were much thickened. The
vaginal portion of the cervix was almost obliterated,
as at term, and dilated for the ready admission of two
fingers. The lower zone of the uterus exhibited no
thinning or formation of Bandl's contraction ring: there
was no disease of tubes, ovaries, or placenta. .\ mi-
croscopical examination was made soon after rupture,
and revealed fatty degeneration of tissue at the point
of rupture.
Porro's Operation — Dr. Edwix Ricketts, of Cin-
cinnati, O., reported a case of " Porro's Operation at
or near the Fifth Month for Small Fibroid of Cervix,
.Accompanied by Hydramnios and Total Retention of
Urine.'' Mrs. M , white, aged twenty-six, of short
stature; the mother of two children, of six and three
years of age; had had an abortion at eight weeks early
in 1895; there was no specific history. She was a
patient of Drs. J. I>. and C. M. \\'arwick, of Lucas-
ville, O. On February 23, 1896, she had severe labor
pains, lasting thirty-six hours and accompanied by
slight hemorrhage. The right portion of the cervix
was soft and the left hard, which condition was also
present at the time of operation. During April and
until May 2 2d. the date of operation, she had great
tenderness over the lower part of the abdomen, and at
530
MEDICAL RECORD.
[October lo, 1896
times had a temperature above 100'' F., with a pulse
running from 90 to 100. Dr. Ricketts saw her in
consultation at her home, April 8, 1896, when for the
first time motion of the fcetus was barely perceptible.
On May 2 2d, Drs. Warwick, Kline, Sellards, and
Ricketts found her abdomen larger than it should be
at full term, which was due to the hydramnios present.
There was no difficulty in moving the fcetus freely in
the abdominal cavity, so thin was the uterine wall. It
was considered unwi.se to delay surgical interference,
and a Porro operation was therefore performed, under
as strict asepsis as the circumstances would permit.
After the abdomen was opened, Dr. Ricketts passed
his hand down into the pelvis, breaking up the pelvic
adhesions. Upon the delivery of the fundus of the
impregnated uterus through the abdominal incision, a
rubber ligature was thrown around it, low down and
tight enough to control any hemorrhage which might
occur. The fluid which escaped, upon opening the
uterus, surpassed in amount any he had seen delivered
per viani tiatitralis. After carefully sponging the parts,
the wire was tightly adjusted below the rubber liga-
ture by means of the Koeberle clamp, and the rubber
ligature then removed. After the delivery of the
placenta, the fundus was amputated, leaving the
ovaries and tubes intact. The abdominal wound was
closed with silkworm-gut sutures, without stitching
any tissue to the stump below the wire. No drainage
tube was used. 'J'he e.xtraperitoneal part of the stump
was dressed with gauze, moistened ir. glycerin and
tincture of iron, the stump being held up by the
double- hooded pin of Tait. The placenta and fcetus
were small for one of nearly five months' gestation,
and the cord was tied in almost a hard knot — harder
than any he had seen. The fcetus had marked cyano-
sis and gasped but once. Recovery of the mother was
satisfactory.
Treatment of Puerperal Infection. — Dr. H. \V.
LoNGYEAR, of Detroit, first spoke of the prophyla.xis
and, under this head, of the difficulty of securing reli-
able statistics regarding puerperal mortality of patients
under the care of midwives in this country. The
])rophyla.\is was divided into general and specific.
He spoke of the treatment of infection from abortion
and from childbirth at full tenri, and presented an in-
strument designed by him for use in removing the
remains of secundines from the uterus. He also
exhibited a self-retaining drainage tube of his own
invention and demonstrated its applicability. He
reported two cases of puerperal infection treated suc-
cessfully by the use of dipiitheria antito.xin serum.
He condemned the perforniiiig of hysterectomy for
puerjieral scpticamia except in very exceptional cases.
Atresia with Retention of the Menses ; Treat-
ment— Dr. Willi.\m G. Meyers, of Fort Wayne,
Ind., read a paper with this title. The author reported
two cases of atresia, one with absence of the vagina
and uterus, and the other with retained menstrual
fluid. The last was operated upon successfully. He
believes that in a case of atresia of the vagina with
retention of menstrual fluid in the uterus, an opera-
tion ought to be completed at one sitting, the direct
method being adopted. He thinks the teaching in a
recent work, that "the best way is to make a small
opening into the mass and allow the contents to flow
away gradually," is not sound. He could not therefore
see in rapid evacuation such great dangers as were
referred to in the books.
Principles and Progress in Gynecology Dr.
Joseph Price, of Philadelphia, delivered the presi-
dent's address. He first thanked the association for
the distinguished honor conferred in electing him presi-
dent, which he said was the most gratifying expression
of personal and professional kindness. He said the
association was made up of earnest, enthusiastic, and
eminent men of the medical profession. We had
more than a passing interest in the record of the
transactions of our medical and surgical associations.
From them the history of the progress of medical and
surgical science would be made up; they would reflect
the advanced thought and opinions, the strength of
the endeavors, the results of clinical experience and
research of the profession of this period. We had the
inspiration of the reflection that our high service was
that of humanity, and. Dr. Price said, the members
were there to learn through the interchange of the
best counsel how to make that service the best.
Some Causes of Insanity in Women. — Dr.
Geor(;e H. Rdhe, of Sykesville, Md., read this
paper, of which the following is an abstract: The
general causes of insanity are the same in women as
in men, but there are modifying conditions in the life
history of men and women that influence the causa-
tion of mental disturbance as between the two sexes.
General paresis and alcoholic insanity are more fre-
quent in men because the latter are exposed to their
causes to a greater degree and intensity. Menstrual,
puerperal, and climacteric insanity are on the other
hand seif-evidently limited to women. Women are espe-
cially subject to mental disturbances, dependent upon
their sexual nature at three different periods of life:
puberty, the child-bearing period, and the menopause.
The functions and activities peculiar to these periods
have an intimate etiological relation to certain insan-
ities. It is probable, however, that these functions
have no influence in tlie production of insanity in
their normal condition. It isonlv when the functions
are disturbed or when patiiological conditions are
present that they have any unfavorable inlluence upon
the psychical functions. At the period of ]Hiberty,
menstrual derangements are not infrequently causative
of mental disturbances which do not yield imtil the
menstruation becomes normal. In the puerperium, in-
sanity is dependent upon septic absorption or ujion the
consequences of other morbid conditions of the repro-
ductive organs. Lactational insanity may be due to
physical exhaustion, but in some cases pathological
conditions of the genitals or of the breasts seem to
have an etiological relation. At the menopause the
disturbances of nutrition associated with the arrest of
menstruation often produce insanity, and in many of
these cases there will also be found abnormal altera-
tions of the reproductive organs. The in.sanities fol-
lowing gynecological operations are either due to
septic conditions, or are merely due to the rapidly
induced menopause. Their frequency has been much
exaggerated.
The Relation of Visceral Disorders to the De-
lusions of the Insane. — 1 )R. W.AI ier J'. Manio.n, of
Detroit, Mich., said that the delusions of the insane
are often an expression of somatic peripheral irrita-
tion has long been recognized, but observation leads
Dr. Manton to believe that the importance of these
mental manifestations as indices of bodily suffering
was frequently ignored and they were regarded as a
mere phase of the brain disorder, especially in the
instance of supposed fancied visceral disturbances.
For convenience of consideration, he placed the so-
called visceral lesions in four classes: i. Delusions
arising de vnvoUom the diseased activity of the brain,
2. Delusions regarding external or visible abnormal
bodily conditions. 3. Delusions arising from easily
determined visceral disorders. 4. Delusions depen-
dent upon obscure rbdoniinal and pelvic states.
Oophorectomy for the Insanity and Epilepsy of
the Female. — Dr. D.wid T. Gilliam, of Columbus,
O., contended in this paper that oophorectomy was a
logical and legitimate oj^eration for the epilepsy and
insanity of the female. Insanity is hereditar)', as is
also epilepsy. They constitute the greatest curse to hu-
i
October lo, 1896]
MEDICAL RECORD.
531
manity. An insane father or an insane mother brings
more misery into the world than any other father or
mother. The offspring of such a parent, when ushered
into tiie world, would be confronted by the awful spec-
tre of impending doom, and though he called on the
rocks or the mountains to fall on him, the curse would
pursue and overtake him. Dr. Gilliam then gave a
picture from real life. He would limit the operation
to those in whom the malady appears in some way to
be connected with or dependent on se.xual disturbance.
He would go further and include all who were willing
to undergo the operation to save themselves and their
ofispring from the miseries which awaited them.
Treatment of the Stump to Prevent Adhesions.
— Dr. J. F. Baldwin, of Columbus, O., followed with a
paper on this subject. He estimated that about one per
cent, of all subjects operated upon die from intestinal
obstruction, the result of adhesions to the stump. To
diminish as much as possible the danger of adhesions
he recommended the careful closing in of stumps by a
peritoneal flap, and described the method of securing
this flap. In cases in which the pedicle is, after a simple
ovariotomy, not too large, he recommended that the
pedicle be so ligated that the ends of the ligature were
on the anterior face of the pedicle; that the ends of
the ligature be then carried across the face of the
stump, down and through the broad ligament, trans-
fi.xing the ligament from behind forward. The liga-
tures should be passed through about half an inch
apart. As the ends were drawn through and tightened,
the raw end of the stump should be rolled down and
under the broad ligament, so as to be entirely pro-
tected. He had used this method in a large number
of cases, and with entirely satisfactory results.
Abdominal Section for Tuberculous Disease. —
Dr. Thom.as E. McArdi.e, of Washington, D. C,
reviewed briefly what has already been done by sur-
gical means for the relief of women suffering from
tuberculosis of the generative organs. There is no
doubt that tuberculous disease of the female genitalia
is more frequent than is generally supposed. Every
portion of the genital tract ma)' be affected, the order
of frequency for the various portions being the tubes,
body of the uterus, ovaries, vagina, cervi.x, and vulva.
The tubes are affected in nearly all cases, the body of
the uterus in about three-fourths of the cases, and the
ovaries in about one-half of all cases. Tuberculosis
of the body of the uterus is not at all a rare affection
and has been frequently discovered in autopsies upon
phthisical subjects. It can be the only focus of dis-
ease in the body, but it is generally associated with
disease of the tubes and is secondary to disease of that
organ. Of all the female genitalia, the vulva is the
least liable to tuberculous infection.
Melano-Sarcoma of the Female Urethra. — Dr.
Charles A. L. Reed, of Cincinnati, O., reported
this case : Mary E. Y , aged sixty-four, single,
was brought to his private hospital December 3, 1895.
The patient had had no previous serious illness.
There was no history of tuberculosis or syphilis in the
family. The virginal condition of the genitalia pre-
cluded the supposition of venereal infection of any
character. Her general health was good, although
there was some emaciation about the neck and breasts,
the latter of which were flabby — changes no doubt in-
cident to age. Careful examination revealed no dis-
eased conditions about either the lungs or heart.
Careful palpation and percussion of the abdomen
yielded negative results. About eight months previ-
ously,— i.e., in .\pril, 1895 — she began to notice some
pain accompanied with blood on micturition. This
was shortly followed by a more or less constant pink-
ish discharge from the genital fissure. The self-ex-
amination which followed revealed a tumor at the
meatus urethra. This tumor continued to increase in
both size and hemorrhagic tendency until she was
prompted to consult Dr. Morris, who curetted the neo-
plasm thoroughly and treated it with styptics. When
the patient came under Dr. Reed's care he found a
black lobulated and eroded mass about three centi-
metres in diameter separating the labia majora. The
orifice of the urethra was in the very centre of this
mass. A careful vaginal examination was not made
at the time, as the virginal structures, present in their
integrity, rendered such an operation very painful.
Operation was done the next day, December 4th.
The small blade of a Jones speculum was introduced;
the patient being in the Simon's posture, the urethra
was by this means exposed in its entire length. A
longitudinal incision was made through the mucous
membrane along the dorsum of the urethra from a
point where the presenting part of the mass was eroded
to the base of the bladder. Another incision through
the mucous membrane was made at right angles to the
foregoing at a point far enough above the eroded mass-
to insure healthy tissue. The mucous membrane was
then dissected back in two lateral flaps and the urethra
was enucleated. The urethra was found to be dis-
tinctly conical in shape, the base of the cone being at
the meatus, the apex at the bladder. Care was taken
to dissect out the canal to a point manifestly above
the zone of malignant involvement. When this point
was reached but a slight distance from the bladder,
the canal, with the neoplastic walls, was excised. The
cut margin of the cystic segment of the canal was
seized at various points in its circumference by
Kocher's forceps, brought down by gentle traction,
and fixed by interrupted sutures of silkworm gut to
the vaginal mucous membrane. A self-retaining cath-
eter was inserted, and the patient was put to bed. The
sutures were removed on the eighth day. The cathe-
ter was dispensed with on the twelfth day. The
patient sat up on the fourteenth day, when she found
that she could retain her urine and void it at will.
She was dismissed December 21st, entirely healed.
She remained in good health until the ist of July fol-
lowing— seven months — when she again summoned
Dr. Morris because of some stomach symptoms. He
found her suffering from persistent vomiting, and with
a large mass in the epigastrium. This mass rapidly
increased in size until it occupied all of the area be-
tween the navel and the breast bone, its nodular char-
acteristics becoming more and more pronounced.
.She died of exhaustion July 14, 1896, having had no
recurrence whatever of the urethral trouble. No au-
topsy was permitted.
Suture of Large Vessels Injured in Operations.
— Dr. J. B. Murphy, of Chicago, demonstrated the
method employed by him. He said in 1762 Lembert
conceived the idea of suturing injuries to vessels. He
made two experiments, in both of which he failed.
Dr. Murphy then referred briefly to the experimental
work of other surgeons along this line, pointing out
their successes and failures. His own researches and
operative work lead him to believe that, when a large
vessel is injured in an operation necessitating a trans-
verse division of it, not exceeding two-thirds of its cir-
cumference, the surgeon can resort to immediate suture
without resection, and, if the field of operation be asep-
tic, can feel more certain that he will have union of the
vessel and continuation of the current than he could
when he sutures the intestine as for resection of the
bowel. He believes from his observations that the
chances are better with the suture. The importance of
this concerns surgeons more in the treatment of aneu-
risms. Coming to the question of stab and bullet
wounds of the extremities, he said there was a
great field for improvement in past operative work.
Formerly, we ligated vessels, and when this was done
the inevitable result was death of the limb. He be-
532
MEDICAL RECORD.
[October lo, 1896
lieves that, now such limbs can be uniformly saved,
particularly in the aseptic cases. With his present
method of suturing large vessels, he is not afraid to
suture any vessel in the body, feeling confident that
adhesion or union will take place.
Contusions of the Abdomen — Dk. V. G. M.\c-
DON.u.D, of Albany, K. V., presented a communication
with this title. Contusions of the abdomen, he said,
are always grave injuries. The question of surgical
intervention, although much discussed, cannot be re-
garded as satisfactorily settled. Seven cases of trau-
maxic rupture of the stomach and small intestine were
reported. Two operations were undertaken, with one
recovery and one death the eighth day after operation
from second rupture. All the inoperative cases resulted
fatallv. Reference was made to the general absence
of evidence of contusions in the abdominal walls when
serious visceral injury has occurred. Very slight
causes, particularly if tlie intestinal canal is distended
with fluids, may produce intestinal rupture, as the fall-
ing out of bed, a blow from a barrow handle. 'I'he early
symptoms of intestinal laceration are not always dis-
tinctive. An analysis of two hundred cases of intestinal
laceration as associated w ith abdominal contusion was
made with a view to determining the symptoms. The
following topics are considered the important ones:
History of the nature of the injury, shock or collapse,
pain, vomiting, pulse, temperature, and physical signs.
Careful investigation of a given case will usually
show suflicient symptoms to make an early exploratory
abdominal section imperative.
Election of Officers. —The following oificers were
elected: Pres'ukiit, Dr. James F. VV. Ross, Toronto,
Can.; First Vice-President, Dr. (Jeorge Ben John-
ston, Richmond, Va. ; Second Vice-President, Dr. John
C. Se.xton, Rushville, Ind. ; Secretary, Dr. William
Warren Potter, BulTalo, N. Y. ; Treasurer, Dr. X. O.
Werder, Pittsburg, Pa.
The ne.xt meeting will be lield at Niagara Palls,
on .\ugust 24, 25, and 26, 1897.
MISSISSIPPI \ALLKY MEDICAL ASSOCIA-
TION.
Twenty-Second Annual Meeting, Held at St. Paul,
ji/iiin., September i^, i6, ij, and i8, i8g6.
The association convened in the senate chamber at the
Capitol. Dr. C. A. Whk.vion, chairman of the com-
mittee of arrangements, called the meeting to order.
Most Rev. John Irel.\.\d, D.D., offered prayer. On
behalf of the State of Minnesota, Gov. D. M. Clouuh
gave an address of welcome. The physicians were
welcomed on behalf of the city by M.wor F. B. Do-
RAN. He referred to the city's reputation as a host,
won by the magnificent record of the recent Grand
Army encampment, and tliat upon that occasion St.
Paul had welcomed the men who had preserved the
nation, and now was happy to welcome the men who
preserved the bodies of the nation's defenders. Dr.
A. J. Stone spoke for the profession in St. Paul, in
extending a welcome to the visitors.
President's Address. — Dr. Henry O. W.vlicer, of
Detroit, delivered the address. He said he had found
it difficult to secure a subject which had not been
thoroughly threshed over and over again. He had,
therefore, departed from the usual course, and would
offer some suggestions in a purely scientific vein, by
reporting three cases, in whicli four operations were
done, representing nearly all the operative procedures
now done upon tiie kidney.
Sacculated Kidney and Nephrolithiasis. — .August
4, 1S96, J. R , aged twenty-nine, was referred to
him for operation, with a history of severe pain in the
left kidnev twenty years previously. The attacks re-
curred at intervals of from one to three months. This
condition continued with increasing severity until three
months before the speaker saw him, w hen the jxiin be-
came constant. There was sediment in the urine for
nearly fifteen years. Examination of the urine showed
pus in quantity, blood at times, but no casts. The
patient presented marked emaciation, rapid pulse;
temperature, 99.6^ F. ; percussion revealed well-marked
dulness on the left side. Nephrolithotomy was first
performed, and subsequently nephrectomy.
Tuberculous Kidney. — The diagnosis was disease
of the right kidney. Microscopical examination failed
to reveal bacilli, but showed large quantities of pus
and epithelium. A nephrectomy was done, August 16,
1896. The nuclein treatment was instituted, with
marked improvement, until the patient left the hospi-
tal, Septeniiier 9th.
Movable Kidney In this case the signs were
chronic constipation, flatulence, indigestion, supra-
orbital neuralgia, and pain in the right hypochondriac
and lumbar regions; there was a freely movable tumor
in the right hypochondriac region. A diagnosis of
movable kidney was made. .The kidney was placed
in its proper position, and the capsule was divided for
a distance of three inches on its convexity. The cap-
sule was then separated from the kidney for one inch
entirely around the cut. The cut edges were fastened
to the fascia and muscle by interrupted catgut sutures,
so that when the suturing was complete there was a
solidity of fixation of the kidney. The most practical
route to the kidney, the speaker said, is tiie anterior
one. The selection of the lumbar route is largely a
following of precedents. A nephrectomy for tubercu-
lous kidney is not always practicable. Fixation of a
movable kidney is best done by stitching its reflected
capsule to the muscles.
A New Operation for Cleft Palate. — Dr. Trim.^n
W. Bkoi'Hy, of Chicago, read a paper with this title.
He took the groun^» that the operation should be per-
formed much earlier than has been the cu.stom of sur-
geons heretofore. It has usually not been thought ad-
visable to operate for the closure of cleft palate until
the child has reached the age of from two to five years.
He held that w hen the operation was thus postponed the
changes in the voice liad become permanent, and a re-
pair of the cleft at that time would not influence fa-
vorably voice production. His operation consisted in
freshening the edges of the cleft: then, by deep suture
of silver wire fixed through a lead plate, conforming
to the palate, the edges of the cleft were drawn together
and .so maintained until healing took place.
Dr. \V. F. D.m.v, of Pittsburg, complimenled the
author in presenting a method so markedly original,
and one which did away with all the objections to the
old operations.
The Psycho-Neural Factor in Clinical Medicine.
— Dr. C. H. Hi<;hks, of .Si. Louis, Mo., read the pa-
per. He said that the physician must consider the
whole mechanism of the system when treating any one
part. Some parts of the body influence the whole less
or more than others. The surgeon must consider the
susceptibility, predis|)osition, powers of resistance, re-
cuperative powers, and natural courage of the patient,
in determining as to the prognosis or operation. In
any case the nervous system is either for or against
him. Painful ovaries are not necessarily to be cut
out, but to be cured by neurological treatment. The
surgeon must have a wide neurological and psychi-
atrical knowledge if he would avoid fatal mistakes.
Much can often be done in improving the case by tran-
quillizing neurological treatment. In fatal surgical
cases the results are often due to overlooked neurolog-
ical conditions.
Trunk Anaesthesia in Locomotor Ataxia. — Dr.
October lo. 1896]
MEDICAL RECORD.
53.
Hugh T. Patrick, of Chicago, read a paper on this
subject. He said in nearly all cases of tabes dorsalis
there is a band of anasthesia about the trunk at the
level of the nipple. It is, early in the disease, ver\-
narrow or even incomplete, or may be represented by
a zone in which the localization of touch is not nor-
mally accurate. I'he sensory blunting on the leg, so
frequent in tabes, is generally an analgesia. I'he
trunk anaesthesia is essentially tactile, and tlie pain
sense may be quite normal. The band of anesthesia
does not correspond to the cutaneous distribution of
the intercostal nerves, but to the nerve fibres arising
from adjoining segments of the spinal cord. In some
cases there are two distinct zones of anasthesia, indi-
cating simultaneous invoh'ement of spinal segments
at some distance from each other. The borders are
inconstant, ordinarily retract on continued testing,
and vary in position with the method of examination.
The same band of anesthesia may occur in syphilitic
pseudo-tabes, as shown by an illustrative case, as far
as known the only one on record. The patient pre-
sented nearly all the symptoms of locomotor ataxia,
including a wide band of trunk anesthesia; but a di-
agnosis of syphilitic disease of the cord was made, and
under an active specific treatment he made an almost
perfect recovery.
Dr. Hughes, of St. Louis, said that it was not sur-
prising that these peculiar areas of anesthesia should
be found in locomotor ata.xia, considering that the en-
tire symptom complex of tlie disease is due to disturb-
ance of the sensory mechanism.
Treatment of Some Inflammatory Diseases of
the Gastro-Intestinal Tract. — Dr. Gustavus 1!lech,
of 1 )etroit, read this paper. He said that the treatment
of cataiih and other inflammatory conditions of the
stomach, as it is practised to-day by most medical
men, meets with failure because the treatment is di-
rected against the symptoms and not against the cause
of the disease. .Vll the usual remedies may improve
one or the other symptoms for a limited time, but, the
etiological morbid conditions still remaining, the
symptoms necessarily will appear again. The treat-
ment should be directed against the inflammation it-
self. He was accustomed to prescribe hydrozone, well
diluted in water, at least a quarter of an hour before
each meal.
Dr. Daly, of Pittsburg, deprecated the very general
use of hydrozone and such remedies, unless a very
careful and discriminating diagnosis had been made.
Dr. Patrick, of Chicago, was sorry that he could
not agree with the author; but he could not until it
was explained which variety of inflammatory condition
in the stomacli was referred to. Gastritis is too com-
prehensive a term. When a cure is proposed, we must
know what form of gastritis we have to deal with.
Dr. I. A. Abt, of Chicago, said that all the diseases
of the stomach cannot be grouped together as gastritis.
Many of these conditions are due to toxins found in
the gastro-intestinal tract. We cannot always make a
positive diagnosis at once, but by experiment only can
we arrive at definite conclusions. Any one remedy
cannot and will not answer for all cases.
Dr. Larratiee, of Louisville, said that he was con-
vinced that the portal ciiculation is a most important
factor in these cases, and one, too, which is often over-
looked. Kxercise is of paramount importance in all
cases of chronic gastritis.
The Therapeutic Action of the Antitoxins. — Dr.
K. ^[. Houghton, of Detroit, read a paper with this
title. The author reviewed the theories of orrhother-
apy, demonstrating the differences between toxins and
antitoxins. It has not as yet been shown, he said,
just how the antitoxin counteracts or destroys the toxin.
He injected three guinea-pigs with toxin cultures, the
other three with toxin and antitoxin cultures mixed.
The discussion of the paper was postponed until the
result of the injection on the animals should be deter-
mined.
Reinfection in Consumption. — Dr. Joseph Muir,
of New \'urk, read the paper. Statistics show that a
first attack is not usually fatal, and death is often
found to be due to other causes. Primary infection is
not usually due to inherited tendencies, but external
conditions play a most important part. Consumption
is best treated among the rich — frequently, indeed, a
permanent cure is effected in this class of cases; so
for evident reasons those who are poor should receive
especial attention. Patients who have been cured
must not be allowed to return to their former environ-
ment. Change of air and outdoor exercise and labor
harden and refresh the tissues, and the respiratory im-
purities of former environment are r.o longer present.
Reinfection may be prevented by thorough disinfec-
tion of the patient and surroundings, and destruction of
the sputum. This protects the patient against himself.
Removal of the Gasserian Ganglion Dr. J. B.
Murphy, of Chicago, read a paper on the indications
for this operation. He demonstrated the technique of
the operation on a cadaver. The operation might seeiu
heroic, but heroic measures were necessary in a con-
dition so severe as trigeminal or facial neuralgia.
These patients would submit to anything in the hope
of relief. This method of operating was more simple,,
as well as more certain in its results, and resulted in
less deformity, than any other yet suggested. The
speaker always suggested some medicinal treatment,
especially by castor oil, before resorting to so heroic
and serious a measure as this operation. The trouble,
however, with all measures was that they do not give a
permanent relief. The castor-oil treatment has given
temporary relief in several cases.
Dr. a. J. Ochsner, of Chicago, had recently had
some experience in these cases in the use of castor oil.
He had given the remedy in half-ounce doses twice
daily for ten days or two weeks at a time, and to his
surprise it had proven to be an excellent remedy. As-
to whether the results will be permanent, he could not
say, but no case had yet returned to its former sever-
ity. He would repeat the castor oil whenever there
were indications of a returning attack.
Electro-Diagnosis and Electro-Therapeutics Sim-
plified.— Dr. Hugh T. Patrick, of Chicago, read a
paper with this title.
Electro-diagnosis is limited to the affirmation or de-
nial of a lesion of the lower neuron; that is, of a
lesion of the motor cells in the spinal cord, or of the
nerve fibre, the peripheral nerxes springing from those
cells. A lesion of this neuron causes the reaction of
degeneration, and this, stripped of all unnecessary
technicalities, may be recognized by two variations
from tire normal, namely, a loss or very considerable
diminution of faradic contractions, and the slow
wormlike contraction of the muscles in response to in-
terruption of the galvanic current. In the electro-
therapeutics of organic disease of the nervous system,
applications of electricity through the brain may be
entirely discarded as useless. Electricity through the
spinal cord is little better. In diseases of the periph-
eral nerves it probably hastens recovery, and that
current is to be chosen which the better causes mus-
cular contraction. In functional nervous disease elec-
tricity is of more practical value than in organic
affections, but it is almost impossible to determine
what proportion of this good effect is due to mental
impression — to suggestion. The galvanic current is
chosen for facial and costal neuralgia, and sciatica ; the
faradic for lumbago, hysterical anesthesia, paralysis,
and pain; the galvanic for exophthalmic goitre and
sometimes for neurasthenic headache and backache.
For facial spasms, tic, spasmodic torticollis, tremor.
534
MEDICAL RECORD.
[October lo, 1896
and chorea; electricity is useful aside from the mental
effect. The highly practical and otherwise unusual
merits of the paper were touched upon in the discus-
sion which followed; all agreeing in the verdict that
the subject of electricity had been presented in a most
practical as well as scholarly form by Dr. Patrick.
A New Method of Fastening the Round Liga-
ment in Alexander's Operation. — Dr. J. Fr.ank, of
Chicago, read this paper. An incision an inch long
is made midway between the anterior superior spine
of the ilium and the spine of the pubes, a triHe above
Poupart's ligament. The transversalis muscle is
pushed back and the ligament is drawn out with a
blunt hook, until the uterus is in the correct position.
Usually three sutures are required to close the wound,
the first one being taken as low as possible through
one flap of the peritoneum, then through the round
ligament itself. Instead of drawing the ligament
through the fascia, as formerly practised, it is replaced
in its anatomical position beneath the transversalis
muscle. I!y this method a slough of the ligament is
prevented. This operation is the simplest of all yet
proposed for the purpose. A pessary should be fitted
in before the operation, and worn as long as may be
necessary afterward.
Tonsillotomy by Cautery Dissection — Dk. J. Ho-
mer Coulter, of Chicago, read a paper on this sub-
ject. No subject in surgery or medicine has been
much more prolific in interest and discussion than
that of the tonsil. In the past ten years over si.x hun-
dred papers have been written on that subject alone.
The size of the normal tonsil is still a subject of dis-
cussion with throat specialists. Some claim there is
normally no tonsil to lae seen ; however, the most usual
opinion is that there exists normally a collection of
follicles between the pillars of the fauces, protruding
slightly above them. The tonsil is an almond-shaped
gland larger at one end than the other and somewhat
flattened.
The methods usually employed for ils ablation are
the guillotine, ignipuncture, the cold or cautery snare,
or the knife. Each of these methods has practical
objections to its use. Most important of these ob-
jections and one which applies to all of them is the
fact that by no one of them can the entire gland be
taken out. Unless this is done the part remaining
will oftentimes produce as much trouble as did the
former condition. The operation he proposed obviates
this objection entirely if properly performed.
With a well-heated small electrode the pillars are
dissected away from the tonsil to one-half its extent.
The gland is then, with suitable forceps, drawn well
out and thoroughly and entirely dissected out to
about one-half its extent. This portion is then cut
off and the surface treated with a strong solution of
silver nitrate. In a week or ten days the other por-
tion of the tonsil is removed in the same manner.
This operation will give cosmetic as well as practical
results unobtainalile by any other process yet sug-
gested.
The Surgical Treatment of Pyloric Obstructions
was the title of a paper read by Dr. \V. J. M.wo, of
Rochester, Minn. He said that this subject had not
received the attention it demands from American sur-
geons. The differential diagnosis of serious pyloric
disease was often a matter of the greatest difficulty.
He had found the free exhibition of strjxhnine for
several days previous to the operation of great value
in preventing shock. The stomach should always be
thoroughly washed out a few hours before the opera-
tion and nothing eaten afterward. For combating
the shock, besides strychnine and dry heat, a rectal
enema of a pint of hot coffee should be given. Nour-
ishment by the stomach should not be too long with-
held afterward. For twenty-four hours rectal alimen-
tation should be used; in thirty-six hours some
champagne, later buttermilk, and then a gradually in-
creasing diet may be given by the mouth.
Submucous Linear Cauterization ; A New Method
for Reduction of Hypertrophies of the Conchae. —
Dr. Norval H. Pierce, of Chicago, read a paper on
this subject. He called attention to the various
methods ordinarily used for the reduction of such
hyi^ertrophies, and showed the disadvantages of each.
The differentiation between hyix-rtrophv and turges-
cence was pointed out. The operation proposed by
the author was as follows: A small incision is made
in the hypertrophied membrane, then with a blunt flat
probe the mucous membrane is carefully separated
from the erectile tissue underneath. Then a sound,
the end of which is cup-shaped and upon which have
been fused a few crystals of chromic acid, is inserted
in the incision and the track already made by the
probe is thus cauterized. The advantages of this
method are that there is no hemorrhage; it is less
painful than by any other method, the functional
activitv of the mucous membrane is not in the least
impaired. Patients will submit to this operation
more willingly than to the burning of the cautery.
The method is the most simple of any 3'et suggested.
The reaction is usually insignificant. There is no
slough. The danger of atresia is obviated.
The Relationship of Diagnosis to Future Surgi-
cal Progress. — Dr. Horace H. Grant, of Louisville,
deli\ered the address on surger}', taking this for his
title. Some common ground must be chosen on which
we can equalize our differences. Many of the most
recent operations are already jjassing away under the
effect of our modern scrutinizing investigation. We
forget there are men in the quiet of their laboratories
doing a work wOiich makes all our wonderful progress
possible and gi\es us these new methods. We cannot
progress much farther in technique or operative skill.
Any great amount of paraphernalia suggests a lack of
personal resource in the operator. .Almost every part
and organ of the human body has been removed, re-
cently, with more or less good to the patient. If we
would make earlier and more careful diagnoses, many
of the possible failures would be precluded. No sur-
geon dare say to the patient: " If I had known yester-
day or before, thus and so, the result would have been
different." Are we not at fault sometimes ourselves?
Rarely will we fail to secure an operation if the ope-
rator be certain of his diagnosis and demand the
operation.
No term in all surgery is so often misapplied as
conservatism. No aim is dearer to the surgeon than
the ways and means of relieving his patient. We
must not fall into the error of making one man great
and another insignificant. The experience which age
gives some men leads them to make valuable and cor-
rect diagnoses. Experience is and should be one of
the greatest aids in diagnosis. The skiagraph has
lately come into importance in surgical work, and it
may be made an excellent adjunct in many instances.
Its recent successes are noteworthy. It is yet, how-
ever, in its infancy, and doubtless is capable of still
more development. May we not soon expect to see
the fcctus />/ i/fc-ro ? No one doorway can open to the
royal road to success in the practice of surgery. The
skilful and intelligent application of prompt relief,
added to a careful diagnosis, will give us the most
wonderful and satisfactory results. What each one
finds to d'l, let him do it with his might.
Appendicitis ; to Operate or Not to Operate. —
Dr. James H. Du.\n, of Minneapolis, read a paper
with this title (see p. 508).
Dr. J. B. Murphy, of Chicago, said that the sur-
geon is brought face to face with a condition which
has a recognized mortality of from about five per cent.
October lo. 1896]
MEDICAL RECORD.
535
to eight per cent. He thought such a percentage is too
high. W'e first have to contend with the presence or
absence of a suppuration. In four hundred and fifty
cases he did not think there had been an entire ab-
sence of pus in one single instance. He was satisfied
there are some cases which can be cured by medicine,
, but can they be differentiated? By medical treatment
we have a mortality of ten per cent., and if we have
three per cent, by the knife then we must operate to
save the other seven per cent. Not every case can be
operated upon, but the conditions will show whether
or not it is advisable.
Nerve Sutures and Other Operations for In-
juries to the Nerves of the Upper Extremity. —
Dr. a. J. OcHSNF.R, of Chicago, read a paper of which
the following were the conclusions : i. Every severed
ner\-e should be sutured even after years. 2. The ear-
lier the operation is performed the better. 3. If neither
sensation nor motion is established within a year, the
ner\'e should again be exposed, the cicatricial tissue
removed, and the end again sutured. 4. The end
should be clean cut, should contain neither crushed
tissue nor cicatricial tissue. 5. Tension must be
avoided. 6. The wound must heal without suppuration
to secure the best results. 7. Hemorrhage should be
perfectly controlled to prevent inter\ening clot. 8.
Carefully prepared catgut is the best suture material.
g. After suturing the ends, either direct or ''a (dis-
tance, it is well to stitch a fold of fascia over the
united nerve ends. 10. The extremity should be placed
at rest. 11. The external incision should be ample.
Woman and Her Diseases versus Gynecology.
— Dr. Henry P. Newman, of Chicago, read a paper
with this title. We are coming, he said, to a period
of transition in the practice of surgical gynecology;
instead of essays on the treatment, we now have stud-
ies on the cure and prevention. Preventive medicine,
hj'giene, sanitation, and sociology are now popular
themes for medical societies. Philanthropy has taken
the cue from medicine, and is attempting to form a
citizen rather than reform him. He desired to empha-
size the fact that we are not dealing with the cold-
science side of our art, but with the highest of humane
interests. The amount of ignorance in the average
woman of nature's requirements is appalling. Wo-
man's sphere has lately widened until now it is as
wide as man's, but she has not equipped herself for
this race. Women in the cities — the stenographers,
saleswomen, business women — daily outrage their bod-
ies by compliance with the dictates of fashion in food,
dress, and habits. The tendency of gynecologists to
practise surgery is to be deprecated. It narrows his
opportunities. He had better stay attached to obstet-
rics and paediatrics. A woman's generative organs
should not be doomed because she has had to visit the
gynecologist. A good diagnostician must know as
much about woman as about disease; as much about
environment and social and domestic relations as
about pelvic lesions. As specialists we must recog-
nize and exercise the important interests in a medical
science which will prevent rather than cure disease.
As we know, what can be acquired may be prevented,
hence we as specialists should lead in the reform of
those conditions which are detrimental to the health
of woman.
The Pathology and Treatment of Suppurative
Salpingitis was the title of a paper read by Dr. I'. ¥.
Lawrence. The tubal mucosa is a true mucous mem-
brane, possessed of all the histological elements of
mucous membrane. The fimbria are prolongations
of the folds of mucous membrane, with a few muscular
fibres beyond the end of the tube. The closure of the
end of the tube is effected by, first, the unfolding of
these plica; and the elongation of the muscular fibres
with coincident inflammatory exudate, and not by
adhesions of the peritoneal surface; second, the form-
ation of adhesions between the fimbria; and other
structures; third, embedding of the fimbria; in in-
llammatory exudate. The closure of tubal ostia re-
sults in the forming of circumscribed abscess, the
pathology of which is the same as that of suppuration
with abscess formations in mucous membrane in other
parts of the body, except for its effect upon important
contiguous tissues. Occasionally the uterine end of
the tube remains patent, when we have the abscess in
the tube communicating with the uterine cavity,
through which it may in part discharge its contents.
The treatment of pus tubes cannot be fixed by any
ironclad rule. I-ach case must be treated according
to the conditions there presented. We must even in-
cise and drain in some cases. Seldom will vaginal sec-
tion be required, and then only in carefully selected
cases. Hysterectomy is indicated in those cases in
which we find abscess of the uterine wall, tuberculous
deposits, fibroids, or malignant disease in the fundus.
As hysterectomy destroys the pelvic floor, it should
never be performed except when there is some tangi-
ble lesion of the uterus. Abdominal section will be
necessary in many cases.
Importance of Physical Signs Other than Mur-
mur in the Diagnosis of Valvular Disease of the
Heart was the title of a paper contributed by Dr.
James B. Herrick, of Chicago. Standard text-books
teach that an endocardial murmur is not always an
evidence of a valvular lesion, and also that a valvular
defect may exist and still no murmur be present.
Practically, however, conclusions are usually based
upon the presence or absence of murmur. This is
wrong, for there may be a valvular disease without a
distinct murmur being audible. Other findings than
murmur must be used in determining the existence of
a valvular lesion. Every valvular lesion must result
in hypertrophy and dilatation of the heart behind the
valve diseased. An increase in tension of the pul-
monary circulation follows any valvular lesion at the
mitral orifice, and later any aortic disease. This will
show in increased force of the pulmonic second tone.
Stenosis of the orifices of the left heart means a small-
er amount of blood in the general arterial circulation;
therefore, lessened arterial tension. Failure of the
right heart is followed by venous congestion, e.g., ve-
nous pulse, hepatic and portal congestion, anasarca,
etc. Hypertrophy may be recognized by the heaving,
forcible apex impulse. Epigastric pulsation may call
attention to enlarged right heart. The jugular pulse,
the hepatic and capillary pulse, are all of diagnostic
value. The visible pulse of aortic regurgitation is al-
most pathognomonic. Palpation is important. Extra-
cardiac causes for murmur, such as might arise in a
heart dislocated by pressure or retraction, can usually
be excluded by percussion. A weak aortic sound may
be an indication of obstruction. The reduplicated
second sound may point to valvular disease. A sharply
accentuated first sound at the apex is common in mitral
stenosis. The peripheral tones in aortic regurgitation
are a valuable confirmation. Error in calling an inor-
ganic murmur organic is readily made, unless the
secondary sounds are carefully sought for. The in-
tention of the paper was not to undervalue the impor-
tance of endocardial murmur, but to insist that it is
only by the complexus of signs and symptoms that an
accurate diagnosis can be made. Of all the evidences
of heart disease, the least valuable is the endocardial
murmur.
Value of Secondary Physical Signs in the Diag-
nosis of Cardiac Diseases.— Dr. K. H. Bakcdck, of
Chicago, reported a case illustrating this. Arrong
other points brought out were: Murmurs are the least
reliable signs of valvular disease. An accurate diag-
nosis cannot be made unless the secondary signs of
536
MEDICAL RECORD.
[October lo, 1896
valvular disease are recognized. If the heart actions
are not sufficiently strong there may not be any mur-
mur; or a grave defect may not be observed for the
same reasons. Secondary symptoms are a modified
pulse rate, character, and rhythm, leading to a
congestion of the veins and internal organs. In
some instances there is also systolic venous pulsa-
tion of the liver. Such systolic jugular pulsation
is diagnostic of insufficiency, even if the murmur is
not audible.
Water. — Dr. I. N. Love, of St. Louis, read a paper
with this title. Drugs, he said, seemed to be the chief
inspiration in the life work of too many men. Hy-
drotherapy has been a wonderful service to humanity.
We can appreciate the necessity of water when we re-
member that seventy-five per cent, of our body is made
up of water. It is just as important as the solids in
life's conditions. The demands for water are affected
by the amount of muscular e.xercise and degree of tem-
perature to which the body is exposed. P'or an irri-
tated stomach or bilious colic, nothing is superior to
liberal quantities of hot water. We need water for
nutrition, but also for a proper elimination. Water
taken freely acts as a purifier of the system, both by
flushing and by its solvent action. The majority of
people drink too little water. The speaker advised
that children be trained to drink more water. It is a
most important agent in improving the complexion.
Medicine should be given in large quantities of water.
In typhoid fever he insisted upon free drinking of
pure water. No solvent will act better in removing
uric acid from the system, and the only pure water
is distilled water. Copious draugiits of water, for its
stimulating effect or the reduction of temperature,
have been used for many years. The hot pack in
convulsions of children is often misused. Better
begin with a tepid heat and add cold water gradually.
Hot water locally in inffammatorv conditions is most
excellent.
Dr. Mani.ev, of New York, said that he had often
thought that if we only realized what could be accom-
plished with water in a medicinal way, its use would
be more general. He was strongly impressed with the
fact that many of the bowel and bladder conditions
could be most effectively treated by the proper use of
water. In the case of cystitis, he knew of nothing
that would take the place of water. Often he had
thought the surgeon's knife might be laid aside if we
knew how to use water. A large number of the cases
of appendicitis, in his opinion, might be relieved by
a thorough washing out of the bowel.
Dr. Hughes, of St. Louis, said that the value of
water had not been overdrawn by tiie author or in the
discussion. He was opposed to limiting the amount
of water used at and during the meal time. Its action
is not only eliminative, but stimulating to both kid-
neys and bowels.
Dr. Stuckkv, of Louisville, would take issue with
the author on the idea that large quantities of water
should be taken along witii the food. He could not
.see how it would increase or aid in t!ie digestive func-
tion in the stomach, but its importance after digestion
is ended could not be overrated.
Dr. B.\bcock, of Chicago, said that in some cases
of Bright's disease it had seemed to him that a suffi-
cient quantity of water migiit have prevented the con-
dition. If the bowels be constipated and the skin
dry, increased work is thrown upon the kidney. Pro-
fessional men, men of sedentary habits, and women
will often escape the severity of Bright's disease by the
unlimited use of water.
Dk. Henderson, of St. Paul, wished to ask the
author whether or not the taking of large quantities of
water would increase the fat formation. Does the fat
man take water because he is fat, or is he fat because
he takes water? The speaker was a lean man, and
did not driuK water except in the morning.
Dr. TukCK, of Chicago, said that the first indica-
tion was to find out what the pathological conditions
are which are to be met by the water therapy. We
must know the condition of the stomach before advis-
ing the ingestion of large quantities of water. The,
habit of taking great quantities of water into the
stomach, even two hours after a meal, will hinder the
process of digestion. On the other hand, if there is
an accumulation of material on the walls and other
viscera, then tiic taking of water would not be objec-
tionable.
Dr. Lov;:, in closing, said that it is w hat is taken into
the stomach as food and becomes nutrient that leads
to development, continued health, repair, and elimina-
tion. In these processes water has an important part,
if taken in the right way. He did not advise that
large quantities of water should be taken while eating,
but moderate quantities could not possibly interfere
with the digestive processes.
The Clinical Significance of the Child's Fonta-
nelle. -Dr. Is.\.\c A. .\i;r, of Chicago, ruad a paper
with this title. In health the fontanelle does not
sink below or rise above its bony frame. It has both
respiratory and pulsatory movements. With in-
creased intracranial pressure the normal bruit may
quite disappear. An early ossification interferes with
brain development and produces a brachycephalic
skull. In rachitis the involution of tiie fontanelle is
delayed. Marked bulging is caused by the collection
of fluid within. The abnormal retraction of the fon-
tanelle always indicates a condition of inanition. It
maybe temporary; if chronic, it is a serious condi-
tion. A deeply-sunken fontanelle is always a danger
signal in any case. Involution occurs normally at
fifteen to eighteen months. Protuberance and tension
indicate meningitis.
Operative Treatment of Pterygium was the title
of a paper read by Dr. Eduard Boeck.mann, of St.
Paul. The author discussed the history of the opera-
tions for the cure of pterygium, pointing out the
objections as well as the advantages of those most fre-
quently u.sed. He suggested an operation which was
a combination of some others referred to. A crescen-
tic piece is cut from the pterygium about five lines
from its head. This part is curetted thoroughly down
to the sclerotic. The head of the pterygium is dis-
sected off. At the convexity of the piece cut out a
stitch is inserted and the opposing edges are drawn
together. This leaves the curetted portion to granulate,
and form a cicatrix. The author thinks the result
from this nietliod superior to that of any other in his
experience. The paper was discussed by Dks. Wilder
and BrcKNER.
Subconjunctival Injection in the Treatment of
Certain Diseases of the Eye. — Dr. William H.
Wilder, of CMiicago, read the paper. The method
consisted in the injection beneath the conjunctiva of
minute quantities of bichloride of mercury or cyanite
of mercury in solution. The operation was not espe-
cially painful unless there were inflammation present.
It had been advocated for many otiier conditions and
diseases. Its exact limitations and indications were
not yet positively decided upon. It had been impos-
sible to get the same good results from the salt injec-
tions that could be obtained from the mercury. We
had in this new treatment a powerful adjunct to the
old and tried methods in some diseases of the eye, but
it was not to be employed to the exclusion of all
others. It was not a panacea, but in cases in which
the mercurial treatment was indicated it was an excel-
lent method.
Dr. Buckxer, of Cincinnati, could see the special
advantage in injecting the solution of mercury under
October lo, 1896]
MEDICAL RECORD.
537
the conjunctiva over the old method of administering
the drug hypwdermically or through the mouth.
Dr. Boeckmann said that he had used these injec-
tions since he first commenced to practise medicine,
but he was still unable to say just how much good
they really do. He carefully injected these solutions
whenever he found an ulceration of the cornea. In
some cases he had found it to act beautifully, in others
it was a failure.
The Use of Oxygen in Chloroform Narcosis. —
Dr. C B. Parker, of Cleveland, O., read a paper
with this title. The e.\hibition of the vital principle,
o-\ygen, with chloroform would seem to be proper on
theoretical grounds. In uniting the two there is no
chemical union formed between them. It is a mechan-
ical mixture, such as we have in the air. The o.xygen
must be jjerfectly pure. That usually supplied in
tanks is not pure. It must be properly made. The
cylinder must ha\e been exhausted of all air before it
is filled. The time required to ana-sthetize is slightly
longer than with chloroform, but the advantages far
outweigh this minor inconvenience. Of the clangers
attendant he was not prepared to say ; as he did not con-
sider an experience of one hundred and eighteen cases
guarantees any statement relative to that point. There
is total absence of vomiting, as well as absence of the
extreme pallor and weakened heart beats with shal-
low respiration. The duration of the shock from
anaesthesia is with this agent very much shorter. The
patient alwavs recovers promptly without any de-
lirium.
The Election of Officers resulted in the choice of
the following: Presideiif, Dr. Thomas Hunt Stuckey,
Louisville; First ^/(■("-/'/vwV/^'///, Dr. Charles A. \\'hea-
ton, St. Paul; Second Vice-Pres'ukttt, Dr. Paul Paquin,
St. Louis; Secretary, Dr. H. W. Loeb, St. Louis;
Tn-asiircr, Dr. W. N. Wishard. Indianapolis: Member
flf Jiidian/ Council, Dr. H. T. Patrick, Chicago.
The next meeting will be held at Louisville, on the
third Tuesday of September, 1897.
MEDICAL SOCIETY OF THE COUNTY OF
NEW YORK.
Stated Meeting, September 28, i8g6.
E. D. Fisher, M.D., Presidext, in the Chair.
Nominations. — The following were nominated for
office : For President, Drs. A. M. Jacobus, Landon
Carter Gray, E. D. Fisher (declined), H. D. Chapin,
Frederic Petersen, H. J. Garrigues, Richard Van Sant-
voort; First Vice-President, Dr. R. A. Murray; Second
Vice-President, Dr. N. E. Brill; Secretary, Dr. C. H.
Avery; Assistant Secretary, Dr. W. E. Bullard; Treas-
urer,Dx. John S. VVarren; Censors, Drs. S. D. Powell,
H. L. Collver. Frank Van Fleet, S. Marx, E. D. Fisher,
B. F. Curtis. F M. Crandall, \V. L. Carr, H. N. Vine-
berg.
Remarks upon the Causes and Prevention of
Chronic Catarrh of the Nose, Throat, and Ear in
Young Children — Dr. Wendell C. Phillips read
the first paper of the evening. Chronic catarrh of the
nose, throat, and ear in children was frequently re-
ferred to some one of the exanthemata as the starting-
point, and correctly so in many instances. Measles
and scarlet fever were most often to blame. It must
be borne in mind, however, that the exanthemata oc-
curred at a time of life when catarrhal diseases were
apt to arise from other causes. Syphilitic and tuber-
culous cases constituted a class by themselves. An
internal deformity or malformation of the nasal tract
might be inherited. Climate was an important factor,
but the author thought Bosworth was correct in the
view that it could only aid other factors. An acute
rhinitis, or cold in the head, was regarded by most
writers as one of the chief causes of chronic catarrh in
various forms. Among other causes named were im-
proper or insufficient ventilation of sleeping and liv-
ing apartments, the presence of large masses of lym-
phoid tissue, injuries to the nose resulting in deformity
of the septinn or displacement of the turbinateds.
^Vhen the cause was mechanical, the development of
the catarrhal process was often slow, but might be
rapid. Speaking of prevention, he said physicians
were often careless in the management of the exan-
themata, in not giving due attention to the upper air
passages. During convalescence, when nature was
trsing to reassert herself, aid should be given by use
of antiseptic and soothing applications. One author
had found that out of six hundred cases of the class
under discussion, 12.5 per cent, had originated during
scarlet fever; twenty-six per cent, during measles.
The nose should be frequently and thoroughly cleansed
in these affections, a spray or douche of warm antiseptic
saline solution, like Dobell's, or solution of boracic
acid, etc., or oily spray being used. Whatever medica-
ment was used, it should be bland and non-irritating.
Steam was very soothing, and was highly recommended.
To the fluid one might add oil of menthol, etc.
Change of climate afforded temporary relief in many
cases, and a permanent change of residence might be-
come necessary when other measures failed. Lym-
phoid tissue, whether present in large or small quan-
tity, should be removed. Due attention to adenoids
would diminish the number of institutions for the
deaf. Colds existed most frequently among children
who were coddled and kept indoors, in heated and
badly ventilated rooms. They ought to live more out
of doors, not only in pleasant but even in threatening
weather, and should be sponged daily with cold water.
Many parents had come to recognize that children
raised in this manner had even better health than
those raised in the countr)% under usual conditions
prevailing there. There might be practitioners who
told parents to let these chronic affections alone and
they would after a time disappear, but the writer had
found such advice was the exception. At first many
children objected to the nasal spray, but under gentle
management they ceased to oppose it. When there
was mucus in the nose, especially when it became in-
spissated, there should be daily cleansing. Every
physician should be able to make an intelligent ex-
amination of the nose, and in a case of injur)- correct
the displacement at once. Operations should never
be undertaken upon the nose of children except when
there was such deformity or destruction as would lead
to tissue changes. In conclusion, the author reminded
the family physician of the grave responsibility resting
upon him in preventing chronic affections of the nose,
throat, and ear.
Familiar Ground Dr. James E. Newco.mb, in
opening the discussion, said the paper had covered
familiar ground, and there should not be great differ-
ence of opinion. The exanthemata certainly consti-
tuted a frequent cause, and sometimes, in spite of much
care, we found our efforts at prevention of no avail.
Enlargement of the glands in front of the ear might
be common during the exanthemata, but he had seen
only two cases, and in one there was suppuration, but
without injury to the internal structures of the ear.
He did not know that it was necessary to use the nasal
douche every day on all children, but it was desirable
to employ it often enough so that they would become
accustomed to it and not struggle when they became
sick. All were agreed that lymphoid tissue should be
removed w'hen present in sufficient quantity to cause
symptoms, but it must be remembered that it was not
a substance entirely foreign to the mucous membrane
jj";
MEDICAL RECORD.
[October lo, 1896
of the naso-pharynx. Solis-Cohen had cautioned not
to remove too much, for the lymphoid tissue was there
for some purpose, although we might not yet know
what that purpose was. The condition was apt to re-
cur after the operation if the child were allowed to
return to the same unhygienic surroundings. As to
maintaining a condition of asepsis in the upper air
tract, he supposed the reader had used the term in the
conventional sense, for a few breaths of air with its
contained germs would destroy that condition if
brought about by the douche. Probably what was
meant was to maintain intranasal cleanliness. An
efficient method was the use of a rubber catheter, with
a number of fine perforations at the distal end, at-
tached to a syringe, pressure upon whose bulb would
throw into the nose numerous fine streams of a solution
of salt, borax, and baking soda, about a third of a tea-
spoonful of each to a pint of warm water.
Ur. E-MIL Mayer mentioned a case of nasal deform-
ity associated with asthma in a man whose son, aged
eight years, suffered from the same conditions, which
went to confirm the influence of heredity referred to
by Dr. Phillips. When the introduction of the finger
into the pharynx was attended by a little bleeding it
indicated adenoids. He had never seen hemorrhage
follow when the pharyn.x was healthy, unless the linger
were introduced in a rude manner.
To Prevent Chronic Catarrh, Prevent Colds. —
Dr. Freudenthai, said that if we would prevent
chronic catarrh we must prevent colds. To do this,
children must be brought up differently. In the ad-
vice to let them remain out of the house, he would
differ from the author only in the suggestion to dress
them properly, which was apt to be interpreted as
dressing them warmly. Dr. Freudenthal thought the
less they were dressed the better. The thought of
cleansing the healthy nasal cavity, as he had under-
stood the author to recommend, was to him a terrible
one. One might as well insist on cleansing the
healthy bladder.
Treats Catarrh Constitutionally.— Dr. ^^'. H. Mc-
Enroe tliought catarrh was a symptom of a constitu-
tional disease, and it was his custom to treat it
constitutionally. One of the best remedies was cod-
liver oil, and sometimes iodine. -As to making local
applications to the nose, he was opposed to tliat, at
lea.st as it was usually practised. Salt water was irri-
tating to the nasal membrane, increased the flow, and
he preferred to use creolin, which had come to take
the place of carbolic acid for this purpose.
Dr. F. M. Crandall expressed his interest in some
of the statistics quoted by Dr. Phillips, as they went
to confirm his view' that measles was a much more
serious disease than the laity and some doctors seemed
to think. He would emphasize the advice to keep
children out of doors.
Dr. Lk.dermax said with regard to cleansing the
nose that the nasal mucus itself was germicidal.
Colonies of bacteria had been planted in the nose
during some experiments, and in a few minutes were
all destroyed, as was proven by culture. This went to
show that too much cleansing was not the proper
thing.
Dr. Meyerhok thought there was usually an under-
lying condition which favored catarrh in some chil-
dren, for others in the same family, under the same
circumstances, remained well. One-half-per-cent. so-
lution of nitrate of silver was frequently useful, and
he had used even four per cent. Ointment of yellow
oxide of mercury was serviceable when crusts fonned
at the entrance to the nares.
Dr. Dessau agreed with those speakers who be-
lieved in an underlying constitutional condition, and
he emphasized the importance of hygienic measures.
He would not say that food was the direct cause of
catarrh, but he thought children who received too
much food or that of wrong quality were liable to-
catarrhal affections.
Dr. A'ietor had observed at the seaside that per-
sons who bathed were less liable to colds than others,
and those who continued their bathing got well soon-
est. Swimmers were least liable of all to catarrh.
Dr. Ferguson thought adenoids in the pharynx
were a common cause of reflex cough.
Dr. H. D. Chapin thought the general practitioner
was more likely to see the con.stiiutional side of ca-
tarrh; the specialist was more likely to apply local
treatment. As to adenoids, they could be recognized,
but it was not so easy to decide whether in a given
case they required removal. Their uniform presence
in certain localities indicated a physiological function.
In children the introduction of the finger, even in the
healthy throat, would cause slight bleeding. When
hypertrophied and obstructive, adenoids should be re-
moved. He employed salt bathing, exercise in sun-
light, borax and salicylic-acid solution as a nasal
douche when necessary.
Dr. Van Santvoort said the frequency of cough
from posterior nasal disease was something which it
had taken him some time to learn. There was only
about one case of cough from bronchial trouble to four
or five from trouble in the ujjper air passages.
Dr. Phillii'S said in some concluding remarks that
he was glad attention had been called to the constitu-
tional side of the question, for time had permitted
him only just to mention it in the paper. In the
ear clinic cod-liver oil was one of the most frequent
remedies prescribed, along with other tonics. He did
not wish to be understood as recommending the re-
moval of more than redundant lymphoid tissue. He
did not use the nasal toilet except in disease or acute
cold. There was not much danger of overfeeding,
but rather of giving food which the child ought not to
have. As to cough, nearly all children with adenoids
had bronchial catarrh. He thought the cough was
due to the latter, and was not refiex. If the ade-
noids were removed the bronchial trouble would dis-
appear, together with the cough.
Krause's Skin Transplantation in Plastic Sur-
gery of the Face. — Dk. John Ekdmann described
Krause's method of skin-grafting, related a case in
which he had employed it to cover a defect from
epithelioma of the face and nose, and mentioned its
advantages over Thier.sch's method. It consisted in
transplanting a piece of skin from some other portion
of the body to the freshened area. The graft required
to be about a third larger, to allow for shrinkage.
The advantages were that it left no cicatrix, the flap
resisted destructive conditions, it did not bind under-
lying tissue, there was no liability to keloid, there
was a normal hairy surface. A second case was de-
scribed in which he had employed the sliding flap to
cover a defective area on the face.
Safety from Lightning Stroke in Cities. — A cu-
rious fact connected with deaths by lightning has re-
cently been noticed in Europe. It appears that, as
compared with the country, towns, and especially
cities, possess remarkable immunity from lightning
strokes. The statistics which have been compiled on
the subject show that between 1800 and 185 1 there
was not a single death by lightning recorded in Paris,
and that only one person out of each million that die
in London is taken off by a discharge from nature's
electric battery. Itetween 185 1 and 1895 only three
persons were struck by lightning in Paris, and only
one of these three cases resulted fatally. In Berlin
only five persons have been struck by lightning since
17 13. — College and Clinkal Reeonl.
October lo,, 1896]
MEDICAL RECORD.
539
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting;. October /, iHg6.
Joseph D. Brvant, M.D., President, in the
Chair.
The resignation of Dr. I. Oppenheimer was accepted.
Practical Points Regarding Senile Insanities,
with Special Reference to Prophylaxis and Manage-
ment.— Dr. Ralph L. Parsons read the paper (see
P- 505)-
Senile Insanity and Malnutrition. — Dr. E. D.
Fisher opened the discussion. He thought senile in-
sanity was hardly a distinct form. The essential fea-
ture in all these cases was a condition of malnutrition
in both the brain and body. The mental deterioration
was more due to malnutrition than to actual disease.
The pathological state was one of arterial degenera-
tion, either the direct result of old age or of disease in
earlier life — nephritis, alcoholism, syphilis. The post-
mortem showed few changes — more or less pachymen-
ingitis and increase of cerebro-spinal fluid, or so-called
wet brain, together with thickening of the walls of the
vessels. Rarely was there evidence of apoplexy or
capillary hemorrhage. The condition corresponded
closely to what the older writers called serous apo-
])lexy. Dr. Fisher could not admit, in the author's
division, an insanity of vigor. When chronic diar-
rhoea existed, it should not be checked suddenly and
entirely, lest it light up the mental symptoms. He
had seen only one case in which the insanity was of
the form of general paresis. As to prognosis, the
symptoms might be improved, but he knew of no cure
for senility. The treatment related chiefly to nutrition
and stimulation. The patients were better off at home
if friends could care for them.
Classification and Treatment Receive Little Aid
from Pathological Anatomy. — Dr. Landon Carter
Gray said there were, in addition to the changes in the
arteries so well described by Dr. Fisher, also changes
in the lymph vessels and lymph spaces ; but, as in
other diseases, these were general, and did not account
for the various forms in which senile insanity mani-
fested itself, nor furnish a basis for treatment. They
were, however, of a nature in accord with the im-
provement often observed under the influence of stim-
ulants and nutrition. Melancholia in the young was
much more controllable tiian in the aged. In the treat-
ment of melancholia the most important thing was to
cut off the expenditure of energy. An abundance of
food and stimulants was required. Opium or some
one of its alkaloids was efificacious. Massage, gently
administered and gradually increased in time to an
hour or an hour and a half a day, he had found of de-
cided value. Regarding dementia, which might occur
at all periods of life and be primary or secondar}-. Dr.
Gray had found the prognosis better comparatively in
the aged than in the. young, while the reverse was true
of melancholia.
Dr. Leonard Weber mentioned three cases of se-
nile insanity, in one of which there were varicocele
and nightly emissions. While arterial sclerosis might
be the fundamental factor in bringing on the senile in-
sanity, he believed functional disturbance of the gas-
tro-intestinal tract had much to do with it.
Dr. A. D. Rockwell repeated the statement that
the nutrition of the brain, effected through the large
cerebral arteries, was last to suffer, and said his ex-
perience as to the comparative curability of melan-
cholia in the young and old was not in accord with
that of Dr. Gray's. He mentioned two cases of cure
in the aged.
Dr. L. F. Bishop related a favorable experience
with cascara and nitroglycerin in a case under his care
the past summer. The nitroglycerin was given every
three hours, one-one-hundredth grain.
Insanity in the Aged Not Always Senile. — Dr.
A. Jacoibi called attention to the fact that there was a
difference between senile dementia or insanity and
insanity in the aged. Tlie latter might be due to
causes acting at any period of life, and which might
be relieved permanently. Senile dementia was due to
nothing else than the anatomical changes which took
place in old age. Atheromatous degeneration was
said to begin at thirty-five, and to advance more or
less rapidly in different persons until death. Massage
was beneficial by stimulating the circulation through
its action upon the muscles. Opium was of benefit in
many cases, but bromides would do harm rather than
good, being more apt to produce anaemia than to cure
it. Digitalis should be avoided, because of its con-
traction of the small arteries.
Dr. Parsons said he always used stimulants.
©ot^resp 0 n tt cn ce.
OUR LONDON LETTER.
(From our Special Correspondent.)
BRITISH association FOR THE ADVANCEMENT OF
science- — -SIR J. lister's ADDRESS — SECTIONS —
METROPOLITAN ASYLUMS BOARD — DEATH ' IN A
PADDED ROOM — CARBOLIC ACID — DEATHS OF SIR
WILLIAM MOORE AND MR. MERRIMAN.
London, September 18, 1896.
The British Association has been sitting at Liverpool
this week. This association is devoted to science and
is the mother of those which hold annual meetings in
different localities, many of which take the name of
British — the medical being one of its progeny. The
full name of the mother is British Association for the
Advancement of Science, but it is always spoken of
by the short name. How much greater it is than its
children may be seen in the attendance, above three
thousand, and sometimes it has mustered near four
thousand. This year the Earl of Derby accepted the
office of lord-mayor of Liverpool in order to do the
honors of the city to the devotees of science. He has
Sir John Lubbock and Lord Rayleigh in his house
party. The leading citizens are ^•ying with each
other in their hospitalities. The ladies muster strongly
at these gatherings, so that amusements and excursions
are much to the front. The healing art, as such, has
no home in the British Association, but the sciences
on which it is founded are all represented. \\'henever
scientific men gather, the profession is sure to be
represented and its members have often contributed
of their best to these congresses.
This year Sir Joseph Lister is president — chosen of
course for his scientific work rather than for his sur-
gical position. He is by no means an eloquent
speaker. He lacks all oratorical talent, but can de-
monstrate his views clearly. He read an address
which, though well adapted to a semi-popular audi-
ence, scarcely does him justice. Due allowance will
be made for this by the majority and it will be re-
membered that no small number went to gaze at the
lion of the day rather than to be instructed by his
statements. Under the circumstances his subject was
well chosen, viz., " The Interdependence of Science and
the Healing Art." Thus he was able to bring before
his audience the relations of medicine and surger)' to
modern scientific development. These he illustrated
by the application of the Roentgen rays to surgery,
Pasteur's researches on fermentation, the antiseptic
540
MEDICAL RECORD.
[October lo, 1896
system, the isolation of micro-organisms, toxins and
antitoxins, phagocytosis, and other allied subjects.
Noticing that this is the jubilee year of anarsthesia,
he said "that priceless blessing to mankind came from
America," though it had indeed been " foreshadowed
in the first year of the century by Sir Humphry
Davy." He pointed out that from first to last anaes-
thesia had been the gift of science. He confessed his
preference for chloroform. Vaccination as a topic of
the day was judiciously dealt with. Needless to say,
his own work could not be ignored in any attempt to
give some examples of what medicine has borrowed
from science and contributed to it in the last half-
century. Equally needless to add that this work w^as
touched with the modesty and reserve of the great
scientific investigator and upright skilful surgeon.
The ten sections have been at work for the rest of
the week, but a medical journal cannot afford space for
their proceedings. The chemical section was pre-
sided over by Dr. Ludwig Mond, who in his address
related the history of chlorine. The age of the earth
was considered by Professor Poulton as president of
the section of zoology. " Present and Extinct Flora"
was the Subject of the address in the botanical section
by Dr. N. Scott.
" Music for the Deaf" was the subject of a very in-
teresting paper in the physiological section by Profes-
sor McKendrick, of Glasgow. He found it possible to
give some appreciation of rhythmical vibrations to deaf
people by putting their hands in saline solution
through which an electric current from the phono-
graph was passed. It gave a new sensation to the
deaf person.
The metropolitan asylums board is unquestionably
a costly one. No doubt its duties are difficult and
necessarily involve great outlay. Its resources have
up till now been practically unlimited, and like all
spending departments thus situated it may have been
wasteful or at least extravagant. Ratepayers are
delighted to learn that the local government board
has rejected the proposal of the asylums board to de-
vote ^54,000 to the purchase of a site for its offices.
The conscience of those who have their hands in the
ratepayers' pockets certainly needs some severe les-
sons, and this at a time when, in spite of the lavish
outlay at Shooter's Hill, the cry still is that the asy-
lums board must build more hospitals to provide for
infectious cases.
An inquest was held on Tuesday on a woman, aged
eighty-five, who died in the padded room of a work-
house. Some contradictory evidence was given. It
was alleged that the nurse had used violence, and the
patient had said she '" had been ill-using her" and
had shown her bruised arms. It was declared tiiat
the patient was not violent but only weak. The doc-
tor seems to have acted on the word of the nurse as to
her being violent and acknowledged he had not con-
cluded that her mind was affected. He visited her
daily and found her always quiet, and did not have
her taken back to the sick ward, as she was ver}' ill
and seemed comfortable. Kut the coroner remarked
that the space in the padded room was very confined,
and the jur)' made some strong remarks and consid-
ered that the case should be investigated by the local
government board.
It is said that the proposal to restrict the sale of
carbolic acid is now under the consideration of the
privy council. It is about time action was taken, as
the continually augmenting list of deaths from this
poison shows.
Surgeon-General Sir \^■illiam James Moore, K.C.
I.E., H.Q.P.', died on the 9th inst., aged si.xty-eight.
He served in the Indian medical service from 1852 to
18S8, and was in the Persian war of 1856-57. His
" Manual of Diseases of India" reached a second edi-
tion; his "Family Medicine and Hygiene for India,"
published under government authority, reached its sixth
edition in 1893. After retiring from the service he
took up his abode in London and contributed valuable
papers to ihe journals.
Mr. J. J. Merriman, of Kensington, retired from
practice about a year ago, when he was presented with
a testimonial from his patients of ^"1,000. This
shows how much he was esteemed. He was a type of
the best class of general practitioners. He died on
the 8th inst. Kensington has had one of the family
practising there for above seventy years.
" MALARIAL H.LMAIL'RIA."
To THE Editor of the Meuicai, Recokd.
Sir: In your issue of September 19th, in the Clinical
Department, appears the report of a case under tlie
above heading, by Dr. Fleming. The case in question
was evidently not one of " malarial ha;maturia," but
was a case of idiosyncrasy against quinine, which
manifested itself by a temporary purpura hemorrha-
gica. Quinine idiosyncrasy is frequently met with
and in various forms, but perhaps most frequently
shows itself as a disturbance of the cutaneous circula-
tion, and this case \\as unusually severe. On the other
hand, " malaria h.-tmaturia" is not a hemorrhagic
trouble; the morbid condition known by that name in
the South, and which I have named lysa.niia, is merely
blood disintegration. There may be many complica-
tions, but dissolution of the red corpuscles from
chronic malarial toxremia is the constant pathological
feature. True hemorrhage does not occur. E\'en epi-
staxis is rare.
In thee ourse of an intermittent or a remittent ma-
larial fever, and often without the previous e.xliibition
of quinine, a sudden disintegration of the red corpus-
cles takes place, and the blood serum becomes saturat-
ed with free haemoglobin, which rapidly stains the
skin and sclera an intense yellow and is excreted by
the kidneys, coloring tlie urine, in proportion to the
amount, from a pale w ine color to a black. " Poke-
berry-juice" color is the most common. As before
stated, there is no hemorrhage nor even a harmatiu'ia,
but a liieraoglobinuria. So, from the description
given by Dr. Fleming, as well as by the latitude of
his patient's residence, we are compelled to exclude
lysa-mia.
But in answer to his final quer)-, as to whetlier the
cases reported by Dr. Bush may not have been pure
malarial fevers complicated by treatment, the answer
is, No and Yes. They were not pure (simple) malarial
fevers, but they were complicated by treatment, if qui-
nine had been administered previous to Dr. Bush's in-
stitution of a more correct treatment. They were
cases of lysajmia, and when that condition exists the
administration of quinine increases the blood disinte-
gration, irritates the kidneys, anfl frequently causes,
from said increase of broken-down corpuscles and from
said irritation, a blocking up of the uriniferous tu-
bules, suppression of urine, uramia, and death.
There seem to be some rare exceptions to this rule,
but in the present state of our know ledge it is far safer
to abandon the use of quinine at the first symptom of
lysaemia, but not before; for while the use of quinine
may be disastrous after the onset of so-called malarial
hematuria, the fact of that morbid condition's presence
is certain evidence that quinine has been neglected
when first needed. If ever)- person in condition to
need quinine were to take the same at the first warn-
ing, and take it intelligently, there would never be
another case of lyssemia.
E. H. M.^RTiN; M.D.
Green Grove, Miss.
Medical Record
A IVeekly yoiirnal of Medicine and Surgery
Vol. 50, No. 16.
Whole No. 1354.
New York, October 17, 1896.
$5.00 Per Annum.
Single Copies, loc.
©vtgiual Jirticlcs.
THE THEORY OF ELIMINATIVE TREAT-
MENT OF TYPHOID FEVER.*
Bv
\V. B. THISTLE, M.D., L.R.C.P. i.OND.,
TORONTO, CAN.,
ASSISTANT DEMONSTRATOR OF ANATOMV. UNIXERSITY OF TORONTO; LECTURER
ON NER\'Ol'S DISEASES AND DISEASES OF CHILDREN IN THE WOMAN's
MEDICAL COLLEGE; I'HVSICIAN TO THE VICTORIA HOSPITAL FOR SICK
CHILDRE.N, TORONTO.
Although the practice of administering purgatives
freely and frequently throughout the entire duration
of tvphoid fever has extended widely in this country
since I'le publication of my first paper on " Elimina-
tive and Antiseptic Treatment of Typhoid Fever,'' in
the Canadian Practitioner for April, 1893, and the ob-
jection that great danger is associated with such a
course is now seldom heard, yet there still e.xists much
misconception regarding the ideas which underlie this
plan of treatment. This misapprehension is mainly
due to a faulty appreciation of what is meant by
■■elimination," the term being made to indicate only
the clearing of bacteria from the intestine, the far-
reaching effects of purgatives on the bodv generallv
being altogether ignored. The misapprehension I
refer to is well illustrated in the inaccurate report of
the eliminative and antiseptic treatment of typhoid
which appears in the recent edition of a well-known
work on the practice of medicine.' In addition to the
common mistake, the writer of the book asserts that
this treatment is based on erroneous ideas of the pa-
thology of the disease. Eliminative treatment is, in the
paragraph referred to, said to depend on the erroneous
idea that the specific bacteria are confined chiefly to
the intestine. Continuing, the writer of the book
makes the positive statement that the specific bacteria
are not present in the intestine until the ninth day of
the disease. It is also pointed out that the specific
germs are found in the spleen and in other parts of
the body, the reader being led to infer that the advo-
cates of the eliminative treatment had failed to appre-
ciate that fact.
In a paper devoted to the theorv of eliminative
treatment I hope to make more apparent the ideas
upon which it is based and to indicate more clearly
the objects to be attained by the continuous adminis-
tration of purgatives throughout the disease; but more
especially do I wish to combat the assertion that this
treatment is based on an erroneous conception of the
pathology of the disease.
I shall at the outset and at the risk of being tedious
briefly set forth the eliminative and antiseptic plan of
treatment, in no wav varying from that which appeared
in the papers published by me in the Medical Record
of March 10, 1894, and September 14, 1895. In the
papers referred to, I subscribed to the view that ty-
phoid fever is a condition in which prolonged poison-
ing occurs, the toxins being produced by certain
bacteria which enter the body and flourish mainly in
* Read before the meeting of the Canadian Medical Associa-
tion, Montreal, .\ugust 27, i8g6.
the alimentary canal, but which are also found in the
glands of the intestinal wall, in the lymphatic nodes
of the mesenterj', in the spleen, and less frequently in
the lungs and other viscera. Their original location,
however, is the intestinal canal; that is, they are first
free in the intestine, but are afterward to some e-xtent
carried by the absorbents into other parts of the bodv.
Wherever located they, as a necessarj' part of their
life, produce a toxic substance, which in turn produces
the phenomena of the disease. Wherever the bacteria
are, there of course will be the toxins which have been
elaborated as a result of their activity; so that in the
course of the disease the absorbents would carry tox-
ins from the bacteria in the intestinal contents; from
the colonies of bacilli within the lymph glands in the
intestinal wall and mesentery, while those generated
by the bacilli which have reached the spleen or are
located in other viscera will be thrown directly into
the circulation.
In the former papers referred to, I held to the view
that the toxaemia of tj'phoid is due to more than one
form of bacillus; that while everything points to a
specific bacillus, such as that described by Eberth, yet
it is impossible to ignore the extreme likelihood of a
portion of the toxa;mia being due to poisons produced
by other bacteria, notably by the bacillus coli com-
munis. In support of that view I cited the facts, that
under certain conditions the colon bacilli do become
exceedingly poisonous; that they produce the toxin
which leads to fatal results in peritonitis: that it has
been pointed out that wherever the intestine is injured
these bacteria take on virulent properties." There is
also the probability that the bacillus coli communis
becomes virulent as a result of association with
Eberth's bacillus.
I also urged that in addition to poisons produced
by Eberth's bacillus and by the colon bacillus, some
portion of toxaemia must be attributed to putrefactive
and other bacteria in the intestine.
Throughout the course of the disease there is a
continual augmentation of the toxaemia by absorption
from the intestine, and from accessions of quantities
of poison produced by the colonies of bacilli in the
spleen, mesenteric glands, or Peyer's patches.
As to the manner in which these toxins affect the
system I quoted Woodhead ^ to show that, like many
substances spoken of as poisons, they had what might
be termed a constitutional and also a local action. In
the circulation they bring about w idespread disturbance
of function, e.g., fever, headache, vertigo, delirium,
coma, etc., and where gathered together or concen-
trated at one point irritation of tissue occurs, w^ith the
usual phenomena of increased rapidity of cell multi-
plication, increased vascularity, and increased exuda-
tion from the vessels into the surrounding tissues. If
concentrated still further, or if the period of contact
be extended beyond a certain point, increased activity
in the tissues is replaced by stagnation and death of
the part, with subsequent casting off of the necrotic
portion.
While there is undoubtedly a great difference in the
virulence of epidemics, as well as a difference in the
susceptibility of individuals, yet in a given case
the symptoms increase in severity in proportion to the
542
MEDICAL RECORD.
[October 17, 1896
quantity of toxins in the system. The symptoms
taken as a whole indicate tlie degree of toxaemia.
Turning now to the most recent English work on
medicine/ I find that the writer on typhoid fever, Pro-
fessor Dreschfeld, of Manchester, believes Eberth's
bacillus to be the primary cause of the disease, but
that many of the symptoms and much of the toxemia
are due to the colon bacilli and to other germs.
He also gives, without comment, the results of in-
vestigation by Pisenti and Piancho-Mariotti to deter-
mine the relation between the typhoid bacillus and
the bacillus coli.
1. On simultaneous injection into animals of cul-
tures of bacillus typhoides and bacillus coli (which
latter had been proved to be inactive), bacillus coli
increased in virulence so as to act like any virulent
bacillus typhoides on animals.
2. If sown on gelatin mixed with filtered cultures
of bacillus typhoides, bacillus coli also gained in
virulence, owing to the typho-toxin acting on bacillus
coli.
3. Healthy intestinal epithelium hinders infection
from the intestine, but if Peyer's patches undergo
changes, this defence is in abeyance.
Filtrates from typhoid cultures exert an inlluence
on Peyer's patches, so that in typhoid fever the toxin
in the blood alters the Peyer's patches and thus bacil-
lus coli enters the body and adds to the virulence of
the typhoid infection.
4. With very virulent cultures of bacillus coli, re-
sults were produced (such as thermometric curves, for
instance) similar to those obtained by very virulent
bacillus typhoides, and animals could be thus immu-
nized against bacillus typhoides. At the same time
the experimenters refrained from any expression of
opinion as regards the identity of the two.
Regarding the mode of infection, Professor Dresch-
feld believes that the bacilli "reach the alimentary
canal, multiply, penetrate into the mucous and sub-
mucous coats, invade the lymphatic tissues, and pass
thence through the lymph channels into the mesenteric
glands. Some of the bacilli reach the blood and pass
to internal organs, principally the spleen. The bacilli
produce various poisons, at present hardly known;
some of these have a pyrogenetic action and thus pro-
duce the fever, .^s a result of their irritant action
and that of their products, we get the intensely inflam-
matory signs in the intestine leading to necrosis.'"
I have quoted sufficient to show the ideas regarding
the pathology of typhoid adhered to in this most re-
cent work on medicine. I submit that these ideas as
to patholog)' and mode of infection in typhoid are
identical with those upon which I based eliminative
treatment, as can be shown by reference to my pub-
lished papers on the subject. In addition, however,
I questioned the correctness of the very general state-
ment that the specific bacteria are not present in the
intestinal contents during the first nine or ten days of
the illness. I maintained that, having in view the
very great similarity between bacillus typhoides and
bacillus coli, and the failure to find methods of differ-
entiation which could be considered at all reliable,
that simply because bateriologists working with un-
certain methods liad not found Eberth's bacillus before
the ninth day, the assumption that this bacillus is
absent from the intestinal contents before the ninth
day was not justifiable. I argued that since there
can be no doubt of their presence and multiplication
originally in the intestine before infection of the
glands — for how otherwise can the simultaneous in-
vasion of Peyer's patches for several feet of the length
of tiie intestine be explained? — and since there is no
ditTerence of opinion regarding their presence in the
intestine after the ninth day, the dogmatic asser-
tion of their absence during the first nine days is
unrea.sonable. More than that, if adhered to, it led
to the absurd contention that the bacilli enter the
intestine, multiply there, penetrate into the intestinal
walls over a large extent, the process occurring with-
out symptoms of any kind, but when the last specific
germ has passed from the intestine into the body, then,
and not until then, are there signs of illness. Such a
theory is manifestly unreasonable, yet, unless it be
maintained absolutely, the contention that the specific
bacilli are absent from tjie intestine during the early
period of the disease must be abandoned. In other
words, the process of invasion of the glands is coinci-
dent with the earlier symptoms of toxamia.
This is the only point in which the ideas expressed
by me in the papers on eliminative treatment differ
from those set forth by Professor Dreschfeld. But he
does not assert the absence of Eberth's bacillus from
the fa-ces in the early period; he merely states 1 hat
they have not been found there during that time. He
appends, however, a paragraph pointing out that since
his article was in press, the new method of Eisner,
which appeared "to fill the long felt want of easily
isolating the bacillus of typhoid and to distinguish it
from the colon bacillus," had been discovered. By this
method, Eisner was able to easily separate Eberth's
bacilli from the faeces in fifteen out of seventeen
cases in the various stages of the disease. The two
cases in which he failed to obtain them were entering
upon convalescence and the temperature was normal.
Eisner's method was tested by Brieger' in eleven
cases and by Lazarus ' in forty-one cases, and his re-
sults were confirmed.
Brieger found Eberth's bacilli in the dejections of
typhoid patients while the symptoms were still ob-
scure.
In repeating Eisner's examinations, in forty-one
cases Lazarus found that the specific bacilli dis-
appeared from the dejections with the beginning of
convalescence, but that in the case of relapse they
were again found in the ffeces.
Thus it seems that what I argued must be the case
in my article in the Medical Record, September 14,
1895, has actually been demonstrated.
That the tests made use of prior to Eisner's method
for the differentiation of bacillus typhoides from bacil-
lus coli were not to be relied upon is shown by inves-
tigations carried on by Professor Dreschfeld and Mr.
Robinson in the laboratory of Victoria College, Man-
chester. They found that some apparently typical
colonies of Eberth's bacillus produced gas in saccha-
rine media, others did not. Of those which produced
no gas, some gave the indol reaction, and three did
not. These three coagulated milk.'
My great error according to the author of the Amer-
ican work on the practice of medicine to which I
referred in the beginning of this paper was in believ-
ing the sjxicific bacilli to be present in the intestine,
during the early period of the disease. I submit
again that, in the light of what has been demonstrated
by Eisner and corroborated by Brieger and Lazarus,
the error is not mine.
I asserted at the beginning of this paper that there
exists much misconception regarding the objects to be
attained by the continuous repetition of purgatives
throughout the disease. I also expressed the opinion
that the misapprehension arose chiefly because elimi-
nation is taken to mean simply the clearing out of the
specific bacteria from the intestine, whereas a much
wider process is indicated by the term "eliminative"
— how much wider I hope to show when we come pres-
ently to the efi'ect of purgation in typlioid.
However, before entering upon the treatment, there
are some fundamental facts which it is necessary to
keep prominently in view in order to appreciate the
logic of the eliminative treatment.
October
/'
[896]
MEDICAL RECORD.
543
1. There is the constant augmentation of the tox-
atmia; the toxin produced by bacilli in the intestinal
contents, and that elaborated by the colonies located
in Peyer's patches and in the mesenteric glands, are
constantly being conveyed into the general system.
Toxins produced by colonies in the spleen or in other
viscera will reach the circulation at once.
2. That during the course of the disease bacilli,
both specific and bacillus coli, as well as toxins are
carried from the intestine still further to increase the
number in Peyer's patches, mesenteric glands, and
spleen, and to increase the toxitmia.
3. That death comes in typhoid fever in two ways,
leaving out of consideration accidents such as epis-
taxis, etc., either by the excessive accumulation of
toxins in the body or by the e-xcessive local action of
the toxins on particular tissues. Roughly, it is said
that eighty per cent, of the mortality of typhoid is due
to toxffimia; that is, the constant augmentation of
poison in the body, either directly by overcoming the
vital centres, or less directly by producing exhaustion
through prolonged interference with the functions of
nutrition and repair, proves fatal.
The remaining twenty per cent, of the fatality in-
cludes, of course, the rare accidents and complications,
but is chiefly made up of the cases that result fatally
owing to the excessive local action of the toxins on
particular tissues. By far the greater part of this
is due to hemorrhage and perforation, two accidents
incidental to necrosis. Necrosis occurs with so great
frequency in Peyer's patches because of the facility
with which bacteria, specific and others, and also tox-
ins, are carried from the intestine to the glands. The
colony originally in possession increases rapidly, elab-
orating at the same time toxins. Moreover, throughout
the disease there is a constant reinforcement, owing to
carriage of bacteria and toxins from the intestine. At
first the gland is swollen, owing to the attempt of the
tissues to destroy the intruders; but finally, in the case
of the glands that ultimately become necrotic, the
tissues are unable to resist the prolonged action of the
ever increasing toxins and death of the part occurs.
Let us now notice the defensive measures against the
condition described.
There are the channels through which toxic sub-
stances leave the body.
In the order of their importance they are:
1. The bile. By way of the biliary secretion much
of the toxins escapes from the body into the intestine
and from there is carried out. So much of the toxin
elaborated in ordinary condition of health escapes
with the bile that Bouchard " estimates the toxicity
of bile as nine times greater than the toxicity of
urine.
2. Next to the bile as a channel for the elimination
of toxins comes the urine.
3. The serous secretion from the intestine carries
with it whatever poisonous substances may be in the
circulation and the body is relieved of so much toxin,
just as it would be if bleeding instead of purging the
patient had been resorted to.
4. In addition to these three channels, toxin of
course escapes by the breath and by the skin.
A further defence is found in the resistance and
agressive action of the tissues themselves. Indeed, in
cases that recover, the bacilli in the body must be
destroyed by the tissues, excepting of course those
that escape by the urine. Just here it may be noticed
that the aggressive and defensive action of the tissues
is in inverse ratio to the extent of the toxaniia.
The plan of treatment which I in 1893 brought for-
ward as the '' eliminative and antiseptic treatment of
typhoid" consists in the administration of frequent
doses of purgatives throughout the entire illness. It
is also considered of primary importance that purga-
tion be secured as soon as possible after the patient
comes under notice.
The purgative medicines chosen are those that
act on the upper and smaller intestine. Perhaps the
most satisfactory is the combination of calomel and
salines. The calomel may be given in several doses,
say of a half or one-grain, and followed in several
hours by a saline, magnesium sulphate or sal Rochelle
in half-ounce doses. However, other purgatives may
be given — cascara, Seidlitz powders, Carlsbad salts,
compound cathartic pill, etc. The quantity of the
dose and the frequency of the repetition must be de-
termined by the necessities of each case.
With the employment of purgation is associated the
use of antiseptics. My experience is with salol
chiefly, and my practice is to give it in ten-grain
doses every three or four hours. I have pointed out
before in the articles above referred to, that antiseptics
may be given in inuch larger doses and with greater
freedom from the occurrence of symptoms due to the
antiseptic, if associated with the frequent administra-
tion of purgatives. To compensate for the withdrawal
of so much fluid from the body by so frequent purga-
tions, as well as to dilute and facilitate the elimina-
tion of poison through the kidneys, the ingestion of
large quantities of water is enjoined. Coming now
to the purpose of this treatment, it is obvious concern-
ing the antiseptics and the giving of large quantities
of water.
The purpose of giving purgatives in the way I have
described is :
1. To interrupt the process of infection; that is, by
sweeping out the intestine to clear away bacilli, spe-
cific and non-specific, and also toxins which would
otherwise go to increase the number of bacilli in the
body and to increase the existing toxa-mia.
2. To counteract at frequent periods the continuous
augmentation of toxins in the body by carrying away
the toxic bile poured into the intestine, which if not
carried away is again taken up and returned to the
system.
3. To further deplete the volume of toxins in the
body by causing a free secretion into the intestine,
bringing with it toxins in solution in the body
fluids.
4. The constant clearing of the intestine must lessen
the extent of the local lesion, because it cuts ofT the
base of supply from which bacilli and toxins are car-
ried to Peyer's patches to reinforce the bacilli and
toxins already in possession. It is apparent, too, that
the earlier this is resorted to, the better for the tissues
in Peyer's patches. Thus, while on the one hand
there is a continual production of toxins in the body,
on the other by the frequently repeated administration
of purgatives we endeavor to eliminate these toxins in
sufficient quantity to keep the total volume of poison
in the body below a harmful point until the period of
immunity is reached. In like manner, keeping the
intestine clear limits the local lesion in the intestinal
glands.
A frequent mistake in carrying out this treatment is
in supposing spontaneous action of the bowels to con-
traindicate the use of purgatives. Such is not the
case, for it is well known that the diarrhoea is most
frequently owing to catarrh of the colon and to tox-
jemia. Thus, while the bowels may be acting many
times a day, yet little in the way of elimination of
toxins is accomplished, the toxic bile in the upper
intestine and the bacterial collections in the ilium
remaining undisturbed. Indeed, in this instance, as in
the mycotic and irritant diarrhcea of children, the flux
is best controlled by giving a ])urgative.
Returning to the details of treatment, I have before
pointed out that it is of the greatest importance to
secure elimination by the bowels as speedily as possi-
544
MEDICAL RECORD.
[October 17, 1896
ble, in order to cut short at the earliest possible period
the process of infection.
Because the case appears to be a mild one is no
reason for withholding treatment, for the case that
appears mild may in ten days' time, by the process of
gradual accumulation which I have described, show
symptoms of the most profound to.xaemia. In many
cases, too, in which the symptoms are not pronounced,
the local lesion may be so severe as to prove fatal.
It has been objected that so frequent purgations
must do harm by carrying out useful bacteria from the
intestine.' There is no ground for such a supposition,
for experiments to determine that point show that a
perfectly sterile intestine in no way interferes with
health."
REFERENCES.
1. Osier: Practice of Medicine.
2. Treves: Lectures on Peritonitis. British Medical Journal.
3. Sims Woodhead : Bacteria and Their Products.
4. Albutt's System of .Medicine, vol. i., i8g6.
5. Zeitschrift fur Hygiene und Infections-Krankheiten, vol.
xxi., 1895.
6. Deutsche medicinische Wochenschrift, December 12, 1895.
7. Berliner klinische Wochenschrift, December 9, 1895.
8. Bouchard : Autointoxication in Disease, page 85.
g. Zeitschrift fiir physiologische Chemie, Bd. 21.
ON THE PREPARATION OF BLOOD FOR
MICROSCOPICAL EXAMINATION.
By henry G. PIFFARD, M.D.,
PROFE.SSOR OF DERMATOLOGY, NEW YORK UNIVERSITV ; CONSlfLTINC SURGEON
TO THE CITY HOSlTrAL, ETC., ETC.
The proper manipulation and mixing of the blood
with diluents to facilitate the accurate counting of the
different corpuscles is fully and properly described in
various text-books, and accompanies the Thonia and
other forms of apparatus that have been devised for
the purpose. I have nothing to add to the published
descriptions.
The various technical points to be considered in
the examination of fresh undried blood are also to be
found in the text-books, but are given in most elabo-
rate detail in Hayem's extensive Treatise on the
Blood. I cannot from my present knowledge im-
jjrove on them.
There is, however, another branch of blood exami-
nation which at the present time is exciting an in-
creased and well-merited interest. I allude to the
preparation and examination of blood spread in a thin
layer and dried on cover glasses. This, too, is
treated of in more or less detail in the text-books and
in special writings, but, I regret to say, is usually
presented in a faulty manner. Instead of the best
technique being given, it is usually the wor.st: impor-
tant points not being alluded to, or directions are
given that tend to obscure rather than elucidate the
objects of the researcli. This criticism is intended to
apply particularly to the German text-books and to the
writings of American laboratory workers who learned
their microscopical technique at the continental uni-
versities, and who in their teachings here still follow
their early practices.
I will admit in advance that no matter how care-
lessly you manipulate the blood or conduct the exami-
nation, some facts can be ascertained; but if you de-
sire to e.x.hibit any given specimen in the clearest and
most distinct manner, and to learn the greatest num-
ber of facts concerning it, the strictest attention
should be given to each and every important detail,
both from a histological and optical standpoint.
It will certainly be conceded that it is better to do
a thing well than to do it negligently, and if the best
results are to be obtained the best technique must be
followed, even should it prove more expensive or
more troublesome than an inferior one; and yet I ven-
ture to say that the majority of blood examinations are
not made under the most favorable conditions even by
those who know or ought to know better.
Errors in technique naturally lead to erroneous ob-
servations, and these, in turn, to false reasoning and
conclusions; and it is to this more than any other one
cause that we have laid before us so many contradic-
tory statements.
Blood films are studied from several standpoints
and with several distinct objects in view. These are
chiefly: (i) To determine the presence or absence of
malarial plasmodia; (2) to ascertain the presence or
absence of the eosinophil, neutrophil, or basophil
granules of Ehrlich; (3) to observe changes and ab-
normal appearances in the leucocytes and red corjius-
cles; and (4) to determine the presence and kind, or
ab.sence, of micro-organisms. In all of these cases
the manipulation is substantially the same, with the
exception of the stains to be employed.
It is this technique which I desire to describe in
the fullest detail, and with special reference to (i) the
slide, (2) the cover glass, (3) the needle, (4) the for-
ceps, (5) the spreading of the film, (6) the fixing and
dehydration of the corpuscles, (7) the staining, (8) the
mounting, and (9) the optical apparatus, and espe-
cially the condenser and objective.
Competition dining the last few years has reduced
the price of slides to an almost ridiculously low figure,
but, unfortunately, this reduction has been accom-
panied with a deterioration in the quality of those
oiTered by most of the supply houses. The glass, cut
roughly to size, is imported, but afterward is groimd
and finished in this country so carelessly that a con-
siderable proportion are smaller than they should be,
and with ends that are not always square. The most
satisfactory slides that I have been able to obtain are
those furnished by Zeiss, at three and a half marks per
hundred. These are cut true to size (76 mm. by 26
mm.) are of good glass, and easily cleaned for use with
a drop or two of alcohol and a piece of Canton flannel.
Zeiss also supplies slides of plate glass at double the
price above mentioned, but these it is almost impos-
sible to clean with either alcohol or acid. The slides
chosen should be of niedituTi thickness. Very thin
ones were formerly of service when attempting diffi-
cult resolution with extremely oblique mirror illumi-
nation. With substage condenser, however, extreme
thinness of the slide is not only unnecessary but un-
desirable, especially in high-power work. The ma-
jority of modern niicro.scopes that pretend to any
degree of excellence are provided with substage con-
densers, either N. A. i achromatic, or N. A. 1.20, or
1.40 Abbe. Now, these apertures are possible only
when there is a layer of cedar oil between the con-
denser and the slide. The princijjal microscope
makers list their condensers as having the apertures
mentioned, but not one of thein, so far as I am aware,
has the honesty to state that these apertures exist
only when they are used with oil immersion, and that
when used dry, as is usually the case, the numerical
aperture is very much less. If, now, the observer de-
sires to employ an immersion objective of high aper-
ture and to work it at its best, he must put oil on the
condenser and focus it for critical illumination. If
the slide is an exceedingly thin one, in biinging up
the condenser to keep the oil in position he will pro-
ject the flame image above the plane of the object un-
der examination. If the condenser be now depressed
so as to make the flame image coincide with the object,
the oil is apt to run out, especially if the microscope
be inclined. The condensers are constructed to work
with slides of medium thickness, and such slides are
the only ones that should be used.
In the selection of cover gla.sses, even greater care
October i 7, 1896]
MEDICAL RECORD.
545
should be employed. The dealers offer both square
and round covers in various sizes and thicknesses.
The square are cheaper tlian the round, and for this
reason are used by many. Little economies of this
sort may be thought well of in German and French
laboratories, but should never obtain a footing among
workers whose aim should be to spare neither pains
nor expense to do their work in the most perfect man-
ner. A hundred slides properly prepared and mounted
will prove of far greater value to the operator and to
the world than a hundred and fifty in which the oper-
ations have been conducted in an unskilful and slov-
enly manner. Square cover glasses should never be
used in tiie preparation of blood films: First, because
it is exceedingly difficult to obtain a good smear; and,
second, it is next to impossible to mount them in a
satisfactory manner for permanent preservation.
The most convenient size of round glass will be
either f", or 18 mm. American dealers supply the
covers in four classes, graded according to thickness,
namely, Nos. o, i, 2, and 3. The first two are altogether
too thin for general use, and should not be purchased
under any consideration. A great deal of blood work
can and had best be done with dry lenses, and the non-
adjusting dry lenses in common use are corrected by
their makers for a certain definite thickness of cover
glass; and if a thinner one is employed, the image
obtained will be imperfect, or " under-corrected," as
the opticians say.
In order that this matter may be clearly understood,
I will enter a little at length into the optical aspect of
the case. The image formed by any lens is the resul-
tant of a vast number of images formed by the dift'er-
ent zones of the lens from near the a.xis to near the
margin. If, now, these different zone images are all
brought together at a common focus, the resultant
image is clear, brilliant, and well defined. If, on the
other hand, the images from the marginal zones come
to a focus before the images from the zones nearer the
axis, the resultant image is said to be "under-cor-
rected," and will be found less brilliant and distinct
than it should be. In fact, an under-corrected image
is a composite, consisting of a vast number of separate
images lying in different planes, and each of them
differing in size from the others; those lying lowest
being the larger. Under these circumstances, sharp
definition is entirely out of the question. To test this
experimentally, take a No. 7 Leitz objective which is
corrected for a cover-glass thickness of 0.17 mm., and
procure some cover glasses of that thickness. On
these covers prepare some blood'films. With the mi-
croscope in a vertical position, put a clean slide on
the stage, and on this lay the co\'er, film side down,
without balsam or any other medium inten-ening. If,
now, the illumination is properly arranged, an exqui-
site image of the corpuscles will be seen. Next raise
the objective and turn the cover over so that the cor-
puscles shall have no glass over them. If we again
examine them, we shall have an image that is under-
corrected to an intense degree. If, now, a blood film
is spread on a cover glass, say 0.05 or o.io mm. in
thickness, and examined film side down, the image will
still be under-corrected, though not so greatly as be-
fore. With oil-immersion lenses of moderate aperture,
N. .\. 1. 20-1. 30, cover-glass thickness is of little mo-
ment. So, also, if dry adjustable lenses are employed.
To obtain, however, the best results with the ordinary
non-adjusting dry lenses, the thickness of the cover
glass used should be that for which the lens is cor-
rected. Most objectives of this sort are corrected for
covers of from o. 1 7 mm. to 0.20 mm., each maker being
a law unto himself in this respect.
The cover-glass thickness will be found to plav an
important part in blood examinations, and I would
strongly advise any one who desires seriously to take
up this work at once to procure an instrument for
measuring the thickness of the covers. Zeiss supplies
such an instrument, and so also do Bausch & Lomb.
The former I have never seen ; the latter I use with
the greatest satisfaction. If the cover-glass gauge be
applied to half an ounce of No. 2 covers, the operator
will probably be a good deal surprised at the varying
thickness of the glasses, some being not thicker than
0.07 or 0.08 mm., while others will run up to nearly 0.30
mm. A half-hour will be well spent in sorting these
over, putting each thickness into a small envelope by
itself. Out of the half-ounce perhaps ten or twelve
per cent, will be found of the exact thickness best
suited to your objective; but if an objective of me-
dium aperture (e.g., Leitz No. 7, N. A. 0.85) is to be
used, a little margin in the thickness may be allowed,
say from 0.15 to 0.20 mm., and the half-ounce will yield
perhaps fifty per cent, of covers coming within this
range. The No. 3 covers, though costing less per
ounce than the No. 2, will yield a much smaller pro-
portion of available covers. Zeiss supplies most ad-
mirable covers, selling only those which fall between
0.15 mm. and 0.22 mm. At a slight advance in price,
he will supply any given thickness that may be de-
sired. Such covers, however, are not carried in stock,
I believe, by any New York supply-house, but will be
imported on special order by Eimer & Amend; and I
have for a considerable time procured most of my cov-
ers in this way.
The next step is the proper cleaning of the covers.
A small glass dish should be partly filled with battery-
fluid (water, nine ounces; bichromate of potash, one
ounce; sulphuric acid, one ounce), and into this the
covers should be dropped, one by one, so that both
sides of the cover may be wetted by the fluid. After
remaining in this for twenty-four hours, the acid is
poured off' and the covers are flushed en masse two or
three times with water. Then each should be taken
separately and dropped into a dish of distilled water,
from which they are to be transferred, singly as before,
to alcohol (preferably pure methylic '). A most con-
venient receptacle for the alcohol and covers is a one-
ounce, square, screw-capped bottle, in which they may
be kept until needed for use.
A very convenient instrument for drawing the blood
is a small, straight, surgical needle, several of which
should be kept in a vial of alcohol until needed. For
a couple of years or so I have used needles made from
an alloy of one part of iridium and two parts of plati-
num. When re(|uired for use the needle is sterilized
at a white heat immediately before and after use.
The blood may very conveniently be taken from the tip
of the finger, though some writers insist that it is better
to draw it from the lobe of the ear. In either case the
part should be thoroughly cleansed.
Two pairs of forceps are required. One should be
of the self-closing variety, with flat, broad points, and
with spring sufficiently stiff to hold the cover firmly
against moderate traction. The other pair may be any
sort that will hold the cover nicely.
A sufficient number, say six or eight, of the covers
are removed from the alcohol, thoroughly dried, and
laid upon any suitable support, projecting a little be-
yond it. One of the covers is seized with the self-
closing forceps and placed ready at hand. The punc-
ture is then made, and another cover is quickly taken
with the second forceps and applied to the droplet of
blood as it issues from the wound. The second cover
is then laid on tiic first, and the blood spreads out
between them. A common fault with beginners is
taking up too much blood; but this will be corrected
after a little practice. As soon as the film is spread,
' I <lo not refer to the stuff c:»lled ''methylated spirits" in
r.njjiish writings, as the latter is ordinary- ethylic alcohol mixed
with common wood spirit.
546
MEDICAL RECORD.
[October i 7, 1896
the projecting edges of the upper cover are taken
between the thumb and index finger, and the covers
are gently slid apart, care being taken to keep them
parallel until entirely separated. The two covers,
with films up, are now laid on a piece of paper to dry,
and a second pair are prepared in the same manner.
If more than four covers are desired, a fresh puncture
should be made. As soon as the films are dry they
may be placed in a small envelope (say 2V by iV).
properly labelled. If stored in a dry place they will
keep unchanged for a long period. It is better, how-
ever, to fix them immediately. If water or any stain-
ing fluid were applied before fixing, most of the cor-
puscles would be washed off the cover, and from those
that did remain the hemoglobin would be removed,
leaving only the almost invisible stroma.
Ehrlich, who was the founder of one branch of hema-
tic microscopy, declared that the corpuscles were best
fixed by heat, and advised that the covers be laid on a
metallic plate supported over a lamp, and be subjected
for several hours to a temperature of 120" to 130° C.
Some operators simply flirt the cover a few times
through a lamp flame, just as they would in fixing bac-
teria. This procedure is to be condemned at the out-
set. However well or ill it may serve for bacteria, it
should not be practised in connection with blood cov-
ers. If there be absolute necessity for haste, the cor-
puscles may be fixed by subjecting them for a few
minutes to the fumes of a two-per-cent. solution of
osmic acid, or they may be placed five, ten, or fifteen
minutes in absolute alcohol, or a mixture of this with
an equal volume of ether. My own experience, how-
ever, with human and other mammalian blood, as well
as with the blood of birds and reptiles, leads me decid-
edly to prefer fixing by heat rather than by any of the
other methods that have been employed.
Ehrlich's metal plate, however, is troublesome and
not altogether satisfactory. If the operator has gas
at his command, he will find a small Fresenius oven
much more satisfactory. This should be fitted with
a Reichert or Dunham thermostat and a centigrade
thermometer. The Dunham is said by those who have
used it to be a. much more satisfactorj' appliance than
the Reichert. I have used only the Reichert, and,
finding it troublesome to manage, abandoned gas in
favor of electricity. For the past )^ear or more I have
used an electric heater controlled by a rheostat, and
am able to obtain a much closer adjustment and regu-
larity of heat tlian I had previously been able to do
with gas.
The covers are heated gradually to about 125' C,
and then maintained at tliis for an hour or more.
When the covers are taken from the oven, they are al-
lowed to cool gradually and thoroughly before staining.
Those who desire to know in how many ways blood
may be stained and for what purpo.ses, may consult the
pages of Friedlander: or, if more convenient, the re-
cent translation of von Kahlden's " Methods of Patho-
logical Histology."
For most purposes, however, double staining with
eosin and methylene blue is all that is necessar\\
Griibler supplies three varieties of eosin, but the "sol-
uble in alcohol" is the only one adapted to our pres-
ent purposes. Of this dissolve one grain in twenty-
five cubic centimetres of alcohol, and after it has stood
twenty-four hours add an equal quantity of distilled
water. The methylene blue to be used should be
Griibler's "rectified.'" Most authors recommend
Loeffler's alkaline solution. This stains the nuclei of
the leucocytes deeply, but is also apt to stain the red
corpuscles and platelets. I prefer, therefore, to dis-
solve 0.50 of the stain in fifty cubic centimetres of a
five-per-cent. solution of formalin. This gives an in-
tense and brilliant nuclear stain without affecting the
other elements, unless its action is unduly prolonged.
When ready to stain the covers, place them film up
on a plate of glass, and cover each with the eosin so-
lution. Leave this on for two or three minutes, and
wash off with distilled water. When the covers are
dr}-, apply tiie methylene-blue solution in the same
manner; and when this is washed off and the covers
are thoroughly dry they are ready for preliminary ex-
amination.
Arrange the microscope vertically, with a clean slide
on the stage, and place on it the cover, film down and
without any inter\-ening medium. Alongside of it, if
you choose, mount another cover in balsam and com-
pare the two. The difference between the two is so
striking and absolutely in favor of the dry cover, that
I venture to say you will never again use balsam for
this purpose. This examination must, of course, be
made with a diy lens. A No. 7 Leitz answers very
well, but a i" or ^\^" objective, with a numerical aper-
ture approximating 0.90, is still better.
If the examination with the dry lens does not give
all desired information, and you wish to examine fur-
ther with a higher-power immersion, it will be neces-
sary to attach the cover permanently to the slide.
Every book and every writing on this subject that I
have seen advises that the cover be moimted in bal-
sam. This advice and practice are decidedly and em-
phatically wrong, and I am amazed that men who have
devoted so much time to the subject, and who rertainl)'
ought to know better, still continue to pursue a meth-
od that certainly destroys one-half the value of their
work.
If you desire to mount blood covers to the best ad-
vantage, the first step is to procure a turntable.
Centre the slide carefully on this, and spin a thin ring
of shellac or other suitable cement, corresponding to
the size of the cover; a second coat may be applied a
few minutes later. Prepare a number of slides in this
wav, and leave them for twentv-four hours or more to
dry.
When the slides are ready for use, take one and hold
it over a flame for a moment or two to expel all sur-
face moisture and to soften the cement a little. The
cover in like manner should be flirted over the flame,
to expel all moisture from its surface. It is then ap-
plied to the cement ring, care being taken to have con-
tact at all points of the circle. When entirely cold, a
fresh ring of cement may be spun around the cover, so
as absolutely to seal it at every point. The slide is
now ready for examination in any manner, and with
any dry or immersion lens.
It matters not whether you are .studying the changes
in the leucocytes, hunting up tlie various granules of
Ehrlich, or searching for the elusive plasmodia, the
optical picture will be vastly superior and much more
instructive than any you can obtain in balsam mounts.
Before closing, I desire to say a few words about
the substage condensers. If circumstances restricted
me to the use of a single condenser for all purposes,
I would choose an achromatic N. A. i, which may be
obtained of excellent quality from Zeiss, Bausch <Sc
Lomb, Watson of London, and other makers, costing
perhaps ten or twelve dollars more than the customary
".\bbe." With dry lenses, except those of the very
widest aperture, I should use it dry, that is, without oil
between the condenser and the slide. By so doing
you impair the nominal aperture about one-third, and
throw it a little oft' its corrections; but even then it
will be better than any of the Abbe construction. If
used in connection with immersion lenses, oil contact
should be used, so as to secure the full aperture. If
circumstances permit the expenditure, an additional
achromatic of N. .\. 1.30 to 1.40 should be added; and
for low-power work, an achromatic of low aperture,
say N. A. 0.60 to 0.75. I know of but one optician
that offers such a low-power condenser, and regret to
October i 7, 1896]
MEDICAL RECORD.
547
say that I have not found it satisfactory. In regard
to the Abbe condensers that are in such general use,
it may safely be said that they are a vast improve-
ment on simple mirror illumination, that was almost
the sole dependence before Professor Abbe introduced
his simple device. The low cost has undoubtedly
been the chief means of its wide introduction, but as
an optical instrument of precision it is decidedly in-
ferior to an achromatic of approximate aperture.
Through force of circumstances, fully nine-tenths of
the laboratory workers employ diffuse daylight as an
illuminant, and for the great mass of work to be done
it is amply sufficient and satisfactory ; but for the most
delicate work a well-arranged artificial light is prefer-
able.
At the present time the blood offers one of the most
inviting fields of inxestigation, as an aid both to diag-
nosis and to therapeutics; and I cannot too strongly
urge on those who design to take it up to pay the
strictest attention to what at first may appear to be un-
important technical details.
10 West T(uktv-Fifth Street.
R-HEUMATISMUS NEONATORUM.*
By R. ABRAHAMS, M.D.,
DISTRICT PHYSICIAN TO THE MOUNT SINAI HOSPITAL, NEW VOKK.
Acute articular rheumatism, in early infancy, is re-
garded by all systematic writers as an exceedingly rare
occurrence. Cheadle' mentions two cases referred to
Senator, and credited by the latter to Stager and
Windeshofer, in which two infants, one four weeks and
the other twenty-three days old, were affected with
acute rheumatism. Striimpell,^ in discussing the etiol-
ogy of the disease, cites "a single interesting case"
which he met in Leipsic. In this instance, the child
was only a few days old, and suffered from " multiple
purulent arthritis." On looking over the literature of
acute rheumatism in childhood, I came across two
more instances of the disease reported as occurring in
two infants, one twelve hours old," and the other three
days old.* I looked in vain for more records of cases.
If any escaped my study and scrutiny, I shall be
grateful to learn of them. If we accept the traditional
causation of rheumatism, viz., exposure to cold and
hereditary tendency, there certainly can be no reason
why a good many of our newly born should escape it.
For the diathesis is admittedly prevalent, and as to
exposure, who knows better than the little newcomer
the cruel extent it is subjected to by the daily oiling,
soaping, and washing, and bathing? With all that and
in spite of that, recorded histories of rheumatic fever
in the very young are so very, very few. To my mind
the scarcity of such observations seems to be due to a
lack of care on the part of the medical attendants.
For instance, when the baby cries, the scion of Hip-
pocrates readily submits to the supposition of the nurse
or of a sympathetic neighboring woman that it must
have colic; the drawing up of its tiny limbs is but in-
fallible light on the diagnosis. The possibility that
the infant may be suffering from painful ankle or knee
joints may never appeal to his deep-seated centre of
thought, and yet it may just be this and nothing else.
'I'his is one reason, apparently, why rheumatismus
neonatorum is not frecjuently recognized. Another and
more potent reason for its non -recognition is the fol-
lowing one: Rheumatism, in infancy and childhood,
does not exhibit those marked and characteristic joint
affections we are wont to see in adult life. The medi-
cal mind is .so accustomed to associate rheumatic affec-
tions with heat, pain, redness, and swelling of one or
more articular joints, that sometimes only through
* Read before the New York Eastern -Medical Society, Sep-
tember 1 1, 1896.
sheer good luck does one escape the brutal mistake
of diagnosing a housemaid's knee as mono-articular
rheumatism. Few, indeed, take the trouble to exam-
ine the heart of a restless, crying, painful infant, a
procedure which may in a moment reveal the cause of
the little one's anguish. Rather than this, the dumb
creature is dosed with the staple remedies for colic —
as, for example, castor oil, brandy, calomel, paregoric,
and other things which will occur to the doctor and
experienced aunts. Says Dr. James Finlayson, in his
excellent article entitled "Diagnosis;"'' "Rheuma-
tism in childhood is at times ratlier difficult of recog-
nition, as the articular affection is only slight, and
perhaps contemptuously spoken of as 'growing pains,'
although such trivial attacks are often associated with
endocarditis, leading to permanent mischief of the
heart."
All authorities agree that rheumatism in early life is
characterized in a majority of cases by valvular le-
sions of the heart; or, to put it differently, the heart,
instead of the joints, is the target of the disease. In
rheumatic fever of that age, a fatal endocarditis is not
incompatible with a total absence of articular affec-
tion. Endocarditis, in the life of an infant or child,
is almost positive proof (si.xty per cent, to seventy-five
per cent.) of either past or present existence of rheu-
matism. The inferences to be drawn from this state-
ment of facts are, first, the importance of the routine
examination of an infant's heart; and second, the
rheumatic origin of an ir "vntile endocarditis.
The lay more than the mc "ical press bristles with re-
ports of sudden deaths of infants. Is it not logical to
assume, from what has been said, that this unexpected
termination of young lives is as much the result of
heart failure as it is in similar cases of older members
of the community? And, furthermore, is it not rea-
sonable to ascribe the cause of this form of infantile
mortality primarily to acute rheumatism? And yet
the abrupt ending of an apparently healthy infant is
most often attributed to " convulsions," rather than to
its true and probably only cause, rheumatism.
Sir Dyce Duckworth ^ lately estimated the percent-
age of chorea as an expression of rheumatism to be
about seventy-five. Now, sometimes in the course of
our daily practice we come across a case of chorea in
a child in whom there is no trace of rheumatism, past
or present, in the joints, heart, or elsewhere: and,
being at a loss to account for its presence, we are
obliged to fall back on the ubiquitous but none the
less perfunctory cause, fright. If, however, we kept
in our minds the possibility of the child's having had
rheumatism in its infancy, which, fortunately, left no
indelible trace on it except the chorea, we would not
adopt wildcat theories to account for the manifesta-
tion of the latter in advanced childhood. Further-
more, if the rheumatismus neonatorum had been recog-
nized, so that the proper remedies could be applied,
there would, perhaps, be no chorea to treat later on.
I must now turn to another phase of the subject of
this paper — from the practical to what may be called
the scientific side.
By recognizing and establishing the existence of
rheumatismus neonatorum, we shall add tremendous
weight to the modern conception of the etiology of
acute articular rheumatism.
Acute rheumatism is struggling hard for recognition
as an infectious disease. Some authors of eminence
have already recognized its claim, and accordingly ad-
mitted it to the republic of infectious diseases; while
others acceded it the right of belligerency only, wait-
ing, meantime, for further proof of its deservedness.
It is undoubtedly owing to the absence of clinical
data, the sheet anchor and touchstone of certainty, that
the profession hesitates to adopt that view of the eti-
ology.
548
MEDICAL RECORD.
[October 17, 1896
The rise and fall of the different theories regarding
the causation of acute rheumatism are interesting.
While all observers agreed upon several factors, such
as chill, fatigue, climatic changes, and, last but not
least, that mysterious entity — diathesis, as necessary-
elements in the etiology of rheumatism, yet they could
not escape the conviction that something more than all
this is at the bottom of the rheumatic constitutional
disturbance and its train of disagreeable sequela;.
Here, then, speculation became rife. As a conse-
quence, we have the neuropathic theory, the uric-acid
theory, the lactic-acid theory, and the compromising
theory, namely, that which promulgates the view that
the disease is caused by an excess formation in the
blood of uric and lactic acids. There are three more
theories: one holds arterio-sclerosis responsible for
some cases of rheumatism ; another says that it is in
a great many instances the fault of the white corpus-
cles of the blood; and still another attempts to lay
the blame at the door of the lymph and its circulation
in the lymph spaces and vessels. Dr. Cheadle,' in an
interesting review of the entire subject of rheumatism,
thus speaks of the chemical theories: "While they
command respect and admiration by the knowledge
and ingenuity with which they are worked out, the)'
must be accepted only as provisional explanations of
the chemical and physiological process by which the
result might be brought about, if uric acid should
prove to be the ultimate factor of the disease."
These theories being pro' lematical and insufficient,
in order to satisfy the m' d it was natural for the in-
genuity of man to invent a new theory. So we find the
theory of infection occupying the arena of specula-
tion. .According to Striimpell, this view was first ad-
vanced by Huter. The final appearance or evolution
of the theory of infection was neither unnatural nor
unexpected. It is a step in the direction of modern
thought and ideas. If you take into consideration the
clinical picture of acute rheumatism, you must be ir-
resistibly impressed with the family resemblance it
bears to other infectious diseases. The variety of
type, the involvement of the heart, pericardium, pleura,
tonsils, joints, and skin : the occurrence of albuminu-
ria, the hyperpyrexia, the liability to relapses; and,
lastly, its prompt yielding to a specific remedy — all
add shape and color to the family likeness. Of
course, this picture is only suggestive, not conclu-
sive. For the theory of infection to become an ac-
cepted and indisputable fact, it must conform to three
rules: First, it must prove that the disease depends
upon a specific micro-organism. The specific germ
must be invariably found associated vviih the disease,
it must admit of isolation, and must be capable of re-
producing the affection when inoculated in a human
being or in a lower animal. .\ good many investiga-
tors set to work to discover the specific microbe. Many
were the attempts and many were the failures. The
serum of the pleura and joints, the urine and blood of
rheumatic patients, and portions of brain and endocar-
dium of patients who died of rheumatic fever were
carefully examined, with greater or less encouragement
and success. .Vmong the many who were engaged in
that work can be prominently mentioned lUrch-Hirsch-
feld, liouchard and Charrien, 'I'riboullat, Soaza,' and
Leyden. While "all repeatedly found the staphylo-
coccus albus and sometimes the .streptococci in the
synovial and pericardial fluids and the cardiac valves
in cases of acute and subacute articular rheumatism,"
it remained for Leyden" " to isolate from a number of
cases of acute rheumatism, attended by complications,
a delicate diplococcus, differing from anv hitherto de-
scribed, and unequivocally distinguishable from the
various forms of staphylococcus, the streptococcus, and
diplococcus of pneumonia." The logical conclusion
therefrom is that this organism is the essential cause
of the malady and its complications. If the work of
this illustrious man be continued by himself or his
followers, we may reasonably expect to hear, sooner or
later, of rheumatism being produced in lower animals
by inoculating them with the specific diplococcus.
Great impetus was lately given to the second of the
three rules by the careful and painstaking researches
of Dr. Newshomles,' of London, viz., the epidemicity
of acute rheumatism, or, as he prefers to designate the
disease, rheumatic fever. To quote the doctor's
words: "All the hospital records, all the Scandina-
vian imperial returns of cases, and all the death re-
turns agree in manifesting very great irregularities in
the yearly incidents of rheumatic fever, the excesses
of prevalence in certain years being so great as to
merit the name of epidemic." On another occasion he
added the following suggesti\e remarks:'" "The clini-
cal and pathological features of rheumatic fe\er were
both best explicable on the supposition that it was
caused by the entry into the system of a specific mi-
cro-organism." He further says: " Low subsoil water
and high earth temperature were two of the most im-
portant conditions under which the specific micro-
organism of rheumatic fever germinated in the soil
and became capable of parasitic life in the human
body."
Now we come to the consideration of the last and,
from a practical standpoint, most important rule or
element necessary in the support of the theory of in-
fection.
In the days of yore, clinical data were everything.
Nowadays, they stand in humble relation to the om-
nipotent instrument, the microscope.
As rheumatism is not an eminently infectious dis-
ease, evidence of transmission of it is comparatively
scant. The same, however, may be said of pneumo-
nia. There are ca.ses on record which apparently show
the transmission of the disease from individual to in-
dividual, in the .same house where rheumatic fever pre-
vailed. But a doubt is thrown on the illustrative ac-
curacy of such records by the probability that all the
victims in the same house might have been a prey to
the same jjernicious climatic or other external influ-
ence. I expect that the foetus and the infant will
furnish the medical world with all the necessary cor-
roborative testimony justifying the cla.ssification of
acute rheumatism among the infectious diseases.
Pathologists are at present engaged in a work which,
though as yet barren of results, is full of rich promises
for the future. I refer to the study of the diseases of
foetal life. There are already on record many cases
of endocarditis of a pre-natal origin. An editorial
writer in the New York Medical Record " thus hope-
fully sums up the literature of this new and intere-sting
subject: "That a pregnant woman, suffering from an
infectious disease, may give birth, prematurely or at
term, to a child suffering from the same disease, has
been recognized for a long time: and recent exitri-
ence demonstrates that the transmission takes place
through the placenta. We have also learned that any
infectious process is capable of causing endocarditis.
It mav thus happen that the pregnant woman is at-
tacked with rheumatism, or typhoid fever, or influenza,
or pneumonia, or other infection, while her unborn
infant, though possibly escaping tiie primary disease,
is the victim of an inflammation f>f the endocardium of
the right side of the heart, the consequences of which
persist through life." Place these inferential remarks
side by side with the accepted origin of the great ma-
jority of endocardial lesions in infants and children,
and they wUl be but a splendid commentary on it.
But, even putting this new light aside, let us ask the
question: Can it be proven that a pregnant rheumatic
woman can give birth to a child with acute rheuma-
tism? I believe she can, and that she does. If we keep
October i 7, 1896]
MEDICAL RECORD.
549
our eyes wide open, if we remember that infants and
children can have rheumatism without articular trou-
bles, if we make it our business to examine a suffering
infant's heart, we shall find in more than one case un-
mistakable signs of rheumatic endocarditis. Better
and more convincing clinical demonstration of the in-
fectiousness of rheumatic fever than that which could
1)6 furnished by the infant and its mother, could not
be desired. I am, as you know, a general practitioner,
and as yet free from the marks of the footprints of
time; still, ever since my attention was accidentally
called to this condition, I have gathered material and
I present to your intElligent and critical examination
three undoubted cases of rheumatismus neonatorum,
which, to all appearances, originated hi litem of the
respective rheumatic mothers — that is to say, women
who suffered from acute articular rheumatism either
shortly before or at delivery of their children. I shall
add to my three cases the histories of the three others
I found recorded, and with them all I will beg to com-
plete my paper:
Case I. — S , infant, twelve days old; referred
to me by Ur. Rosenblueth in the fall of 189 1. The
baby was perfectly developed, was carried to full term,
and naturally delivered. According to its mother, the
child did not stop crying from the moment it was
born. On being handled, its cries were most pitiful
and loudest. At the second bathing, about twelve
hours after delivery, the midwife noticed that the child
was a little feverish and seemed to be pained when its
lower limbs were touched. On closer inspection she
found the joints of both knees and ankles, one wrist
and one elbow-joint, slightly red and somewhat en-
larged, but intensely tender. The left knee was larger
and redder than any other of the joints. Thinking
that the trouble was a "cold," she applied to both
knee-joints "potato poultices," and to the others flan-
nel and wadding. The child seemed to feel better
under this treatment, for it nursed and slept quite well.
On the fifth day the infant was decidedly feverish, the
knees being considerably inflamed. With this change
of symptoms the treatment underwent some modifica-
tion, for now the midwife applied hot linseed poul-
tices. The latter treatment was kept up for four davs;
the child got worse, and then Dr. Rosenblueth was
called in. When he saw the child the left knee-joint
was inflamed and suppuration was threatened. A day
or two after I assumed, through the kindness of the
doctor, full charge of the case.
My examination revealed the following points;
Fair-sized baby, crj-ing, restless, and very tender to
the touch. Skin moist and acid in reaction. Here
and there on the body small erythematous blushes
were noticeable, which disappeared on pressure, and
were probably the result of irritation caused by the
rough flannel in which the child was wrapped. Bowels
costive, mouth aphthous; head and fontanelles normal
in shape and size. Bones in the body presented noth-
ing unusual. The temperature was 103.5^ F. Pulse
was so rapid that I could not count it with certainty.
The heart's action was tumultuous and irregular.
Respiration, from 50 to 60 to the minute. Excepting
the shoulder-joints, all the rest were very tender when
quiet, and especially so when moved. 'I'he left kne,^-
joint, which was diligently poulticed with lard and
linseed, was cedematous and purulent. This joint was
incised and a thin pus escaped. A few days later the
second knee-joint showed signs of suppuration, while
the rest of the joints remained in the former condition.
The child failed pretty rapidly and died on the eighth
day after I took ciiarge of it. The diagnosis of puru-
lent rheumatic arthritis, complicated by acute endo-
carditis, was arrived at after mature consideration and
exclusion of every other possible disease, as syphilis,
tuberculosis, rachitis, erysipelas, or pyamia. The
parents were absolutely free from all infectious, con-
tagious, or communicable diseases, past or present,
save one, and that was rheumatism. The cord was
healthy, and no other avenue for entrance of sepsis to
cause pyaemia could be discovered. I must add that
the diagnosis of piuulent rheumatic arthritis was made
after the death of the infant, when in my leisure I
could go over the entire history of the case with ex-
treme care and minuteness. Mrs. B , the infant's
mother, suffered from an attack of acute rheumatism
tviro weeks before delivery, and, while her acute symp-
toms were gone at delivery, she still had pain in some
of her joints. Mr. B was a victim of a mild
chronic rheumatism and experienced frequent exacer-
bations. There may be humor and truth in his wife's
remark that he had an equal share in the infant's
death, for at the time of conception he suffered an ex-
acerbation.
Case II. — Mrs. M , twenty-eight years old;
family and personal lustory negative; pregnant for
the third time. When she entered her ninth month of
gestation, she was attacked by acute articular rheuma-
tism. On the fourteenth day of her sickness I was
called in to see her. I found her lying in the recum-
bent position, unable to make the slightest movement.
I was informed by her relatives that she had been on
her back ever since she was taken sick. All the
joints, small and large, were involved. Both hip- joints
were very tender, but there were no visible signs of
inflammation. On forcibly turning her on one side,
I discovered in the lumbar region an immense bed-
sore undergoing sloughing and ulceration in several
places. The temperature never ran lower than 104° F.
morning and evening. The heart was rapid, but no
damaged valve could be discovered. The pericardium
and pleura were normal. In spite of large doses of
salicylate of sodium, there was no diminution in the
severity of symptoms and no reduction in the tempera-
ture. The bedsore, owing to d.ifficulty in turning her,
could not be treated as well as was desired, and
therefore it made very little progress in the direction
of healing. At the end of the twenty-first day of her
illness the temperature began to rise, and in less than
twenty-four hours it reached io6° F. At this period I
could detect for the first time an aortic murmur. Her
pregnancy all the while went on undisturbed. The
foetus showed unmistakable signs of life by ^■iolent
kicks, which added much to the poor woman's agony.
On the twenty-fourth day of the disease the tempera-
ture went up, at times as high as 107° to ro8' F.
The condition of the heart became alarming; the aortic
insufficiency was very much pronounced, the heart
action was frequently irregular and tumultuous, and
the patient at times was quite delirious. The urine
showed no lesion of the '.kidneys. At this stage I de-
cided to induce premature labor to save the child and
possibly relieve the mother; but before doing so I
consulted Prof. Paul 1\ Munde. The professor saw
her in the evening of the twenty-fifth day of her sick-
ness. He regarded the case as very serious, but de-
tecting feeble uterine contractions and finding the os
somewhat dilated, advised against the induction of
labor, predicting that she might be delivered in twelve
hours. She was delivered the next evening of a boy
weighing about nine pounds, well developed in every
respect. Shortly after delivery the symptoms abated,
but not for any great length of time. 'I'hree days af-
ter delivery the temperature rose again; the heart ac-
tion was very rapid and very feeble. She was removed
in this condition to Bellevue Hospital, where she died
with a temperature of 109" F. The autopsy showed,
in addition to other and minor things, an acute endo-
carditis invoh ing the aortic and mitral valves; very
little fluid in the serous cavities; serum of some of the
joints was purulent: the uterus was perfectly normal.
550
MEDICAL RECORD.
[October i 7, 1896
In bathing the infant two hours after it was born, I
noticed that it was not quite as supple as other infants
are. I also noticed that its legs were somewhat drawn
up, and when they were straightened it protested in
unmistakable tones. E.\amining carefully, I discov-
ered tender, somewhat stiff, but not swollen knee-
joints. It seemed that the calves of the legs, as well
as the muscles of the arms, were sensitive to the
touch. Examining the heart, I found a distinct, soft,
blowing, mitral systolic murmur. The temperature
was 101.5° E. The highest point the temperature
reached was on the fifth day, when it went up to
103.^" F. In that condition the heart was so irregu-
lar and the pulse so small and rapid that it was super-
fluous to count it. On the sixth day the temperature
went down again to 101° F., and the heart action im-
proved. There was considerable difficulty in keeping
the infant in a good condition. The food was arti-
ficial, the feeder was careless, and all the surroundings
were pretty bad. In spite of all these disadvantages,
the child got along fairly well, and under the careful
and judicious use of salicylate of sodium (two to six
grains per day) liie little patient completely recovered
within six weeks of his iDirlh. The joints were sup-
ple and free from pain, and the heart ceased to show
any abnormal sign ; in other words, the baby was
cured. It kept up in excellent health until the age of
six months, when it developed acute gastro-enteritis
and died.
Case III. — Mrs. K , primipara, aged twenty-
five. Rheumatism in the family; mother and father
had it. In the beginning of the seventh month of her
pregnancy she was attacked with subacute articular
rheumatism; different joints became stiff and painful
from time to time; her temperature was never higher
than 100° to 100.5° F- Her heart was normal. Under
the use of salicylate of sodium (sixty grains per day),
she recovered in ten days. She felt well up to the
middle of the ninth month of gestation, when she was
seized with quite a violent attack of chorea; the cho-
reic movements were bilateral. Within twenty-four
hours of the attack labor began, and terminated in for-
ceps delivery under chloroform anaesthesia. It may
be interesting to note that the chorea stopped the min-
ute the placenta was expelled. The infant, which was
a female, was apparently healthy, nursed, and slept
well. It could twist and turn its limbs whichever way
it pleased with safety. No tenderness was ever elic-
ited. 15ut one thing was noticed, viz., when it cried
the face and finger tips became abnormally blue.
This condition suggested endocardial trouble, and ac-
cordingly I examined the heart, with the result of
finding an aortic insufficiency. No elaborate explana-
tion was necessary to account for the origin and pres-
ence of endocarditis. The result of treatment in this
case with salicylates is not satisfactory.
The following cases are those which were referred
to in the beginning of the paper, and in which the di-
agnosis of acute rheumatism was made;
Case IV. (Strumpell's case). — He refers to it in
this wise; "We may be permitted to mention a single
interesting case which we met in Leipsic, where a
child who died when only a few days old, and whose
mother at the time of its birth was suffering from a se-
vere attack of acute articular rheumatism, was found
to have multiple purulent arthritis."
Case V. (Pocock). — The reporter calls this "A
Case of Acute Rheumatism, Occurring in a Newly
Born Infant, treated with Salicylate of Sodium." On
May 25th the doctor was called to see a Mrs. A ,
whom he found suffering from acute rheumatism, with
a temperature of 106.5" F. She '' was pregnant within
a month of her confinement." Thirty-six hours after
she was seen labor set in. Delivery was accomplished
in four hours. •" The child was a verj- cross one and
cried very much, which the nurse and mother attrib-
uted to flatulence and want of food. However, dill-
water, aniseed, etc., having no effect, I was sent for
about twehe hours after birth. The child was decid-
edly feverish, with a moist skin, and an acid smell
about him. I noticed that he appeared to cry more
loudly whenever his right arm was moved. On re-
moving the dress his right shoulder and elbow joints
were found reddened ; and on moving either joint he
cried lustily. On using the tiiermometer I found the
temperature 103.5" F., and his pulse 170, as accu-
rately as I could count it. Under the circumstances,
it occurred to me tliat he might have the rheumatic
poison in his blood, and that, in fact, I had to do with
a case of congenital rheumatic fever.'" The diagnosis
was corroborated by the inliuence the salicylate had on
the patient, for the child was completely cured.
Cask VI. (Sch.^fter). — 'I'he reporter of this case
calls it a "■ Case of Acute Articular Rheumatism of the
Mother and her Newly Horn Child." A woman, aged
thirty-five years, in her fifth pregnancy, suffered from
an attack of acute rheumatism a few days before deliv-
ery. At full term a thoroughly healthy child was
born. The child was rapidly delivered. "The mid-
wife noticed on the third day a slight swelling on the
back of both feet; the temperature was 38.7" C. ; ap-
petite poor. On the following day the swelling of the
feet increased. The phalangeal joints of the first fin-
ger of the left hand began to show signs of redness
and swelling. A doughy swelling was found in the
neighborhood of the left hip-joint. There was no rec-
ognizable change in the heart. ,\ day later the red-
ness spread over both hands and all the finger-joints
and both hip-joints. Temperature, 39.5° C. l"he child
lies now more motionless, tightly-drawn hips; the
arms, when slightly moved, make the child ciy piti-
fully."
The writer of this report was sanguine in his con-
victions that this was a case of acute articular rheu-
matism in the newly born, acquired in the intra-uter-
ine life.
Now, gentlemen, if I have succeeded in convincing
you of the existence of the disease which I ventured to
christen rheuniatismus neonatorum, my work will be
sufficiently recompensed ; but if I also succeeded in
rousing your interest in this unrecognized disease, so
that in time you may help, through your intelligent
observations, to increase its literature, I shall consider
myself doubly and trebly rewarded.
156 Clinton Street, New York.
REFERENCES.
1 . Cheadle ; Keating's Cyclop.iedia of the Diseases of Chil-
dren, vol. i,, p. 7g2.
2. Strtlmpell : Text-Book of Medicine, p. 901; last American
edition.
3. I'ocock : London Lancet, 1882, vol. xi., p. 804.
4. Schaffer : Berliner klinische Wochensehrift, 1886. S. 79.
5. Keating's Cyclop.xdia of the Diseases of Children, vol. i.,
p. 1 10.
6. Hritish Medical Journal, January 11, 1S96.
7. Editorial : New York Medical Record, December i,
1894.
8. Medical News, Philadelphia, January ig, 1895.
9. London Lancet, March 9 and iG and April 3, 1895.
10. Hritish .Medical Journal, January 11, 1896.
11. Mkdicai. Rkcord, 1896, xlix., 702.
Dieting in Dyspepsia. — Dr. Balfour, in liis work on
"The Senile Heart," gives the following rules for
dieting which are applicable in many cases of dys-
pepsia; (i) There must never be less than five hours
between each meal. (2) No solid food is ever to be
taken between meals. {3) All those with weak hearts
should have their principal meal in the middle of the
day. (4) All those with weak hearts should have
their meals as dry as possible.
October 17, 1896]
MEDICAL RECORD.
551
SENILE ENDOMETRITIS AND VAGINITIS.'
By AUGUSTIN II. GOELET, M.D.,
PROFESSOR OF GYNECOLOGY IN THE NEW YORK SCHOOL OF CLINICAL MEDI-
CINE, ETC.
The assumption that women are necessarily exempt
from uterine disease after they have passed the meno-
pause is an error. It is a mistake also to think that
they are peculiarly e.xempt from inflammation of the
genital tract, though it may be true that they are not
so liable to acute inflammatory conditions as younger
women, or rather when inflammation occurs at this
age it is not apt to be so active. This belief con-
cerning women past the climacteric is prevalent with
the laity and is strengthened by the attitude of the
profession at large, who are prone to regard the ques-
tion with indifference. This may be due to the be-
lief that there is little to be done for chronic inflam-
mation of the uterus if it e.xists at this time and
that it is incurable, hence it had better be left undis-
turbed. This is an error which is the result of past
ineffective methods in dealing with inflammation of
the uterine mucosa in general and of the attempt per-
haps to apply here the same method of treatment that
is effective in other forms of endometritis depending
upon quite a different cause and presenting quite a
different pathological condition.
If the general practitioner will come to realize that
women past the menopause may be liable to a chronic
inflammation ' of the uterine mucosa and that it is
amenable to treatment, he will begin to look for signs
and symptoms denoting it and he will find that it is
by no means infrequent. He must be prepared for
opposition on the part of the patient, who at this age
is always reluctant to admit the possibility of such a
condition and who would endure anything rather than
submit to treatment for it. He will find it difficult to
convince her that, having enjoyed, as she believes, an
immunity from womb trouble previously, she can pos-
sibly have any such disease after the menopause.
Yet, strange as it may appear, senile endometritis is
more frequently found in women who have not re-
ceived treatment for uterine disease earlier in life.
This may be explained on the assumption that catar-
rhal inflammations, if they existed previously, were
neglected because of the reluctance of most women to
submit to treatment unless forced to do so on account
of the severity of the symptoms. Still this does not
by any means account for all of the cases of senile
endometritis, for it has been discovered not infre-
quently in women who from the closest scrutiny of
their histories gave no evidence of any uterine disease
whatever during their menstrual life, and I have seen
it in women who had never married and never had
children, and v\ho had remained virgins. Hence I
believe that, while senile endometritis may result from
neglected endometritis occurring during menstrual
life, the change in the uterus incident to the meno-
pause is directly responsible for a great number of
cases.
There can be no doubt that an impaired condition
of the general system may be a strong factor in the
production of senile endometritis which should not be
overlooked. Yet by far its most active cause is the
atrophic changes which the uterus undergoes at this
time of life, depending upon a diminished activity of
the pelvic circulation resulting in impaired nutrition
of the organ. Not only does this alter the character
of the glandular structure and of the secretions, but the
epithelium of the mucous membrane undergoes a rad-
ical change and in some instances disappears com-
' Read before the New York Medico-Surgical Society, October
5, l8g6.
' Skene is inclined to regard this condition as a senile degenera-
tion in the majority of cases rather than as a chronic inflamm.-i-
tion. with which view the author concurs.
pletely. A general shrinkage and contraction occur
and the canal of the cervix becomes narrower in cali-
bre and eventually becomes obstructed, sometimes
even almost obliterated. This condition is hastened
by destruction of the mucous membrane in places, due
to the acrid character of the discharge, resulting in
the formation of bands of cicatricial tissue. These
changes are not limited to the mucous membrane of
the canal of the cervix, but involve the whole endo-
metrium and are also to be observed in the vagina,
where not infrequently, if the disease has been ne-
glected, the vaginal vault is so narrowed from con-
traction of cicatricial bands that it is difficult to reach
the cervix in some cases. I have been able to show
at my clinic repeatedly cases of this kind and also to
demonstrate the cicatricial contraction of the cervical
canal.
The appearance of the mucous membrane of the
vagina is characteristic in these cases. The rugJE
are effaced and the surface is pale and glistening in
places, a more nearly normal membrane intervening,
upon which may be observed minute ecchymosed spots
or apparently elevated intensely reddened papillae,
which consist of exposed capillary vessels, the epithe-
lium being destroyed, they show through the delicate
structure covering them. In some cases the whole
surface of the vagina is intensely injected and in-
flamed, and is covered with an acrid muco-purulent
discharge, derived in great part from the uterus. An
active vulvitis is sometimes produced by contact of
this discharge.
The uterus is the seat of change beyond that of the
mucosa. Its walls are in some cases atrophied and
the organ is much reduced in size. In other cases
the walls are softened and the organ is enlarged and
relaxed, which may be due to constant distention from
the secretion retained within the cavity.
The character of the discharge is muco-purulent or
sero-purulent, depending upon the duration of the
disease and the extent of the changes that have oc-
curred. It is usually more profuse and acrid as the
disease advances and if it has been neglected. It is
profuse at times, then again almost absent, because
it is often retained from obstruction of the canal until
over-distention causes its expulsion. The discharge
is sometimes, though rarely, mixed with blood.
The symptoms which this condition gives rise to
are by no ineans constant or invariable. Sometimes
the patient will complain of a burning on the top of
the head or a burning pain in the lumbar region or
over the sacrum, but seldom is pelvic pain a prominent
symptom. Pain is more often complained of when a
posterior displacement of the uterus complicates the
case. I have known these patients to suffer positive
discomfort while riding in a carriage even over a
smooth road.
Rectal tenesmus, due to a chronic proctitis, is some-
times complained of. Vesical tenesmus is more fre-
quent, and in some instances there is a chronic cystitis
with urethritis and a discharge from the urethra,
muco-purulent in character.
The digestion is often impaired and with it there is
marked evidence of malnutrition, giving a worn expres-
sion and the appearance of premature old age (Skene).
This is perhaps due as much to chronic sepsis as to re-
flex disturbances caused by the local irritation. The
appearance is so characteristic that patients suffering
with senile endometritis may often be told by their
general appearance, the facial expression, and the
peculiar bronzed appearance of the skin. The general
circulation is poor and tiiese patients suffer with cold
extremities, a dry irritable condition of the skin, great
nervousness, and not infrequently insomnia.
If a patient past the menopause complains of dis-
ordered digestion, is thin and poorly nourished, the
552
MEDICAL RECORD.
[October 17, 1896
skin is dry and irritable, and the general circulation is
poor, a diagnosis of senile endometritis is safe, even if
she denies the existence of any discharge or pelvic
symptoms, and I always insist upon an examination,
especially if her symptoms have resisted treatment
for their relief.
Treatment. — To apply here the same method of
treatment that is employed for endometritis in younger
women will meet with signal failure. The attempt to
dilate the obstructed canal with the steel dilator or
graduated bougies in the usual manner will in many
cases result in rupture. When the disease has pro-
gressed to the stage in which cicatricial bands have
formed, rupture is certain to occur if forcible dilata-
tion is attempted. These bands will not yield, conse-
quently the intervening soft, friable tissue gives way.
The use of the curette in most cases is unwise and un-
necessary. The mucous membrane has already been
destroyed and nothing remains to be removed. Like-
wise the application of caustics and irritants to the
endometrium is most injudicious. Enough injury has
already been done by the acrid secretion and only harm
can result from such harsh measures.
Dilatation of the canal to promote free drainage of
retained secretions is most important, in fact abso-
lutely imperative, for persistent drainage with abso-
lute asepsis of the endometrium is the only manner of
effecting a cure. How drainage is best accomplished
and how maintained, is the main question at issue.
In the early stage, when only a year or two liave
elapsed since the menojjause, and particularly if there
is retroflexion of the uterus, dilatation to rectify the
malposition and careful curettage, followed by appro-
priate after-treatment, are unquestionably the wisest
measures to adopt, but later these are not only useless
but unwise. At this stage dilatation if carefully done
will produce no injury, and the curette may be used
to advantage, but after-treatment to maintain a patu-
lous condition of the canal and an aseptic condition
of the cavity by repeated irrigation must be persis-
tently carried out.
In the beginning the patient's confidence must be
gained, and she must be made to appreciate the fact
that her disease is essentially chronic and dependent
upon the natural changes that the uterus must undergo
at this period; that these changes are progressive and
continuous up to a certain point, and that conse-
quently a cure cannot be accomplished quickly. She
must therefore be made to realize the importance of
keeping herself under observation and under treatment
at gradually increasing intervals until these changes
are completed. This done, we are prepared to under-
take the treatment of the case and can promise not
only speedy relief of her symptoms but a positive cure,
if it has not been too long neglected and malignant
degeneration has not occurred.
In those cases in which the disea.se iias progressed
and forcible dilatation is not permissible, some other
me.ins must be adopted for freeing the canal and
maintaining drainage. For a number of years I have
employed with entire satisfaction in these cases the
negative pole of the galvanic current through conical
electrodes of gradually increasing size. This will
inflict no injury if care is taken to avoid cauterization
or destruction of tissue by using a moderate strength
of current. When the necessary degree of dilatation
is accomplished in this manner, a small clinical
double-current irrigator is inserted, and the cavity is
thoroughly irrigated with a weak solution of lysol
(one-half to one per cent.). The irrigator has an
attachment which permits it to be utilized as an elec-
trode, and it is connected with the negative pole of the
battery and the current (ten to fifteen milliamperes)
turned on while the irrigation is going on, from a half
to one pint of the solution being used each time. Thus,
through the medium of the water, the stimulating effect
of the agent is obtained upon the whole endometrium,
and the cavity can be most effectually cleansed. The
reaction of the current seems to enhance the value of
the lysol solution in removing the sometimes tenacious
secretion which adheres to the surface of the endome-
trium and is not othenvise easily removed. It seems
likewise to neutralize the virulence of the discharge,
which has an acid reaction.
After one or two applications the canal will usually
remain sufticiently patulous to permit the introduction
of the small irrigator without using the dilating elec-
trodes previously, if too long an interval has not inter-
vened. The irrigation should be repeated every two
or three days during the first week or two, and as the
condition improves the interval should be lengthened.
Thus, during the second month once a week will suffice
in some cases and during the third month once in two
weeks. Then the patient should be required to return
for treatment once a month for a few months. Some
cases will improve more rapidly and others will re-
quire even a longer time before a positive cure is
effected.
The surface of the vagina must be cleansed also,
either by means of the irrigator with the lysol solution
or it is wiped out with a pledget of absorbent cotton
wet with the same solution and held in the grasp of
a dressing-forceps. The vaginal surface and vulva as
well are then dusted freely with some bland non-irri-
tating anti.septic powder. For this purpose I have
employed with much satisfaction markasol. a new
preparation, said to be borophenate of bismuth, which
answers the purpose admirably in counteracting the
virulence of the discharge and soothing the inflamed
membrane.
The patient is directed also to use the same powder
in a vaginal douche once or twice a day, dissolving a
teaspoonful in a quart of warm water. If the vulva is
inflamed or excoriated, the surface after it has been
thoroughly washed with the solution and dried is kept
dusted freely with this ]K)wder. Tlie labia are kept
separated with a layer of absorbent cotton, which is re-
moved when it becomes moist.
If the uterus is retroflexed it must be rectified, and,
when possible, a vaginal pessary inserted. In those
cases particularly not long past the menopause, the
displacement can best be overcome by first carefully
dilating and straightening the canal in the manner I
have described elsewhere for overcoming retrodevia-
tions. In some cases, however, the shrinkage and
contraction of the vaginal wall will make impossible
the employment of a pessary to any advantage. In
these cases ventral suspension of the uterus may be
resorted to. I cannot think that a hysterectomy would
be justifiable for this condition, since I have never yet
met a case that did not yield to the plan of treatment
here outlined.
When the Isladder is involved, it must receive atten-
tion also. It should be washed out twice or three
times a week in the beginning with a saturated solu-
tion of boric acid, or, what I very much prefer, mar-
kasol, half a teaspoonful to a quart of warm water,
because it is more soothing and the relief which it
affords is more permanent. For this purpose the
double-current irrigator or a glass catheter may be
employed. It will usually be found that the urethral ■
mucous membrane has undergone a decided change
and has lost its epithelium in places, as shown by the
intensely injected folds which project at the meatus,
resembling very much urethral canmcle. At the en-
trance to the bladder the membrane is hypertrophied
and very hyper.fsthetic, and complete evacuation is
prevented. This retained urine becomes decomposed
and provokes irritation. For this condition I have
found that dilatation of the urethral canal with the
October 17, 1896]
MEDICAL RECORD.
S55
conical dilating-electrodes connected with tlie nega-
tive pole yields the best result. Only a moderate
strength of current (five milliamperes) should be used
for two or three minutes each time the bladder is
washed out. The vesical tenesmus and inflammation
are promptly relieved by this method of treatment, and
the patient will feel well repaid for the inconvenience
it causes at the time.
In some instances the treatment of these cases of
senile endometritis and its complications is tedious
and taxes the patience of both physician and patient.
But if in the beginning she is made to understand the
situation clearly and can be made to appreciate the
fact that improvement and relief of symptoms do not
mean a cure, she can be controlled and kept under
observation until a positive cure is effected, and she
will be amply repaid by the relief it affords. I know
of no gynecological disorder the treatment of which I
undertake with more certainty of success.
108 West Seventy-Third Street.
CHRONIC ENDOMETRITIS.'
By JOSEPH BRETTAUER, M.D.,
ASSISTANT GYNECOLOGIST, MOUNT SINAI HOSPITAL; ASSISTANT Sl'KGEON, NEW
YORK CANCER HOSPITAL.
I OUGHT to apologize for bringing before you a sub-
ject apparently so trite and so often discussed. It is,
however, my firm belief that there are no, or at least
not many, pathological conditions which we meet so
frequently, e.xplain, and consequently treat so differ-
ently, as chronic endometritis. It is this circumstance
which induces me to read this short paper, which is
not meant to solve scientific questions, but simply to
deal with clinical facts.
It has been, and with some observers is still, cus-
tomary to distinguish between cervical and corporeal
endometritis. Although there is normally a vast
difference in the structure of the cervical and corpo-
real epithelial linings, there is very little when they be-
come chronically inflamed; in other words, the process
and results of chronic inflammation are the same in
both parts of the uterus. Furthermore, it is extremely
difficult in most cases to decide to which part the dis-
ease is limited, if such a thing as limitation in a
chronic state of inflammation actually exists. For
these reasons I shall embrace the whole subject as
endometritis, instead of differentiating endometritis
corporis and endocervicitis.
For practical and clinical purposes, I still adhere
to the distinction of simple or catarrhal and infectious
or purulent endometritis; although I quite agree with
a lately advanced opinion, according to which endo-
metritis is always caused by bacteria.
The etiology of catarrhal endometritis may be va-
ried in its factors, but it must be distinctly understood
that there can be no actual endometritis unless patho-
genic bacteria have entered tissues whose resistance to
their invasion has been lowered. Normally, we find
the gates open for the entrance of bacteria to the en-
dometrium; but, unless the vitality of this mucous
membrane has been impaired by disturbances of circu-
lation, their presence is harmless. These circulatory
disturbances consist either in active hyperacmia, as,
for instance, in a fibromatous uterus; or in passive
congestion, as in displacements, stenosis of the ceni-
cal canal, habitual constipation, and in numerous vas-
cular and neurotic conditions. The results of these
vascular disturbances are cedema and hypertrophy,
both of which are increased in proportion to the per-
manence of their existence, and furnish an excellent
culture medium for the producers of the inflammatory
process.
' Read before the Metropolitan Medical Society, May 26, i8y6.
In instances of purulent endometritis, however, we"
are not obliged to seek such a complicated etiology;
for we can usually trace the condition directly to a
previous acute infectious process. This may have'
been general, as an accompaniment of any acute infec-
tious disease (scarlatina, cholera, diphtheria, etc.); or
it may have been local. The local infection may have'
been gonorrhoeic or septic; the latter subsequent to
abortion, puerperium, or instrumental manipulation.
As a matter of interest only, I will add that lately,
in some cases of endometritis, protozoa (amcebae) have
been found, and were supposed to be the cause of the
disease.
Pathologically, we can distinguish two kinds of en-
dometritis, one of which affects mainly the glandular
structure of the endometrium, the other its interstitial
tissue. In the glandular form of endometritis we have,
first, an increase in the epithelial cells, a growth and a
dilatation of the glands — an hypertrophy. If the proc-
ess continues, an actual hyperplasia of the glandular
elements follows, very often at the expense of the in-
terstitial tissue. This hyperplasia may occupy only a
part of the endometrium and form polypoid growths,
or it may involve the entire cavity, the so-called fun-
gous endometritis. If the interstitial connective tis-
sue is the main seat of the morbid process, there is
primarily a round-cell infiltration of a greater or less
degree, depending upon the participation of the cellu-
lar elements alone or the intercellular substance as
well. We always find connective-tissue proliferation
in inflammatory processes of long duration, and this
may lead to an increase in the size of the uterus as
well as to a rarefaction of the glandular structure of
the endometrium. I may add here that in cases of so-
called senile endometritis, which appear during and
after the menopause, in which there is often a total
disappearance of the glandular apparatus, it is more
than likely that the process does not rest on an in-
flammatory basis, but more probably upon a purely
physiological atrophy or upon a general disease of the
blood-vessels.
We find, of course, that the two distinct forms of
endometritis may be blended, or that a mi.xed form
may appear, in which all the histological elements of
the uterus are involved, although not necessarily in
equal measure. In these cases we have the endome-
tritis combined with metritis, a condition which to my
mind is more often the rule than the exception.
Although, commonly, a chronic endometritis seems
to be free from serious results, it may and frequently
does evoke symptoms, after a duration of some time,,
which would point to a much more serious disease
than actually exists.
As in all chronic conditions, we find the symptoms
of chronic endometritis to be local and general.
Among the local symptoms one of the most prominent
is an increased secretion, muco-purulent or purulent,
often with a secondary effect, pruritus of the vulva.
Menorrhagia, metrorrhagia, and dysmenorrhcta, all in
greatly varying degrees of intensity, are the symptoms
which most often cause the patient to seek medical
advice. Sterility or frequent miscarriages are found
to be due to chronic endometritis. Bimanual exami-
nation often discloses an enlarged, flabby uterus; the
introduction of the sound is more painful than usual,
and is easily followed by slight bleeding.
Erosions of the vaginal portion and hypertrophy of
the cervi.x are symptoms which are almost pathogno-
monic of a very long existence of the disease. Among
the group of local symptoms, we must include the ex-
pulsion of parts of the endometrium or of the endome-
trium in its entirety, as it occurs periodically in that
peculiar form of endometritis which we call membra-
nous dysmenorrhcea. In this variety, by the way, an
interstitial inflammatory process unquestionably exists,
554
MEDICAL RECORD.
[October 17, 1896
as described in other forms, with this difference, that
the process is influenced by the menstrual wave and
is localized between the endometrium and the submu-
cous tissue. An intense exudation into both of these
layers is followed by a necrosis and shedding of the
more superficial one.
The general symptoms of a chronic endometritis
vary widely in individual instances, and it must be
noted that they are frequently in their severity entirely
out of proportion to the local conditions. Some of
these manifestations are the logical and natural out-
come of the disease present; others depend on ner-
vous origin — for a sensitive woman, once told that her
sexual apparatus or any part of it is not in normal
state, is apt, as is well known, to imagine pains and
sensations which are far from real. The gastro-intes-
final tract furnishes the most pronounced array of
symptoms in this group. The most frequent manifes-
tations are indigestion, nausea, vomiting, and flatu-
lence, which may produce or be accompanied by
diminished peristalsis. Headaches, more or less per-
sistent, emaciation, and irritability of temper, or phys-
ical depression, not infrequently appear in connection
with endometritis. These latter symptoms it is per-
missible to refer to reflex influences, since the intimate
connection of the sexual organs and the central ner-
vous system is so well known as merely to require
mention. The fact that the gastro-intestinal symp-
toms above mentioned are, in a more intense degree,
typical symptoms of acute septic processes within the
pelvis, makes the supposition more than probable that
in chronic endometritis these symptoms depend also,
to some extent, upon a continuous absorption of toxic
elements into the blood.
The treatment of chronic endometritis at the present
day retains some relics of a bygone therapeutic age;
but the indications and contraindications for every
form of treatment must be clearly set forth. I can
scarcely emphasize too strongly the noli t<vi}^t-re which
should apply to cases based on constitutional condi-
tions occurring in virgins and young married women.
Believe me, the harm resulting from local treatment
in these particular instances far outweighs the benefits
derived. The mechanical irritation at the vulva, the
pain necessarily produced by treatment, and, above all,
the deep psychical eft'ect of such measures upon the
patient, are more pronounced in tiieir bad results than
the good we might possibly be able to do. Should
there be symptoms, however, which clearly indicate
interference — as, for instance, prolonged menorrhagia
or obstinate metrorrhagia, which do not yield to in-
ternal medication — thorough curettage under anaes-
thesia, with the correction of existing retrodisplace-
ments, is the only rational treatment. In other cases
of chronic endometritis, the treatment that has been
advocated is so varying and so diff'erent in its tech-
nique, that I am comix;lled to restrict myself to a few
of the most important.
The methodical irrigation of the uterine cavity
with antiseptic solutions was believed, a few years
ago, to be of great value in the treatment of this dis-
ease. Hut experience has shown that the throwing of
bactericidal agents into the uterus produced no bene-
ficial effect upon tissue already diseased. Although
in the acute stage of endometritis dilatation and irri-
gation are followed by excellent results, this method
has no hold in chronic cases. Another form of
treatment was received with great favor at the
time of its promulgation, but is at present considered
even inferior to the first. This consists in the dilata-
tion and packing of the cavity with iodoform gauze,
to procure drainage. It was found, however, that
only serous fluids escaped through the capillar)- action
of the gauze, but solid substances, such as clots of
fibrin and necrotic tissue, were retained, and not infre-
quently caused alarming complications. Still, in cer-
tain selected cases of endometritis combined with
metritis, the tamponing of the uterus may yield bene-
ficial sequelae, since the gauze, acting as a foreign
body, may cause contraction of the organ, an effect
very much to be desired.
The electrolytic or galvanic treatment of chronic
endometritis was heralded as a panacea for this ail-
ment. It was alleged that finally the treatment for
chronic endometritis had been found. But in its re-
sults it proved no more satisfactory than methods pre-
viously tried and discarded. In cases in which metror-
rhagia is stubborn and the process is limited to the
superficial glandular tissue, some good effects may oc-
casionally be seen from galvanic currents of from one
hundred and fifty to two hundred milliampere strength.
i)Ut, in general, it may be safely said that the electric
treatment of chronic endometritis may be omitted
from our therapeutic resources without loss.
At the present day the most effective treatment of
chronic endometritis consists of two elements — rational
intra-uterine cauterization with chemical agents, and
curettage; and, in some cases, the combination of
both measures. The most important agents used are
the nitrate of silver, the compound tincture of iodine,
the strong mineral acids, and the chloride of zinc.
The purpose of this cauterization is to destroy the
diseased layers of the endometrium and arouse reac-
tionary inflammation, followed by necrosis and final
expulsion of these tissues. The remaining tissues
then take on renewed growth, and normal endome-
trium is usually the ultimate result, or at least the
expected result. The destruction of tissue varies, of
course^ in intensity under the influence of different
reagents.
In the use of these therapeutic measures, one must
always remember the length of time required for each
of the caustics to act, since it is impractical as well as
useless to repeat the cauterization until the effect of
the previous one has disappeared.
After an application of the tincture of iodine, for
instance, it takes from three to four days for the pe-
riod of expulsion to be reached; whereas, the applica-
tion of a stronger solution of chloride of zinc — from
twenty-five to fifty per cent. — requires two to three
weeks to effect a similar change in the endometrium;
but the diseased layers are then affected to a much
higher degree.
My own exix:rience is that in those cases of chronic
endometritis in which there is an increased secretion,
be it muco-purulent or purulent, the chloride of zinc
is an invaluable therapeutic agent. I am accustomed
to use a twenty-five-per-cent. solution applied on an
ordinary applicator twice during the menstrual inter-
val— that is, from twelve to fourteen days apart.
After a very few applications I have found in the ma-
jority of cases a radical change for the better. I be-
lieve that the fear, so often expressed, of causing a
stenosis of the uterine canal by the use of this agent,
is overrated, for I have never seen any such result af-
ter its use in the strength and at the intervals men-
tioned. In no one case do I use this method more
than from four to six times; for, if decided improve-
ment is not then manifested, another plan of treat-
ment, usually curettage followed by cauterization,
is indicated. After quite an extensive experience
with the use of a number of chemical agents in vary-
ing strength, I have reached the conclusion that by the
use of chloride of zinc in a stronger solution (twenty-
five per cent.) I require a smaller number of applica-
tions and accomplish better results more quickly.
In cases of chronic endometritis in which hemor-
rhage is the leading symptom, or in which there are ex-
tensive erosions, an hypertrophied cervix, or deep
lacerations, it is practically useless to begin a course
October 17, 1896]
MEDICAL RECORD.
555
of local treatment before curetting the uterus thor-
oughly and performing the necessary plastic opera-
tions. After these operative measures have been
carried out, and there are still symptoms which show
that a radical cure has not yet been effected, this lat-
ter will be attained by a very few applications of the
chloride of zinc. It is, I think, a mistake to make an
intra-uterine application immediately after curettage,
since the endometrium is filled with blood, partly
fluid, partly clotted, and the caustic never touches
the surface it is supposed to affect.
In conclusion, let me say that since following the
principles that I have briefly attempted to elucidate
here, I have had the satisfaction of attaining good re-
sults, even in that class of cases which formerly re-
sisted all possible measures, and, in fact, seemed
incurable.
45 East Sixtv-Fourth Street.
ERUPTIONS OF THE SKIN PRODUCED BY
THE LOCAL APPLICATION OF ICH-
THYOL.
Bv J. C. McGUIRE, M.D.,
DERMATOLOGIST, GARFIELD HOSPITAL ; PROFESSOR OF DERMATOLOGY, GEORGE-
TOWN UNIVERSITY, WASHINGTON, D. C.
Though it is acknowledged that many drugs when
applied to the integument are capable of producing
eruptions in those peculiarly susceptible to their effects,
the. fact is frequently overlooked or ignored, much to
the discredit of the diagnostician and the discomfort
of the patient.
We not infrequently find that the very remedies used
either locally or internally, for the relief of cutaneous
diseases, are really the chief factors in the causation
and aggravation of these maladies.
Ichthyol, called by Unna sodium sulpho-ichthyolate,
and first recommended to the profession by R. Schro-
ter, is the distillate of a deposit of petrified fish and
marine fossils found in Tyrol and Seefeld.
It has been used extensively as a substitute for sul-
phur to lessen hypera;mia, to cause desquamation of
the epidermis and increased action of the sebaceous
glands; though highly recommended by some derma-
tologists in such diseases as sycosis, acne, psoriasis,
and the dry forms of eczema, it has been vigorously
condemned by others. Piffard, who was the first to
employ it in this country, said he used it as long as he
could afford to, but he at last had to stop it or lose his
patients. G. T. Jackson says that it is an unreliable
preparation and not so good as many old and well-ap-
proved remedies; he found that it aggravated some of
the diseases in which he applied it locally. Unna,
though enthusiastic in regard to its beneficial effects
in certain diseases, declares that when it is applied
to raw surfaces it will produce catarrhal inHammation
with oedema and pain.
I can find only one reference to any unpleasant re-
sult from its local application to the sound skin or in
cutaneous diseases in which the corium is not ex-
posed.
Dr. Morrow in his treatise on drug eruptions does
not refer to it, nor have I seen any reference to it in
the magazines or text-books, with the exception of
Hyde's "Diseases of the Skin," 1893. He says,
quoting Sinclair: "The unpleasant results have been
reported as followirig its apjjlication in only a single
instance. A four-months-old infant sank in a state of
stupor two hours after its head and limbs were smeared
with a salve composed of one part of ichthyol to five
of vaseline."
Considering the infrequency of any deleterious re-
sults from its local use, the report of the following
cases may be of especial interest:
Mrs. C , referred to me by Dr. Cuthbert, re-
ported that she had a scaly eruption of several weeks'
duration on the back of the hands and wrists. Within
forty-eight hours it had grown much worse in ap-
pearance and had caused much itching. On exam-
ination the hand and wrist were found to be swollen
and extremely red. I ordered a sahe containing fifteen
per cent, of ichthyol in lanolin and water to be con-
stantly applied. The next day the parts were more
swollen and exuded serum from many ruptured ves-
icles. The sensation of itching had given place to burn-
ing and pain. The rash had extended over the whole
hand and most of the forearm. I immediately stopped
the ichthyol salve, and substituted lotions and dusting
powders. Within twenty-four hours the parts were look-
ing even more angry and inflamed. An acute vesic-
ular eruption had appeared on the face. Here the
exudation was so excessive that the features were almost
obliterated; the nose and lips were enormously swol-
len, and the eyelids were completely closed. Dr.
Cuthbert then informed me that he too had advised
a mild ichthyol salve two days before I had seen
the patient. A few hours later the symptoms had
grown much worse. Though I was convinced that the
ichthyol had caused the trouble, after the rash was
looking somewhat better the same salve (with the full
knowledge of the patient) was applied to the unaf-
fected hand and wrist, when the same phenomena
occurred within three weeks. The first eruption dis-
appeared, however, and even " the rough itchy con-
dition" of which she first complained was entirely
relieved. In one year there has been no return of the
trouble. She declared that this was the first time she
ever had a rash upon the skin.
Mrs. S , referred to me by Dr. W. \V. Johnston.
A week previously the physician who was then in at-
tendance had applied an ichthyol ointment to her
knee, which she had severely sprained in falling from
a bicycle. She had rubbed the salve above and be-
low the knee and over the calf of the leg. When I
first saw the patient the skin was intensely inflamed
from the middle of the thigh to the ankle, exuding a
great quantity of serum that caused her stocking to
adhere to the leg. The face was very much swollen;
the eyelids were almost closed; there were a few dis-
crete vesicles over the right thigh and leg. The pa-
tient was in a highly nervous hysterical condition,
crying from the intense priu-itus that gave her no rest
night or day. She stated that she had never had an
eruption of any kind on her body previously to
this time, that her skin had been unusually free
from all blemish. The eruption had appeared only
a few hours after applying the salve, at first simply
as a hyperjEmia, followed the same night by a vesicular
eruption and most intense itching. I applied cooling
lotions and dusting powders. There was immediate
improvement in the appearance of the eruption, which
continued until, two weeks after the first appearance
of the rash, there was hardly a sign of it left, but
the pruritus still persisted. Carbolic acid and oil of
peppermint lotion sprayed on the parts, followed by
dusting powder of talc, gave relief, though she still
complains of some pruritus. As there are no eruption
and no scratch marks, this subjective sensation can
be accounted for by the liysterical and nervous con-
dition of the patient, brought about by worry and loss
of sleep.
In both of these cases the eruption was probably
caused by direct contact of the ichthyol, rather than by
absorption through the skin, as the epidermis was un-
broken (especially in the case of Mrs. S ) when
it was applied to the perfectly sound integument.
Though it is usual in all medicinal rashes for the
556
MEDICAL RECORD.
[October 17, 1896
local manifestations to improve 011 the withdrawal of
the drug, in some cases they continue for quite a little
while. A disease of the skin may continue long after
the cause has ceased to act, whether the etiological
factor is local or constitutional.
818 Seventeenth Street,
progress of 33ttetliC(il Science.
Congenital Absence of Kidney. — Ballowitz has
gathered all available recorded cases of congenital
absence of one kidney. They number two hundred
and thirteen, to the exclusion of cases of fused kidney
and of partial atrophy of one kidney. Relative to sex,
this imperfection occurs nearly twice as often in males
as in females, a circumstance attributable in a measure
doubtless to the greater frequency of necropsies on
the former ; relative to age, there were twenty-three in
fcetuses, most of which had some other malformation,
especially imperforate anus; the others were about
evenly distributed up to seventy years of age. All
cases considered, this deficiency is more often on the
left than on the right side, and though the left kidney
is more generally lacking in males than the right, in
females the defect is equally common to both sides.
In form and relation, the solitary kidney was almost
invariably normal but much enlarged, apparently
owing to hyperplasia rather than to hypertrophy. In
many cases there were attendant deformities of the
procreative organs, most constant on the side of the
renal defect, the conducting channels being modified
more than the glandular portions. — Yak Medical
Journal.
Preventive Treatment of Inflamed Breasts. — Dr.
Briiideau points out that galactophoritis plays a great
part in the causation of mammary abscess. The in-
flamed breast may have been infected through the
blood or through the lymphatics, but most frequently
the poison reaches the gland through its excretory
ducts. Mammary abscess is the homologue of the
abscesses in surgical kidney infected through the
ureter. In galactophoritis tlie staphylococcus albus
and aureus are found, but both six;cies exist in healthy
mammary ducts. Infection extends through excoria-
tions of the nipple, through the hand of patient, nurse,
or doctor, fouled with tlie lochia, or, most frequently,
directly from the child, as its mouth is full of microbes,
and coryza or more severe infantile disorders render
its saliva septic. There is also, not unfrequently, in-
flammation of the child's fingers at the roots of its
nails. About the second week the symptoms apjjear —
the well-known earlier signs of inflamed breast. On
pressure of the nipple milk exudes from some of the
ducts, but pus from others. The pus is, of course,
yellower and more tenacious than the milk, but sus-
pected exudations of this kind should be tested by
absorbent wool, which takes up the largest drop of
milk immediately, but cannot absorb pus. That fluid,
when expressed from the duct, lies on the surface of
the wool in the form of a greenish-yellow drop.
Sometimes a drachm or more can be expressed. The
process should be repeated twice or thrice daily, and
the nipple carefully washed afterward with an anti-
septic solution. Tlie child must not be fed from the
inflamed nipple. If the expression of the pus be
neglected abscess will follow. Suckling from an in-
flamed nipple does great harm to the infant. Gastro-
enteritis, pemphigus, and conjunctivitis are undoubt-
edly caused by the ingestion of pus with milk.
Purulent conjunctivitis in infants is a direct cause of
infection of the mother's mammarj' ducts. — British
Medical Jourtial.
Diseases Simulating Tuberculous Coxitis. — In
referring to a case under treatment in w hich hip disease
had been diagnosed, but in which it was entirely absent,
Duplay states {New York Medical limes) that such
mistakes are by no means uncommon, and divides
conditions simulating hip disease, but with the joint
quite unaffected, into two groups — viz., those in which
there is an appreciable lesion more or less in the
neighborhood of the articulation, and those in which no
local lesion e.xists at all. As to the first group, he
mentions inflammatory states of the pelvic bones or
femur, suppuration in the bursa: beneath the glutei,
and neoplasms of pelvic or femoral origin. Such
cases are recognized as not originating in the hip-
joint by the absence of one or other typical symptoms
of the disease. The main point of the lecture, how-
ever, consists in the discussion of the diagnosis of
hysterical hip when there is no local lesion. It oc-
curs naturally most in women ; it often starts suddenly
from some insignificant cause, and may even arise
from imitation. Various deformities arise from mal-
position of the limb, and any of the characteristic
postures may be met with, although flexion with ab-
duction and inward rotation is perhaps the most com-
mon. The great resistance to movement is also a
marked feature, since in tuberculous disease, with time
and patience, one can almost always obtain a certain
amount of mobility, while in the hysterical form noth-
ing is gained thereby. The gait, too, differs in the
two cases: a neurotic patient will allow herself to be
moved out of bed, and can get about without pain by
hopping, though still retaining the deformity; a tuber-
culous subject will not be able to do this. Hysteripal
contraction rarely leads to atrophy of the muscles,
which is so marked a feature of the true joint affec-
tion. P'inally, it may be necessary to ana;sthetize the
patient in order to demonstrate the integrity of the
articulation.
Disseminated Spinal Sclerosis. — Dr. Oppenheim
lays stress upon the importance of various intoxica-
tions as a cause of this disease. In taking the history
of these cases the previous occupations of the patients
should not be overlooked. In twenty-eight of thirty-
six cases treated by the author during the last few-
years, the history was carefully inquired into, and in
eleven out of the twenty-eight the patients had long
been exposed to the influence of such poisons as lead,
copper, zinc, etc. Intoxications rank in the author's
opinion among the most important causes of dissemi-
nated sclerosis. On the other hand, other causes must
not be overlooked. Not a few cases have been known
to follow upon the infective diseases, such as influenza,
malaria, etc. Trauma also plays some part in causing
the disease. It must not be forgotten tiiat occasionally
the first beginnings of the disease may date from child-
hood, and that, therefore, congenital causes mzy exist.
The author relates the case of a painter, aged forty-
eight, who had suffered repeatedly from lead poison-
ing. During life his disease imitated very exactly
disseminated sclerosis, but after death it was found to
be a combined systemic disease of the cord. There
were profound vascular changes both in the cord and
brain, no doubt caused by the lead poisoning. In an
atypical case related by the author there was a one-
sided spastic paralysis, with early and marked meiital
changes. Another case began in a girl aged fourteen,
death occurring from tuberculosis some twenty years
later. The characteristic lesions of disseminated
sclerosis were found. Oppenheim adds some inter-
esting remarks in regard to the tremor, oculo-pupillary
changes, bulbar lesions, etc. The relapses in dissem-
inated sclerosis may often be traced to definite causes,
over-exertion, exposure to cold, trauma, pregnancy, or
parturition. — Bcrlitu v kliuische Woche/ischrift.
October i 7, 1896]
MEDICAL RECORD.
557
Medical Record:
A Wi-ek/y Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, &. 47 East Tenth Street.
New York, October 17, 1896.
THE ERYSIPELAS TOXINS.
One by one our fondest therapeutic hopes seem
doomed to the crushing process, and still that hope
which springs eternal in the physician's bosom rises
above the disappointments of the past, which do not
deter the scientific investigator from another attempt.
The time seems to have arrived for the final verdict in
the case of the curative effects of the toxins of erysip-
elas in the cure of malignant growths. Dr. Coley's
experiments and cases treated have been watched with
an interest which could be called forth only by the de-
sire to find in the toxins a cure for otherwise incurable
conditions. Many times the results seemed so favor-
able that much enthusiasm was elicited. Surpris-
ingly good results were shown, but a close following
up of the cases has resulted again and again in disap-
pointment. Patients looked upon as cured would
sooner or later turn up in the practice of other physi-
cians, or return to report themselves only temporarily
improved.
Some months ago the whole question w-as discussed
in one of the medical societies, and the unanimous
opinion was reached that this method of cure should
no longer be held out to sufferers from cancerous dis-
eases. Subsequently, the New York Surgical Society
took the matter up, and, as a result, the following con-
clusions were presented by Drs. Stimson, Gerster, and
Curtis :
" I. That the danger to the patient from this treat-
ment is great.
"2. Moreover, that the alleged successes are so few
and doubtful in character that the most that can be
fairly alleged for the treatment by toxins is that it may
offer a very slight chance of amelioration.
"3. That valuable time has often been lost in oper-
able cases by postponing operation for the sake of
giving the method of treatment a trial.
" 4. Finally, and most important, that if the method
is to be resorted to at all, it should be confined to the
absolutely inoperable cases."
And now, just as we on this side are beginning to
acknowledge the inadequacy of these injections, they
seem to be coming into favor abroad. Dr. Matague,
of Brussels, as announced in the Medical Record of
August 8th, has treated fourteen cases by the mixed
toxins of erysipelas and the bacillus prodigiosus, with
"one complete cure."' In the others there wasnothini;
very favorable to report. In the case of cure, the di-
agnosis was based wholly upon the clinical signs of
cancer. The growth occurred in the floor of the mouth
of an old man. It is not stated how long after cure
the patient was kept under observation, to see if he
remained cured. In so momentous a question we are
not justified in accepting the diagnosis, in view of the
fact that no histological examination of the tumor was
made. When a malignant growth has advanced to that
point where operative procedures are no longer to be
entertained, then, perhaps, no harm may come from
attempts in any legitimate direction; but to hold out
the hope of cure by this or any other means in condi-
tions which are non-curable cannot be too strongly
condemned.
"N^VUS UNIUS LATERIS."
To a physician who is not a dermatologist, and who
has acquired that elementary knowledge of Latin
which the average practitioner is now usually credited
with, the designation nsvus unius lateris, if it meant
anything at all, would convey the impression of some
kind of a nasvus situated upon or limited to one side
of the body.
In the April number of the Journal 0/ Cutaneous
Diseases, Dr. C. C. Ransom contributes " An Unusual
Case of Nffivus Unius Lateris;" and upon first glance
at the picture of the young girl in nothing but a strik-
ing attitude the inference is drawn that the unusual
feature consists in the naevus unius lateris being in
this case bilateralis. Whether or not this impression
was the one intended to be conveyed does not clearly
appear from the text, w^hich describes warty pigmented
lesions distributed over both sides, affecting one, how-
ever, more than the other. According to von Baren-
sprung, one side only should be affected when this
designation is employed. Turning to the latest edi-
tion of an American skin book at hand — that of Dr.
Jackson — we read that naevus unius lateris '' may be
unilateral and confined to one region, or bilateral
and on several regions."
The writer of the paper, therefore, has authority for
his "bilateral unius lateris eruption;" but in all sin-
cerity we would implore the gentlemen with dermato-
logical proclivities to amend their nomenclature for
the benefit of the outsider. The nerven na;vi of the
Germans, or ichthyosis hystrix, or, in fact, anything,
would be preferable to such a bilateral one-sided name.
A PHYSICIAN ON THE WHEEL.
Until Dr. Gihon gave his opinions on the bicycle and
its riders, at the recent meeting of the Public Health
Association, it was thought that the only medical men
who did not ride were those who lived in mountainous
regions, where the hill climbing was too great, or on
the seaside, where the sand was too deep. When, there-
fore, w'e speak of " Dr. Gihon on the wheel," we do it
in the same sense that we would refere to " Hare on
the Stomach" or " Skinner on Cutaneous Diseases."
We would not imply that he had ever had a closer
connection with this wonderful instrument of progres-
558
MEDICAL RECORD.
[October 17, 1896
sion than arises from the practice of writing about it.
Indeed, we are at a loss to know where, unless upon a
bicycle racetrack, the writer could have gained por-
tions of his knowledge and almost all of the inspira-
tion which enabled him to write of "the gliding
throng" of crouching forms " peering intently and anx-
iously with contracted brows." Now, we rather pride
ourselves in New York upon our erect and manly car-
riage, and every wheelman who has the true interests
of the sport at heart thinks of little else, while out for
an afternoon turn around the now completed Grant
monument, than to keep his brow smooth and his lip
curled, so that no one can suggest the presence of the
so-called bicycle face.
Accidents happen to devotees of the new sport, and
the perineum may come in for a due proportion of re-
sulting injuries; but the alarm the gentleman feels
that the number of genito-urinary specialists now ex-
isting may be far too small for the demands of the
immediate future, because of injury inflicted upon this
region, we believe groundless. In point of fact, those
who confine themselves largely to this branch of sur-
gery find more leisure than ever for their own bicycle
exercise, as Dr. Gihon may convince himself any fine
day he will take a cab and drive up the Boulevard.
PARALYSIS FOLLOWING ANESTHESIA.
The mere possibility of death occurring from the ad-
ministration of an anjesthetic is so appalling to the
mind that it is liable to make one forgetful of certain
other occasional accidents which would be considered
very serious if they were to take place under different
circumstances. Among these lesser and rather rare
but really serious accidents, is that of paralysis of cer-
tain groups of muscles. This paralysis may be cen-
tral or peripheral in origin, temporary or permanent in
duration. It may not occur sufficiently often to attract
the attention of those who only occasionally give an
anaesthetic, and when it does take place the relation of
cause and efi^ect may seem too obscure to excite more
than suspicion.
In a paper read at the recent meeting of the French
Medical Congress, Vautrin related three cases of post-
anaesthetic paralysis — one involving the right deltoid,
biceps, and brachialis anticus; the second involving
the right deltoid and long supinator; the third affect-
ing the face. Only the first had remained permanent.
In two it is stated that chloroform was the anaesthetic
used. The author comments upon the fact that the
paralysis is nearly always of the right brachial plexus,
but it may affect the face or the tongue, and is often
accompanied by ocular trouble — dilatation of the
pupil, amaurosis, etc. It may be observed just after
the patient awakes from an.-Esthesia, or not until hours
or days afterward. Sometimes there is partial loss of
sensation, but this soon passes off. Certain German
writers have designated it chloroform paralysis, but
chloroform is not always the anesthetic employed.
Two forms are to be recognized — one of peripheral, the
other of central origin. The first is the more frequent,
the arm being the part usually affected. Biidinger
attributes it to pressure on the brachial plexus, espe-
cially when the arm is elevated to facilitate operations
on the breast and abdomen. Traction on the arm or
shoulder may produce the same result. But this can-
not be the explanation of some cases in which no such
pressure has been exerted, and for these Vautrin sug-
gests a toxic origin provoked by the anasthetic. The
paralyses of central origin are due to cerebral hemor-
rhages favored by the struggles of the patient during
the period of excitement.
^cius ot the "Smecli.
Mothers and Babies' Hospital.— Dr. J. Carlisle De
Vries has been appointed resident house physician of
the Mothers and Babies' Hospital in connection with
the New York Polyclinic.
Dr. George B. O'Sullivan died on October in!),
at ins home in Brooklyn. He was born in i866. and
was graduated in medicine from the Long Island
College Hospital in 1887.
The Plague in Bombay Between October 2d and
7th ninety-seven cases of the bubonic plague were re-
ported, and since the beginning of the epidemic two
hundred and seventy-six deaths have occurred. A
quarantine against Bombay has been declared at Aden
and at the Egyptian ports.
Academy of Medicine. — In the section on general
medicine, October 20th, there will be a demonstration
upon patients of the phonendoscope. On October
28th, in the section on laryngology, photography of
the larynx will be illustrated by a lantern exhibition
and demonstration of apparatus.
The Flower Hospital Annex. — The new building
erected as an annex to Flower Hospital, at East Sixty-
third Street and the Eastern Boulevard, was occupied
by patients for the first time on October 12th. In it
are three large wards, one of which is for women.
There are also fourteen private rooms.
Physician's Wife Injured in a Bicycle Accident.
— The wife of Dr. Lorenze, practising at 1,658 Lex-
ington Avenue, was severely injured in a collision
with a carriage on October loth, at Bronxdale. The
driver of the colliding vehicle tried to escape, but has
been arrested.
The Bicycle in First Aid to the Injured. — A
suggestion made a year or more ago by the Medical
Record was shown to be of practical utility a few days
ago in a bicycle accident in this city. One of the first
to reach the unconscious wheelman was a mounted
policeman (on his wheel). Acquainting himself with
the serious nature of the case he immediately re-
mounted and sent in an ambulance call from the
nearest box. Before the spectators had time to realize
that any proper steps were being taken, a surgeon with
the red cross of his calling upon his sleeve arrived
upon his bicycle and took charge of the case, while the
ambulance to which he belonged followed with the
lesser speed of horse-power propulsion.
October i 7, 1896]
MEDICAL RECORD.
559
Spanish Losses in Cuba. — It is estimated in Ma-
drid that, since the beginning of the Cuban revolution,
tlie army of occupation has lost nearly fifty thousand
men, of whom by far tlie greater number died from
disease. The total number of patients in the mili-
tary hospitals on one day recently was 9,475, of
whom 1,035 were suffering from yellow fever, 1,331
from malaria, and 520 from wounds.
A New Serum. — This one comes from Bogota,
where Dr. Juan de Dios Carrasquilla has injected kids
and horses with leprous blood and with the serum
from these animals has treated lepers. A report made
to the New York Academy of Medicine shows decided
improvement in the patients, such as return of sensi-
tiveness to skin areas, resorption of tubercles, cicatri-
zation of ulcers, and, more than this, no development
of new lesions in some patients.
The Brooklyn Naval Hospital Secretary Herbert
has adopted the plan submitted in competition by yir.
Smithmeyer, the designer of the Congress librar)-, for
the new ward of the Brooklyn Naval Hospital, and in
a few days will invite proposals for its construction
within the $50,000 appropriated by Congress. The
plans call for a structure of white brick and marble, of
classic lines, designed in accordance with the most
approved modern practice at home and abroad in pub-
lic hospitals.
The Roentgen Rays in Nature. — At the recent
meeting of the British Association for the Advance-
ment of Science, Dr. Dawson Tucker stated that the
ordinary glowworm emits .r-rays which will pass
through solid bodies, even a thin sheet of aluminium.
It is probably not the visible light from the insect
which does this, for Dr. Dawson Tucker in his experi-
ments had a good deal of difficulty in getting the
worms to glow, but he found that even when not visi-
bly glowing they gave off a radiation which affected the
photographic plate.
Prosperity of the Dispensaries. — Private practice
in and about New York is reported to have been unu-
sually quiet during the early fall. Not so in dispen-
sary service. During the month of September 124,081
patients were treated at the outdoor department of Bel-
levue, against 92,434 in September, 1895 — an in-
crease of twenty-five per cent. The factors accounting
for this would seem to be hard times, increase of pov-
erty, and a tendency on the part of the frugal minded
to save on the doctor's bill.
Dr. Hamilton's Conflicting Duties. — In speaking
of the recent order of the marine hospital service,
transferring Dr. Hamilton, the editor of \}ci& Journal of
the American Medical Association, from Chicago to San
Francisco, the Medical Standard says that the transfer
was made in direct violation of the promise of the su-
pervising surgeon-general to Dr. Hamilton that he
should have at least two terms in Chicago, and it is
apparently for personal reasons, rather than for the
good of the service. Dr. Hamilton promptly appealed
to the secretary of the treasury, but the latter has de-
clined to interfere in the matter. The Medical Stand-
ard intimates that personal reasons or jealousy, rather
than the needs of the service, are responsible for the
transfer. The Journal has persistently opposed the
scheme to convert the marine hospital ser\-ice into a
department of public health. Possibly, therefore, it is
thought that the needs or the ambitions of the ser\-ice
would be promoted by the removal of the editor to an-
other sphere of usefulness.
Died in the Doctor's Oflice. — It is always a re-
grettable occurrence for a physician to lose a patient
at his own office. When death results from an anaes-
thetic administered or as a consequence of an opera-
tion performed, the disquieting features are the more
pronounced. In the case of Dr. Bosburg's patient,
who died of apoplexy or heart disease in his physi-
cian's waiting-room on Sunday last, no reflection can
possibly be made upon the doctor, since he was not
at home when the unfortunate accident happened.
Medical assistance was, however, required, not only
for the daughter of the patient, who had accompanied
him and who became hysterical, but the physician's
daughter, having been ill for some time, was pros-
trated by the shock, it is said, and her condition ren-
dered serious.
Tuberculouc Cows Destroyed A report has been
made by Chief Inspector Martin upon the sanitary
condition of all cows within the city limits, and the
condition of the premises where they are kept. Be-
low the Harlem there are one hundred and sixteen
different locations, in which a total of three hundred
and forty-three cows are stabled. Out of one hundred
and fifty-three examinations made with the tuberculin
test, twenty-eight tuberculous cows were found and de-
stroyed. The post-mortem examination confirmed the
test in every single instance. The health of a large
number of persons has been in danger from the milk
supplied from these sources, and it is sincerely to be
desired that the work thus entered upon may be pur-
sued until it becomes no longer possible for so manv
diseased animals to exist at any time, either within
the city's limits or in herds from which the city's milk
supply is drawn.
College of Physicians of Philadelphia At a
stated meeting of the section of otology and larj-n-
gology on October 6th Dr. E. B. Gleason described a
new operation for the correction of deflection of the
nasal septum and exhibited four patients in whom the
procedure had been carried out successfully. Drs. E.
L. Vansant and M. B. Miller reported conjointly a
case of carcinoma of the antrum of Highmore, appar-
ently originating from the alveolus of the upper jaw,
with such extensive recurrence after operation as to
preclude hope of success even from excision of the
entire superior maxilla. Dr. A. W. MacCoy made a
preliminary communication dealing with certain path-
ologic conditions of the fossas of Rosenmiiller and the
Eustachian tubes. Dr. Harrison Allen related the
case of a girl in whom a copious white deposit of
uncertain nature reappeared upon the tonsils after
removal, in the absence of local evidences of irritation
other than pain and of constitutional manifestations.
56o
MEDICAL RECORD.
[October i 7, 1896
Di. E. B. Gleason presented a specimen of cystic
polypus removed from the pharyngeal aspect of the
nasal septum. At a stated meeting of the college on
October 7th Drs. W. J. Taylor and C. VV. Burr reported
conjointly a case of sarcoma of the medulla oblongata
unattended during life with changes in the eye-grounds.
.At a meeting of the section on general surgery on Oc-
tober gth Dr. Randolph Farles demonstated a modified
form of antero-posterior brace for the treatment of
Pott's disease, in which the pressure is diverted from
the spinal column and undesirable pointing of ab-
scesses avoided.
Protest against Senate Bill 1,552. — The Ameri-
can Association of Obstetricians and Gynecologists
assembled in annual session in Richmond, Va., Sep-
tember 22-24, 1896, desires to present to the Con-
gress of the United States a protest against the passage
of Senate bill 1,552.
Whcfeas, The enactment into law of the specified
bill would greatly interfere with and retard the inves-
tigations that are at present being conducted at Wash-
ington by the laboratories connected with the Marine
Hospital, the offices of the surgeon-general of the
United States army and navy, and the bureau of ani-
mal industry of the department of agriculture ; and
Whereas, The results of their investigations have
been of immense importance to the health and w^ealth
of the people of the country ; and
IV/iereas, More brilliant results are promised for
the near future in connection with preventive medi-
cine and the health of men and animals;
Therejore, be it Resolved, That this association pro-
tests against the proposed legislation by Congress
which has for its object the restriction of animal ex-
perimentation in the District of Columbia, and, while
opposing needless cruelty and experiments upon ani-
mals in the public schools, this association considers
that those who are trained in the special line of re-
search necessary for the conduct of the work referred to
are the ones best able to decide upon the advisability
and utility of animal experimentation, and should not
be hindered in the prosecution of their humane work.
Resolved further. That a copy of these resolutions
be sent to the members of the House and Senate of
the United States Congress and also to the President
of the United States.
Schuylkill County (Pa.) Medical Society.— At a
meeting of the Schuylkill County Medical Society,
held at Pott,sville on October 6th, Dr. G. H. Halber-
stadt delivered an address on surgery. Dr. George
Farquhar read a paper on " Chronic Endometritis,"
and Dr. Wendell Reber reported a case of spinal dis-
ease attended with blindness. Dr. Joseph M. Spel-
lissy reported " A Death during the Administration of
Ether," in a case of umbilical hernia operated upon
after symptoms of intestinal obstruction had existed
for five days, and in which not more than one ounce
of the anaesthetic had been most cautiously used. Af-
ter death degenerative changes were found in heart and
kidneys. Drs. J. William White and A. C. Wood read
a joint paper, entitled " Some Recent Cases of Renal
Surgery," detailing twelve cases of various kinds — ab-
scess, tuberculosis, calculus, hydronephrosis— all suc-
cessfully operated on, although death occurred in one
case two years after the operation, as a result of amy-
loid disease from protracted suppuration. Dr. John
B. Roberts reported " A Successful Operation for Cleft
of the Soft and Hard Palates," and exhibited the pa-
tient; and Dr. G. Hudson Makuen described the steps
by which the movements of the tongue were increased
and improvement in speech brought about by manipu-
lation and exercise.
The Seventh Italian Medical Congress will be
held in Rome, on October 20th and subsequent days,
under the presidency of Dr. Baccelli.
The Cholera Epidemic in Egypt during August was
of an unusually fatal type. Cairo returns show that
of 4,816 cases, 4,004 were fatal.
Dr. William Mabon has been invited to the super-
intendency of the Ogdensburg Insane Asylum in place
of Dr. Wise, who was appointed State lunacy commis-
sioner. Dr. Mabon is now superintendent of the Wil-
lard Asylum. Before he went there he was the first
assistant at Utica.
Medical Women in Turkey.— It is stated in The
Hospital that the gentle Sultan of Turkey has forbid-
den women physicians to attend upon his subjects,
and that Dr. Grace Kimball, who had established her-
self with success in Turkey and worked there for four-
teen years, has now returned to London.
" La Revista de Medicina y Cirujia " is the title
of a new journal published in Havana, under the edito-
rial supervision of a committee of physicians. The
first number is dated September loth. The secretary
of the editorial committee is Dr. Jose' A. Presno.
American Dentists Not Wanted in Germany. — .\
dentist was recently arrested and fined in Berlin, for
displaying upon the door of his office a plate describ-
ing him as a doctor of dentistry, with a diploma
granted by an American dental college. The court
held that it was against the law for him to use a for-
eign title in practice in Germany.
Vital Statistics of Newark. — Twenty-five of the
seventy-six deaths reported in Newark during the week
ending October loth, were from infectious diseases.
The number of cases of infectious disease reported
was fifty-two — ten of typhoid fever, eight of scarlet
fever, and thirty-four of diphtheria.
The Health of the Army In the report of the
surgeon-general of the army for the year ended on
June 30th it is stated that the health of the army w^as
better last year than ever before. Dr. Sternberg
writes: "All the rates that are usually considered by
statisticians as throwing light on the physical condi-
tion of a community have been lower than in any pre-
vious year of the recorded history of our army. The
number constantly sick was 33.89 per thousand of
strength, as compared with 34.49 during 1894, and
41.87 as the average annual rate of the preceding ten
years. The mortality rate from all causes was 5.16
per thousand of strength, as compared with 6.69 in
1894 and 7.85 for the preceding decade. The lowest
previous rate was 6.35, in 1889."
October 17, 1896]
MEDICAL RECORD.
561
Bovine Tuberculosis in San Francisco. — It is
stated that nearly fifty per cent, of San Francisco's
dairy cows will have to be slaughtered to stamp out
tuberculosis.
Medical Study in New Zealand. — A bill has been
introduced into the legislature of New Zealand which
will lengthen the course of study necessary for a de-
gree in medicine from three years, as at present re-
quired, to five years.
The Jenner Centenary In Russia, which was post-
poned from May to October, on account of the Tsar's
coronation, has been put off for another month for the
reason that his imperial majesty is out of the country.
It is now hoped that the ruler's movements will per-
mit the celebration to take place on December 3d.
Loss of Life in the Fishing-Fleet. — A summary
of the disasters among Gloucester fishermen for the
year just ended shows that seventy-four lives have
been lost, against an average of ninety-nine for the ■
twenty-two years previous. The number of vessels
lost was thirteen.
Bovine Tuberculosis in New York City — The
board of health is making a thorough inspection of all
milch cows kept within the city limits in order to ex-
terminate tuberculosis. Of three hundred and eight
animals which have been examined by the tuberculin
test fifty-two have been found diseased and have been
killed.
Norristown (Pa.) Insane Hospital. ^ — Dr. Alice
Bennett, after a service of sixteen years as chief of
staflf, resigned her position. The trustees showed
their appreciation of her valuable services by passing
appropriately complimentary resolutions.
Addition to a Hospital. — A new annex to the Sa-
maritan Hospital of Pliiladelphia was opened with
imposing ceremonies on September 26th. Several
addresses were made and a memorial stone was placed
in position. The addition to the hospital has been
erected at a cost of $10,000, collected by subscription.
The new building is three stories high, fifty-eight feet
deep by forty-four feet wide, and will accommodate
twenty-two additional beds. It contains on the ground
floor an accident ward, a bathroom with a cemented
floor and provided with a portable bathtub, a waiting-
room for patients, a kitchen, a drug room, and a ma-
ternity ward; on the second floor a children's ward, a
ward for men and one for women, and a commodious,
well-lighted operating-room; and on the third floor
are quarters for the nurses. A sterilizing plant cost-
ing $500 has been introduced and is capable of ster-
ilizing enough water for all the needs of the hospital.
A training-school for nurses will be organized. The
hospital has been further enriched by the donation by
Mr. P. A. B. Widener of a pair of fine horses for
ambulance purposes. Dr. W. F. Haehnlen is phy-
sician-in-chief to the hospital.
Pathological Society of Philadelphia.— At a stated
meeting of the Pathological Society of Philadelphia,
on October 8th, the following oflicers were elected for
the ensuing year: President, Dr. J. H. Musser; Vice-
Presidents, Drs. John Guitdras, William E. Hughes, F.
A. Packard, C. W. Burr; Secretary, Dr. A. A. Eshner;
Treasurer, Dr. T. S. Westcott; Recorder, Dr. \\". S.
Carter: Curator, Dr. D. Riesman.
Faith Curists Called to Account. — The coroner of
Scranton, Pa., after investigating the death from diph-
theria of a boy who received no other therapeutic
consideration than the prayers of Christian Scientists,
held the boy's father and two other faith curists for
criminal neglect, and the district attorney has issued
warrants for their arrest.
Epidemic Disease in Pennsylvania Typhoid
fever is extremely prevalent in Chester County, al-
though the number of deaths is not yet large. Diph-
theria of a virulent type prevails at Harwood, a small
mining town, two miles west of Hazelton. Hog chol-
era of a fatal character has appeared in Smithfield
Township, Monroe County, and is causing considera-
ble anxiety among the farmers.
Association of Lehigh Valley Railway Surgeons.
— The seventh annual meeting of the Association of
Lehigh Valley Railway Surgeons was held at Bethle-
hem, Pa., on October 6th. Dr. J. G. Zern, of Lehigh-
ton, delivered an address; Dr. Frank D. Dowe, of
Rochester, read a paper on " Untoward Factors in
Traumatic Surgery;" Dr. G. R. Trowbridge, of Buf-
falo, one on the "Treatment of Fractured Clavicle by
Means of the Dowel Pin;" Dr. C. R. P. Fisher, of
Bound Brook, one on "Sprains;" Dr. L. E. Hollister,
of Newark, one on the " Conservative Treatment of the
More Severe Injuries of the Extremities, Particularly
the Joints.''
A Surgeon Disciplined. — The Columbus Academy
of Medicine recently censured one of its members for
violation of the code of ethics in permitting the pub-
lication in a daily paper of the report of an operation
performed by him. The report was accompanied with
a picture of the operator. The charges brought
against the surgeon were three : First, that while con-
ducting an operation at the clinic of the Ohio Medical
University he had permitted a layman to be present
and witness the operation and hear the lecture on the
same; second, that he had revised the manuscript of
the article which was published; and third, that he
had erred in not withholding the article from publica-
tion while it was in his possession. The committee
in charge of the trial found the accused guilty of the
charges as presented, but it is claimed by the sur-
geon's friends that no censure was implied in this
finding. The chief stress was laid upon the fact that
a layman was allowed to be present at the operation.
Responsibility of Hypnotists. — Judge Foute, of
Atlanta, has rendered a decision holding that the
hypnotist is directly responsible for tlie acts of his
subjects. During a performance at a local theatre a
hypnotic subject grabbed a hat belonging to a man in
the audience and bit a piece out of it. The man giv-
ing the exhibition and his business manager declined
to make good the cost of the hat, and the hypnotist
was prosecuted before Judge Foute upon a charge of
malicious mischief. The judge sustained the charge
and bound the defendant over to a higher court.
562
MEDICAL RECORD.
[October 17, 1896
^ocietMi Reports.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON P.EDIATKICS.
Stated Meeting, October 8, i8g6.
Walter Lester Cakk, M.D., Chairman.
Congenital Stenosis of the Pulmonary Valves.—
The evening was devoted to the presentation of cases.
Dr. Henry Koplik said lie liad the rare opportunity of
presenting two cases illustrating the extremes, so far as
the symptoms were concerned, of congenital stenosis
of the pulmonary arteries. The first patient was an
infant, eight months of age. The mother stated that
the labor was a severe one; forceps were used. She
did not see the babe until it was nine weeks old, when
she noticed that when it cried it became blue. The
skin then was of grayish color, and the extremities
even in summer were cool and below the normal tem-
perature. On percussion Dr. Koplik found nothing
abnormal about the heart, but on auscultation he could
hear a distinct rasping murmur over the second inter-
costal space to the left of the sternum, conducted to
the ape.\ and also to the base of the heart. The ends
of the fingers and toes were slightly bulbous. It was
not what was called a blue baby, but only at times
became cyanosed.
The second case was that of a boy, aged sixteen
years, who up to the fourth year was healthy. Then,
after gastro-intestinal disturbance, he became blue and
even in the summer the extremities were cool. At the
present time the boy was markedly blue, the conjunc-
tiva; and lips showed cyanosis, the surface temperature
was below normal, the extremities of the fingers and
toes were bulbous; on exertion he had attacks of great
dyspnoea. There were frequent attacks of headache.
In this case, in addition to the loud murmur over the
second intercostal space to the left of the sternum
there was dilatation of the heart. It was not unlikely
that there was, besides stenosis of the pulmonary
valves, a patent foramen ovale.
The discussion on these cases took place after others
had been presented.
Arthritis Deformans.— Dr. W. L. Stowell pre-
sented a girl, nine years of age, and photographs taken
at different periods, illustrating arthritis deformans.
There was no family history of rheumatism and in
other respects it was negative. The patient's trouble
dated from an illness in the summer of 1893 when she
had fever and chills for two weeks. She then had
much lameness of the feet, and a month later the
joints of the hands and wrists became involved, and
within three months the elbows and knees were swol-
len. She was in a hospital three months, and in the
fall of 1895 was sent to Randall's Island Hospital, at
which time the head was immovable and nearly rested
upon the sternum; the shoulder-joints were semi-
ankylosed; the elbows semi-flexed and enlarged; the
wrists enlarged, tender, and almost motionless; the
metacarpal and carpal joints stiff, the hips fixed, the
knees much enlarged, the ankles thick, tender, and stiff,
and the foot was partly extended. The muscle's were
atrophied. There was no evidence of visceral trouble.
The condition had been stationary lor nearly two
years until some months since, when in addition to
medicinal treatment the nurse began patiently and
systematically to carry out massage and encourage
voluntary movements, including attempts at walking.
The improvement had been striking, but all the joints
were still more or less enlarged and stiff, and the
muscles atrophied. The medicinal treatment had
included from time to time iodide of potassium, wine
of colchicum, cod-liver oil, iron, hypophosphites, and
strychnine, but the improvement was attributed for
the most part to massage, motion, and hot baths.
In a brief review of the literature of arthritis defor-
mans it was stated that Dr. J. G. Mitchell regarded it
as neurotrophic entirely, and Dr. Osier agreed with
him. There was no evidence that gout or rheumatism
predisposed to it.
Progressive Muscular Atrophy. — Dr. Stowell pre-
sented a girl, aged thirteen years, with progressive mus-
cular atrophy, which began, it seemed, after an attack of
diphtheria when she was at the age of five years. The
family history was negative except that one uncle
committed suicide during an attack of melancholia.
About a month after she had had diphtheria the parents
noticed that the patient's face began to get smooth,
lose its folds and expression; later the eyes could not
be closed tightly; she could not whistle; within a
year she would stumble easily; the muscles of the arm
wasted, but the forearm had remained well to the pres-
ent time. All of the muscles of the back and shoul-
ders had wasted greatly. The gluteals were well
developed. The author quoted Sachs to the effect
that the several types of progressive muscular atrophy
— the facial, the scapulo-humeral, and the pseudo-
hypertrophic— were the same disease. Out of forty-
nine autopsies thirty-four showed lesions of the spinal
cord, so that the weight of evidence was in favor of
its being due to a central lesion. The treatment had
been tonic, including iron, strychnine, quinine, and
arsenic, but the disease had progressed constantly.
Progressive Muscular Dystrophy — Dr. Charles
E. Na.mmack presented a man aged twenty-six; family
history negative except that his mother had died of
phthisis. The patient remembered no illness, denied
syphilis, but admitted free use of alcohol before the
commencement of his present trouble. Eight years
ago he began to have sensations in the back as of
over-tire. Seven months later the shoulders began to
diminish, the muscles wasted, and three years later
the muscles about the hip and thighs began to waste
and he lost power to walk. There was no muscular
twitching and no sensory disturbance. The man's
occupation threw some light on his disease, he ha\ ing
been a public contortionist. The disease had ad-
vanced so far as to render him almost helpless.
Progressive Muscular Atrophy. — Dr. Nammack
presented a colored boy, about nine years old, with
commencing muscular atrophy or pseudo-muscular
hypertrophy. Three months ago the mother noticed
that he was disinclined to stand, and about a week
ago he began to stumble and fall easily. The shoul-
der muscles showed greatest atrophy, but those of the
back were also weak, permitting of marked antero-
posterior curve of the spinal column. The thigh and
calf muscles were large, presenting apparently pseudo-
muscular hypertrophy. The neck and arm muscles
also showed wasting.
Arthritic Muscular Atrophy. — Dr. Nammack pre-
sented a third patient, a boy of about thirteen years,
who was said to have had rheumatism three years ago,
affecting the right elbow and shoulder. The atrophy
seemed to have been limited chiefly to the supra-
spinatus and infraspinatus of the one side. It was
an interesting fact that since the mother had begun to
rub the region (with soap linimentj in September the
atrophy had largely disappeared.
Rachitic Muscular Atrophy. — Dr. H. D. Chapin
presented an infant, fifteen months old, which had
been well up to the sixth month, and then it was
noticed that the head seemed too heavy for the body.
It became very irritable, and at times would lie in a
semi-comatose condition. There was flattening of the
occiput, the muscles of the body were very weak, but
seemed not much atrophied. Dr. Chapui thought the
case was one of rachitis, a disease which manifested
October i 7, 1896]
MEDICAL RECORD.
563
itself in various forms, in some instances tlie muscles
being most affected.
Cardiac Disease ; Epistaxis. — Dr. Koplik pre-
sented a girl of about seven years, who at about the
age of two years began to have attacks resembling
rheumatism, with fever and pain in the joints. These
attacks recurred nearly every year. Later she began
to ha\e attacks of very persistent nasal hemorrhage,
recurring at intervals of a week, a month, or several
months. The last hemorrhage threatened life, and
left her nearly e.\sanguinated, but finally ceased of its
own accord. The child was still anamic. Examina-
tion of the heart showed double mitral lesion and di-
latation of the left ventricle, and possibly also of the
right.
Early Enlargement of the Liver. — Dr. Tho.mas S.
SouTHWORTH presented a boy of five years,with enlarge-
ment of the liver, which he attributed to fatty infiltra-
tion. There had been four other children in the same
family, of whom one had died of tuberculous meningitis,
one of gastro-intestin.il fever, one was feeble-minded.
The patient presented had always had a large abdomen,
and when a baby had diarrhcea, was in a condition of
marasmus, and was given brandy. The abdomen con-
tinued to increase in size, which increase at the second
vear was attributed to sarcoma of the kidney; but this
was proven not to exist. Before coming under Dr.
Southworth's observation at the fourth year, the boy
had convulsive seizures, which had been pronounced
epileptic. Under treatment directed more particularly
to the gastro-intestinal tract, the convulsive seizures
had ceased and the patient had improved ; yet during
the past summer he had had occasional attacks of
fever, vomiting, pain in the abdomen, slight jaundice,
sometimes diarrhoea. There was purulent otitis media.
In connection with the etiology of the fatty liver, men-
tion was made of the use of starchy food, as well as of
brandy during infancy.
The Treatment of Cretinism. — Dr. Koplik pre-
sented two patients and reported progress on the treat-
ment of cretinism. The patients were about three
years of age, and had been under treatment over a
year. When first seen the signs of cretinism were
well-marked — dwarfish appearance, protuberant abdo-
men, thick lips, thick tongue, flattened nose, o^dema-
tous eyelids, dull appearance. One patient had ab-
scesses; rectal temperature, 96° F. ; extremities blue;
hemoglobin, twenty-five per cent. The treatment had
been use of thyroid extract. When the patient was
last shov.n, a year ago, the percentage of hx-moglobin
had risen from twenty-five to forty-five, and at present
was seventy-five. In the other case there had been a
similar rise from eighteen per cent. He had been
told by Dr. West that the original dose of thyroid
could not be adhered to as the children grew older;
they should be kept on just as large doses as they could
stand. Notwithstanding there had been marked im-
provement, he thought his patients would become still
brighter under larger doses of the thyroid.
Dr. J. P. West, of Ohio, presented by invitation
photographs of the case of cretinism treated with such
success w ith thyroid, and reported by him in the Ar-
(hivcs of Pediatrics.
Dr. W. p. Northrup congratulated Dr. West on the
success attained in the treatment of his case of cret-
inism. He had himself treated two cases by thyroid,
and was able to bring them up to a certain point of
improvement; but they would return again to their
former condition. He had thought a change of the
proportion of thyroid might help, but the relapses con-
tinued to take place.
Dr. West said that after nine months' treatment
he was able to increase the dose, given twice a day,
to a grain and a half, and within a year the girl grew
eight and one-fourth inches and gained fourteen
pounds. At one time the thyroid was left off three
months, and there was a relapse. He thought it ad-
visable to increase the amount whenever relapse threat-
ened.
Congenital Cyanosis and Cerebral Abscess. — Dis-
cussion of the several cases being in order. Dr.
Northri'p said, with regard to congenital narrowing
of the pulmonary arteries, that two cases of " blue
baby" had appeared at the foundling asylum about tw^o
years ago, and, on turning to Dr. J. Lewis Smith's
book on " The Diseases of Children,'' they concluded
that the lesion must be congenital narrowing of the
pulmonary artery and defect of the septum ventriculo-
rum. In the same book it was stated that manv such
subjects, surviving the second year up to the twenty-fifth
year, died of cerebral abscess. One of the patients
had whooping-cough, and they expected then soon to
confirm the anatomical diagnosis: but the patient sur-
vived, and also passed successfully through an attack of
measles. It was then expected to live indefinitely, but
one day was found blue, delirious, and stupid. They
made the diagnosis of cerebral abscess. Autopsy re-
vealed congenital narrowing of the pulmonary artery,
defective septum ventriculorum, and cerebral abscess.
They expected a similar result in the second case, but
the child was still living. One of the physicians con-
nected with the Presbyterian Hospital in the neigh-
borhood, who was interested in these cases, met a
young man on the street whose face and hands were
blue, and ventured to ask him some questions and re-
ceived the promise of a visit to the hospital, where he
could be examined. He did not, however, come on
the appointed day, but later was brought in delirious
and with symptoms pointing to cerebral abscess.
As in the cases presented this evening, and in Dr.
Xorthrup's, there was a purring thrill at the second
costal cartilage on the left, pointing to the diagnosis
already suspected to exist. Autopsy revealed narrow-
ing of the pulmonary artery, defective septum ventric-
ulorum, and cerebral abscess. Dr. Northrup said two
similar cases had been reported at the recent meeting
of the American Pediatric Society.
Dr. Mary Putnam Jacob: remarked that not all of
these subjects died of cerebral abscess, for she knew of
one ''blue" young man, who at the age of twenty-four
went to Spain for the advantages oiTered by the cli-
mate, and after remaining two years died of the fever
of the country.
L)r. E. I). Fisher regarded the case of the man pre-
sented by Dr. Nanimark as a typical one of progres-
sive muscular atrophy of hereditary type. Such cases
commencing in youth, w^hether of the scapulo-humeral
or other form, were, as a rule, of hereditary taint, and
were quite distinct in their course and in their pathol-
ogy from the progressive muscular atrophy of spinal
type. In the former no lesion was found in the spinal
cord. He had shown this man to classes at the L^ni-
versity Medical College the past two years, and re-
garded the case as typical, but had not been able to
obtain a history of hereditary taint. The subject be-
longed to a family of acrobats, and it was not unlikely
this career had had something to do w'ith his disease.
As long as the muscular atrophy was not complete, there
was always some electrical reaction. In his experience
there was rarely complete reaction of degeneration,
but there might be partial reaction.
Dr. Fisher said, in relation to Dr. Northrup's re-
marks, that he knew no reason why there should have
been abscess of the briin, unless some lesion in the
heart should cause septic abscess.
Dr. Frederick Peterson thought the colored boy
had not pseudo-hypertrophic paralysis, although there
were some of the symptoms of that disease. The gait
was rather a spastic paretic gait, the knee jerks were
much exaggerated, there was ankle clonus — symptoms
564
MEDICAL RECORD.
[October 17, 1896
pointing to a lesion in the pyramidal tracts, probably
somewhere in the cord. Furthermore, there had been
some incontinence of urine and some rigidity of the
neck muscles. There was weakening and wasting of
the muscles of the arm, without loss of power in any
particular muscle. Everything pointed rather to a le-
sion in the cervical cord, yet in the short examination
made he would not pronounce that a final diagnosis.
The statements of Dr. Northrup had interested him
very much. He had never before heard of the fre-
quent connection of abscess of the brain with cyanosis.
The pathological relation would make an interesting
study. As a rule, the differentiation between atrophies
and dystrophies was not difficult. The atrophies were
generally called spinal, the dystrophies were primarily
muscular. In the latter the muscular fibres, as a rule,
underwent degeneration at an early period of life.
The differentiation was made by about four symptoms:
In the spinal form of progressive muscular atrophy
there were atrophy and fibrillary tremor, no heredity,
no hypertrophy, presence of reaction of degeneration.
In dystrophy there was heredity, atrophy with hyper-
trophy, no fibrillary tremor, no reaction of degenera-
tion. As long as any of the muscle remained, it re-
acted in the normal manner. Dr. Peterson had never
seen even partial reaction of degeneration in such
cases.
Dr. J. L. Smith remarked, with regard to cerebral
abscess referred to by the last two speakers, that he
did not remember having attempted to give an ex-
planation of its occurrence. The case of the colored
boy seemed to him one of incipient pseudo-hypertro-
phic paralysis, as stated by Dr. Nammack.
Dr. Dessau mentioned a case of arthritis deformans
of perhaps three years' duration, in a patient of six
years, which had not improved under hydrotherapy,
etc. ; but he would now apply massage, in view of the
success obtained with it by Dr. Stowell.
©tinicaX gcpiirttitent.
UTERINE FIBROID AND PREGNANCY.
Bv KR.A.NK L. BURT. M.D.,
BOSTON, MASS.
Pregnancy and uterine fibroid are associated suffi-
ciently often to occasion little if any comment, and
might call for nothing more than ordinary ability and
good judgment in the way of making a good differen-
tial diagnosis. The following case is of sufficient
importance for record as a surgical case on its own
merits, but is doubly interesting because of a condi-
tion of accompanying pregnancy which is unique from
a surgical and embryological standpoint.
Mrs. T , colored, was brought to me in Septem-
ber, 1895, and history and examination were as fol-
lows : Aged thirty-six ; twice married, covering a pe-
riod of ten years. She had had no children and no
miscarriages, and pregnancy was considered as impos-
sible. A small bunch was developing in the pelvis,
which she first noticed about ten years ago. Its
growth was gradual and constant. She was especially
troubled in the left groin, having considerable bear-
ing-down, which increased to severe pain at the men-
strual period. There w^as at this time very little flow;
Backache was constant and more or less severe. The
bowels were interfered with by pressure. Added to
these symptoms, which gradually became more severe,
were those from frequent inflammatory attacks, which
confined her to bed for two or three weeks at a time
and resulted in the production of adhesions. She had
managed to work, except at these periods. The men-
strual flow, which was always small, began to grow
less in March, 1895, and was still less in April, May,
and June. There was very little in July, and none in
.■\ugust. On June loth she left her home in New
York for Bar Harbor, to fill a position for the summer.
Taken sick late in August, an attempt was made tO'
move her home, but she could not get beyond Boston.
On September 6th, lacking three days of thirteen
weeks since she left home, I operated on her. Her
condition was such that to operate or not to operate
was a serious question, although I considered that she
had a very favorable chance, notwithstanding the fact
that her case had been pronounced inoperable by sev-
eral expert surgeons and had been refused at large hos-
pitals of reputation. I decided to perform abdominal
hysterectomy. The uterus occupied the whole of the
abdomen, extending up under the ribs and pressing
on the chest organs. It was absolutely immovable. I
incised to the umbilicus. I found the growth flattened
(spleen shaped), and strongly adherent over the whole
anterior wall. After breaking down these adhesions,
the top of the tumor was felt as high as the hand could
reach. It was manipulated so as to draw the top
of the growth out from the cavity. Below there was
an extensive adhesion to the omentum, about fifteen
inches in length and supplied by numerous vessels as
large as a pencil. The vessels were tied and adhe-
sions cut away.
After the tumor had been pulled out, the breathing
was greatly relieved. A rubber tube was drawn
around the stump, as low as possible in the pelvis. I
incised the growth just above the tube, and, strangely,
out popped an ovum sac, very small, containing very
little fluid, and, to judge from a macroscopical exam-
ination, it could not be of more than eight weeks' de-
velopment. The stump was treated extra-abdominally
in the usual manner. Loss of blood was little, and the
shock was not great. Recovery was perfect.
It is interesting to ask how it could be that a wo-
man, married twice and for a period of ten years, with
no previous pregnancy, could have become impreg-
nated at this late date and under these conditions.
How was it possible for those unhealthy ovaries to
develop an ovum which could bear fruit.' And
how could an ovum pass through those unhealthy,
adherent tubes, and tlie heavy, dense, large fibroid
growth, so as to deposit itself and pregnancy result.'
The process could not have gone on to any great
length. The foetus would probably have been thrown
oil by pressure, or would have died /// titero, with its
consequences. It was probably removed at about the
right time.
The embryo shows points of great interest, as will
be seen from the report on the examination made by
Prof. J. S. Flagg, as given below :
" September, 1895, Dr. Frank L. Burt, of the Union
General Hospital, Boston, handed me an embryo,
which on the day previous he had removed from an
uterine fibroid of some seventeen pounds' weight. Ex-
amination revealed these facts: Age of embryo,
slightly over twelve weeks. Weight of embryo, with
amnion only (emptied, yet fresh), forty-six grains.
Length of embryo, one and nine-tenth inches. Cho-
rion thin and imperfectly tufted. Development of
foetus uneven, especially in sense organs and all
fissure unions. Amnion perfect, false amnion not
united well to chorion. Placenta not well formed,
and associated tenuity of umbilicus. Whole embryo
showed evidence of deficient nutrition, and in general
appearance was like a fcetus of eight weeks."
The Physicians in Belgium at the beginning of
the year 1S95 numbered J, 965. The proportion of
doctors to population was one in 2,100. In addition
to these there were 2,394 midwives, 1,828 pharmacists,
and 522 veterinarians.
October 17, 1896]
MEDICAL RECORD.
56!
A CASE OF UNILATERAL BRONCHOCELE
WITH MYXCEDEMA.
Hv KKANR D. MERRITT, M.H.,
HROOKL^■N, N. \.
The case tluit I herewith report is of interest because
it differs from any case of either goitre or myxcedema
that has come to my notice.
Mrs. F , aged thirty-eight; born and resided in
Westchester County, N. Y., until five years ago; since
then in Brooklyn. Her history up to the time of the
birth of her first child, which occurred seven years
ago, presents nothing worthy of note. The labor was
a difficult one, requiring the application of forceps.
Two years later she gave birth at term to a still-born
infant. The cause of death I am unable to learn.
Since that time siie has had two miscarriages, believed
in both cases to be at about the fourth month of utero-
gestation.
On March 6th she presented herself for treatment,
complaining of a swelling in the neck, which she
stated had existed since the birth of her first child,
seven years before, and which was increasing in size
so that it was beginning to interfere with her respira-
tion. She complained of violent headaches of almost
daily occurrence, and loss of memory, and stated that
she was fearful lest she was about to lose her reason.
She was extremely nervous; speech was slow and hesi-
tating; expression was dull, the eyes having a waterv
look; the nose and lips were thickened, the face and
ankles cedematous; the skin was very dry and the hair
thin and lustreless.
Upon examination I found a firm mass on the left
side of the neck, extending from near the median line
a distance of about .seven centimetres, and measuring
from above downward about five centimetres, the
lower border extending slightly below the left clavi-
cle, moving with tjie larynx when the act of deglutition
was performed. The skin over it was freely movable.
There was no perceptible abnormality on the right
side of the neck. Heart normal; pulse small, fre-
quency 84; temperature, 97.8° F. Urine normal;
specific gravity, 1.016. Exophthalmos entirely ab-
sent; tongue slightly coated.
In answer to my questions the patient admitted that
she suffered from habitual constipation and drowsi-
ness during the day, with inability to sleep soundly at
night. She did not sweat even when undergoing se-
vere exertion. I prescribed a five-grain tabloid of
thyroid extract, twice daily an hour after eating.
March loth. — The patient has neuralgic pains in
the lower extremities; otherwise her condition reveals
no change.
March i8th. — The bronchocele is greatly reduced
in size; dyspncea is lessened; there have been no
headaches for over a week. The patient sleeps well,
the bowels are open, the expression is improved. She
complains of loss of flesh and spells of dizziness and
weakness. The heart is irritable, the pulse running
up to over 100 at times; there is a pruriginous erup-
tion on the back, chest, and limbs. Temperature,
98.2° l'\; tongue clean; appetite good. Urine con-
tains no alljumin. There is excessive thirst and some
sweating.
The thyroid tabloids were continued, and two min-
ims each of tincture of digitalis and strophanthus
were ordered to be given four limes a day. For the
eruption a mild solution of carbolic acid was given.
March 27th. — A further reduction of the goitre has
occurred; no return of headaches; skin normal; the
eruption has vanished, but the fluttering .sensation in
the region of the heart persists.
April 5th. — The tumor in the neck is scarcely percep-
tible. There has been one slight headache since my
last visit. Enunciation distinct and without hesita-
tion; face full of expression ; eyes clear; cedema com-
pletely gone. Pulse, 92; temperature, 98.8" F.
Urine normal; specific gravity, 1.020. There has
been a loss of over twenty pounds in weight since be-
ginning treatment.
April 20th. — Tumor gone; a flabby tissue feeling
like an empty sac can be indistinctly made out.
There is excessive sweating.
The digitalis and strophanthus were discontinued,
and the thyroid extract was reduced to one five-grain
tabloid a day.
I saw the patient at frequent intervals until June
3d, when all treatment was stopped.
On July 20th the patient returned, stating that she
had remained well until three days before, when the
severe headaches had reappeared. The thyroid gland
had not enlarged, and there were no other symptoms
of a return of her former disease. I ordered one five-
grain tabloid of the thyroid extract daily for two weeks.
At the present writing she is taking the above-men-
tioned dose for two weeks every second month, and
the disease is apparently held entirely in abeyance.
I believe the headaches above noted were premonitory
to the return of other symptoms, which were checked
by prompt recourse to the thyroid extract. Dr. George
R. Murra\-, to whom we owe the introduction of thyroid
feeding in myxcedema, in a paper read before the
British Medical Association, in July, 1895, states as a
result of his experience that '"a relapse might be ex-
pected in about one hundred days after a patient had
given up the dose of the extract.''
An additional interest is given to the case I here
report, in that the patient's mother suffered from a tu-
mor in the neck, presumably thyroid, from the pressure
effect of which she died. I am also informed that a
young woman, living on a farm adjoining the one
on which the subject of this article was born, has a
goitre and has recently become insane, and is at pres-
ent confined in an asylum.
The differentiation of this case of simple goitre from
Graves' disease rests upon the absence of exophthal-
mos; the absence of tachycardia or even irritable
heart until the treatment w-as pushed; the involve-
ment of one lobe only of the thyroid gland ; the pres-
ence of symptoms of myxcedema, due to impairment of
function ; the relief of symptoms by the administration
of thyroid extract.
689 Lafayette A\enue.
RUPTURE OF THE URETHRA.
Bv H. A. GATES, M.U.,
DELHI, N. Y.
I w.AS much interested in the discussion at the meeting
of the Practitioners' Society of New York, April 3d,
of the paper of Dr. R. F. Weir, regarding the treat-
ment of ruptured urethra, as it was my fortune to en-
counter one of those rare cases recently, which I beg
to report.
Mr. B , aged forty-two, fell astride of a wagon
wheel from a hay mow at 9 a.m., September 6th, and
sent for his physician at 3 p.m., because of inability
to void his urine. The latter made inefi'ectual at-
tempts to pass a catheter, and sent for me, but I was
also unable to pass the instrument. These attempts
were followed by a discharge of blood from the mea-
tus; there was extensive swelling of the scrotum and
also of the perineal region, but no lesion of the skin.
I advised and performed perineal section on Sep-
tember 7th, and found extensive extravasation and clot,
and entire severance of the urethra in the posterior
part of the bulbous portion, the ends being at least one
and one-fourth inches apart ; the laceration was very
566
MEDICAL RECORD.
[October 17, 1896
extensive, and it was impossible to locate the poste-
rior portion at first, even after irrigating the tissues.
I, however, resorted to the device of directing an "as-
sistant to press gently, w'ith both open hands, over and
on the fundus of the bladder, when the orifice was lo-
cated by the escape of urine. A soft catheter was
passed into the bladder through the meatus, and fast-
ened. No attempt was made to appro.ximate the di-
vided ends of the urethra at this time, on account of
the extensive injury and extravasation. Afterward
the tissues on either side of both the anterior and
posterior portions of the divided urethra were deeply
caught with silkworm ligature and drawn together.
This procedure brought the ends of the divided ure-
thra well together over a soft catheter, which had been
previously passed through into the bladder.
The perineal wound was kept clean and allowed to
unite by granulation, and the bladder kept washed out
with boric-acid solution and glycerin. When the
wound healed the sound was substituted for the cathe-
ter, and the patient is now entirely well.
It would seem to me that the suprapubic opening is
very seldom required, that repair of the urethra may
be shortened by stitching, but that most of the firm
union comes by granulation long afterward.
A CASE OF CHRONIC APPENDICITIS.
By S. p. PRESTON, M.D.,
LVNCHBfRG, VA.
E. W , male, aged thirty-four; occupation, busi-
ness man. Family history good. As far back as the
patient can remember he has suffered pain in the right
iliac region, especially after increased exertion. On
his remaining quiet, the pain was of a dull, aching
character, and most acute anteriorly above Poupart's
ligament, ranging back toward right lumbar region.
On exertion the pain would become intense or aggra-
vated even by walking, and at times he would be seized
with a paroxysm of the most agonizing pain, lasting
for perhaps half an hour or longer and abruptly end-
ing, followed by sleep; and on his awaking the pain
in its acute character had disappeared, leaving the
dull, aching pain as before, but aggravated. There-
after he would not suffer enough inconvenience to
keep him from his ordinary daily aftairs.
Status prtbsens: The patient is a large, powerfully
built, well-nourished man; complexion dark, at times
bluish. He states that although the pain is much less
than it was at former times, he still suffers consider-
ably; in fact, during his whole life he has never been
absolutely free from it. The appetite is good. The
bowels are extremely constipated at times; the stools
are well colored ; the urine is normal. Physical exami-
nation shows a spot of tenderness three inches above
the middle of Poupart's ligament, two inches within
the right superior spine of the ilium, and a line of ten-
derness extending back to the lumbar region, parallel
with the crest of the ilium and about an inch above it,
and becoming more sensitive at its termination to the
right of the spine. When the patient suffers with the
acute paroxysm, the spot in the iliac region becomes
exquisitely painful. The pain is somewhat relieved by
warm applications, and is especially lessened by flex-
ion of the thigh on the abdomen. Patient states that
during the acute paroxysm, priapism often occurs. In
the past six years the pain has become progressively
better, owing to his having paid better attention to his
health; but he is still annoyed to such an extent as to
seek constant medical advice.
Diagnosis: Chronic catarrhal appendicitis: dilata-
tion of appendix, with formation of stercoliths, and
expulsion of concretions at times into the csecum (as-
indicated by acute seizures, short in duration).
Indications for treatment: An exploratory incision
is advised, with excision of the appendix, if it be
found diseased as supposed.
AN EXCEPTIONAL LAPAROTOMY.
By JAMES E. MOORE, M.D..
MINNEAPOLIS.
In April, 1895, Miss A. M , aged twenty-five,
came under my care at the Northwestern Hospital.
She gave the history of having suffered a criminal
abortion in November, 1894, which was followed by
an abscess to the left of the uterus, which finally
opened near the umbilicus. After many weeks of
suffering the patient got about, with a sinus near the
umbilicus, which discharged both pus and fecal mat-
ter.
When I first saw her she was weak and greatly ema-
ciated. Her appetite was good, but digestion poor.
Diarrhoea was present most of the time. There were
at this time around the umbilicus fi\e openings dis-
charging fecal matter. The abdomen was slightly dis-
tended and yielded tympanitic resonance everywhere
on percussion. The patient was weak, suffering, and
in an altogether pitiable condition, so I concluded to
try to relieve her.
Upon passing probes into the fistula about the um-
bilicus, it was found that all led to one cavity under-
neath. They were thrown into one by an incision
and a cavity was found underneath the umbilicus,
seemingly in the abdominal wall, which ommunicated
with the abdominal cavity by one small opening. I
removed the umbilicus completely to gain better access
to the deeper opening. A probe passed into this
opening seemed to enter the intestine. There was
tympanitic resonance just below, so I made an incision
in the median line, in order to get into the abdominal
cavity and reach the bowel into which the fistula
opened. Very much to my surprise and disgust, gas
and fecal matter appeared in the wound as soon as I
got through the abdominal wall. It seemed certain
that I had opened into adherent intestine; but upon
introducing a finger I found tliat I was in the general
abdominal cavity, and that the tympanitic resonance,
supposed to be due to distended bowels, was due to gas
in this cavity.
I then began with the fistula at the umbilicus, and
laid the abdomen open well down toward the symphy-
sis. After washing a large quantity of fecal matter
from the abdominal cavity, I found that the intestines
were all bound down to the posterior abdominal wall
in a mass, and that by introducing the nozzle of an
irrigator underneath one side of this mass, fecal mat-
ter could be washed from the other side. It was sim-
ply impossible to form any idea as to the locality of
the opening into the bowel, so I introduced .some
iodoform gauze into the wound and left it open.
.\fter a few days the patient began to improve, but the
dressings were filthy in the extreme; so I removed all
of the gauze and ordered the abdominal cavity to be
flushed with warm water twice a day or oftener, if
necessar)'. The patient gradually improved, and the
opening in the bowel closed. The large abdominal
wound closed, the abdomen filled out, and at the end
of three months the woman was in perfect health and
had a very presentable abdomen. I have recently
learned that she is employed in a neighboring city as
a domestic, and that she enjoys good health.
The Offspring of the Corset is what a contempo-
rary calls the obstetrical forceps.
October i 7, 1896]
MEDICAL RECORD.
567
QJovres;i o n d cncc.
OUR LONi:)ON LETTER.
(From our Special Correspondent.^
DEATH OF SIR J. E. ERICHSEN, F.R.S., LL.D., ETC.
BRITISH ASSOCIATION — BANQUET AND SYMPOSIUM TO
SIR JOSEPH LISTER METRIC SYSTEM — EVIDENCE AT
INQUESTS THE LATE DRS. MILLETT AND POWELL.
London, September 25, 1S96.
Sir John E.richskn died on Wednesday (23d). His
name will be familiar to all your readers and his per-
sonality will be remembered by not a few who wel-
comed him to the States in 1873. He was a man of
pleasant presence, courteous in manner, upright in all
his relations — in a word, a gentleman. All who knew
him — and who among us did not? — speak well of him.
He had retired from active practice, but continued to
be a conspicuous figure in professional circles. It
seems a long time since he used to come down to lec-
ture in his faultless attire and new primrose gloves,
which some thought made him the dandy of Univer-
sity College, but his geniality made him a favorite
with most of his pupils. His intimates could see
that he had been breaking for some time. He ad-
mitted that the less he did the better he felt. Occa-
sional attacks of angina pectoris had troubled him of
late and loss of control of some muscles lasting only
a few minutes had also occurred. On the 17th inst.
he retired at night in his usual health, but the ne.xt
morning his valet found him to be unconscious. He
soon recovered consciousness, but aphasia and hemi-
plegia remained. On Tuesday the lungs became en-
gorged, and he died on Wednesday afternoon, the last
illness being thus under a week's duration.
Erichsen's " Science and Art of Surgery" is known
everywhere as the most successful surgical te.\t-book
of this generation. It first appeared in 1853. The
fifth edition was extended into two volumes in 1879,
and it has continued in that form, the tenth edition
being published last year. It has been translated
into German, Spanish, and Italian. The American
issues have been very large.
Besides this tnagnnm opus he wrote a small work on
"Railway Injuries" and one on " Hospitalism," and
contributed to the societies and journals. In his
early days he received the Fothergillian medal of the
Royal Humane Society for his work on " Asphyxia."
He became a member of the College of Surgeons in
1839, ^ fellow in 1845, ^"^^ served all the offices in
due course up to the presidency (1880). So at Uni-
versity College, of which he was an alumnus, he
became professor of surgery and surgeon to the hos-
pital, and held these offices until he resigned. He
was elected president in 1887 and retained this post
until his decease. He was the recipient of honors
from academies, universities, and societies in various
countries and last year was created a baronet.
The British Association continued its sittings at
Liverpool until Tuesday. Besides the proceedings I
have mentioned, there were interesting papers in the
physiological section and a good number of medical
men in this and other sections joined in the discus-
sions.
The chief event was perhaps the splendid banquet
to Sir Joseph Lister given by the medical institutions
of the neighborhood, at which more than three hun-
dred and fifty of his admirers were present. In the
galleries about one hundred nurses occupied seats and
were in uniform. They were highly complimented by
Sir Joseph in returning thanks for the toast of his
health proposed by Dr. Caton and received with en-
thusiasm. There was another large gathering in his
honor at a symposium held on Friday.
In the section of mechanical science Sir Frederick
Bramvvell ridiculed the metric system in a light humor-
ous wa\', and said that in France he found when a sum
was in metres or kilograms the ordinary Frenchman
first worked it out in fractions and then converted
it into decimals. So he held the English system to
be better, as it only required the work to be gone over
once.
The metric system had been ably advocated by Sir
Douglas Fox in his address as president of tliis section.
We are accustomed to curious incidents at inquests
and often have to complain of coroners, but it must
be acknowledged that doctors do not always shine in
these courts. Only on Wednesday the newspapers
reported a case in which a jurj^man remarked in the
midst of his evidence that the doctor seemed " slightly
fogged," and after he left another said he " was at
least a rum 'un." And looking at the answers he
gave, I cannot say the criticism was unjust. Take
this colloquy between coroner and doctor and draw
your own conclusions. " Then you say death was due
to fatty degeneration of the heart?" '" Well — er — not
exactly." ■' Was it due to heart disease then ?" " Not
valvular disease." " Syncope then?" "No, I should
say not." " Well, doctor, tell us the cause. You have
made the post-mortem." " I think the state of the
heart prevented proper circulation." " Then you mean
heart failure?" "Well, yes, but not in the regular
way." " Really, doctor, I do not understand you."
"Well, the heart didn't stop in the manner as if he had
taken poison." " But you don't suggest he had taken
poison?" "Oh, dear! no. I think if he had been
woke up he might be alive now." " \\'ell, shall I be
wrong to certify that he died from heart failure due
to fatty degeneration?" "No, I think that is the real
cause."
Mr. George B. Millett, medical officer of health for
Penzance, died on the 17th inst. He was a well-
known authority on Cornish antiquities, president of
the Penzance Institute, vice-president of the Anti-
quarian and Natural History Society, and honorary
surgeon to the Infirmary.
A sad case comes to me from Ireland. Dr. G. H.
Powell, of Toomevara, was eating an apple, when a
wasp which was in the core stung him on the tongue,
and he died in three hours from the glossitis induced.
He was only thirty-five years of age.
OUR PARIS LETTER.
(From our Special Correspondent.)
BEGINNING OF THE MEDICAL YEAR — LOWEST DEATH
RATE IN PARIS KNOWN SINCE 1879 — DIPHTHERIA
NO LONGER FEARED THE ACADEMY OF MEDICINE-
— THE ACADEMY OF SCIENCES— NEV OTOSTETHO-
SCOPE PROPOSED LAW AGAINST THE CREATION OF
NEW FACULTIES OF MEDICINE, ETC.
Paris, October i, 1896.
It is the beginning of the medical and academic year.
Janitors are sweeping and cleansing laboratories, am-
phitheatres, and libraries; every day brings back from
their vacations one or more professors or some hos-
pital and private-practice celebrity, students are seen
once more in the Quart'er Latin, and professional
Paris is getting into swing again.
We begin the year with a clean bill of health as
regards epidemic and zymotic diseases: that is to say,
the lowest record since the .service of the Statistique
Municipale of the city of Paris has been established,
whicli was in the year 1879. The number of deaths
for the thirty-eighth week of the year is six hundred
and ninety-eight — even in the thirty-fifth week the
mortality was only seven hundred and fifty-three, a
very low figure for that or any time of year. Zymotic
;68
MEDICAL RECORD.
[October i 7, 1896
diseases corrtinue to be rare; for instance, there were
but six deaths for the week just ended instead of
twelve, the average, from typhoid fever: one from
small -pox instead of two, the average; measles three,
instead of six, the average; scarlet fever two, average;
whooping-cough two instead of five, the average. Fi-
nally, diphtheria has caused no deaths in the city of
Paris. There were, it is true, two deaths in the hos-
pitals, but these were of children from the country who
had been brought to Paris to be treated. This total
absence of deaths from diphtheria is remarkable, for
previous to 1893 the average of deaths from this dis-
ease was twenty during the weeks of September and
the number of deaths never went below seven, which
figure it reached in the thirty-sixth week of 1886,
which was regarded as very exceptional. During the
last few years, thanks to the discoveries of modern
science and above all to orrhotherapy, diphtheria has
become much less deadly, and already the thirty-fifth
week of 1895 has passed without a single death attribu-
table to that malady. Whatever may be said for or
against orrhotherapy, these facts are irresistible. It
is now only necessary to detach from the pharynx or
tonsils a small portion of suspected membrane, to
make a bacteriological examination and diagnosis at
the same moment, to inject a few grams of antidiph-
theric serum, and we master one of the most if not the
most dreaded and fata! of all diseases, thus relegating
gargles, washes, applications, caustics, and cataplasm
to the past.
As might be expected so early in the year, there is
very little doing at the Academy of Medicine or at
the Academy of Sciences.
There was a meeting of the Academy of Medicine
on September 2 2d. Professor Debove read a report
on Dr. Clozier's work on "Toxaemia in Cases of Gas-
tro-Enteropathy." Professor Debove maintains, con-
trary to the opinion of the author, that the ner\-ous
complications in cases of gastro-enteropathy are not
due to digestive troubles but to a general neuropathic
condition. Dr. Clozier assumes tliat the stomach and
intestines pathologically alYected manufacture poisons
and that these poisons engender a toxa'mia, which in
turn provokes the appearance of nervous phenomena.
This hypothesis not being justified by the facts
upon which the author bases his opinion, it appears
much more natural, in the reporter's judgment, to sup-
pose that the patients of Dr. Clozier were affected by
divers nervous disturbances, among them disorders of
the intestine, than to admit a production of intestinal
poisons, a toxxmiia, and nervous phenomena depen-
dent upon that toxcemia.
I would note in this connection that, notwithstanding
the opinion of so eminent a physician as Professor
Debove, in the practice of internal medicine many
cases of auto-infection or toxa;mia are met with and
that this auto-infection manifests itself not infre-
quently in the nervous system — usually through irrita-
tion of the sympathetic directly due to the absorption
of toxins or ptomains, for the development and multi-
plication of which the intestines, above all tracts or
organs of the body, are the most fertile ground; and I
am now treating a case of polymorphous eczema of
nervous origin caused by the generation of just such
enteric poison.
Professor Debove was followed by Dr. Bendersky,
of Kiev, who spoke on auscultatory percussion as a
method of delimiting internal organs. This method
consists in percussing lightly the region of a given
organ and that the sound, which cannot be heard at
a distance, may be gathered by the ear, Dr. Bendersky
uses a soft stethoscope like those often employed by
American and English diagnosticians (really a modi-
fication of Flint's double-tubed bell-shaped instru-
ment) ; only Dr. Bendersky's stethoscope has one long
tube of one hundred and forty to one hundred and fifty
centimetres, one end of which is adapted to the base,
the other being fastened to the end of an otoscope.
This is placed against the ear. With his left hand
he steadies the base on the organ and percusses with
his right hand. The sounds or resonance, as the case
may be, are thus brought out verj- clearlv, and may
even be heard through the clothing.
Dr. Bendersky added a few words on gastric mobil-
ity, stating that the diagnosis of gastroptosis was made
when the inferior limit of the stomach passed below
the umbilicus — and that this diagnosis was greatlv
facilitated by the above-mentioned method. Dr. Le-
reboullet read the oration that he delivered at the
grave of Dr. Rochard, recently deceased.
At the Academy of Sciences on the 14th of Septem-
ber Dr. Joachimsthal made a communication upon a
new adaptation of the muscles of the leg after the cure
of clubfoot. He said, in substance, that a patient after
the cure of a clubfoot had recovered the functions of
walking; nevertheless the gastrocnemian muscles pre-
sented a deformity characteristic of diminution in the
extent of movement of those muscles; the gemelli were
considerably reduced in size, and the relief of the upper
calf of the leg was hardly half its normal length. As
regards the protuberant outline of the soleus, that had
disappeared entirely. Dr. Joachimsthal in order to
ascertain whether the nujdification of the muscles was
due to any change in the length of the calcaneuni,
photographed the skeletons of the U\o feet of his
patient by means of the Roentgen rays. These photo-
graphs showed on the abnormal side a marked atrophy
of the calcaneuni, but without change in the length of
that bone as regards the lever of the tibio-tarsal
articulation. Then photographs were made of the two
feet in their positions of flexion and extension. The
second photographs showed plainly what might already
have been deduced from the first, viz. : that the extent
of movement on tlie abnormal side was extremely
limited. It was therefore to this cause that the dimi-
nution in length of the fibres of the gemelli mus-
cles must be attributed. These muscles, however,
had retained their action as flexors of the knee; this
explains their partial con.ser\ation, while the soleus,
having its function abolished by the tibio-tarsal
ankylosis, appeared to have been completely efTaced.
This case is not only a remarkable example of what
the Roentgen rays have done and are doing for sur-
gery, but also of the adaptation of muscles to the
change of their functions in general.
Faculties of medicine are not numerous in P'rance,
there being only six on the official list, these being
part of a composite whole designated as the Univer-
sity of France. And yet M. Deandreis. senator, has
filed in the " bureau" of the senate a proposition that
no new faculty shall be created without the enactment
of a law. The principle of protection as regards med-
ical schools and medical practice in France is. meta-
phorically speaking, a cast-iron one.
OUR BERLIN LETTER.
(From our Special Correspondent.)
THE PSYCHOLOGICAL CONGRESS.
Berlin, October 3, 1896.
At present quiet reigns supreme, for all local medical
meetings have ceased. The International Psychologi-
cal Congress held its third session at Munich a few
days ago. In all about one hundred and fifty medical
papers were presented and read. .Aliout four hundred
and fifty men from all parts of the world participated.
The congress was opened by the president. Profes-
sor Stumpf, of Berlin. He gave a very interesting
review of the scientific work performed by this body
October i 7, 1896]
MEDICAL RECORD.
569
since its first meeting, which took place at Paris in
1889. The work was divided into five different sec-
tions, viz. : I. Anatomy and Physiology of the Brain
and the Senses. II. Normal Psychology. III. Psy-
cho-pathology and Criminal Psychology. IV. Psy-
chology of Sleep, Dreams, and the Hypnotic Condition.
V. Comparative and Pedagogic Psychology.
After the address of welcome was delivered by the
minister of state, the mayor of Munich followed.
Then lastly the rector of the Munich University
spoke. These welcomes were answered by Richet of
France, Baldwin of America, Sedgwick of England,
and Tokowsky of Russia.
Professor Richet then spoke on " Pain." He re-
garded pain as a sensation given to us by nature
which prolongs life. Pain is called forth by any ill-
treatment of the nerves which changes their condition.
Richet expressed the belief that even smell and taste
could cause pain under certain conditions.
Professor Flechsig ne.xt spoke on '" The Associated
Centres of the Human Brain." He did not like to
see the brain divided into lobes, but rather into
"areas" and therewith communicating filaments, or as
he termed them " Leitungsbahnen." The centra for
the senses on the surface of the brain he considers
very small. They form four distinct areas or parts.
In these four areas there are neither motor nor sensory
communications. This paper, which was profusely il-
lustrated by brain specimens, aroused great interest
and created an animated discussion. Dr. Wendensky,
of St. Petersburg, believed he could prove by animal ex-
periments which part of hemisphere of brain was used.
Dr. Patrizi found that music induced a greater blood
supply. Dr. Epstein found that light influences mark-
edly the circulation (vascular ),tlie strongest effect being
produced by red; the weakest was tliat of green light.
Dr. Liszt, of Halle, read a paper on " Medico-Legal
Responsibility." This he believed should be deter-
mined by the age ; so, for e.xample, according to German
law responsibility is not determined below the twelfth
year. He did not believe that a chronic criminal is
to be held absolutely responsible for his deeds. For-
merly all weak-minded people were regarded as crim-
inals. He reconnnended that all habitual criminals
should be put into insane institutions, although he
believed that they should be kept separate and classed
as criminals.
Dr. Lehmann, of Copenhagen, had devoted some
study to the question of " fright," as, for example, its
influence on the pulse, and had found at times perma-
nent conditions caused by this influence.
The " Pathology of Memory" was the subject of the
next paper by Dr.Strumpell, especial attention being de-
voted to traumatism, epileptic attacks, and intoxication.
A most interesting subject was brought out by Dr.
F. C. Mailer, of Munich, in a paper entitled "The
Relation of Suicide to Alcohol." He found tiiat both
the consumption of alcohol and the number of sui-
cides have increased very much lately. In thickly
populated districts, workingmen's towns, the number
of suicides is enormous and the alcoholic consumption
is positively the cause of the suicide, inasmuch as
neurastiienia is caused bv alcohol. It is false to be-
lieve that beer is not det. imental or less so than whis-
key. In countries where wlii-.key is prohibited, f.^'., in
Norway, the number of suicides is surprisingly small.
The author belie\ed that alcohol so completely de-
moralizes the human being that suicide is a sort of
relief to him. He was sorry to see alcohol introduced
into therapeutics, for its ill-effects are far greater than
its benefits. He believed alcohol to be a poison and
thought that physicians should take a decided stand
against it. In fact he believed we should be as care-
ful in prescribing alcohol as we are in prescribing
morphine or digitalis.
An interesting communication was one by Dr. Bon-
jour, of Loussanne, in wiiich he reported the treatment
of warts by suggestion. The author claimed to have
been cured of a wart by suggestion.
Dr. Ebbinghaus read a paper on the necessity of
examining school children to determine their mental
sufficiency or insufficiency.
Along with these papers there was an exhibition of
various apparatus and one of especial value built by
the Berlin Electrical Company for Roentgen illumi-
nation. All the internal viscera, more especially the
heart, stomach, and diaphragm, and the movements
of the latter, could be plainly followed on the fluores-
cent screen.
Professor Strumpf adjourned the congress, which
had lasted four days, until 1900, the next session to
be held at Paris the year of the exhibition.
"THE APPENDICITIS CONTROVERSY."
To THE Editor of the Medical Record.
Sir : As a constant reader of the New York Medical
Record, I have taken a great deal of interest in the
recent discussion carried on in your columns about
the effectiveness of the operation for the removal of
the appendix vermiformis in cases of inflammation of
the appendix. I am, as a section of the Populists call
themselves, a middle-of-the-road man, believing that
while the operation has saved a large proportion of
patients, it has also killed not a few of them — not for
lack of skill in its performance, but for lack of judg-
ment in the selection of cases to be operated on.
Nowadays it is quite the style to belittle the physician
and to elevate the surgeon. I honestly believe that
the mortality arising from operative surgery would be
decreased if the physician were given a little more
consideration. To differentiate between the qualities
which enter into the makeup of the successful physi-
cian or surgeon would take up too much of your space,
even if I were capable of doing it properly; so I will
content myself with detailing a brief and incomplete
history of the following case, which may, perhaps,
serve as an illustration of the point I wish to make.
I was the family physician of the patient, but, as the
history will show, was not responsible in any way for
the treatment.
A telephone message was sent to my office on the
evening of September 15th, asking if I was at home.
The sender of the message was the father of the pa-
tient, who said if I was at home he would take his
son down to my office, as he had been complaining of
stomachache. On being told that I was absent and
would not be home for some hours, he asked that I
call at his house the next morning to see the boy.
The boy, R. H , eleven years of age, had returned
from the country the previous Saturday, September
1 2th, and, as his mother expressed it, "was in the
pink of condition, never looked better in his life."
On Sunday, September 13th, he complained of pains,
supposed to be colicky and attributed to the fact that
he had eaten some muskmelon the previous day. His
mother gave him a dose of rhubarb and castor oil,
w-hich opened his bowels freely, and the pain ceased.
He was up and out during the morning; toward even-
ing the pain returned, but was less violent. He vom-
ited several times during the day. Hot applications
were imperfectly applied, and in the evening he went
to sleep and did not again complain until early on
Monday morning. He kept to his bed Monday (Sep-
tember 14th), resting at intervals and not complaining
of pain. Thus the time passed until Tuesday (Sep-
tember isth) evening, when, the pain having returned
and in a more violent form, the father telephoned to
my office. The parents became alarmed and sum-
570
MEDICAL RECORD.
[October 17, 1896
moned a neighboring physician about nine o'clock that
evening. The doctor remarked that the patient made a
correct diagnosis of his own case, as he placed his hand
over his appendix, pointing out the seat of trouble.
The physician recommended his immediate trans-
mission to the hospital, and removed the appendix and
had his patient resting in bed by 11 p.m. the same
night. The father of the patient told me that the doc-
tor said: "There was no pus found in the appendix,
but it was in a catarrhal condition." The following
day (September i6th) was passed comparatively quiet-
ly, with little rest, occasional vomiting, and more or
less mental excitement, due probably to the ether in-
haled.
I saw him, not in my professional capacity, but as a
friend of the family, on Thursday (September 17th).
I took his pulse very carefully, and found it beating
1 20, thready and dicrotic. To me he seemed dying,
but I learned that the attending physician had ex-
pressed a hopeful opinion of his chances. He de-
clined day by day, his temperature varying from 99'^
to 103° F., ]3ulse from 1:0 to 140, until tiie following
Monday (September 21st), when he died at about 5 a.m.
Now, here was a healthy boy, suffering from appen-
dicitis, who seemed to start for the grave, not rapidly
but gradually, from the moment of operation. At no
time after the operation did there seem a chance for
his recovery. The operation was uncomplicated, as
shown by the rapidity with which it was done. Would
it not be reasonable to infer that the wrong time was
chosen? Might it not be even inferred that without
the operation the patient would have recovered.'
Even with the operation, the chances of recovery would
have been better if it had been delayed for twenty-four
hours, during which time every effort might have been
made to reduce the tendency to general peritonitis by
warm applications effectively applied, by the adminis-
tration of opium, and the consequent rest. In cases like
the above, tiie physician, in my opinion, would be a very
important factor in determining the ultimate fate of
the patient. His training and his powers of observa-
tion are very different from those of the surgeon, who
is always looking for the concrete, while the physician
takes both abstract and concrete into consideration.
Frederick J. Halton, M.D.
Brookly.n, N. Y.
CONGENITAL INFERIOR INCISORS.
■ To THE Editor of the Medical Rkcokd.
Sir: The undersigned was called February 22, 1896,
to Mrs. L who was in her second confinement and
at the eighth month of gestation. TwinsAvere born and
on examination one of them was found to have two
congenital inferior incisors. The teeth were project-
ing probably one-sixteenth of an inch above the gums
but were very loose and movable, and could have been
removed with the fingers. The children were both
small, poorly developed, and rachitic in appearance.
One tooth disappeared at the tenth week and the child
died the twelfth week. This occurred suddenly and
away from home. Tiie physician who was called
found it in convulsions and considered death due to
meningitis. The remaining tooth was removed and
given to me. The case was seen at various times by
a large number of medical students and physicians,
was shown at the April meeting of the Obstetrical
Society of Cincinnati, and the tooth was presented to
the Cincinnati Academy of Medicine. None of the
gentlemen had ever seen a similar case. Margitot,
Schiirig, Pliny, Bartholin, Ballantyne, Vargas, Buist,
Mackenzie, ForchJieimer, Jacobi, and Pierce have
written on the subject.
E. S. McKee, M.D.
Cincinnati, Ohio, October 6, 1896.
MOVABLE EARS IN MAN.
To JHK Edmok of the Medical Rlculu
Sir; I have read with great interest an article in your
issue of September 12, 1896, on "Rudimentary Or-
gans," by Cora H. Flagg, M.D. In reading what the au-
thor says of the external ear, I remembered having seen
two or three people who were able to move voluntarily
their ears. There is a good anecdote of a German
professor of anatomy (of course such things occur only
with German professors) whose son possessed that ex-
ceptional gift. Every year, when the time came, the
professor used to take his son to the class and at the
proper moment said to him: "Now, Charlie, move
your ears for the gentlemen.''
I once knew an old man from Central America
whose ears had a peculiar animal-like form. They
were elongated and pointed above and covered all
over with upward-tending hair of about one inch in
length, forming at the point a brush as we find it on
the ear of the squirrel.
F. Semeleder, M.D.
Cordoba, State of Vera Cki'z, September 28, i8*>6.
•COLLAPSE FROM EXCESSIVE VOMITING."
To the Editor of the Medical Record.
Sir : I was much interested in the article appearing in
the Medical Record of September 26th, by Carlos C.
Booth, M.D., of Youngstown, O., relating the history
of a case entitled "A Case of Collapse from Exces-
sive Vomiting Successfully Treated by Intravenous
Infusion of Saline Solution." He states that he found
his patient, at 5 p.m., July 28, 1896, vomiting large
quantities of fluid, associated with general cramps,
for which he administered a large hypodermic injec-
tion of morphine, and repeated the same large dose at
8 p.m. On the following day, "although he had re-
ceived large hypodermic injections all this time at in-
ter\'als of two or three hours, the vomiting continued."
July 30th, at 9 a.m., he was still vomiting, and from
excessive loss of fluid (?) was rapidly approaching
death. Now the treatment was changed to nitroglyc-
erin and strychnine.
As I look upon the situation, it was the patient's
good fortune when the doctor began the use of the two
last-named drugs and stopped the morphine, as it is
well known that in many the use of morphine produces
vomiting and depresses and weakens the vital forces,
especially in those unaccustomed to its use, and par-
ticularly so when used in " large doses" and repeated
at frequent intervals for a considerable time. I be-
lieve the doctor can congratulate himself, not only
upon the use of the saline solution, but upon the disuse
of the morphine and the substitution in its stead of
nitroglycerin and strychnine. I further believe that
too great caution cannot be exercised in the adminis-
tration of morphine in large and repeated doses, espe-
cially at a time when the patient is sulfering from a
disease that is prostrating in its effect, as collapse may
precipitate the case beyond reaction before we are
aware. In the case to which the article refers, there
was no secretion of urine from July 28th to the 31st.
I believe this condition of suspension of the function
of the kidneys was also largely, if not wholly, due to
the use of the morphine rather than to the disease it-
self. F. L. Santwav, M.D.
Theresa, X. V,
Blood Purifiers and Nerve Tonics. — The chemist
of the Massachusetts board of health has made an
analysis of ten of the most popular nerve tonics and
blood medicines, and has found them to contain from
7.9 to 26.2 per cent, of alcohol.
October 17, 1896]
MEDICAL RECORD.
571
Tuberculous Glands should be removed without
rupture of their envelopes, as otherwise systemic in-
fection is liable to result.
Puerperal Septic Disease. — Dr. G. A. Solovioff,
of Moscow, in discussing tlie treatment of diphtheroid
lesions of the womb and vagina in puerperal cases,
recommends painting the affected areas with iodine
tincture.
Compound Fractures Tyson says the time has
come when all compound fractures should be treated
by uniting the ends of the bone, the wound being thor-
oughly irrigated. Five cases of apparently hopeless
fractures of the ankle-joint are reported by Bach as
giving very good final results.
Epilepsy. — Among the causes of reflex epilepsy may
be mentioned ingrowing toenails and even corns,
scars about the limbs, disorders of the genitalia
(phimosis with adhesions, irritative conditions of the
clitoris and mouth of the vagina), ' pinworms, rectal
disorders, and even defective teeth.
Neoplasms Dr. Wiggin {North Carolina Medical
Jotiriial) says that neoplasms occur with greater fre-
quency in the female than in the male subject. Sta-
tistics show that the breast, next to the uterus, is the
most usual site of these morbid changes — seventeen
per cent, in the latter. Williams found, in a collec-
tion of 13,824 primary neoplasms, 2,397 cases in which
the female breast was affected.
Acute Osteomyelitis of Long Bones. — Dr. Walter
is reported in the Hcvue tie Cliirurgie, December,
1895, as saying that: i. The results of treatment de-
pend on the thoroughness and promptness of opera-
tion. 2. The bone shaft must be freely opened ; thor-
ough curettage, disinfection, and drainage must be
employed. In mild forms bone trepannage with local
and constitutional measures may succeed.
Shock. — In France, for cases of severe shock from
hemorrhage, instead of the intravenous injection of
normal salt solution (six parts salt to one thousand
parts sterilized water), hypodermi injections of Hay-
em's serum are employed. This serum consists of five
grams of sodium chloride, twelve grams of sulphate
of sodium, and one litre of distilled water. This fluid
is -Sterilized by being brought to the boiling point. —
Medical Recorder.
Varicoceles. — Dr. Dardignae {Revue de Chirurgie,
September, 1895) reports eighteen cases of resection
of the scrotum for painful varicoceles. The resection
was bilateral when the varicocele was double or very
large and the scrotal tissues were badly stretched. In
tluee cases the resulting hajmatoma made it necessary
to relieve tension by cutting the stitches, but these
were the only unfortunate events in the series. Most
of the operations were done three to five years ago, and
tiie patients express themselves as perfectly satisfied
with their condition. All have been actively' employed
and some wear no suspensory.
Phlebitis — Dr. White treats phlebitis arising as a
sequela of typhoid fever as follows: He elevates the
limb and keeps it at rest. He applies over the vein
an ointment of equal parts of the ointments of bella-
donna, mercurj', compound iodine, and cosmoline.
He ajjplies a flannel bandage to secure a proper
amount of pressure. As the swelling subsides, cau-
tious massage is applied. Rest is imperative, other-
wise there is danger of embolism and consequent
paralysis.
Osteomyelitis. — Dr. Wyeth says that when osteo-
myelitis is present, it is not necessary to amputate the
whole limb, as has been taught, and many a leg has
been sacrificed that might now be saved. Bones
affected by osteomyelitis can be saved, provided good
drainage is established. In the femur a large opening
just above the knee, in the humerus just above the
elbow, is to be made, and the canal thoroughly curet-
ted from one end to the other, under irrigation with
some powerful antiseptic solution, and a large drain-
age tube inserted, with iodoform gauze stuffed lightly
around it. Antiseptic irrigation has to be made every
day or two, the tube being gradually withdraw'n. This
practice has been attended with invariable success.
Prognosis in Cerebral Hemorrhage.— Dr. Barr, in
a lecture delivered at the Leeds General Infirmary,
concludes as follows: In any case of apoplexy due to
hemorrhage into the hemisphere, if renal disease,
Cheyne-Stokes respiration, or hyperpyrexia, either or
all of them, or two of them, are present, the patient
will almost certainly die. If no one of these is pres-
ent and does not supervene, he will probably recover,
regardless of the degree or duration of insensibility.
Diabetes, chronic alcoholism, typhoid fever, or extreme
anajmia (idiopathic) exert an effect just as fatal as
associated disease of the kidney in hemorrhagic apo-
plexy.
Mammary Growths. — Dr. Rodman closes a paper
on the subject with the following propositions: First,
all mammary growths should be removed at once, for
innocent tumors carried for a long time become a
menace. Second, the complete operation should al-
ways be done in cases of malignant disease. Third,
in nearly every case it is simply impossible to detect
enlarged glands until the axilla is opened. Keen says
that he cannot do so once in ten times. Fourth, the
mortality should be w ith average operators about three
per cent. Fifth, a radical operation should promise
from twenty-five to fifty per cent, of permanent cures,
according to the time when patients apply. Sixth,
when in doubt, operate; never wait for symptoms.- —
Amirican Practitioner and Ncic's, March 7th.
Cerebral Tumors. — Dr. H. G. Brainerd, professor
of diseases of the mind and nervous system, Uni\er-
sity of Southern California, says the symptoms of cer-
ebral tumors are of two kinds, viz. : those of cerebral
irritation; and those arising from involvement of defi-
nite areas, which we call focal symptoms. The classi-
cal symptoms of cerebral irritation are : Pain (exacer-
bations paroxysmal), vertigo, vomiting, convulsions,
slowness of speech, mental hebetude, emaciation, slow
or irregular pulse, and double optic neuritis — all of
which are increased by meningitis or softening, one
or both of which usually accompany tumors. Focal
symptoms varj' with their location, the rapidity and
character of the tumor, and may be either sensory or
motor — which latter may be either convulsive or
paralytic.
Only Once Before. — Dr. Keen, of Philadelphia,
tells a good story of the famous Langenbeck. A pa-
tient was brought in whom he had examined pre-
viously and whose case he had diagnosed as a malig-
nant tumor of the breast. He proceeded to remove the
entire gland in a rapid and very brilliant manner.
While an assistant was dressing the wound. Dr. Lan-
genbeck, in the presence of the class, cut into the tu-
mor to verify his diagnosis. The result was a liberal
discharge of pus. He looked surprised, but with
great composure remarked : " I never did that but once
before in my life." An incision before removing the
breast would have saved the great clinician some hu-
miliation and the woman her mammary gland.
57-
MEDICAL RECORD.
[October 17, 1896
New Wound Dressing. — The Japanese surgeons
during the hite war employed as a dressing for wounds
the ash of rice; the contained carbonate of potassium
making it antiseptic. — Medical Age.
Painful Urination. — Dr. Parker (Kansas Medical
Journal) sa)-s : '"Causes other than gonorrhoea are as
follows: Acrid vaginal secretions, endocervicitis, en-
dometritis, discharges from malignant disease, pus
from a healthy abscess, powerful injections, rough
catheterism, passage of stones, and other causes."
Vulvo-Vaginal Catarrh. — Dr. Randolph ^^■ilson,
of Baltimore, Md., says that in his experience nearly
all cases of \ulvo-vaginal catarrh are of gonorrhoea!
origin; even in children as young as two or three
years this is true, infection occurring through soiled
linen, etc. Dr. Lanphear, of St. Louis, has recorded
one case in a child of eight months, the nurse girl
wiping her infected vulva with the napkin which she
subsequently placed on the baby.
Lacerated Wounds of the Hand. — In cases of se-
vere injury to the fingers by laceration or contusion,
put the entire hand into a very ample soaking-wet
dressing. Do not even trim off a piece of flapping
skin. Incision for drainage is all that is allowable
until healing is very well under way or even quite
. complete. You may then look over the ground and
see whether it is worth while to sacrifice anything.
A half-inch of boneless finger may be of incalculable
value to the possessor. — Cincinnati Lancet and Clinic.
CoUes' Fracture. — The splints should never be al-
lowed to remain more than five or six days at the be-
ginning of treatment, and after that not more than
three days at any one time. It has always been my
practice to remove all dressings on the fifth day and
examine the condition of the arm, using massage and
slight passive motion. After that I remove the splints
and use massage and passive motion every second day
until union is complete, which is from four to five
weeks later, according to the age of the patient. — Dr.
Beattv, Maryland Medical Journal, April, 1896.
Hip-Joint Disease. — In young children the very
beginnings of hip-joint disease are announced by mus-
cular twitchings during sleep; added to this, the sub-
ject is irritable, the secretions are disturbed, the ap-
petite is fictitious, the muscles are flabby and shrunken
away on the affected side, the countenance is pale, and
the signs of illness are very apparent. Soon follows a
little limp in the gait, attended by pains in the knee or
ankle-joint — not often in the hip. These pains are at
first very slight and may escape attention, unless the
medical attendant is very alert. A rise of tempera-
ture will sometimes be noticed in the evening, and it
may be continuous; toward the last of this stage more
or less spasm of the muscles will have supervened. —
Medical Arena.
Indications for Nephrectomy. — Dr. Kuster (Brit-
ish Medical Journal ) restricts this operation to the fol-
lowing conditions: I. Tumors of the kidney. 2. Tu-
berculosis of the kidneys; experience has shown that
renal tuberculosis occurs very often primarily and uni-
laterally; it affects tlie genitals and the lower urinaiy
passages more frequently than some other parts of the
body. Severe persistent catarrh of the urinar\- blad-
der is one of the first symptoms which tuberculosis of
the kidney presents; in cases of this kind nephrectomy
gives excellent results, and complete recovery ensues.
3. Suppurating kidney caused by metastatic processes
and foreign bodies, especially calculi. 4. Renal
h.-emophilia. 5. Movable kidney. 6. Injur}- to the
kidney. 7. Calculous diseases of the kidney. 8.
Uretero-abdominal fistula.
Buried Sutures of Silkworm Gut — Dr. Edebohls
(American Gynecological and Obstetrical Journal, May,
1896) says : " Proof was thus forthcoming, in the course
of time and in the shape of resurrected buried sutures,
that aseptic burial and primary union did not always
end the matter. The aseptically buried silkworm-gut
suture did not always remain as an innocuous and en-
capsulated foreign body in the tissues, but in a pro-
portion of cases — estimated in my experience at
between five and ten per cent, of all sutures thus
aseptically buried at the time of operation — the suture
at a more or less remote period caused suppuration,
and, either with or without extraneous help, found its
way to die surface and was discharged. I have given
up trying to make the cceliotomy incision exactly in
the median line, but, with a number of other operators,
prefer to make it through one of the recti muscles, a
little to one side of the median line. The purpose is
to get bare muscle surfaces on either side of the
wound, which, when brought together by suture, will
help by the strength of their union to make the cica-
trix just that much stronger."
Gauze Dressing. — Dr. Martenson (/<? Medccine
Aloderne, February 22, 1S96J prepares dressings as
follows: Rolls of cheese cloth, about thirty yards, are
placed in jars, and different kinds of gauze are pre-
pared by tlie following solutions:
Carbolized gauze, five per cent. : Colophene, 50
parts; castor oil, 15 parts; carbolic acid, 28 parts;
alcohol, ninety per cent., 207 parts. Three hundred
parts by weight of this mixture to 500 parts of gauze.
The following may be used: Vaseline, 30 parts;
carbolic acid, 28 parts; benzene, 242 parts. Three
hundred parts to 500 parts of gauze.
Thyniolated gauze: Thymol, 10 parts; spirits of
turpentine, 3 parts; paraffin oil, 10 parts; benzene, 200
parts. Equal parts of the solution and of the gauze.
Sublimated gauze: Bichloride of mercury, i^ parts;
chloride of sodium, 1 part; glycerin, 15 parts; dis-
tilled water, 500 parts. Equal parts of this solution
and of gauze.
Iodoform gauze: Iodoform, 20 parts; paraffin oil,
10 parts; ether, 400 parts. The weight ratio is 460
parts to 500 parts. The gauze is allowed to soak for
twelve hours, and is then dried and stored in an anti-
septic air-tight jar.
Hernia. — Dr. Bannister (Kansas Medical Journal')
concludes as follows: i. The radical operation for the
cure of hernia as now practised, especially by the
Bassini and Halstead methods, is in the immense ma-
jority of cases eminently successful. 2. When per-
formed by a competent operator under strict asepsis
on a patient in good general health, the operation is
devoid of danger to life. 3. By operating and secur-
ing a good result, the patient will not only be relieved
of a great affliction, but will be spared the ever-threat-
ening complication of strangulation, with all its dan-
gers. 4. These propositions being true, it is the
duty of the surgeon to advise operation in suitable
cases, that is, in all cases in which the patient is not too
old, or too fat, or in poor general health, whether the
hernia can be retained by a truss or not. In the latter
case, operation is urgently demanded.
Dr. De Garnio, of New ^■ork, sa)s: (i) All reduci-
ble hernias should be operated upon, unless contrain-
dicated by age or condition of the patient. {2) All
omentum found outside the abdomen, or that will pro-
trude under gentle traction, should be removed. (3)
Multiple independent ligatures of good-sized silk,
which surround the vessels alone or small pieces of
fatty tissue, are believed to be safer. (4) The use of
some film-forming substance, as aristol, on the stump,
is believed to protect in a measure from subsequent
adhesions.
October 17, 1S96]
MEDICAL RECORD.
573
Acute Pancreatitis — Dr. Fowler {Brooklyn Mcdkai
Journal, April, 1S96) gives the following diagnostic
points: 1. The location of the primary seat of the
disease in the epigastrium. 2. The suddenness of the
attack, with severe gastric, epigastric, or abdominal
pain, accompanied by great prostration and vomiting.
3. Tenderness in the epigastric region, with tympanites
and a mass recognizable by deep palpation. 4. Ab-
sence of fever, or but moderate fe\er during the first
two or three days of the attack.
Germs in the Vagina — Many of the germs found
in the vagina have no action upon the tissues. The
fact ■■ that micro-organisms are present in great vari-
ety" in the vagina does not endanger the parturient
woman. The bacteria that possess pathological sig-
nificance are mostly anaerobic. They do not enter the
circulation or thrive in the blood, neither are they
absorbed through the vaginal walls. They may be
the source of fetid odors, which reflect upon the cleanli-
ness of the patient. Doederlein has discovered a ba-
cillus which intensifies the acid reaction of the vaginal
secretion, and renders it unfavorable to the multipli-
cation of the streptococcus. — William T. Lusk (before
the section on gynecology of the College of Physicians
of Philadelphia, January 16, 1896).
Division and Immediate Suture of the Left Va-
gus Nerve — Dr. M.ikins {Britis/i Medical Journal,
May 16, 1896), in removing a secondary epithelioma
of the neck, divided the left vagus nerve above the
centre of its cervical portion and sutured it immedi-
ately. The muscles supplied by the recurrent laryn-
geal branch were paralyzed. The qualit}' of the voice
improved rapidly, and two months later it was nearlv
normal. Laryngoscopical examination showed the left
vocal cord fixed near the middle line, and in pho-
nation the right cord moved up to it. Apparently the
adductor fibres partially recovered, but not the ab-
ductors. The operator admitted that the functional
activity of the vagus might have been lowered by long-
continued pressure by the tumors. He thinks it proves
that one vagus can be divided without danger, and
that at least a partial restoration of function is possi-
ble.
Wounds of the Peritoneal Cavity i. A penetrat-
ing wound of the peritoneal cavity is not accompanied
by symptoms commensurate with the extent of the in-
jury. 2. Many fatal lesions may be present, yet give
rise to no marked symptoms. 3. Fatal lesions may ex-
ist, yet shock be wanting. 4. The wound of entrance
should be enlarged, and, if the missile have entered
the abdomen, a section is called fon 5. Operation is
proper soon after the injury, before the peritoneal
membrane has become infected or much blood has
been lost. 6. Flushing the open peritoneal cavity with
hot water or hot normal salt solution is an excellent
stimulant to the heart. 7. The abdominal wound
should be closed when practicable without drauiage.
— Dr. Tiff.\xv, A?nfrioin Journal of the Medical Sci-
ences, May, 1896.
Shock. — I. Inhalation of nitrite of amyl, not alone
while the patient is on the ojjerating-table, but re-
peated afterward at intervals. 2. The hypodermatic
injection of nitroglycerin in large doses; that is to
say, when this drug is indicated at all we must secure
its full effect speedily, and in order to accomplish this
the dose must be such as under ordinary conditions
might be toxic. One-fifteenth to one-twentieth of a
grain, repeated until the effect on the pulse is evident,
should be the rule. 3. Repeated injections of hot
saline solution, given by high enema so that the fluid
will pass into the transverse colon, are most valuable
adjuvants, not only tending to relieve vasomotor
spasm, but also supplying to the circulation the fluid
lost by hemorrhage during the operation. 4. Finally,
hypodermatic injections of strychnine, in the dose of
one-fifteenth of a grain, assist markedly.— Boise.
Brain Tumors — 1. A new growth maybe present
in the brain without causing any general cerebral
symptoms whatsoever. In order to make an early di-
agnosis of a new growth it is well, therefore, to be
guided by the symptoms present rather than by the
absence of other customary symptoms. 2. A cystic
tumor of the brain not of parasitic origin is not so in-
nocent in character as many would believe. 3. The
simple evacuation of such a cyst when found is not
sufficient; if it is surgically possible, the wall and the
surrounding brain tissue should be excised, in order
to prevent a future growth of the malignant elements
left in the wall of the cyst. 4. If the immediate ex-
cision is not possible, it would be advisable to open
the wound a few months later and attempt to excise
the collapsed cyst wall, which is compressed into a
small space by the general cerebral pressure, in the
same way in which an abscess cavity is quicklv oblit-
erated after evacuation. — Drs. Stieglitz, Gerster,
LiLlEXTHAL, American Journal of the Medical Sciences,
May, 1896.
How to Protect the Internal Organs in Gonor-
rhoea.— Dr. Auvard {Arch, dc Tocol. ct de Gynec, June,
1895) advises against the use of the curette in the
course of acute gonorrhcea. Experience has shown
that its use is attended with the danger of extending
the disease to the tubes and ovaries. In spite of the
greatest care, a minute piece of infected glandular tis-
sue may be left behind. The entire surface of the
uterine cavity may be disinfected by and after the
scraping, yet then the mucosa, which acts as a ram-
part against microbic infection, has been destroyed.
The probable entrance of specific pus from the vagina
sets up a uterine gonorrhoea whose type is worse than
the first attack. In order to prevent inflammation of
the tubes and ovaries, complete rest must be enforced.
In gonorrhoeal salpingitis the great danger is sterility.
The uterine cavity is best left alone. The vagina and
cervix should be swabbed with a one-per-cent. solu-
tion of nitrate of silver once or twice a week, and a
solution of bichloride of mercury (i to 1,000) should
be employed twice daily as an injection. In the early
stages of inflammation of the appendages. Dr. Auvard
uses ice topically. When pain is less intense, blis-
ters will be of use. The patient should not get up till
after all the pain has passed oft". Then glycerin
plugs should be applied about three times a week. By
these methods of procedure, employed sufficiently early,
sterility and the need of removal of tubes and ovaries
mav be averted.
Nitroglycerin — It is an excellent stimulant in syn-
cope, in threatening heart failure or collapse from
various causes; in acute lobar pneumonia, used early
enough and boldly enough, it may render venesections
unnecessary, and its skilful use often aids recoveiy
from apparently desperate conditions. It is useful in
chronic interstitial nephritis, in conditions of arterial-
fibrosis and atheroma, in gout and rheumatoid arthri-
tis, and sometimes in anamia, ciilorosis, and the anae-
mia of tuberculosis. In the management of cases of
muscular and valvular disease of the heart it finds a
wide field of usefulness; in dilatation it may- be used
with digitalis; in fatty heart it may be used without
other drug; in cases of mitral lesion it may be con-
joined with digitalis, strophanthus, sparteine, and the
like; in cases of aortic lesion, atropine, strychnine,
and caffeine may be used with it. — Philadelphia Poly-
clinic.
574
MEDICAL RECORD.
[October 17, 1896
imcdicat items.
Contagious Diseases — Weekly Statement Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending October 10, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Smallpox
Antitoxin Collective Investigation (Second),
American Pediatric Society. — To the Profession:
The American Pediatric Society is encouraged to
ask the co-operation of tlie profession in a further col-
lective investigation. Laryngeal diphtheria is be-
lieved to furnish a crucial test for antitoxin; the
present aim is to ascertain: (i) What percentage of
cases of laryngeal diphtheria recover without opera-
tion, under antitoxin treatment. (2) What percentage
of operated cases recover.
The society asks for records of cases of diphtheria
involving the larynx, whether operated or not, occur-
ring in private practice in the United States and Can-
ada, treated with antitoxin. It is expected that cases
occurring this year will probably be treated with
reliable preparations of the serum, will be treated
early, and will be given efficient doses.
In order to secure data which shall make the tables
complete, circulars containing blanks for ten cases
have been printed and are now ready for distribution.
It is desired that physicians shall fill out the circular
as cases occur, not trusting to memory, and shall urge
their friends having similar cases to record them.
Circulars can be had by applying to the committee,
(address below-). Several groups of cases in the first
investigation arrived too late and were lost to the
report. It is desired that circulars as soon as filled
(ten cases) be returned to the committee. The col-
lection of cases must close at the end of March, 1897.
The second report is designed to be a study of cases
occurring between the closing of the first report. May
I, 1896, and the closing of the present collective in-
vestigation, April I, 1897.
For extra circulars (blanks), for returning circulars
(filled), and for further information please address the
chairman of the committee, ^\^ I'. Northrup, M.D., 57
East Seventy-ninth Street, New York, N. Y.
The action of the society upon the first report, (i)
Dosage. For a child over two years old, the dosage
of antitoxin should be in all laryngeal cases with
stenosis, and in all other severe cases, 1,500 to 2,000
units for the first injection, to be repeated in from
eighteen to twenty-four hours if there is no improve-
ment; a third dose after a similar interval if necessary.
For severe cases in children under two years, and for
mild cases over that age, the initial dose should be
1,000 units, to be repeated as above if necessary; a
second dose is not usually required. The dosage
should always be estimated in antitoxin units and not
of the amount of serum.
(2) Quality of antitoxin. The most concentrate
strength of an absolutely reliable preparation.
(3) Time of administration. Antitoxin should be
administered as early as possible on a clinical diag-
nosis, not waiting for a bacteriological culture. How-
ever late the first observation is made, an injection
should be given unless the progress of the case is
favorable and satisfactory.
Syphilitic Reinfection. — According to the conclu-
sions of a paper read at the late congress of dermatol-
ogy in London by Dr. Cotterrell, one attack of syph-
ilis, though generally conferring life-long long immu-
nity, does not always do so, and reinfection, though
rare, is surely possible. The negative evidence pre-
sented by several who spoke was preponderatingly
outweighed by the statements of those who had seen
instances.
A Doctor's Manifold Duties — The following ex-
tract, sa)s Lit France AJedicale, is taken from the
" Memoirs of Marshall Castellane :" The Marchioness
of Talarn is over fifty, but she believes it is absolutely
necessary for the good of her health that she should
have a man beside her at night. Whenever M. de
Talarn is absent she consequently makes her people
sew up M. de Courtivron, one of his relatives, or else
M. de Chavagnac, one of his friends, in a sack, and
has him put into her bed. In the morning she is
careful to summon her attendants, or, at all events, the
chambermaid, in order that they may testify that the
sack has not been unsewn. At present MM. de Cha-
vagnac and de Courtivron both happen to be away at
Madrid, attached to the embassy of M. de Talarn, so
it is M. Boirot, physician of the Ne'ris hydropathic
establishment, who for the moment occupies the post
of honor. I can assure you that this is in no wise a
jest. My secretary is connected with the doctor, who,
positively, is shut up in the sack every night.
The Surgical Corps in the Cuban Army consists
of eighty physicians, distributed among its six differ-
ent corps. The head of the service is Dr. Joaquin
Castillo Duany, surgeon-general, a graduate of an
American university, and formerly attached to the
United States navy, in which capacity he formed part
of the crew that started in the Rodgers relief expedi-
tion to the Jeannette. When the present revolution
broke out he was medical inspector at the Juraque
iron mines. He joined the ranks of the Cubans, to-
gether with Mr. Kilpatrick, one of the managers, and
several of other employees, all Americans. Surgeons
in the Cuban army have no limited time of service,
receive no pay, acquire no fame or rank. These men,
brought up under the refining influences of civiliza-
tion, abandon their practices, their homes, their fami-
lies, and start on a gloomy career of hardship and
danger, with the possibility of being caught by the
Spaniards and shot by the roadside. The surgeons
are all provided with first-class French instruments
and in their operations they always make a lavish and
intelligent use of antiseptics, for in Cuba's burning
climate tetanus and secondary suppuration set in with
astonishing rapidity. Drugs are often hard to obtain,
there being no regular base of supplies. In many
cases in which mercur)', bichloride, iodoform, and car-
bolic acid are unattainable, wounds are sprinkled over
with finely powdered burnt coffee, which proves a
powerful antiseptic. Fevers are often and success-
fully treated, in default of quinine, with a decoction
of the " condeamor" leaves from creeping plants of
valuable febrifuge properties. As alcohol can be had
plentifully at any sugar plantation in a reasonably
pure state, tinctures of many native plants are con-
stantly prepared which have been found effective by pre-
vious trials. Chloroform and ether are things unheard
of in those wildernesses, and nothing illustrates more
graphically the Spartan heroism latent in the Cuban
nature than the unflinching way in which they submit
in full consciousness to the ominous knife. It is not
strange there to see a man light his cigar and look on
coolly while his arm or leg is being amputated, ju.st
as if it were a matter of no concern to him. — Journal
of the American Medical Association.
October 17, 1896]
MEDICAL RECORD.
575
The Total Abstainer's Tipple.— The following
preparations were recently examined by the Massa-
chusetts State board of health, with reference to the
percentage of alcohol contained in them: Ayer's sar-
saparilla, 26.2; Paine's celery compound, 21 ; Hood's
Sarsaparilla, 18.8; Greene's nervura, 17.2.
The Drug Habit. — The American people ha\e
been called a medicine-taking nation. If the quantity
of drugs prescribed by physicians, the masses of pat-
ent medicines, the barrels of so-called home remedies,
such as teas, decoctions, infusions, and other mon-
strosities, swallowed by the American people were
ascertained, collated, arranged, and published in a
book, it would strike the reader duml) with astonish-
ment.— Ulrich.
War Dogs. — In the German military manceuvres of
this year, dogs will be used in the ambulance depart-
ment. At the command "seek," accompanied by a
gesture indicating the direction in which search is to
be made, the trained dog goes oft" to the field, finds the
wounded man, returns with a cap, helmet, or piece of
clothing, brings this to the ambulance men, and then
returns with them to the spot at which the wounded
man lies. — The Phrsician oiul Surgeon.
Every Medical Man should be a member of a med-
ical society. He will never know how great a man he
is till some one praises him in a di,scussion, nor how
small a man till some pompous fellow-member takes
him to task; but all these frictions serve but to round
and smooth a busy life, and no one can do without it
who desires to be a physician in the highest accep-
tancy, and not a man who doctors. — Atlantic Medical
Weekly.
Effect of Occlusion of the Nutrient Vessels of
the Brain in Rabbits. — In some recent experiments
{Arch de Biol.) C. Giltay found that temporary occlu-
sion of the carotid and vertebral arteries in the rabbit
caused, through vasomotor influence, dilatation of the
collateral vessels arising from the subclavian arteries,
recognizable by the augmented pressure in the cephalic
portion of the carotid. The dilatation of the collateral
vessels was sufficient to enable the animal to live after
permanent occlusion of all four cerebral vessels if it
were not brought about too suddenly (two or three
minutes). The experiment was not successful unless
the subclavians were left unoccluded.
False Alarm. — There is a physician in Cleveland
who is pretty sure to stutter when under the stress of
excitement. Some time ago he had occasion to offi-
ciate professionally on an interesting occasion, and
his vocal infirmity was the cause of a funny misappre-
hension. The husljand and prospective father, who,
by the way, had set his heart on a son and heir, was
nervously pacing the library when the doctor entered.
"Well, doctor," cried the husband, forcing a smile,
"is it twins?" "Tr — tr — tr," began the doctor.
"Triplets! Great Caesar!" "Qu — qu — qu — " stam-
mered the doctor. "Quadruplets! Holy smoke!"
" No, no," cried the doctor. " Qu — Qu — quite the
contrary. Tr — tr — try and take it ph — philosophi-
cally. It's just a girl." — Cleveland Plain Dealer.
Longevity and Labor. — An Knglisli report men-
tions thirty-three persons upward of one hundred
years of age alive in Great Britain in the year 1893.
The oldest was a woman, one hundred and sixteen
years old, if the claim was correct, though such cases
are usually to be taken with some discount. One of
the most striking facts regarding these centenarians is
that their lives were those of simplicity and industry.
It is not useful work, but anxiety which kills men.
Overwork of the stomach, liver, or kidneys is vastly
more damaging to a man than overwork of the brain
or muscles, since so long as the stomach is intact,
overworked muscles may be easily repaired; and so
long as the liver and kidneys retain their integrity,
the effects of excessive brain work are easily removed
by the elimination of the resulting poisons from the
body. Many die from overwork, but it is overwork at
the dinner table rather than in the field, workshop, or
counting-room. Hard labor is healthful. The ma-
jority of men, and women also for that matter, are
suffering, not from overwork, but from too light work.
More work is required. It may be more mental activ-
ity or more muscular exercise. Evil results from work
flow not from excessive work, but from a lack of the
proper distribution of w^ork so that every organ and
every faculty receives its own share and not one organ
an excess and another a deficiency. — The Journal 0/
Hygiene.
The Survival of Typhus Fever Typhus fever
has long been the reproach of Liverpool. Though
greatly reduced in its proportions, it still lingers there
in spite of all the eft'orts of the sanitary authorities.
It looks, indeed, as if students of this disease would
soon have no other field for its observation. It is
disappearing in Ireland. Doubtless Glasgow could
still supply a few cases. But in the hospitals of the
Metropolitan Asylums Board of London last year
there were only three cases, all in the Eastern Hos-
pital; all the patients happily recovered. In any
general hospital of London it is a veritable rarity, but
in Liverpool the disease still has a habitation and a
name. There were last year in the city, according to
Dr. Hope's report, one hundred and sixty-two cases,
of which twenty-four died. Even in Liverpool the
increasing rarity of it makes diagnosis difficult, espe-
cially in the dirty and dark conditions under which
the poor in Liverpool live. The first cases, it is said,
usually occur among children. The symptoms are
obscure and the eruption much covered and concealed.
The ages at death of the cases were as follows: from
two to five years, two ; from five to ten years, one ; ten
to fifteen years, one; twenty to thirty years, one;
thirty to forty years, eight; forty to fifty years, eight;
fifty to sixty years, one; and sixty years and upward,
two. — The Lancet.
Crimson Clover Hair Balls in Horses.— The
division of botany of the United States department
of agriculture has recently investigated the cause of
death of horses that have been allowed to feed on
overripe crimson clover (Trifolium incarnatum), a spe-
cies of clover recently introduced from Europe. The
calyx of this clover is densely beset with stiff hairs,
which at maturity become thick-walled, and doubtless,
though not so stated by the department, the cellulose,
constituting the young cell of which the hair is com-
posed, is transformed into lignin, or some other sub-
stance indigestible for the horse. The surface of the
hair is marked by sharp-pointed tubercles bent toward
the apex. Taken into the stomach of the horse, these
hairs form themselves into masses of a spherical shape.
They are arranged with their bases toward the centre
of the ball, this position being facilitated by the
tubercles pointing toward the apex of the hair. When
the balls reach a certain size, apparently in from a
few days to several weeks, they pass into the intes-
tines, where they form obstructions, causing intense
suffering and death in a few hours following the ap-
pearance of the first .symptoms. No bad effects are
observed when the clover is eaten before the seed
matures. The fatal effects have mainly occurred
when the plants were allowed to fully ripen and the
straw and refuse, after threshing, had been fed to the
horses. — Pittsburg Medical Revieio.
;76
MEDICAL RECORD.
[October 17, 1896
Teacher :' Name the most important canal in Amer-
ica. Bright Youth: The alimentary canal. — Kansas
City Mcilical Record.
The Hair of the Dog The natives of Bushman-
land, in South Africa, swallow the poison from the
glands of freshly killed snakes to obtain immunity
from snake bite. — North West Lancet.
Roentgen-Ray Dermatoses. — iJr. Marcuse, of Ber-
lin, has obseiTed a peculiar brownish-red discolor-
ation of the skin after exposure to the .v-rays, fol-
lowed by desquamation and falling of the hair, as in
alopecia areata. — Lancet.
Management of Disease in Infancy. — No matter
how strongly we may be convinced of the value of
any drugs or combination of drugs, if they continue
to disturb the stomach they are worse than useless.
The use of all drugs is of very minor importance as
compared with dietetic and hygienic treatment. In
the management of any single (acute) case the im-
portant points are thorough evacuation of the stomach
and bowels, and then rest to these organs again for
from twelve to twenty-four hours. No patients do
worse than those whose mothers cannot appreciate
the value of starvation and insist upon giving milk in
violation of the rules laid down. — Dr. L. Emmet
Holt.
A Certain Doctor had occasion, when only a be-
ginner in the medical profession, to attend a trial as
a witness. Counsel, in cross-e.xamining the young
M.D., made several sarcastic remarks, doubting the
ability of so young a man to understand his business.
''Do you know the symptoms of concussion of the
brain?" asked the learned counsel. ''I do," replied
the doctor. " Well," continued the attorney, " suppose
my learned friend, Mr. Bagwig, and myself were to
bang our heads together, should we get concussion of
the brain?" "Your learned friend, Mr. Bagwig,
might," said the doctor quietly. — Argofiaut.
The Goat and Sheep Will Not Cross.~-Ch. Cor-
nevin stated before the French Academy of Science,
August 3d, that certain biologists admitted that the
sheep and goat were capable of cross-breeding, and
that Gay in his writings had accepted this as the ori-
gin of the wool-producing animal of Chili called the
chabin. Cornevin, however, found that while the
male goat copulated freely with ewes, yet there was no
offspring, and the same observation had been made
during experiments instituted at the school of agri-
culture of Santiago. Further, it was shown at this
school that the sheep and the chabin crossed freely,
proving that the latter was only a race of sheep, as
was further attested by its anatomy, which resembled
that of the sheep and differed from that of the goat.
Graveyard Soil Dr. J. B. Young {Journal of the
Royal Microscopical Society) writes that the soil of gra\e-
yards contains, as a rule, more bacteria than virgin soil,
the difference being most marked in the deeper layers,
although the number of bacteria is not so great as one
might expect. The bacteria are not most numerous
immediately surrounding the coffin, but at some dis-
tance above, while at a short distance below the coffin
there is a marked diminution in the number. Lique-
fying bacteria are abundant in the soil in the imme-
diate vicinity of the coffins. Burial has little if any
effect in increasing the organic matter in the upper
reaches of the soil, whereas it has a very marked effect
on the layers containing the coffin, i.e., at depths
greater than four feet from the surface. The organic
nitrogen and carbon in graveyard soil are by no means
so great in amount as is commonly supposed.
Nostrum Selling in France According to the
Paris Journal de Medecine, the tribunal of the Seine
has decided a case against certain parties named
Hirschfield, Bryant, Guillon, and Picard, who opened
a store on the Boulevard Poissonifere, where they sold
a " Le Tueur de Microbes Radam," or Radam's Mi-
crobe-Killer— a watery solution of sulphuric and sul-
phurous acids. The courts held that this was illegal
practice of pharmacy and medicine. Each defendant
was fined Si 00 and expenses under the criminal code,
and under the civil code were compelled to pay the
Seine Society of Pharmacy $200, with damages and
interest. This finding must be published at their ex-
pense in two daily papers. The nostrum shop of
Radam's wonderful American germ-slayer was ordered
closed. Alas, that such a great discover}' should be
shutout! It is to be feared that American nostrum
dealers will find fatal opposition in France.
While the MEDICAL Recoru is pleased to receive all new publi-
cations luhich may be sent to it, and an acknowledgment ivill be
promptly made of their receipt under this heading, it must be ipitk
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it which in the judgment of its editor -anti not be
of interest to its readers.
A System of Sirgerv by V.akiols Authors. Edited by
Frederick Treves, K.K.C.S. Volume II. Svo, I,120 pages.
Illustrated. Lea Brothers & Co., Philadelphia, I'a.
Foods, Their Composition a.nd A.valysis. By Alexander
Wynter Blytli. Fourth Edition. Svo, 735 pages. Illustrated.
D. Van Nostrand Company, New York. Price, $7.50.
Tra.nsactigns of the Medical Society of the Sta 1 v.
OF Pennsylvania. Forty-sixth annual session. Volume XXVII.
Svo, 499 pages.
Veterinary Homceopatuy in its Application to the
Horse. By John Sutcliff Hurndall. Svo, 343 pages. Boericke
& Tafel, Philadelphia. Pa. Price, §2.18.
Royal Infirmary Cliniques. By Ale.\ander James, M.l).
Svo, 167 pages. Oliver & Boyd, Edinburgh.
A Text-Book for Training-Schools for Nurses. By
P. M. Wise, M.D. In two volumes. Svo. Volume I.. 247
pages; Volume II., 327 pages. Illustrated. (!. P. Putnam's
Sons, New York.
\V.\ter and Water Supplies. By John C. Thresh.
i2mo, 438 pages. Illustrated. W. B. Saunders, Philadel-
phia, Pa. Price, 32.25.
A Text-Book of Histology, Descriptive and Practi-
cal, FOR THE Use of Students. By .Arthur Clarkson. Svo,
554 psgss. Illustrated. W. B. Saunders, Philadelphia, Pa.
Price, $6.00.
De CiHKUKiaic, Cliniqle et Operatoire. By various
authors. Edited by Dr. A. le Dentu and Dr. Pierre Delbet.
Vol. I., Svo, S23 pages. Illustrated. J. B. Bailliire et Fils,
Paris.
.\N .\merican Text-Book of Physiology. By various
authors. Edited by Dr. William H. Howell. Svo, 1,052
pages. Illustrated. W. B. Saunders, Philadelphia, Pa. Price,
cloth, $6. 00; half-morocco, $7.00; sheep, S7.00.
A Vest-Pocket Medical Dictionary. By Albert G. Buck,
M.D. 32mo, 529 pages. W'm. Wood & Co., New York.
Price, $1.00.
Functional Disorders of the Nervous Svste.m in
Women. By T. J. McGillicuddy, M.D. Svo. 367 pages,
Illustrated. Wm. Wood & Co., New York. Price: extra mus-
lin, $3.00; fle.xible leather, $3.50.
A HANDnooK of P.whological Anatomy and Histol-
ogy. By Francis Delafield, M.D., and T. Mitchell Prudden.
M.D. Fifth edition. Svo, S46 pages. Illustrated. Wm.
Wood & Co., New York. Price : cloth, $6.00 ; leather, S7.00.
The Medical and Surgical Uses of Electricity. By
A. D. Rockwell, M.D. New edition. Svo, 628 pages. Illus-
trated. Wm. Wood & Co. , New York. Price : cloth, $4.00 ;
sheep, $5.50.
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 50, No. 17.
Whole No. 1355.
New York, October 24, 1896.
$5.00 Per Annum.
Single Copies, loc.
©ricjiual Jk^vticlcs.
PROSTATIC ENLARGEMENT: REMARKS IN-
TRODUCTORY TO A DISCUSSION ON ITS
NATURE, DIAGNOSIS, AND TREATMENT.*
By J. \V. S. GOULEY, M.D.,
BURGEON 10 RELLEVfE HOSPITAL.
Although the subject proposed for discussion has
long been under the scrutiny of the profession, and
notwithstanding the progress made toward its elucida-
tion, there is still need of much additional nifornia-
tion respecting an ailment which is so distressing to
humanity. The suffering caused by obstructed urina-
tion was graphically recorded by many observers in
remote limes, but the origin of any particular kind of
obstruction was not discovered until the dissection of
human bodies became frequent, and until Riolan,
early in the seventeenth century, suggested that the
neck of the bladder could be obstructed by a tumor of
the prostate. Marked advances toward a more e.xact
knowledge of the nature and treatment of prostatic
enlargement and its effects began with this centuiy,
and honorably associated with these advances are the
names of Everard Home, Jean Civiale, and Auguste
Mercier. These eminent men were trul}' veneralile
pioneers in'this field of investigation, and the present
generation is reaping the benefits of their labors.
The results of recent researches into the nature,
effects, and treatment of prostatic enlargement will,
this day, be made known to the association, by sev-
eral inquirers, in the hope that the debate they evoke
may serve to help the general physician in the difficul-
ties he sometimes encounters while endeavoring to
form a diagnosis, and to enable him to give safe and
speedy relief to the sufferers who have recourse to
him in their distress.
The questions propounded for discussion are:
I. What is the nature of prostatic enlargement?
II. How is prostatic enlargement recognized?
III. What are the effects of prostatic enlargement,
and how may they be counteracted ?
IV. When is operative interference indicated, and
what operations may be safely performed for prostatic
enlargement?
Some consideration of the few subjoined points in
the anatomy and physiology of the prostate is sug-
gested as likely to be a helpful preliminary step in
the direction of a right estimate of deviations from its
normal state. This vesical prostatic body — said to
have been discovered by Nicolas Massa about the
middle of the sixteenth century — this mass of muscu-
lar and glandular substance, though ordinarily shaped
somewhat like a chestnut, is subject to many varia-
tions, not only of form but of size and weight, as as-
certained by the dissection of great numbers of speci-
mens taken from men between the ages of twenty-five
and fifty years, that apparently had had no serious
urinary disorder, .\mong these specimens are very
flat and short prostates, one inch in length, not over
* Kt-ad before llit New Vork State Aledical .Association. Oc-
tober 13, 1S96.
half an inch in thickness, but occcasionally very
broad at the base, reaching two inches; there are also
long and disproportionately slender prostates; and a
few examples of the nearly globular which are one
inch and a quarter in mean diameter. In a few cases
they are undersized though of regular form; while
others are in excess of size and weight of the normal
typical organ, whose average length, from base to apex,
is one inch and a half, whose average breadth, near
the base, is one inch and three quarters, whose average
thickness, near the base, is seven-eighths of an inch,
and whose average weight is five drachms.
Springing from the antero-inferior part of the
bladder, the prostate is directed downward and for-
ward, its base embracing the vesico-urethral orifice
and the anterior e.xtremities of the seminal vesicles
together with the ends of the spermatic canals, its
apex being lost in the membranous portion of the
urethra. Its antero-superior convex surface, distant
from the pubic arch about three quarters of an inch,
is covered by a closely adherent layer of muscle-tissue
bands derived from the anterior wall of the bladder.
Upon and among these superficial muscular bands are
many veins which end in the plexus of Santorini,
whose efferent veins pass along the sides of the pros-
tate where the muscular layer is much thicker and
gives attachment to the pelvic fascia and to the leva-
tor ani muscle. Its postero-inferior nearly flat sur-
face, resting upon the lower end of the rectum, is in-
vested with a prolongation of the thin layer of muscle
tissue covering the seminal vesicles. This muscular
layer is attached to the prostate by moderately dense
connective tissue, and to the rectum by very loose
connective tissue. Thus the prostate is securely en-
capsulated by layers of connective and muscular tis-
sue. Its two lobes are united, from base to apex, by
a superior isthmus and by an inferior isthmus, and
this union forms the prostatic region of the urethral
canal. The posterior third of the inferior isthmus,
much thicker than the anterior two thirds, is called
by Home the third lobe, and by Mercier the supra-
montanal region because it is above the veru mon-
tanum.
The prostatic body consists largely — from two-
thirds to three-fourths of its bulk — of smooth muscle
tissue which encloses the acini and tubes of great
numbers of compound racemose mucous glands; the
acini containing microscopic albuminoid sympexia,
which first make their appearance during adolescence.
The writer has found sympexia in the acini of pros-
tatic mucous glands of boys of sixteen years. These
acini, in adults, are about the one-three-hundredths of
an inch in mean diameter; some of them are round
and others are oval or oblong. In disease they are
often distinctly visible to the naked eye. 1"he tubes
of different bunches of acini unite to form larger tubes;,
and these coalescing make up terminal excretory ducts,
the greatest numbers of which open obliquely on the
Hoor of the prostatic sinus at either side of the ure-
thral crest. The orifices of some of the excretory
ducts appear on the upper and lateral walls of the
sinus, and a few open inside the utrii uhis. The pos-
terior third of the tower isthmus ("third lobe'") .seems
to be the part which is richest in mucous glands.
578
MEDICAL RECORD.
[October 24, 1896
The prostate is well supplied with blood and lymph
vessels, and derives its innervation mainly from the
sympathetic system; the acini, the vessels, and the
nerves being accompanied by fibres of connective tis-
sue which form their delicate framework.
Physiologically considered, the prostate is both a
genital and urinary organ. Genital, because its mu-
cous secretion contributes largely to the dilution of
the semen, and because, as a muscle, it helps much
the ejaculation of the semen; urinary, because it aids
in expelling the urine, being an integral part of the
urethra. As a genital organ it is practically rudimen-
tary until the period of adolescence, and does not at-
tain its full size until about the age of twenty-five.
It increases slightly in bulk after the age of fifty.
Question I. What is the Nature of Prostatic
Enlargement ? — Before endeavoring to answer this
question, it is proper to say that the term enlargement
is here used instead of " hypertrophy" with its strict
meaning of overnourishment and its arbitrary signifi-
cation of increase in size of existing individual com-
ponent parts of organs as distinguished from hyper-
plasia— the multiplication of cellular elements — which
occurs in the prostate as well as in other parts of the
body. Although increase in size of the acini occurs
in the prostate, hypertrophy cannot, with accuracy, be
employed in respect of this organ, because the morbid
states which give rise to increase of its volume are
many and in none of them is the organ overnourished.
The contrary seems to be the case, for the venous
stasis which exists in diseased conditions of the pros-
tate surely points to under rather than overnourish-
ment. Physical exploration during life and dissection
after death have long since demonstrated that prostatic
enlargement is neither a single morbid entity nor a
single morphic entity.
The chief morbid states that cause increase in bulk
of the prostate are as follows;
1. Acute inflcitnviatory action gives rise to prostatic
enlargement which disappears when resolution is
completed or which persists longer, as in the case of
suppuration and abscess formation. In some cases
acute prostatitis ends in the gradual shrivelling of the
organ instead of its enlargement. A variety of acute
inflammation with oedema of the prostatic mucous
membrane extending to and closing the urethro-vesical
orifice, and involving the prostatic ducts, causes not
only retention of urine, but often general swelling of
the prostate which, ordinarily, is transitory. Some-
times, however, this prostatic swelling persists several
weeks or even several months after the subsidence of
the acute inflammation. In subacute prostatitis the
persistence of swelling is even more common than in
this variety of the acute form.
2. Chronic parenchymatous prostatitis is a cause of
transitory as well as of permanent enlargement of the
organ. Transitory when, after a suitable course of
treatment, the swelling vanishes, or, when rapidly in-
creasing calcified sympexia are artificially removed,
the prostate soon decreases or even shrivels. Perma-
nent when dilatation of the acini occurs together with
some increase of the muscle tissue, the calcified sym-
pexia remaining almost microscopic in size. Such
prostates generally become very large, are compara-
tively soft, and occur with greater frequency than the
other kinds. In his work on •' Diseases of the Uri-
nary Apparatus," " Phlegmasic Affections," 1892, the
writer discusses the subject of chronic prostatitis and
its effects at p. 170 et scq.
3. Dilatation of the prostatic sinus sometimes greatly
increases the bulk of the organ. Of this kind, three
cases have been observed by the writer. In one case
the ectasia was due to the damming up of the urine
by a narrow urethral stricture. The cavity thus
formed had a capacity of sixty cubic centimetres. The
walls of the sac, consisting of the substance of the
prostate, were of irregular thickness, from three to
twelve millimetres. In consequence of cystitis and of
frequent violent efforts to urinate, the bladder capacity
was diminished, the walls of this viscus were thick-
ened to more than a centimetre, and there was on the
right side, close to the ureter, a diverticulum whose
capacity was seventy cubic centimetres. There was
also a well-marked urethro-vesical bar. The kidneys,
which were not preserved after examination, showed
signs of inflammation and fatty degeneration, and
weighed two hundred and six grams. In another
specimen the dilatation was quite as great and the
prostatic sac contained a calculus which nearly filled
it.
4. Retention cysts — due to extreme dilatation of
acini from accumulation of the secretion owing to
closure of excretory ducts — sometimes attain such
dimensions as to increase very considerably the bulk
of the prostate or interfere with urination. A prostate
of normal size, dissected by the writer, contained a
superficial retention cyst, one centimetre in diameter,
at the right of and almost closing the urethro-vesical
orifice. Large degeneration cysts are also sometimes
found in this organ. Hydatid cysts very rarely occur
in the substance of the prostate; they are generally
found in its immediate vicinity and by mechanical
pressure interfere seriously with urination.
5. Tubercuhsis, though of rare occurrence in the
prostate, increases markedly the volume of this organ,
which it finally destroys. One specimen of this kind
is in the writer's collection.
6. True adenomata — new-growths of adenoid sub-
•stance with imperfectly elaborated and sterile struc-
ture— which do cause increase in size of the prostate,
are very rare, and are transformable into carcinomata
and sometimes into adeno-sarcomata. Careful exam-
ination of many hundreds of diseased prostates, during
the past thirty years, has revealed to the -writer only
three cases of carcinoma of this organ.
7. Fil>rous tumors are of extreme rarity and are
transformable into sarcomata, but primary sarcoma
does sometimes occur in the prostate to give rise to its
enlargement.
8. Diffuse increase of the prostatic fibrous framnvork
is also very rare and, like the isolated fibrous tumors,
is liable to sarcomatous metamorphosis. Although
diffuse increase of the fibrous tissue causes but little
augmentation in bulk, it obstructs urination nearly as
much as do very large prostates, owing to its hardness
and to the urethro-vesical bar which it forms.
9. Circumscribed multiple myomata are known to
cause increase in size of the prostate. Oood illustra-
tive specimens of this kind are preserved in tlie writer's
collection.
10. Diffuse increase of muscle tissue makes up the
greater part of the substance of some hard prostates,
which do not always become very large, but cause ob-
struction to urination by forming a bar at the vesical
neck.
Although the prostate is often uniformly enlarged
without producing serious effects, it is clear that its
enlargement cannot reasonably be regarded as a sin-
gle morphic entity, as shown in the following state-
ment of the main varieties of form :
1. The enlargement may be limited to one lobe of
the prostate or may involve only the two lobes.
2. Enlargement of the lobes may be unequal, one
being much larger than the other.
3. One or both lobes may project into the bladder.
4. One or both lobes may encroach upon and nearly
close the prostatic region of the urethra, rendering its
course irregular or even spiral.
5. The posterior third of the lower isthmus alone
may be enlarged in the form of a roundish peduncu-
October 24, i8g6]
MEDICAL RECORD.
579
lated tumor, or of an irregular sessile mass, or of two
separate sessile growths.
6. The whole of the lower isthmus alone may be
enlarged.
7. Both lobes and the posterior third of the lower
isthmus may be enbirijed.
8. Both lobes and isthmi may be enlarged.
g. The enlargement of both lobes may be downward
and backward toward the rectum, overlapping the an-
terior third of the seminal vesicles.
10. There may be only a bar at the neck of the
bladder with little if any general enlargement of the
prostate.
11. There mav be intramural isolated tumors which
are not perceptible before incision of the organ, or
which, being sometimes superficial, are discoverable
through rectal exploration.
12. Multiple tumors, from one or both lobes, may
project into the urethra, with or without enlargement
of the posterior third of the lower isthmus.
13. Multiple tumors, with or without general en-
largement, sometimes spring into the bladder from the
posterior third of the lower isthmus, and cause true
incontinence of urine.
Here then are greatly differing morbid states which
cause enlargement of the prostate with many varieties
of form. Does it not seem plain, in consideration of
such diversity of morbid states and freaks of form,
that no exclusive method of treatment of these con-
ditions can consistently be adopted, and that the
proper management of any case must be premised by
a diligent inquiry into the nature of the particular
morbid state and the form and e.Ktent of the enlarge-
ment?
Chronic progressive enlargement, being the most
frequent of the diseases of the prostate in elderly men,
is entitled to the largest share of attention. Very
often physicians are consulted by younger brethren in
behalf of patients, under the age of forty, supposed
to be suffering from chronic enlargement of the pros-
tate, but in reality are harassed by dysuria due to
transitory prostatic swelling or to spasmodic contrac-
ture of the vesical neck, either being a common sequel
of urethritis or of persistent hyperlithuria. This mis-
conception of the nature and era of chronic prostatic
enlargement still exists in the minds of some physi-
cians, notwithstanding the frequent reiteration, for
many years past, that this alTection does not generally
occur until the sufferer has attained two score and ten
years of age. The inexperienced are constantly mis-
taking transitory inflammatory swelling of the prostate
for the chronic, slow, steady increase in bulk of this
prostatic body, which very seldom begins before tlie
age of fifty. It therefore seems justifiable to empha-
size the often repeated statements that chronic progres-
sive enlargement of the prostate is a disease of elderly
men ; that not more than forty per centum of men
between the ages of fifty and seventy years are af-
fected with chronic enlargement of the prostate; that
the ailment does not ordinarily manifest itself before
the age of fifty-five; that it rarely begins after the age
of seventy; and that out of the forty per centum of
cases not more than one in every six suffers seriously
from disordered urination.
During the first half of this century, progressive
enlargement of the prostate was regarded, by some
physicians, as a result of chronic inflammatory action,
but that opinion was not shared by many others, who,
however, offered no better explanation, although they
admitted the existence of passive congestion of the
organ. A re-examination of the question, with the
aid of modern methods of study, has led to the belief
that phlegmasic action — often excited by persistent
hyperlithuria, which is so common between the ages of
fifty and sixty — is a potent factor in the causation of
this chronic enlargement. Post-mortem evidences
point to a low grade of inflammation of the prostatic
parenchyma, and microscopic inspection of the soft
enlarged prostate of elderly men shows that its struc-
ture is not identical with what is known as a new
growth, but that the increase of bulk is due to dilata-
tion of the acini with augmentation of muscle-tissue
bands. Such increase of muscle tissue seems to be
an effect of \iolent and frequent contractions of the
bladder and prostate in their efforts to expel retained
urine. Therefore, this increase of muscle tissue is
secondary to the diseased state of the acini involved
in the passive phlegmasia, that yields an exudate suffi-
cient to distend them and float the sympexia, which
are soon encrusted with concentric layers of calcium
phosphate, and thus become irritant bodies serving to
aggravate the existing condition. Many of these cal-
cified sympexia are discharged through dilated ducts
and are found in the urine, but others remain in the
acini or are impacted in ducts, and the consequence is
accumulation of the secretion, further dilatation of
the acini, and general or local increase of the prostate.
Among the dissected prostates of men between the
ages of fifty and fifty-five, many of the specimens
showed marks of beginning enlargement of the lower
isthmus and lobes and also in the form of small foci
of dilated acini in the substance of the organ. In a
few instances the foci projected to the surface of the
posterior third of the lower isthmus. Some of these
foci were not more than a millimetre in size, others
were between two and three millimetres. The process
of enlargement is so slow that the organ does not be-
come inordinately bulky until the sufferer is much
advanced in years. In some cases the muscle tissue
is greatly in excess, while in the vast majority it is the
dilatation of the acini which predominates. The
gritty calcified sympexia are discernible when the
prostate is incised with a sharp knife.
Analysis of the record of nearly every new case
affords some evidence of the phlegmasic origin and
slow development of chronic enlargement of the pros-
tate. The following example is cited out of many
carefully studied cases: A patient — now, May, 1896,
fifty-five years of age — who had suffered from persist-
ent hyperlithuria for more than five years before his
first symptoms of chronic prostatitis, noticed, at the
age of fifty-two, a slight muco-purulent urethral flow,
particularly during defecation, together with uneasy
sensations in the perinasum and rectum, but did not
apply for treatment until a year thereafter, when he
began to be annoyed by unduly frequent urination, for
which he consulted the writer. At that time — when
he was fifty-three years of age — there was no apprecia-
ble prostatic enlargement and he was able to empty his
bladder. In the course of a year he was again exam-
ined through the rectum and the volume of the pros-
tate seemed slightly increased, but there was no
residual urine in the bladder. Six months after this
he had an attack of cystitis, during which his urine
was purulent and fetid, but became clear after six
weeks' treatment, when his physician declared him
well. Nevertheless, the frequency of urination by
day increased and he was obliged to rise to urinate
twice each night. He returned to New York, in May,
1896, complaining of pain in the hypogastric region
and perinteum, and of frequent desire to urinate day
and night. His act of urination, in presence of the
writer, was characteristic of urethro-vesical obstruc-
tion. At the first attempt he could pass only an ounce
of urine; after moving about for two or three minutes,
he passed four ounces, and a few minutes later two
ounces; in all seven ounces. A curved silk-web
catheter was then easily introduced and four ounces
of clear residual urine drawn. Digital rectal explo-
ration revealed undue rotundity of the prostate and an
58o
MEDICAL RECORD.
[October 24, 1896
increase in volume estimated to be about one-third in
excess of the normal average. By the aid of Mercier's
■short-beaked rectangular staff, a moderate increase of
the posterior third of the inferior prostatic isthmus
together with a correspondmg depth of the lower vesi-
cal fundus was detected, and this accounted for the
residual urine drawn. The hatching of the prostatic
enlargement, in this case, seems to have lasted at least
si.x years.
In the case of a man aged seventy-seven years,
prostatic enlargement had existed ten years before
complete retention of urine occurred and subsequent
regular cathelerism became necessary. In that time
the prostate had not more than doubled in size. In
another case fourteen years had elapsed from the be-
ginning of enlargement before the catheter became
indispensable. The patient was at that time eighty
years of age, and during these fourteen years the pros-
tate had more than quadrupled in size.
Mercier recognized the dilatation of the acini and
the calcification of the sympexia, but was one of those
that rejected the notion of the phlegmasic origin of
chronic enlargement of the prostate (" Recherches,"
etc., 1841); and yet he believed this enlargement to
be due, in great part, to passive congestion. This ad-
mission is surely favorable to the phlegmasic theory.
Some modern writers regard chronic enlargement of
the prostate as adenoma, but this \ie.v is certainly
not in accord with the present definition of an ade-
noma, which is: a new growth of adenoid substance
■with imperfectly elaborated and sterile structure. It
has already been stated that adenomata, as well as
other new growths, are found in the prostate, but that
their occurrence is very rare. In the great majority
of cases of chronic enlargement, there is not the least
appearance of new growth of glandular substance.
The acini are not increased in number, but are
greatly dilated — some of them from five to twenty
times their normal dimensions — and ordinarily the
muscle tissue is only slightly increased. Besides,
there are, in and around these prostates, unmistakable
signs of secondary phlegmasic action. The peripros-
tatic veins are gorged with blood, and in some cases
are occluded by phleboliths Although the surround-
ing tissues are indurated, the substance of the prostate
is soft and spong)'.
The diseased prostate sometimes attains very great
dimensions. Among the last specimens dissected,
one, taken from a patient who died at the age of sixty-
seven, was, by external measurement, two inches
and a half in thickness, two inches and a quarter
from base to apex, and three inches and a half from
side to side In addition, the posterior third of
the lower isthmus, one inch and a half broad, pro-
jected one inch and a quarter into the bladder,
bulged toward the rectum, and pushed aside the sper-
matic canals and seminal vesicles, which were shriv-
elled and hardened. The length of the prostatic re-
.gion of the urethra was two inches and three-fourths.
The vesical wall at the lower fundus was much indu-
rated and irregularly thickened from half an inch to
three-fourths of an inch. The bladder, whose capacity
did not exceed four ounces, contained a small phos-
phatic calculus. The calibre of the ureters was more
than doubled, and there was on both sides pyelone-
phritis, the kidneys being more than twice their natu-
ral size. Notwithstanding the great increase of this
prostate, the introduction of instruments was excep-
tionally facile; and the fact was accounted for after
dissection, when the two lobes were found to be equally
enlarged and the prostatic urethra very slightly cur\'ed,
owing to inordinate thickness of the superior isthmus,
the whole of the inferior isthmus being also very much
enlarged. In a specimen prepared some years ago,
the posterior third of the inferior prostatic isthmus
made up about one-third of the bulk of the diseased
organ, in the form of a rounded mass, two inches in
mean diameter, which nearly filled the lower vesical
fundus. Many examples of extreme prostatic enlarge-
ment are on record, but only a few of them need now
to be mentioned. In his work on "Diseases of the
Prostate," fourth edition. Sir Henry Thompson figures
and describes a prostate which w as " nearly the size
of a cocoanut, and weighed nine or ten ounces."
The patient ."expelled his urine very frequently and
with difficulty, but emptied his bladder completely."
This is a valuable illustration of the fact that general
enlargement of the prostate, with great protrusion of
the so-called third lobe, does not always abolish uri-
nation. Ford is cited by Mercier as having published,
in i8o2, the account of a diseased pro.state that
weighed nine ounces. Bartholinus is said to have
seen a prostate equal in size to a man's head. This
was regarded by l^Iercier as an exaggeration. Proba-
bly the largest prostate exhibited in modem times is
the specimen figured by Dr. F. S. Watson, of Boston,
in his essay on "The 0]3erative Treatment of the
Hypertrophied Prostate," 1888, plate xvii. The blad-
der having been dissected away, the diseased mass was
photographed. The picture measured seven inches
and one-eighth in extreme longitudinal diameter, five
inches and three-fourths in largest transverse dia-
meter, and four inches in smallest transverse dia-
meter.
The other extreme in point of development is illus-
trated by a specimen taken from an elderly man whose
death was due to the consequences of obstruction to
urination by a ver}' slight enlargement of the posterior
third of the lower isthmus, which, how^ever, had almost
entirely closed the urethro-vesical orifice; the rest of
the prostate being not more than two-thirds the aver-
age size.
Qtiestion II. How is Prostatic Enlargement Rec-
ognized ? — To ascertain the existence of prostatic en-
largement is often easy, but to identify any particular
kind of enlargement requires a clear discernmenl of
the several morbid states and varieties of form to
which this organ is subject. Hurried, superficial ex-
amination is almost certain to lead to erroneous diag-
nosis, and tills to improper treatment. A case in point
is that of an elderly man, affected with prostatic en-
largement, whose physician seemed to take into ac-
count only the fact of the enlargement, and therefore
suggested what he conceived to be a radical operation.
The patient then consulted another physician, who,
after a very careful examination of the case, advised
against any operative interference, for the time being,
other than evacuative catheterism and daily vesical
irrigation, because his di.agnosis was sarcoma of the
prostate, with a secondary nodule in the hypogastric
region of the abdominal wall. The prostate then in-
creased so rapidly that suprapubic cystotomy for
drainage became necessary, and afforded great relief
to the doomed sufferer.
In Its inception, enlargement of the prostate is sel-
dom recognized. Patients very rarely seek medical
advice until the disease has advanced sufficiently to
impede urination. In the case of those who do not
suffer in consequence of the enlargement of their
prostates, this condition is often only incidentally dis-
covered. Large prostates, that had not caused the
least inconvenience and the existence of which was
never suspected, have been found in the bodies of old
men dead of acute disease. In like cases, the enlarge-
ment is generally uniform. It should, however, be
borne in mind that these prostates are liable to such
swelling — due to exposure or to debauch on the part
of the patients — as to cause retention of urine and cys-
titis, necessitating frequent catheterism; and that this
swelling often lasts many weeks or even months, finally
October 24, 1896]
MEDICAL RECORD.
581
subsiding so that the patients are able to urinate in a
good stream and empty their bladders.
When urination is much disturbed, day and night,
in an elderly man free from urethral stricture or vesi-
cal stone or tumor, the e.xistence of multiform enlarge-
ment of the prostate- may be predicated. It has al-
ready been said tliat the hatching of chronic prostatic
enlargement is a very slow process, several years gen-
erally elapsing before any symptoms of impediment to
the exit of urine are percei\ed. The patient then first
becomes conscious of something being wrong with his
urinary apparatus, on account of frequent desire to
urinate, and, later, of difficult and sometimes painful
urination ; but these symptoms, being common to sev-
eral other urinary affections, are likely to lead him
astray as to the nature and, consequently, as to the
management of his complaint. Frequent and difficult
urination by day and by night, a sense of fulness and
weight in the perina;um and rectum, lumbago, and sci-
atica, are valuable symptoms when rightly interpreted.
Frequent urination points to stagnation of urine and
consequent cystitis. Difficult urination is evidence of
obstruction, but the obstruction may be of the nature
of a urethral stricture or of the impaction of a calculus
in the urethra. However, in the ca-se of an elderly
man, free from urethral or calculous disease, difficult
and frequent nightly urination forebodes prostatic ob-
struction. Chemical and microscopical examinations
of the urine, so helpful in diagnosis, prognosis, and
therapeusis, need to be made from time to time during
the conduct of each case.
The mode of urination as indicative of prostatic
obstruction is worthy of special notice. The patient
stands leaning forward with his legs spread. After
some delay the urine issues in a small, feeble, vertical
stream, which soon stops, to be followed by the drib-
bling of twenty or thirty drops, that are succeeded by
the small stream; and this continues until, in the
course of tw'o or three minutes, one or two ounces may
thus be expelled. This process is repeated two or
three times, with varied success, when the introduction
of a catheter reveals the presence of six or eight ounces
of residual urine. This kind of urination only spe-
cializes obstruction from prostatic enlargement; it
does not characterize any of the varieties of form.
Digital rectal examination reveals, with sufficient
precision, the extent of enlargement of one or both
prostatic lobes, abnormal rotundity of these lobes, or
multiple nodules indicating the presence of large cal-
cified sympexia, isolated myomata, or cancerous
growths. Hardness does not necessarily signify in-
duration of the whole prostatic mass, for the peripheral
parts only may be indurated, while the central portion
may be soft and spongy. Exploration through the
urethra with Mercier's rectangular short-beaked me-
tallic staff reveals the existence of a urethro-vesical
bar, or of a more or less extensive growth of the poste-
rior third of the lower isthmus. Digital rectal ex-
ploration is negative when there is no enlargement of
the prostatic lobes. In that case the physical diagno-
sis is made entirely by the urethral route, either with
the rectangular staff or with the cysto-pylometer, by
the aid of which the thickness of a urethro-vesical bar
may be determined.
Tiie e.xact statement of the diagnosis of prostatic
enlargement is of importance not only to the practis-
ing physician but to the vital statistician. Too fre-
quently only a condition common to prostatic enlarge-
ment, urethral stricture, and stone in the bladder
appears in tables of diseases without explanation, as
"retention of urine, chronic cystitis,'" etc. The writ-
er, in endeavoring to obtain information respecting
the relative frequency of the urinary diseases of males,
examined the annual reports of many institutions for
the care of disabled elderly men, and found it very
difficult and sometimes impossible to determine the
character of the diseases catalogued in these reports,
whose great value would undoubtedly be much en-
hanced if the compilers were permitted to place in
brackets and in italics the name of the primary dis-
ease— as, for instance: Retention of urine [from im-
tliral stricture, from prostatic cnhirgiincnt, ox from vesi-
cal stone\, as the case may be; chronic cystitis \from
prostatic enlargement, from urethral st!-icti/re, or from
z-esieal stone], etc. Such additions would lighten the
labors of, and be gratefully appreciated by, medical
in\-esiigators and statisticians.
Question III. What are the Effects of Prostatic
Enlargement, and How may They be Counter
acted ? — Uniform general enlargement of the prostate,
without encroachment upon the uretlira or bladder, ex-
cept in the case of malignant disease or of tuberculo-
sis, gives no inconvenience to the affected indi\idual,
who, however, if he be exposed to cold and moisture
after excess in drink, is likely to suffer from retention
of urine, due to transitory swelling of the already en-
larged prostate, which generally yields to rest, syste-
matic catheterism, and vesical irrigation.
The effects of those forms of prostatic enlargement
by which the capacity of the urethra or of the vesico-
urethral orifice is lessened are soon felt by the blad-
der, that vainly struggles, for weeks or months, against
the obstacle, to rid itself of irritating urine. Hence
the dysury, the strangury, and the increase of muscle
tissue of the bladder and of the prostate itself. The
stagnant, alkaline, slimy urine affords sustenance to
myriads of saprophitic and other organisms, and the
resultant cystitis adds to the distress of the patient.
Later, the phlegmasic process, if not checked, creeps
up the ureters, reaches the kidneys, and the sufferer
succumbs to ascending microbic pyelonephritis. Such
is the end of neglected cases of prostatic obstruction
to micturition. These ill-effects are often counteracted
by regular evacuative catheterism — from two to five
times in the twenty-four hours — and thorough cleans-
ing of the bladder with a solution of corrosive chloride
of mercury, r to 10,000, adding thereto one per centum
of phenol, or i to 1,000 of formalin. In the course of
a few days, a solution of nitrate of silver, i to 5,000,
may be used once daily for \esical irrigation. This
weak solution of silver nitrate seems to act beneficially
upon the vesical epithelium, while it is as destructive
of the bacteria as are the other antiseptics. When the
bladder is very foul, the sublimate and phenol solu-
tion may be used in the morning, and the silver-nitrate
solution in the evening, after ha\ ing rinsed the blad-
der with warm sterilized water. Not more than four
ounces of fluid should be injected into the bladder at
a time, but three or four such injections may be made
at each sitting. This palliative treatment is of great
value, and often is the only kind indicated or practi-
cable. In the case of small recurring phosphatic con-
cretions, irrigations with acidulated water — one part
of hydrochloric acid to two hundred parts of warm
water — destroy the calculi without injuring the vesical
mucous membrane. The same result is obtained by
the use of acetate of lead, first suggested by Dr. Hos-
kins, of Guernsey — one part of acetate of lead and one
part of acetic acid to four hundred parts of warm water.
The treatment designed to counteract many of the
ill-effects of prostatic enlargement ma\- be summed
up as follows, and consists in taking suitable means:
I. To combat hyperlithuria.
II. To secure moderate acidity of the urine.
III. To empty the bladder artificially — slowlv and
gradually when it is much overdistended.
IV. To effect gradual hydraulic dilatation of the
bladder when its capacity is lessening.
V. To combat existing cystitis by daily vesical irri-
gation.
582
MEDICAL RECORD.
[October 24, 1896
VI. To disinfect the urinan- tract, as well as the
prepuce and glans penis.
VII. To prevent calculous formation.
VIII. To preserve or improve the physical condi-
tion of the patient by such hygienic or medicinal
treatment as may be required.
It is often asked: "What kind of catheter is best
and safest for general use in cases of retention of urine
due to prostatic enlargement.'" If this enlargement
were invariably the same in form and size, one single
kind of catheter would undoubtedly always answer the
purpose of relieving the bladder. But, since the en-
largement is so frequently multiform and progressive,
the physician must be provided with several species
and varieties of catheters, out of which he may select
one of a form suitable to the particular variety of pros-
tatic enlargement affecting his client. The pliable
catheters, with lateral or terminal eye, made of silk
webbing coated with varnish, or of India rubber, are
the safest that can be used. There are ordinarily
eight different forms: (i ) The straight, which may be
used with a stylet, in the case of false routes, accord-
ing to the method of Hey; (2) the curved; (3) the
elbowed; (4) the crutched; (5) the double elbowed;
(6) the straight olive tipped; (7) the curved olive
tipped; (8) the "velvet-eyed" India-rubber catheter.
No instrument which cannot be rendered aseptic should
be used, neither should any fatty substance be em-
ployed to anoint the catheters. Soap, deprived of
glycerin and free alkali, is an efficient and unirritating
lubricant when mixed with a decoction of quillaja and
duly sterilized. The following is a modification of
the formula for a saponic lubricant, published in the
New York Medical Journal, July 22, 1893:
V, White castile soap, powdered ; i.
Water fl. ; iij.
Mucilage of chondrus crispus fl. 3 iij.
• Forinalin (40 per cent.) ni x.
Thymol gr- v.
Oil of thyme 'U v.
Alcohol "I .XV.
Mode of preparation : Heat the soap and water, and
stir until a homogeneous slime is formed; then add
the three ounces of mucilage (made of the strength of
one ounce of chondrus crispus to the pint of water).
When cool, pour in the formalin, then the thymol and
oil of thyme mi.xed with the alcohol; stir, strain, and
keep in a covered vessel until all air bubbles have
vanished. The result is an opalescent, slimy sub-
stance, of the consistency of honey, which should be
put up at once in two-ounce collapsible tubes and
sterilized. The chondrus crispus is substituted for the
quillaja of the original formula, because of the objec-
tionable quantity of alcohol in the tincture, and be-
cause quillaja decoction imparts to the mixture a dirty
pinkish tint, whereas the chondrus crispus mucilage is
colorless. The Cetraria Islandica was tested repeat-
edly and found unsuitable. The lubricant, in its pres-
ent form, is sufficiently viscid, adheres well to the
surface of all instruments, does not lump, and is unir-
ritating to mucous membranes. The same quantity of
chloral hydrate, or half the quantity of chloroform,
or thirty grains of boric acid, may be used instead of
the formalin if desired, since it is intended solely as
a preservative of the mucilage.
All web catheters should be kept at full length and
never coiled; otherwise the varnish will surely crack.
Web catheters should be loosely wrapped in dry
antiseptic gauze, and preserved in tightly-closed metal
cases until wanted for use.
Before using a web catheter it should be slightly
warmed by friction in clean hands, and by a momen-
tary immersion in a warm one-per-centum carbolic-
acid solution to prevent cracking of the varnish, par-
ticularly during cold weather.
After using a web catheter it should be well washed
by forcing a stream of water through the instrument,
which should then be dipped for a moment into a one-
per-centum carbolic-acid solution. It should then be
thoroughly dried, wrapped in antiseptic gauze, and
enclosed in a metal case. Catheters may be carried in
hollow walking-sticks, but never in the pockets of pa-
tients.
All web catheters are liable to harden, lose their
suppleness, and be unfit for use in the course of a few
years, especially when they have not been in use. On
the first appearance of the hardening process, the in-
struments should be cast aside.
Soft India-rubber catheters should be kept at full
length, never coiled, and should be wrapped in moist
antiseptic gauze, and preserved in tightly corked glass
tubes, because exposure to the air leads to rapid oxi-
dation, whicii causes the instruments to become hard
and brittle.
Before using a rubber catheter, it should be well
washed and momentarily dipped into a one-per-centum
solution of carbolic acid.
Rubber catheters become brittle in about two years,
and sooner if unused and exposed to the air. But
when daily lubricated with fats they seldom last more
than three or four weeks; then swell, lengthen, and
become so soft as to be liable to be torn across during
withdrawal. Several inches of such deteriorated rub-
ber thus often remain in the bladder.
When it is possible to teach a patient the use of the
catheter, perhaps the safest instrument that may be
placed in his hands is the "velvet-eyed" India-rubber
catheter, which he must cleanse thoroughly before and
after its employment.
Metallic catheters, with very few exceptions, should
not be employed in attempts to relieve the distended
bladder, because of their likelihood to damage the
urethral canal and plough their way into the substance
of the prostate, sometimes even when introduced with
ordinary care. Being absolutely rigid, they cannot
readily follow the abnormal incun'ations of the ure-
thra common to multiform enlargement of the prostate.
The so-called prostatic catheter is particularly dan-
gerous, for it seldom reaches the bladder without detri-
ment to the urethra, and too often finds lodgement in
the recess of some false route, which, perhaps, it has
made. When a false route renders impossible the pas-
sage of ordinary instruments, the contrivances known
as Hey's and Mercier's modes of catheterism are gen-
erally successful. Hey's method consists in passing,
as far as, but not into, the mouth of the false route, a
silk-web catheter. No. g or No. 10 (English), armed
with a curved stylet, which is withdrawn with one hand
at the same moment that the catheter is pushed toward
the bladder with the other hand, when the instrument
overrides the false route and enters the bladder, Mer-
cier's method consists in the use of two catheters,
which together he has named the invaginated catheter.
This instriunent is composed of a female and a male
part. The female part is a No. 10 (Knglish), slightly
curved, thin-walled, metallic catheter, eleven inches in
length, having in its concavit)', half an inch from the
point, an oval eye five-eighths of an inch long and
three-sixteenths of an inch broad. From the vesical
extremity of this eye is an inclined plane, lost in the
opposite wall of the catheter at about one-fourth of an
inch from the vesical edge of the eye, serving to tilt
up the point of the male part, which is a No. 6 (Eng-
lish), silk-web, one-eyed catheter eighteen inches long,
and fitting loosely in the lumen of the female part.
In using the invaginated catheter the male part should
first be slid into the female part down to the eye there-
of. The instrument thus armed is passed into the
urethra as far as the obstacle, engaging its point in
and with it blocking up the false route. The male
October 24, 1896]
MEDICAL RECORD.
583
part, which is then projected, soon reaches the bladder.
It sometimes happens that no urine flows after the
successful introduction of the male part. This is ow-
ing to closure of the eye by a clot of blood, which can
be washed away with a little water injected into the
catheter. The female part may then be withdrawn,
and the male part left in as long as desirable. This
is the reason for the great length of the male part.
Some of the other effects of neglected prostatic ob-
struction to urination, besides the damming up of a
few ounces of urine and my.xo -cystitis, are chronic
retention of urine, the management of which has al-
ready been detailed (Transactions of the Association,
1890); increase of the vesical and prostatic muscle
tissue, contracture with diminished vesical capacity
(Transactions, 18S5), interstitial cystitis, abscess in
the thickened vesical walls, calculus formation, sac-
culation of the bladder (Transactions, i885), ureteritis
with dilatation, pyelitis, pyonephrosis, pericystitis,
paracystitis involving the seminal vesicles and sper-
matic canals, and consequent abolition of the genetic
function. Unclean and roughened catheters, used
several times daily b)' careless patients, have often
been the exciting cause of several of these disastrous
consequences.
The frequent evacuative catheterism necessitated b}-
prostatic obstruction causes a subacute urethritis,,
which demands daily irrigation of the urethra, who^e
mucous membrane sometimes becomes so adematous
as to render catheterism difficult and even dangerous.
In such cases the careful introduction of flexible web
bougies or of steel sounds, of increasing size to No. 15
(English), every second or third day for two or three
weeks, relieves the sodden mucous membrane, restores
the suppleness of the canal, and facilitates the evacu-
ative catheterism. Another ill-eft'ect of this indispen-
sably frequent catheterism is acute orchitis, due gen-
erally to the use of unclean and fissured instruments.
This occurs, in some patients, as often as every three
or four months, first on one side, then on the other,
seldom on both sides at the same time. After several
attacks the orchitis becomes chronic, and sometimes
small purulent foci are formed in the substance of the
testes. These abscesses generally open spontaneously
and are rarely incised, the patients objecting until they
are taught b\' experience that early incision is wise
and proper. Finally, the spermatic canals are oc-
cluded, and the genetic function is at an end.
Chronic inflammation of the seminal vesicles and
spermatic canals appears to be frequently associated
•with chronic inflammation and progressive enlarge-
ment of the prostate. In seventy-five per centum of the
chronically enlarged prostates of elderly men dissected
by the writer, there were marks of phlegmasic action
between the base of the bladder and the rectum, such
as induration of the ambient connective tissue, partic-
ularly that which bounds the seminal vesicles; and
these vesicles were, in general, hardened and shriv-
elled, and in some cases their fluid was purulent.
The absence of spermatozoids and the presence of
many enlarged sympexia were conspicuous in the mu-
cus of the vesicles. The spermatic canals were ab-
normally hard and sometimes occluded. In a few
cases there were cystlike dilatations in the vesicles,
due to the occlusion of their excretory ducts.
Question IV. When is Operative Interference
Indicated, and What Operations may be Safely
Performed for Prostatic Enlargement ? — The deter-
mination of the indication of operative interference
for the relief of obstruction to urination due to pros-
tatic enlargement requires serious consideration, a
judgment founded on extended clinical study of the
phases and complications of the diseases of this organ,
and correct notions of its patho-histology.
Operative interference is indicated when the blad-
der is permanently contractured and its capacity inor-
dinately and irremediably lessened, when catheterism
is extremely difficult or is followed by rigors and fever,
when there are prostatic false routes, or in some cases
when autocatheterism is not possible. Early opera-
tive interference is justifiable, as prophylactic of the
lesions consequent upon stagnation of urine.
Operative interference is contraindicated when the
upper urinary organs are damaged beyond remedv.
Operative interference may be palliative or radical.
Palliative Operative Interference is resorted to in
the case of malignant or of tubercular disease of the
prostate, in the case of permanent contracture with
diminished vesical capacity, in the case of beginning
involvement of the upper urinary organs, and some-
times in the case of prostatic false routes. The palli-
ative operations are: (i) Suprapubic cystotomy; (2)
the establishment of a suprapubic fistula; (3) divul-
sion of a false route; (4) puncture of the bladder.
1. Supra-pubic cystotomy, with maintenance of a free
opening for drainage and daily irrigation, may be re-
garded as a palliative measure of great value in the
case of malignant or of tubercular disease of the pros-
tate, of permanent contracture with diminished vesica!
capacity, and in the case of beginning involvement of
the upper urinary organs, particularly when catheter-
ism has become insupportable. In these circum-
stances, the last few months of the sufferer's existence
are rendered tolerable by the easy exit of the urine
through the ample artificial orifice.
2. The establishment of a permanent supra-pubic Jis-
tiila, as a palliative measure, in cases of great protru-
sion of the lower isthmus, in which catheterism has
been extremely difficult, has proved useful in many in-
stances, and has been successfully effected by Van
Buren, Thompson, McGuire, and many other surgeons.
3. Dr.iilsion of a false route, impeding catheterism
attempted for the relief of a bladder distended with
urine, has given results that warrant its adoption as a
safe palliative agent. This mode of palliation, em-
ployed frequently bv the writer, is as follows: M'hen
the point of the female part of the invaginated cathe-
ter is once lodged in a prostatic false route and the
male part has entered the bladder, the two parts to-
gether are pushed onward until there is no longer any
resistance; the urine flowing through the female part
on withdrawal of the male part indicates that the di-
vulsion is complete. This operation should be done
with the geatest care or else abandoned, particularly
if much force be required, for then no divulsion would
be effected, and the male part would be likely to be
severed by the distal edge of the eye of the female
part, and perhaps remain in the bladder. As a gen-
eral rule, divulsion occurs on very moderate pressure.
The deep rent extends beyond the obstacle, and is
similar in efl^ect to incision of the vesical neck. Al-
though spontaneous urination continued on an aver-
age of only two years after this procedure, and the pa-
tients were then obliged to return to autocatheterism,
the false routes were cured by the operation, catheter-
ism was thereby rendered easy, and the temporary re-
lief was comforting.
4. CapiHary puncture of the bladder, in the hypogas-
tric region, with pneumatic aspiration of retained
urine, is rarely necessary. In cases of emergency it
may be done once for the mitigation of suffering, and
should not be repeated unless better means are not
soon obtainable. Many observations of the ill-effects
of repeated punctures have led the writer to abandon
the practice of puncturing the bladder in anyway and
for any purpose, and to regard suprapubic cystotomy
as a safer measure in cases of retention of urine from
prostatic obstruction when other modes of operation
are not clearly indicated.
Radical Operative Interference is resorted to in the
584
MEDICAL RECORD.
[October 24, 1896
case of urethro-vesical bars, of outgrowths of the pos-
terior third of the lower prostatic isthmus, and of in-
crease of the lobes. The radical operations are: (i)
Incision of urethro-vesical bars; (2) excision of ure-
thro-vesical bars, or of the central part of the posterior
third of the lower isthmus; (3) excision of peduncu-
lated urethro-vesical growths; (4) avulsion, excision,
or enucleation of the posterior third of the lower isth-
mus and of portions of the lobes; (5) enucleation of
the whole prostate.
1. Jiicision of uretho-vesical hars^ originally suggested
by Guthrie, was performed by Mercier, then by Civi-
ale, Leroy, Costello, and other physicians. The oper-
ation is now known as internal prostatotomy. Mercier
devised ingenious instruments to be introduced by way
of the urethra, and to divide the bar or valvule, as he
called it. One of these instruments is designed to
clamp tightly and to divide the compressed bar when
the operator slides to and fro a long metallic stem
with a cutting blade concealed in the jaws of the in-
strument. This last improvement in the operation is
intended as a bloodless method. Mercier has some-
times found it necessary to repeat tlie incision several
times in 'the course of a year or two years. The after-
treatment consists in daily vesical irrigation and in
dilatation and depression of the urethro-vesical orifice
every third day for two weeks, then every week for two
or three weeks, or until cicatrization is perfect. Com-
plete division of the bar has given good results in
great numbers of cases.
2. Excision nf urelhro-icsical bars or of the central
fart of the posterior third of the lower isthmus was first
performed by Mercier, with an instrument introduced
through the urethra by which a segment of the bar or
of the lower isthmus was punched out. The operation
is now designated internal prostatectomy. Se\eral
modifications of this prostateclome have been made,
but they all retain the original principle of action.
The writer has combined internal and external prosta-
tectomy with advantage, and recommends performing
the internal operation first, then immediately following
it by opening the urethra in perinao fordramage. Ex-
cision should be resen'ed for certain cases of thick
urethro-vesical bars, and of comparatively slight in-
crease of the posterior third of the lower isthmus, with
little if any increase of the lobes. Hamorrliage has
seldom been excessive in this operation. The after-
treatment is the same as in prostatotomy. (Seethe
writer's article on " Some Points in the Surgery of the
Hypertrophied Prostate," in the Transactions of the
American Surgical Association, vol. iii., 1885.)
3. Excision of a pedunculated urethro-vesical grou'th
was performed by Amussat during suprapubic lithoto-
my, and this operation has since, from time to time,
been resorted to by others. Some of the (perineal)
lithotomists of the past two centuries, among whom
may be named Covillard and Desault, have occasion-
ally, by accident, seized with the forceps and torn
away urethro-vesical pedunculated growths mistaken
for calculi, or extracted them together with calculi.
The same accidents have repeatedly occurred in the
hands of modern lithotomists, who have, in other cases,
incised and enucleated the growth after extracting the
stone. The results were generally good, and the pa-
tients were able to empty the bladder spontaneously
(Fergusson, Cadge, Williams, Bickersteth, and others).
4. Avulsion, excision, and enucleation of the intraxes-
ical protrusion of the enlarged lower isthmus, and oc-
casionally of portions of the lobes, have been effected
through suprapubic cystotomy, sometimes supple-
mented by perineal incision of the urethra. On No-
\ember 11, 1887, Mr. A. I". McGill read, before tlie
Clinical Society of London, a paper bearing the title
of " Suprapubic Prostatectomy," in which he gave a
full account of three successful cases. The operation
consisted partly in avulsion and partly in excision of
the intravesical growth. The subsequent drainage was
entirely suprapubic, as the perina;um was untouched.
Some of the advocates of the suprapubic method have
since added the urethral incision in ferinceo, the better
to control ha;morrhage and also for drainage. \\'hile
the details of the operation are often varied, the fun-
damental idea of removing parts of the prostate from
above is uniformly carried out by tire several operators,
who in certain cases substitute enucleation for avul-
sion and excision. Drs. Atkinson, Eelfield, Briddon,
Browne, Bryson, Cabot, Dittel, Fuller, Keyes, McKin-
non, Moullin, Raffa, Robson, Rohmer, \\'atson, Wy-
eth, and others have reported cases of suprapubic
prostatectomy with divers modifications and very sat-
isfactory results that have led to the undertaking of
the seemingly bolder, though in reality safer, bimanual
enucleation of the whole prostate, as performed by Dr.
James H. Nicoll, of Glasgow, and Dr. Samuel Alexan-
der, of New York. Exactly how far back may date the
idea of removing the entire prostate, the writer does
not know. The only records he has found thus far re-
lating to this operation are the following; It appears
that total extirpation of the prostate was proposed by
Kuechler {Deutsche Kliiiik, No. 50, 1866), and later
was performed by Billroth, and still later by Demar-
quay, who, in 1873, reported, in the Gazette A/etticale
de Paris, two cases in which the prostate and part of
the rectum were remo\ed. In the Arch, fir klin.
Chir., Berlin, vol. xxviii., 1882-83, P- Sl^< i^ ^ paper
entitled ''Tumor Prostata;; Totale Extirpation der
Prostata," by H. Leisrink. The patient, sixty-four
)-ears of age, was suffering from the effects of a large
prostate. The diagnosis was malignant disease, and
it was decided to extirpate the prostate in totality.
The operation was performed on December 24, 1881,
and the patient died of exhaustion on the thirteenth
day thereafter. Extirpation of the prostate or of any
part thereof for malignant disease is surely unjustifia-
ble, and the only proper operative procedure in such
circumstances is a palliative epicystotomy solely for
drainage.
5. Enucleation of the johole prostate through the peri-
na-um is apparently the latest legitimate endeavor of
modern surgery to eradicate the evil of obstructed
urination. It seems to be the outcome of a more pre-
cise knowledge of the organ in healtli and disease, and
of the analysis and comparison of the several operative
methods already named. Experiments on the dead
subject have shown tliat the normal prostate is with
great difficulty if at all enucleable, that the diseased
//tf/v/ pro.state is not at all enucleable, and that tiie dis-
eased soft prostate is enucleated with comparative fa-
cility. Moreover, the dissection of enlarged prostates
of elderly men has demonstrated that while thev are
often dense and hard peripherally — owing to second-
ary phlegmasic action — they are soft and spongA' in-
teriorly— from great ectasia of the acini — and eiuxle-
able with the finger. Therefore, eniicleation is
applicable only to the soft prostate, which happens to
be the most frequent of the morbid states of this organ
in elderly men. The cases of perineal enucleation
of the prost;ite so far reported are too few for general-
ization, but the indications for its performance are
clear. This operation, founded on a sound anatomico-
chirurgical basis, is a valuable addition to the re-
sources of the surgeon, and is worthy of extended trial,
particularly in the early period of senile enlargement
of the organ, before any serious implication of the
bladder. It is hoped tliat it will not be performed in-
discriminately, for, in the case of involvement of the
upper urinary organs, the mortality will surely be dis-
couraging.
The chief advantages claimed for this, over other
methods of operating, are:
October 24, 1896]
MEDICAL RFXORD.
585
I. The combination of suprapubic and intrapu
bic section for exploration, as well as for bimanual
enucleation.
II. The rapidity with which the operation is per-
formed, the patient being under anaesthesia not more
than half an hour.
III. The slight and controllable haemorrhage during
and after enucleation.
IV. The little mjury done to the urethra and blad-
der.
V. The suprapubic irrigation and thorough perineal
drainage.
Ur. Nicoll's method of operating is substantially as
follows: The bladder is opened above the pubes, and its
edges are stitched to the cutaneous wound. A median
perineal incision is made to and through the prostatic
capsule, without opening the urethra or neck of the
bladder. The prostate is then pressed down and
steadied from above, so as to be within reach of the
right forefinger, with which it is shelled out througii
the perinaum, all drainage being effected through the
suprapubic opening. Dr. NicoU has published four
cases successfull} treated in this manner (^Lancet, April
14, 1894).
Dr. .\le.\ander's mode of operating is as follows:
After due preparation, disinfection, and anaisthesia,
the patient being supine on the operating table, the
bladder is opened longitudinally above the pubes, to a
sufficient extent to admit two fingers for exploration
and the determination of the size of intravesical pros-
tatic growths. This done, "the suprapubic opening is
covered w ith gauze, the patient placed in the lithotomy
posture, and a staft" is passed through the urethra and
held by an assistant. The membranous urethra is
then opened by a median [longitudinal] perineal sec-
tion, the door of the urethra being thoroughly cut from
just behind the bulb back to the apex of the prostate.
The staff is then withdrawn and the gauze removed
from the suprapubic wound. Two fingers of the left
hand are then passed through the suprapubic wound,
and by these the prostate is pressed downward into the
perinaium. With the forefinger of the right hand, the
surgeon begins the enucleation, which is performed
entirely through the perineal opening. The outer
sheath of the prostate is broken into by the finger just
beneath the mucous membrane of the prostatic urethra,
and the entire prostate is shelled out from within its
sheath by digital dissection. The mucous membrane
of the bladder and prostatic urethra, with the underly-
ing muscular tunic, is stripped up, but is not opened.
The right and left lobes are first removed, after which,
if there be a middle projecting tumor, this can be
pressed downward into the perineal wound and enucle-
ated in the same manner. During the enucleation the
prostate is to be drawn down into the perineum bv for-
ceps. After the removal of all the jsrostatic growths,
the wound is Hushed with i to 5,000 bichloride solu-
tion, a perineal tube is inserted into the bladder, and
a rubber drainage tube of moderate size is placed in
the bladder above the pubes. The after-treatment
consists in daily washings of the bladder, fluid being
injected into the suprapubic tube. All urine flows out
of the perineal tube. The upper tube is removed on
the sixth day, and the lower tube three days later, after
which the bladder is washed by catheter through the
perineum for a few days. A full-sized sound is passed
at the end of the second week, and then ever}' five
days until the perineal wound closes. The wounds
have usually healed in the course of five weeks" (New-
York Medical Journal, February 8, 1896).
Of eight enucleations performed by Dr. Alexander,
two patients died from suppression of urine due to py-
elonephritis, and six recovered and were al)le to uri-
nate spontaneously. One of these six patients, exam-
ined by the writer six months after the o]x;ration. had
only three drachms of clear residual urine in the blad-
der. In this case but one lobe and the lower isthmus
had been removed. In all of the cases hamorrhage
during the operation was inconsiderable, and the peri-
neal drainage was complete. In one case there was
incontinence of urine for several weeks after union of
the wounds, but this finally ceased, and at last ac-
counts the patient was able to retain his urine and to
empty his bladder at normal intervals without artificial
means.
When, HI 187S, the writer introduced to the Ameri-
can medical profession Dr. Mercier's operations for
the relief of prostatic obstruction, very few surgeons
were willing to perform them or afterward to test the
modifications proposed and successfully practised.
At that time and long thereafter, these operations were
condemned by leading continental and English sur-
geons, except by the late Mr. W. T. Teevan. Now,
eighteen years after the date of the writer's first ope-
ration, prostatotomy and prostatectomy are performed
with such excessive frequency, not to say recklessness,
that they are in danger of falling into utter discredit,
if not of being altogether abandoned. It is, there-
fore, hoped that persistent efforts will be made to pre-
•serve them from these besetting dangers by those who
know so well the real value and special indication of
each of these procedures, and employ it with due dis-
cernment.
Time and space forbid even the enumeration of the
medicinal and chirurgical contrivances that, during
the past three decades, have been proposed, tried, and
found wanting in efficacy, or positively mischievous,
for the "cure" of prostatic enlargement. Kach failure
has been quickly succeeded by a "new cure," whicli,
however, has proved as pernicious or as preposterous
as its predecessor, but, fortunately, quite as ephemeral.
The fact that enlargement of the jsrostate is not a sin-
gle morbid or morphic entity, is more than suggestive
of there being no easy or exclusive way to the proper
management of this ailment. Therefore, no treatment
can be rational or successful which is not based upon
accurate diagnosis, and which is not adapted to the
particular condition of the diseased organ and to its
effects upon the organism. In stating his appraise-
ment of the several modern therapeutic procedures per-
taining to prostatic enlargement, the writer has not
deemed it necessary to specify those that he regards
as useless or harmful.
Infantile Diarrhoea. — Stomach washing should be
employed in cases in which vomiting is obstinate, and
irrigation of the lower bowel will often be found very
useful in acute cases. In the acutest form of diar-
rhoea and vomiting, known as "cholera infantum" and
characterized by great general irritability, by innu-
merable and copious watery motions soon becoming
neutral or alkaline, and by rapidly ensuing collapse
and wasting, with sunken fontanelle, stupor, coma, or
convulsions, we must at first give nothing but frequent
small doses of brandy and plenty of cold water or
barlev water to assuage thirst, and should endeavor at
once to arrest thelomiting and diarrhoea by repeated
subcutaneous injections of morphine, beginning, in the
case of children under a year old, with not more than
oneone-hundredth grain. If vomiting still continue,
brandy or ether must be injected subciitaneously. Hot
mustard baths are to be ordered in the stages of col-
lapse. When in the early irritable stages the temper-
ature nms high, a warm bath gradually cooled down
to about 85" F. should be given and repeated with
subsequent accesses of fever. — Dr. H. IJrv.an Dox-
Ki.N, Ihi: Diseases of C/tilti/iood, p. 54.
586
MEDICAL RECORD.
[October 24, 1896
NOTES ON
THE TREATMENT
FISTUL.-E.'
OF FrECAL
By Frederick: holme wiggin. m.d..
VISITING GYNECOLOGIST TO THE NEW YORK CITY HOSI'ITAL AND VISITING
•iURGEON TO ST. ELIZADETH's HOSPITAL.
The three cases to which it is the chief purpose of
this paper to call attention seem to be of sufficient
general interest to warrant their presentation for con-
sideration and discussion. All of them were success-
fully treated by surgical procedures — one by enterec-
tomy and anastomosis, by the method of Maunsell;
and the others by enterorrhaphy. There are few con-
ditions to which patients are liable that cause them
greater mental and, at times, bodily distress, than do
the occurrence and persistence of a fa;cal fistula.
While it produces directly serious disturbance to bod-
ily nutrition only when it is situated at some distance
above the ileocecal valve, it indirectly causes bodily
deterioration, as wherever located it causes much cu-
taneous irritation and entire loss of control by the pa-
tient of tlie intestinal contents, rendering those so
afflicted most offensive, in spite of all that can be done
for them by means of pads and trusses, and limiting
their usefulness during the duration of the defect.
The most frequent cause of the occurrence of faecal
fistula may be stated to be the delay in resorting to
operative measures for their relief to which patients
suffering from typhlenteritis and strangulated hernia,
whether it be of the internal or external variety, are
too often subjected while their ailment is carefully di-
agnosticated. Among the other more common causes
are the employment of drainage following abdominal
operations, especially by means of tubes: imperfect
technique in operations upon or about the intestines:
as a result of an ulcerative process within the gut: or
from gunshot or stab wounds. A recent writer on the
subject under consideration stated that, in his opinion,
" the best treatment for this condition consists in
its prevention, when possible, .by a resort to early ope-
ration in those cases in which the occurrence of a fae-
cal fistula is a possible result." In this \ie\v the
writer of this paper heartily concurs.
But in a case in which this dread condition has fol-
lowed in the train of some intestinal disorder, what-
ever the cause, what course should the physician ad-
vise his patient to follow, to the end that he may be
relieved from his distressing disability with as little
risk to life and the least possible inconvenience? .\s
is well known, many of these fistulrc gradually con-
tract and close spontaneously; and, therefore, it is
well, if the fistula is of small size, with only a slight
faecal discharge, and can be located near or below the
ileo-caecal valve, to postpone operative measures for a
reasonable time, in the hope that it will gradually
contract and eventually close spontaneously. In those
more serious cases in which tiie opening, on account of
its size, location, and the fact that it is accompanied
by an intestinal flexure or a growth causing obstruc-
tion to the passage of the bowel contents, fails to di-
minish in size after a few weeks, operative measures
should unhesitatingly be advised.
On May 16, 1896, the writer received an invila
tion, extended to him by reason of a vote of the medi-
cal board of the Hartford (Connefticut) Hospital, as
well as a personal, request from the visiting surgeon.
Dr. H. G. Howe, then doing duty, to visit that institu-
tion for the purpose of operating upon two patients,
each of wliom was suffering from a faecal fistula, with
a view to demonstrating the method of intestinal anas-
tomosis by invagination and suture devised by Maun-
sell, which the writer has advocated for several years
past as preferable to and more surgical than that orig-
' Read at the thirteenth annual meeting of the New Vort;
State Medical Association, October 13, i8g6.
inated by Murphy, of Chicago, in the event of simple
suture of the bowel opening not sufficing to remedy
the defect. Accordingly, on May 17th, the writer vis-
ited the hospital, and, with the kind and valuable as-
sistance of Dr. Howe and Dr. Ingalls, the operations
were performed. For the histories of the two cases the
writer is indebted to the house surgeon, Dr. Naylor.
Case I. — L. M , male, aged twenty-two years, a
farmer, was admitted to the Hartford Hospital, on Au-
gust 3, 1894. He said that about six weeks previous to
admission he had had an attack of what was diagnosti-
cated as bilious colic, and for nine days nothing had
escaped from the bowels. Under medical treatment
the bowels finally moved, greatly to the patient's re-
lief. Four weeks after the seizure, an abscess opened
spontaneously in the patient's groin, near the lower
end of Poupart's ligament. P'our days later, another
opening occurred in the right iliac region. Both open-
ings remained patent, and discharged pus and farcal
matter freely.
On August 7 th the patient was operated upon. The
whole layer of the abdomen above the muscle was cov-
ered with pus and faecal matter. On opening the
abdomen an abscess cavity was discovered, in which
the appendix was found in a gangrenous condition.
This was removed, and the abscess cavity drained.
Fffices, however, continued to be discharged through
the wound.
On August 2Sth, another attempt was made to close
the opening which was found in the gut. The perito-
neal surfaces were approximated by means of Lembert's
sutures, over which the omentum was grafted.
On September 1st it was noted that the stitches had
not held, and that in consequence the fistula had re-
opened and was discharging fa-cal matter.
On No\'ember 25th the patient left the hospital, with
the bowel opening still patent.
He was readmitted on May 3, 1896, with the local
condition unchanged. He was given light diet, and
on May i7tli, after the usual preparation, he was anaes-
thetized, and examination revealed the fact that a fae-
cal fistula of large size existed, the external opening -
being located at a point in tiie old cicatrix opposite
the anterior superior spine of the ileum, about two and
one-half inches to its inner side. The peritoneal coat
of the intestine surrounding the opening in the gut had
united to tlie parietal peritoneum, and the mucous coat
of the intestine had united to the cutaneous tissue and
was everted, forming an artificial anus. The parts,
including the interior of the bowel adjoining the fis-
tulous opening, were washed with hydrozone. The
foam resulting from the decomposition of the liquid
and the liberation of the contained oxygen was al-
lowed to remain for some minutes before it was re-
moved; after which an incision, about four inches in
length, was made, having the opening in the gut for
its centre. The old scar tissue was excised as far as
possible, and the remaining fistulous tract vigorously
scraped with a sharp spoon. When the peritoneum
was reached, the gut was freed from it by dissection.
The edges of the opening in the gut were then caught
and held by clamps, while the adhesions which
bound down the flexed knuckle were dissected away
and broken up. The loop of gut containing the
opening was then brought outside of the abdominal
cavity, which was shut off by means of gauze and
sponges. It was found to be located in the lower por-
tion of the ileum. It was laterally situated, involving
a large portion of the intestinal calibre, and was so
irregular in shape that it was thought wise to excise
the damaged and thickened portion of the bowel,
which was about four inches in length.
This was accomplished after the application of Mc-
Laren's clamps to the gut at some distance from the
points of incision, and the anastomosis of the divided
October 24, i8g6]
MEDICAL RECORD.
587
ends was effected by means of the technique already
alluded to, devised by the late Professor Maunsell,
and described by the writer in an article entitled
"The Technics of Maunsell's Method of Intestinal
Anastomosis," which appeared in the New York Alcd-
iaxl Jitiinial oi December 14, 1895. Before the anas-
tomosed bowel was returned into the peritoneal cavity,
the points of suture were well washed with a fifty-per-
cent, solution of hydrozone in sterilized water. Some
of the full-strength hydrozone was again poured over
the tissues in the former site of the fistulous tract, for
the double purpose of arresting the oozing, which was
free, from the remaining cicatricial tissue, as well as
to render the parts aseptic. After the return of the
bowel into the peritoneal cavity and the placing of a
single row of silkworm-gut sutures, which included all
the layers in the abdominal wall, the cavity was flushed
with saline solution, some of which was allowed to re-
main. The sutures were then tied, thus closing the
wound without drainage. The cutaneous surface about
the wound was washed with hydrozone and then freely
dusted "over with acetaniliil powder, and the usual
dressings were applied,
The convalescence was uneventful. The patient's
bowels moved four times on the fourth day, and daily
thereafter. On the same day his pulse rate and bodily
temperature became normal, and have remained so.
The wound in the abdominal wall united primarily,
except for about one inch of the skin, in the middle.
On the twelfth day following the operation the patient
was allowed to lea\e his bed, and was given ordinary
diet. At this time it was noted that the patient slept
well, that his pulse was strong, that he was free from
pain, and that his general condition was good.
Case II. — W. R , male, aged five years, was
admitted into the Hartford Hospital during May,
1895, suffering from typhlenteritis. The abdominal
cavity was opened and a large abscess was found, the
cavity of which was washed out and drained without any
attempt being made to find the appendi.x. Soon after
the performance of the operation, fa'cal matter appeared
in the discharge. During the year several unsuccess-
ftil efforts were made at intervals to close the fistula
by suture, prior to May 17, 1896, when the following
procedure was undertaken for the patient's relief:
The fistulous opening was located about one inch
and a haif from the anterior superior iliac spine, on a
line drawn therefrom to the umbilicus. After the
usual preparations the surrounding skin was washed
with hydrozone, and this was also injected into the
sinus. An incision was then made on either side of
the old cicatri.x, and it was removed. The peritoneum
was separated from the opening in the gut, the edges
of which were held together by clamps. The intes-
tinal opening, which was one inch and a half in diam-
eter, proved to be situated in the ca;cum near the
ileo-cacal valve. The head of the colon and adjoining
gut were freed by dissection till that portion contain-
ing the opening could be brought outside of the abdo-
men. The general cavity of the peritoneum having
been shut off by gauze, the gut was again washed with
a fifty-per-cent. solution of hydrozone. The edges of
the fistulous opening were approximated by a purse-
string suture of silk. The peritoneal coat of the gut
was then approximated by means of Lembert's sutures,
and, finally, after using more of the fifty-per-cent. so-
lution of hydrozone, a portion of omentum was placed
over the gut at this point and caught down on either
side by sutures, and the bowel was returned into the
peritoneal cavity. The old opening in the abdominal
wall was scraped and washed with hydrozone, and the
edges of the abdominal wound were united by silkworm-
gut sutures, which included all the layers. As there
had been such long-continued discharge of faecal mat-
ter and pus, it was thought best to leave one of the
stitches untied, and for drainage a narrow strip of
gauze was passed down to the bottom of the cavity.
The convalescence was uneventful, except for the
formation of a small abscess at the point where the
gauze drain was inserted. This was cleaned out with
hydrozone and healed kindly, and on May 30th, the
thirteenth day after operation, it was noted that the
patient was free from pain, that he had a good pulse
and appetite, and that his general condition was all
that could be desired.
Case HI. — On May 17, 1896, the writer was in-
vited by Dr. Nathan Mayer and Dr. P. H. Ingalls, of
Hartford, to see in consultation C. H , male, aged
fifty-two years, whose history was as follows:
On March 17, 1896, he had been seized with an at-
tack of what proved to be typhlenteritis, and on March
25th a large abscess was opened and its contents were
evacuated. After the cavity had been irrigated, it
was packed with gauze. No attempt was made to
find the appendix. About five weeks after the op-
eration fa:-cal matter began to escape from the re-
maining wound and a fa.'cal fistula developed, through
which more or less of the contents of the intestinal
canal passed. On examination, an artificial anus was
found, situated about one inch and a half from the an-
terior superior iliac spine, on a line from this point to
the umbilicus, and about one inch in diameter. The
mucous lining of the bowel was adherent to the cuta-
neous tissue, and was everted and protruded. As it
was possible by the use of pads largely to control the
passage of f.Tecal matter through the opening, and the
patient's condition was not considered favorable, im-
mediate operation was not advised; but the opinion
was expressed that on account of the size of the open-
ing and the attachment of the mucous membrane to
the cutaneous tissue and its eversion, it was improba-
ble that the opening would close spontaneously. A
few weeks later, the patient's general condition hav-
ing improved, on account of the annoyance caused
him by the lack of control over the bowel contents
and the irritation of the skin by the passage over it of
fa;cal matter, it was deemed best to attempt the clos-
ure of the opening.
On June 17th, assisted by Dr. Ingalls, Dr. Mayer,
Dr. Shepard, and Dr. Steam, of Hartford, and Dr.
Parker Syms, of this city, at the patient's home,
the following operation was performed: After the
preparation of the patient in the usual manner and
the administration of the anassthetic, the skin sur-
rounding the opening was washed with hydrozone,
some being also injected into the interior of the
bowel. Then a small sponge attached to a piece
of silk was passed into the bowel, plugging the
opening. An incision was made on either side of the
old cicatrix, having the bowel opening for its centre.
Thus the old scar tissue was excised. The parietal
peritoneum was next freed from its attachment to the
gut, and existing adhesions were broken up and the
gut was withrawn from the peritoneal cavity, which
was shut off by gauze. The opening proved to be sit-
uated in the side of the caecum, above and about one
inch and a half from the point of attachment of the
appendix, of which two and one-half inches remained.
This was removed after the opening in the gut had
been closed, first by a purse-.string suture, and then by
several rows of Lembert's sutures. After this, the
bowel surface was washed with a fifty-per-cent. solu-
tion of hydrozone, and as an additional precaution
the omentum was drawn over and sutured to the bowel.
The abdominal walls were approximated by silkworm-
gut sutures, which passed through all the abdominal
layers; but, as there had been some loss of tissue dur-
ing the continued suppuration, the fascia was approxi-
mated by interrupted sutures of catgut. Drainage was
not employed.
588
MEDICAL RECORD.
[October 24, 1896
Convalescence was uneventful, aside from the for-
mation of a stitch abscess, and the patient has re-
mained in good health up to the present time.
The cause of the fistulous openings in Cases I. and
II. was undoubtedly the failure in the first, and de-
lay in the second, to resort to surgical measures for
their relief. In both of these cases the trouble appar-
ently originated in an attack of typhlenteritis, to which
was added, in the first case, probable strangulation of
the lower portion of the ileum by a band, and which
perforated after it had become shut off from the gen-
eral cavity by adhesive peritonitis. In the second
case, the abscess apparently ruptured into the caecum
before the external opening was made. In the third
case, the cause of the opening was either the pressure
on the gut of the material used to drain the abscess
cavity, or it was the result of an inflammatory process
within the ca;cum, as the perforation did not manifest
itself until five week's after the opening of the abscess.
Another point of interest in Cases I. and II. is the fact
that several previous unsuccessful efforts to close the
openings in the bowel had been made. The reason
why these efforts had proved ineffectual, in the writer's
opinion, is that the operative measures undertaken for
their relief were not sufficiently radical in character,
the efforts being directed to closing the bowel opening
onlv, and no attempt Iseing made to restore the fa-pal
passage by breaking up the e.xisting adhesions which
had caused more or less intestinal angulation, and
consequently too much pressure was brought to bear
on the sutures, and they quickly cut out, allowing the
fistula; to reopen.
I'he method of closing frccal fistula; without open-
ing the peritoneal cavity and relieving the obstruc-
tion from adhesions seems to be approved by J. Gregg
Smith, in a paper which appeared in the Bristol
Medko-Chinirgiuil Rerifi,; March, 1895. Undoubt-
edly, it is well when possible to close the opening
in the bowel before breaking up the peritoneal adhe-
sions, but as soon as this has been accomplisiied an
effort should, in all cases in which operation is deemed
a necessity, be made to remove the existing obstruc-
tion to the fa;cal current by destroying the adhesions
which hold the bowel in a malposition. In fact, few
cases which would not heal spontaneously will be ben-
efited by simple closure of the bowel opening, if the
obstruction is allowed to continue.
p:ver since September, 1893, when the writer proved
the value of hydrogen dioxide as an effective antisep-
tic which in proper solution did not unduly irritate
the peritoneum, when followed up by a six-tenth-per-
cent, saline solution, he has had little reason to fear
the danger of causing septic peritonitis from the acci-
dental escape of pus or facal matter while operating.
He employs all po.ssible measures to prevent the oc-
currence of this complication, but when it occurs it is
invariably successfully met by the use of hydrogen di-
oxide, as heretofore described. In those cases in which
the gut around and about the opening is much thick-
ened and friable, by reason of the longstanding in-
flammatory process, it is the writer's belief that it is
best to resect the diseased portion of the bowel, and
join the ends of the bowel by the suture method of
Maunsell. With a proper understanding on the sur-
geon's part of the techniciue and the objects to be at-
tained by operation — i.e., the restoration of the integ-
rity of tiie intestinal canal, as well as the closure of
the bowel opening— the operation undertaken for the
relief of patients suffering from facal fistula should
be devoid of unusual danger, and failure to succeed
in rescuing these patients from their unfortunate and
distressing plight should prove the exception rather
than, as at present, the rule.
55 West Thikt\-Sixth Street.
THE ADMINISTRATION OF THYROID IN
EPILEPSY, WITH REPORT OF FOUR TRI-
AL CASES.
By L. pierce CLARK, iM.D.,
ASSISTANT l-HVSICIAN,
CKAIG COLONY, SONVEA, N. V.
Since the administration of thyroid in various nerve
lesions, aside from myxcedema, has been attended with
favorable results, a trial of its efficacy in epilepsy was
made. To be sure, its administration was not rational,
but it was given, as it has been in many other nerve
lesions, purely from empiricism. The cases selected
were those in which many congenital defects were no-
ticeable, and in which epilepsy had been a prominent
feature of the patient's life since early infancy. Xn
effort was also made to select those cases in which de-
fective development mentally as well as physically was
manifest.
Case I.— C. D , male, aged twenty-one, no oc-
cupation. His epilepsy began at the age of six. No
prenatal causes were found, and all bad heredity was
denied. The cause of his epilepsy was not given.
His attacks were of the grand-mal type, preceded by no
aura and followed by considerable stupor and mental
depression. The attacks occurred generally at night.
On his admission the physical examination showed
marked cardiac hypertrophy. The pulse registered 80,
of fair quality and quantity. There were retraction and
consolidation at the apex of the right lung. The right
shoulder had suffered displacement downward, and
joint atrophy had taken place as a result. Yet it is a
question as to whether this condition of joint atrophy
was caused bv trauma or whetiier it was a result of con-
genital defect, such as is described by various authors
as often attending epilepsy in idiocy and imbecility.
All active muscular movements of the patient were very
slow, awkward, and uncertain. Intellection was very
difficult and imperfect. At the time of the patient's
admission to the colony it was necessary to assist
him to dress and undress. For some years previous
to his admission to the colony, the patient had been
addicted to inhaling the smoke of large numbers of ci-
garettes daily, and conseciuently suffered from a con-
dition of atrophic rhinitis. I'his case was placed upon
thyroids, the same as the following cases— five grains
of' the desiccated thyroid, t.i.d. After the first three
days of the administration of the thyroid, the patient
showed the toxic effects of the drug, which were mani-
fested by a profuse perspiration, increase in rapidity
and irregularitv of pulse beat, and a diffuse congestion
of the skin of the face and hands, giving a typical
"boiled-lobster" appearance. The patient was a lit-
tle more active in his physical movements, and his
mental processes were a little brighter, but not more so
than might arise from the stimulating effect of the thy-
roid. Fifteen grains per day were administered for
twentv-one days, at which time treatment was discon-
tinued. Some permanent improvement in the physical
and mental condition has been noticed in this case.
Whereas before commencing the treatment he was not
able to care for himself, he is now able to do so, and,
in addition, engages in field labor with the farmers for
two or three hours each day. Notwithstanding the
treatment did not materially lessen his attacks, yet it
was followed by physical and mental changes warrant-
ing its use in such a case. Itesides, the writer is not
prepared to admit that a diminution in the frequency
of attacks is the only favorable indication of improve-
ment in an epileptic, especially in such a one as is
described here.
Case II.— O. H , male, aged sixteen, no occu-
pation. His epilepsv began at the age of five months.
\ cousin had been afflicted with epilepsy and a sister
suffered from exophthalmic goitre. Phthisis had been
quite prevalent in the family. The cause of the pa-
October 24, 1896]
MEDICAL RECORD.
589
tient's attacks was not stated, but they were evidently
due to congenita! defect plus a bad heredity. His
seizures were of the grand-mal type, preceded by no
aura and followed by a prolonged sleep stage. The at-
tacks occurred both by night and by day. Considerable
hypertrophy of the heart was found, but circulation
was normal On his admission the pulse registered 84,
and was normal in force and rhythm. The speech was
monotonous and expressionless. 'I'he patient presented
left thyroid enlargement, but no noticeable e.xophthal-
mos. He had a narrow, high-arched palate : thick,
rough lips; and massive, underhanging jaw. The pa-
tient's active muscular movements were sluggish, awk-
ward, and uncertain; and his mental processes were
slow, indefinite, and purposeless. He required some
assistance to dress and undress. This patient did not
manifest so many toxic efTects of the thyroid treatment
as did the patient in Case I. After the first day of the
administration of the thyroid, the patient began to
dress himself and engaged in daily out-door work,
which he has continued to perform up to the time this
report is made. Although the physical health of the
patient has improved during the thyroid treatment, but
little mental change is manifest. His epilepsy re-
mains unchanged.
C.^SE ni. — M.J , female, aged seventeen. She
was able to perform some light housework. Her epi-
lepsy made its appearance in very early infancy. The
cause was probably a congenital defect plus any slight
e.xcitant. Heredity unknown ; prenatal influences un-
known. Her attacks were of the grand-mal type, and
occurred monthly, both by day and by night, preceded
by no aura and followed by prolonged mental stupor.
The patient was a low-grade imbecile, very talkative,
industrious, and cheerful. The heart action was irreg-
ular in force and rhythm, and the pulse rate was go per
minute. Patient presented a great number of the stig-
mata of degeneration — somatic and physical. The
administration of thyroid in this case was attended by
nearly the same toxic effects as were noticed in Case
I. During the latter part of her treatment her seizures
became very much less frequent, and she was able to
perform mental and physical acts with giiater celerity.
C.\SF. IV. — E. McC , female, aged seventeen.
On admission she was able to perform light household
duties. Her attacks began in cirly infancy: cause,
probably a congenital one. Her attacks were reported
to be grand mal in character and to occur every two
months. They were preceded by no aura and fol-
lowed by but little mental depression. Patient was a
high-grade imbecile. Physical examination showed
that the heart was normal and pulse rate was 96. .\
convulsive tic of the orbicularis palpebrarum of the
right side was discovered. The treatment in tiiis case
was followed bv an increased motor restlessness and
mental activity. The latter named condition was in
marked contrast to her former apathy and indisposi-
tion. She became very mischievous and unmanage-
able. On July 26, 1896, three weeks after treatment
was established, the patient had her first seizure since
her admission to the colony (February 14, 1896). The
convulsive seizure began with the typical epileptic cr\%
followed by tonic and later by clonic muscular spasm.
The attack lasted for five minutes, and in three hours
was followed by another, and in four hours by a third.
The last two were, to all appearances, of the same
general character as the first. It would seem as though
these seizures were caused, in a measure at least, by
the administration of the thyroid; or the administra-
tion of the thyroid and the occurrence of the seizures
just at this time was a remarkable coincidence.
Case V. — C. W . In this case the thyroid was
administered principally for the purpose of reducing
obesity, and it resulted in the patient losing nineteen
pounds in one month. It is true that this subject was
also placed upon restricted diet and made to perform
considerable physical labor, which undoubtedly in-
creased the reducing power of the treatment. An im-
portant fact which seems to the writer to show quite
conclusively that the reducing power of thyroid is
mainly due to its toxic properties, is that the four se-
lected subjects quickly regained their lost weight, al-
though under the same diet and performing the same
amount and kind of physical labor. In Case V. the
patient gained twelve pounds in weight in two weeks
after the discontinuance of thyroid, diet and exercise
remaining the same as during the administration.
It would appear that the administration of thyroid
in these cases was not attended with ver\' good results.
While all seemed to be benefited for the time being
in some ways, I doubt whether there will be any per-
manent improvement. .Mthough remarkable reducing
power in obesity seems to be due to the toxic effects of
thyroid, yet in some cases in which it is given for the
sole purpose of reducing weight it is not attended by
such marked physical disturbances as in those cases in
which but little weight is lost. All of the trial sub-
jects lost from three to ten pounds in weight during the
treatment. This the writer attributes mainly to the
drug's toxic properties and the excess of tissue changes
produced by such upon the organism. On the whole,
its small effect upon epileptic seizures in these trial
cases would not seem to justify its continued use in
epilepsy, and its further administration has not been
attempted.
progress of |]tXedical J^cience.
Chloride of Calcium, in dose of eighteen grains
dissolved in half a glass of water, to which a teaspoon-
ful of tincture of bitter orange peel and two dessert-
spoonfuls of chloroform water are added, taken al-
ways after meals, is advised by Dr. ^^'right in the
treatment of pruritus and urticaria. The dose in ob-
stinate cases can be increased gradually to twice the
quantity mentioned. — Re-\ Iiifrniaf. dc Med.et dc C/iir.,
September 25, 1896.
Is Inherited Syphilis Contagious? — Dr. Robert
W. Parker, after twenty years' experience at the East
London Children's Hospital, has arrived at the fol-
lowing conclusions; i. The children of syphilitic
parents very frequently show manifestations of a dis-
ease which is almost universally called ''inherited
syphilis." 2. In a large proportion of cases this
inherited disease is not syphilis at all, in that the dis-
ease is non-contagious, and would be better named
"inherited from syphilis." 3. This inherited disease
is true syphilis only if it conform to the ordinary tests
which pertain to contact syphilis and pro\e to be in-
fectious and contagious. 4. Tiie children of syphilitic
parents occasionally inherit syphilis. 5. The mother
suckling a child with such a disease may be infected
by it. 6. A healthy wetnurse and other persons
brought into contact with such a child are even more
liable to be infected by it than the mother. 7. Lymph
taken from such a child, even although apparently
well at the time, will probably, or possibly, invacci-
nate syphilis. 8. In reply to the question. Can a
healthy woman give birth to a syphilitic child ? the
answer must be No. 9. Many women give birth to
children who suffer from what is called "inherited
syphilis" without themselves appearing to be infected.
The explanation is obvious: this " inherited syphilis"
is not syphilis in the true sense, and the mother's so-
called escape depends on this fact. 10. There is no
recent clinical evidence which fully realizes Colles'
teaching, viz., a mother suckling her own syphilitic
590
MEDICAL RECORD.
[October 24, 1896
infant and escaping an infection to wliich a healtliy
wetnurse suckling the same infant and otiier mem-
bers of her family, who have merely handled this
infant, have succumbed, the latter facts being essen-
tial, if only to establish the contagiousness of the
infant's disease in any and every given case asserted
to be " inherited syphilis." — Ediinmrgli Medical Jour-
nal.
The Treatment rf Pain in Renal Colic. — In
this condition, in which the pain is often atrocious
and perhaps associated with persistent anuria, with
danger of uramia, the following treatment is recom-
mended. In the first place a poultice containing a
large amount of laudanum is placed upon the lumbar
region or upon the anterior abdominal walls. The
heat not only acts as an antispasmodic and thereby
modifies the spasmodic contractions of tiie ureters, but
also in this way fa\'ors the escape of the stone. Full
doses of the extract of opium or morphine should be
given, and should the stomach be too irritable to re-
tain it the extract of opium or laudanum may be given
by rectal injection. The great difficulty in using
hypodermic injections of morphine in these cases is
that the patient gets into the habit of handling the
syringe himself. As a rule it is wise not to use any
more morphine than is absolutely necessary to make
the pain bearable. In some instances the following
suppository is useful :
I^ E.\tract of belladonna gr. y^.
E.\tract of opium S^- 'A-
Cacao butter '. gr. xlv.
In other instances it has been found that the ad-
ministration of antipyrin by the mouth or by hypo-
dermic injections is useful, although hypodermic
injections of this drug are exceedingly painful for the
first few minutes. It is thought by some that the
antipyrin also aids in the elimination of uric acid. If
hypodermic injections are used, the following formula
may be employed :
H Antipyrin gr. xl.
Water 3 'ij.
A hypodermic syringeful of this solution to he given at
a dose.
In other instances chloral by rectal injection tends
not only to produce nervous quiet, but also to permit
sleep. The following formula may be used:
I^ Chloral gr. .\xx.
Wine of opium gtt. x.
Decoction of marshmallow 3 iv.
This injection should be warm. The advantage in
adding the opiate is a double one, in that it relieves
pain and tends to cause the retention of the injection
until the chloral can be absorbed.
If the pain is very severe, chloroform or ether may
be used until the development of an anesthesia equiv-
alent to that produced ordinarily during parturition,
or, in other words, until enough is given to relieve
the acme of the paroxysm. Sometimes a general hot
bath is of value in relaxing the local spasm and pro-
ducing general relaxation. — Therapeutic Gazette.
Subcutaneous Wiring of the Patella Dr. Bar-
ker (British Medical Journal, April 18, 189G) de-
scribes his method of operating for fracture of the
patella. The ligature used is silver wire instead of
silk. The operation is to be done at once on the en-
trance of the patient to the hospital, usually within
twelve hours of the fracture. The method is not
adapted to old cases, but only to recent ones. No
splint is used, simply the dressings, and massage and
slight passive motion are made immediately following
the operation. He operates as follows: The field of
operation is made aseptic and the lower fragment
steadied between the operator's left finger and thumb
while a narrow-bladed knife is thrust exactly through
the middle of the upper attachment of the patellai liga-
ment, with its upward edge cutting on the bone. When
the blade has entered the joint it is withdrawn, still
cutting on the lower edge of the lower fragment, and
enlarging the skin wound upward to the extent of two-
thirds of an inch. Through this opening a long stout
needle is thrust into the joint behind both fragments
and made to pierce the tendon of the quadriceps close
to the upper edge of the upper fragment, exactly in the
middle line. A knife is then entered alongside of the
needle and a cut made down to the bone. A stout
silver wire, the size of a No. 1 English catheter, is
then threaded in the needle and withdrawn. The
needle is unthreaded and passed from the lower to the
upper opening between the skin and upper surface of
the fragments. It is then threaded with the wire and
withdrawn. The two ends of the wire emerging from
the lower opening are then wrapped around a couple
of rods to secure a firm hold, and crossed, drawn tight,
and twisted three times. Before twisting, the blood
should be squeezed out of the joint. The whole ope-
ration should not take more than five minutes. By
this method a firm limb is said to be obtained with
good rtexion and extension and apparently bony union.
In cutting olT the w ires, ends half an inch long should
be left, which are to be passed back into the opening
and spread out in the soft parts. The broken ends of
the bone should be well rubbed together before ope-
rating, so as to clear the separated parts of all clots
and fibrous tissue. — The University Medical Magazine.
Penetrating Wounds of the Spinal Cord.— Dr.
Enderlen has announced the following conclusions,
based on experiments on animals: i. The degenera-
tion of the spinal cord after a wound is not localized
to the point of the lesion, but extends to adjacent
parts. 2. The extension of the degeneration is not
always uniform; that is, there does not appear to be
any rule governing the process; however, the more
extensive the lesion, the greater the extent of degene-
ration. 3. In the course of time the number of swol-
len axis cylinders decrea.ses, but they may be found
for a comparatively long time (thirty-fiftli day). 4.
In consequence of the lesion there is an increase in
the neuroglia. 5. The gray substance assumes its
normal condition in a short time ; aboie and below the
wound there is seen an increase of the ganglion-cells;
in the region of the wound these cells degenerate. 6.
Independently of the point of lesion there are points
of degeneration in the spinal cord, partly on the side
of the puncture, and partly in the other half. 7. As
regards the arrest of degeneration in the several fibres,
it will be found that in many cases the posterior fibres
are already free, while in other tracts there are still
swollen axis cylinders and wide glia meshes. In a
few cases the opposite may exist. As regards the
swelling, the author noted its presence two hours after
the wound. He could find no instance of regeneration
after injury. The author also injected fresh blood
above and below the dura, and also introduced small
particles of kidney beneath the dura, and found de-
generation as a result. This he did not think due to
pressure, hut to disturbance of the circulation, either
active or passi\e. — Deutsche Zeitschrift fiir Chirurgie.
The Pathogeny of Diabetes. — Dr. Kaufmann says
in the Medical Week that the functional activity of the
organism determines not only the consumption of
sugar, but its formation by the liver. The consump-
tion of sugar is an inherent property of the vitality of
the cells, like the consumption of o.xygen, and any
variations in the amount of sugar in the blood depend
not upon this, but upon the supply, which is, however,
October 24, 1896]
MEDICAL RECORD.
591
governed by the demand. In hibernating animals the
sugar in the blood diminishes during the period of
stupor, but rapidly increases after the awakening,
which is quite contrary to what we should expect if
the amount of sugar in the blood were dependent upon
its consumption in the tissues. In the horse glyca:mia
increases under the influence of muscular exertion.
The liver forms sugar and stores it, but if its storage
limits are exceeded an excess may pass into the blood,
and this occurs during the digestion of saccharine
substances. The storage capacity of the liver is di-
minished by pathological changes which interfere
with the vitality of the hepatic cells, eg:, in cirrhosis.
The internal pancreatic secretion moderates the glu-
cose-formative power of the liver and at the same time
expands its storage limits. Toxic and asphyxial gly-
cosuria are due to over-stimulation of the glucose-
formative function of the liver. In true pancreatic
•diabetes there is no valid reason for supposing that
the mechanism is otherwise. The most recent re-
searches (Voit, Leo) have reversed the older conclu-
sion that diabetics absorbed less oxygen and exhaled
less CO, than healthy persons. The observation of
Le'pine and his collaborators that diabetic blood has
a diminished power of destroying sugar is at least
exceptional, as the author found the consumption of
sugar in healthy and diabetic animals to be the same,
not in one experiment but in a series of comparative
experiments. He does not deny that in some cases of
diabetes at certain stages there may be a decrease in
the consumption of sugar, but this is not constant and
appears only under special circumstances. Diabetes
mellitus, however caused, is invariably produced by
an excessive production of glucose and not by arrested
or defective destruction of sugar in the capillaries.
Camphorated Naphthol by injection in the treat-
ment of lupus is particularly indicated in nodules of
medium size without ulceration. Two parts of cam-
phor to one of naphthol are employed. The skin is
rendered aseptic with a sublimate wash (four per
cent.). Half a drop of the injection fluid is deposited
in the centre of three or four nodules at each sitting.
An interval of from four to eight days is advised be-
tween the sittings. In mild cases a cure is effected
in from two to four months, during which time the pa-
tient goes about his usual occupation. Cod-liver oil
■n'ith creosote is administered at the same time. — Za
Med. Moderne, September 23, 1896.
Potassium Nitrate in the Treatment of Burns.
— Dr. Poggi, in a recent thesis on this subject, gives
an account of a treatment that has given excellent re-
sults in all kinds of burns of whatever degree. It
consists in the emplovment of potassium nitrate, which
is administered in baths or in applications of com-
presses that have been wetted with a saturated solution
of this salt, or in lotions that contain the nitrate. Ac-
cording to M. Poggi the nitrate acts especially as a
refrigerant. As it becomes dissolved in the water it
produces a notable lowering of the temperature of the
liquid of from 5^ to 9^ F. If a burned hand or foot
is plunged into a basin of water to which a few spoon-
fuls of the nitrate have been added, the pain ceases
rapidly; if the water becomes slightly heated, the pain
returns, but it is allayed as soon as a fresh quantity of
the salt is added. This bath, which is prolonged from
two to three hours, may bring about the definitive
disappearance of the pain and even prevent the pro-
duction of blisters. The application of the com-
presses also exercises the same influence. By this
means the pain is allayed and cicatrization takes
place without delay. Another remedy in the treat-
ment of burns is calcined magnesia, which, says the
■writer, has been employed by M. Vergelv, who ob-
tained favorable results with it in burns of the tirst
and second degree. The afTected parts are covered
with a thick layer of a paste, which is prepared by
mixing the calcined magnesia with a certain quantity
of water. This paste is allowed to dry on the skin,
and when it becomes detached and falls ofi' it is re-
placed by a fresh application. Very soon after the
paste is applied the pain ceases, and under the pro-
tective covering formed by the magnesia the wounds
recover without leaving the cutaneous pigmentation
which is so often observed to follow burns that have
been allowed to remain exposed to the air. — IiJew York
Medical Journal.
Pyosepticaemic Puerperal Exanthem Simulating
Hemorrhagic Variola. — Ur. Heitzmann has recently
published, in the W'ieiwr tnedizin. IVoc/ieiisdiii/t, a
case in which the eruption appeared a few' days after
confinement, first as a diffuse redness covering the
w'hole body like a scarlatina, accompanied by abun-
dant sweating and oedema of the lower extremities.
Two days later there were rheumatoid pains in the
shoulders and knees. There was high temperature
and rapid pulse. On the eighth day appeared small,
disseniinated pustules, covering the trunk, some of
which resembled those of small -pox. Between the
pustules were hemorrhagic points and petechiee, as
well as sudamina and ecchymoses. Small dermic ab-
scesses subsequently appeared, some of which had to
be opened. The general appearance, especially of the
trunk, was that of variola.
The Ultimate Results in Eighty-Six Cases of
Fibromata of the Uterus Treated by the Apostoli
Method. — Dr. G. Betton Massey reported to the Am-
erican Electro-Therapeutic Association at its annual
meeting in Boston, September 28, 1896, eighty-six
consecutive cases of uterine fibroids treated by the
Apostoli method. After considerable correspondence
and inquiry, the ultimate results (or those existing from
two to eight years after cessation of treatment) were
ascertained in seventy- five cases, and were found to
be as follows:
Anatomic and symptomatic cure :
{a) Destroyed piecemeal by electrolysis through cervix. . . i
(/'). Extruded through cervix in whole or part 4
(c) Disappeared under absorption 12
Symptomatic cure:
(</) With great reduction in size 16
(l>) With slight reduction in size 21
(1) Without change in size 10
Total cases resulting in practical success 64
Symptomatic improvement only 4
Failure to effect any change 6
Made worse i
Total cases resulting in failure to relieve 11
The sixty-four successful cases give a p)ercentage of
85-33 per cent, of successes, and the eleven cases of
slight improvement and no improvement and the one
made worse give a percentage of 14.66 per cent, of
failures. The one case that was made worse was a
cystic intra-uterine growth, that was improperly treated
by electricity before it was generally known that such
cases should not be treated by the classical Apostoli
method. Future statistics will naturally be clear of
such errors of practice; hence it may be said that the
practical ultimate results in a hundred cases projjerly
treated by electricity will be at least eighty-five cases
successfully and satisfactorily handled, and fifteen
cases in which electricity will do no good nor yet any
harm, leaving the tumors unchanged for other methods
promising greater relief. Of the twelve tumors re-
ported as having disappeared by ab.sorption, this fact
was verified by the reader of the paper in but seven
instances, the remainder being reported by the patients
themselves.
592
MEDICAL RECORD.
[October 24, 1896
The Bubonic Plague. — The report of Dr. Aoyoma,
who was sent by the Japanese government to study the
clinical and pathological features of the disease in
Hong-Kong, has recently appeared, and has been made
the subject of an article by Dr. Simon Flexner, in the
Johns Hopkins Hospital BiillcHn, October, 1896. Dr.
Aoyoma contracted the plague himself, but recovered,
while the mortality among the (Chinese was very great,
as shown by the following statement:
Xiimber Affected. Number Diec!
Europeans 11 2
Japanese 10 6
Manilanese . ■ 31 i
Urasinese . . 5 3
Indians 13 10
Portuguese i3 12
Malayanese 3 3
West Indians i i
Chinese 2.6ig 2,447
The symptoms of the disease during the last plague
were not, as was stated by most authors, protean, but
they were quite simple. The disease began for the
most part without prodromata, with a chill, or even in
the first instances with pain and swelling of the glands
and with succeeding chill and fever. Prodromata
when present were usually short and varied in duration
from a few hours to two or three days, or perhaps
somewhat longer. The symptoms in the prodromal
•Stage are prostration, headache, nausea, vomiting, loss
of appetite, vertigo, and only rarely pains in the lum-
bar region or in the back. In the cases of the affec-
tion of the more intelligent population, even before the
outbreak of the fever, slight swelling and pain were
noted in the glands; whereas in the more obtuse Chi-
nese these slighter phenomena were not noticed. The
greater number of cases occur in young males. The
temperature rises quickly to 40° C, or higher. Delir-
ium sets in early. The pulse is usually dicrotic, and
from 90 to 120 per minute. The urine is dark and
contains albumin. The glandular enlargement is
characteristic, beginning in one grouo and involving
others in succession. After the swelling the perigland-
ular tissues become involved, and then the skin.
There may be post-mortem ri.se of temperature to 43"
C. or higher, and muscular contractions may occur af-
ter death, as in cholera. Death occurs from the sec-
ond to the eighth day. In three cases proven by
autopsy to be bubonic, no glandular involvement was
to be made out during life. As regards the cause of the
plague, it maybe said that Kitasato discovered bacilli
in the blood and in the lymphatic glands which
differed somewhat in their morphological characters
but which agreed in their cultural properties. Ac-
cording to Kitasato, the bacillus which appears in the
blood resembles the organism of chicken cholera, pos-
sesses a capsule, the middle portion staining very
faintly; while tlie bacillus obtained from tlie lym-
phatic glands is somewhat longer, has rounded ends,
and stains more uniformly tiian the otiier. The ba-
cillus obtained by Versin is st.ited to have rounded
ends, to be easily stained with the aniline dyes, and
to be decolorized with Gram's method. The ends
again stain more uniformly than the middle part. It
is suggested by Aoyoma that the forms described by
Kitasato as occurring in the blood and retaining the
Gram stain may have been pairs of cocci and not ba-
cilli at all. He regards the association of the bacilli
and cocci as of great importance, inasnuich as in the
greater number of instances the affected glands sup-
purate. Hence it is considered that the suppuration
is caused not by the plague bacilli which are always
present, but through the action of pus-producing bac-
teria which entered along with the former or later than
these; and Aoyoma has further found that in suppu-
rating glands the plague bacilli are either much dimin-
ished in numbers or have entirely disappeared. Tiie
pest bacilli were also, though not constantly, found in
the interstitial substance of the kidneys and in the
glomerular capillaries. They were also present in the
inter- and intra-acinous tissues of the liver. Themes-
enteric glands sometimes contained the bacilli in small
numbers.
Hygienic Rules for the Eyes. — When the eyes ache
close them for five minutes. When they burn bathe
them in water as' hot as can be borne, with a dash of
witch hazel in it. After weeping bathe them in rose
water and lay a towel wet in rose water over them for
five minutes. When they are bloodshot sleep more.
When the whites are yellow and the pupils dull, con-
sult your doctor about your diet.
Remedy for Stage Fright. — The I.yon Medical,
September 6th, states that, according to La Medecine
Moderne for .\ugust 22d, an American physician ad-
vises students to combat the nervous asthenia which
paralyzes their faculties and causes them to lose the
thread of their ideas, by taking ten drops of tincture
of gelsemium three times a day. An Knglish special-
ist prescribes \\ ine of opium to be taken by actors and
singers before going on the stage. From five to six
drops, he says, will give to the most timid actress the
self-possession of the most spirited old player.
Chloroform in Labor. — Dr. Earle (Chicago Clinical
Re-,iu-, No. 7, p. 389 j advocates chloroform in labor
for the following reasons: i. Chloroform is safer in
the parturient than in any other condition. 2. Its
safety is greatly enhanced by proper administration.
3. It diminishes shock. 4. It destroys future dread,
and therefore robs childbirth of one of its principal
objections. 5. It does not affect the fcetus even in
prolonged use. 6. Labor is not prolonged, and the
puerperium is uninfluenced. 7. Uterine inertia is not
more frequent. 8. Its use is invaluable in normal
labor, and positively indicated in all operative proce-
dures.
Uterine Cancer. — The great error so often made is
in expecting to find these women emaciated, with
marked cachexia, hemorrhage, pain, stinking dis-
charges, etc., as evidences of the presence of ma-
lignant diseases. Pain comes on late and is often
absent. Bleeding of a profuse character is rare, es-
pecially very early in the history of the disease. Foul
watery discharges, so often alluded to, are sometimes
absent. .\n irregular flow between the periods is the
symptom most often noticed, and is an important one,
especially if occurring in a woman past the climacteric,
and following sexual intercourse. Man)' cases are
much complicated, and the dangers from the operation
much increased from adhesions, the result of delays
and tinkering. — Intcnmtionol Journal of Surgery.
Alcoholism in Europe and Its Relation to Insan-
ity.— Dr. Darin states, in a paper recently published
in his These dc la Jujiultc dc J'aris, No. 219, that alco-
holism is increasing in Italy and Belgium, and espe-
cially in France, while it is decreasing in Norway,
Switzerland, and Germany. The number of lunatics
in France has also increased. This increase has
been chiefly in the two types of insanity known as al-
coholic mania and general paralysis. This relation
between alcoholism and insanity is shown by the sta-
tistics of different portions of the country, insanity
being most common where alcoholism is most pro-
nounced. The hereditary effects of alcohol are also
striking. According to Legrain, among 814 children
of alcoholic parentage, 322 were degenerates and 174
had not sufficient vitality to live. Among the surviv-
ors are fourteen per cent, of hysterics and seventeen
per cent, of epileptics. General paresis has increased
in Paris in proportion to the frequency of alcoholism.
October 24, 1896]
MEDICAL RECORD.
593
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, October 24, 1896.
THE TREATMENT OF ACUTE ARTICULAR
RHEUMATISM.
Before the days of salicin and salicylic acid, no dis-
ease more than rheumatic fever or rheumatism of the
joints baffled the attempts of the physician to cut short
the attack or to keep the patient fairly comfortable
while It ran its course.
As Dr. Maclagan says, in the preface to the second
edition of his work, which has just appeared : "It was
the despair of physicians. For weeks it went on —
the agonizing pain, the sleepless nights, the drenching
perspirations, the look of misery, the piteous appeals
for relief, in response to which we had nothing to give'
but words of sympathy and encouragement, an occa-
sional opiate, and 'six weeks in bed.'" Surely, a
very decided change for the better has taken place
since these ante-salicyl days, and still the matter is
not so simple as one would believe. The thousand
and one remedies of olden days, including blood-
letting, of which Sydenham thought so well, cannot
be considered as wholly superseded and satisfactorily
replaced by the salicylate of sodium. We must re-
member that in many instances this valuable salt is
contraindicated, as in chronic nephritis; and in many
others cannot be tolerated by the stomach in sufficient
dose to effect its beneficial purpose.
Even when taken in milk or in Vichy water it may
persist in disagreeing with the patient. The dose re-
quired, for the first days at least, is, according to
Morain, eight grams daily; and Germain Se'e believes
that its administration should be continued in gradu-
ally decreasing quantity for a fortnight, in order to
secure a lasting effect. Upon the fibrous thicken-
ings left about joints as sequelae of acute rheumatism,
the salicylic group of remedies seems to have little or
no effect.
In a paper recently published by Dr. Lee, of Chi-
cago, on " How to Cure Rheumatism," the supply of
proper and sufficient nutrition is considered the first
indication to be met. Next in order is the restoration
and preservation of the normal volume of the blood,
its high specific gravity being looked upon as an evi-
dence of deficiency in the liquid element of the blood.
This deficiency he would meet by administering from
two to four litres of pure water daily. Water applied
in various ways to the surface is also advocated. Hy-
drotherapy does not always receive the consideration
its usefulness warrants. In William Murrell's excel-
lent manual of " Pharmacology and Therapeutics,"
just published, eight lines are devoted to the water
cure. One of these lines says, " It is useful in rheu-
matism;" and another that "in persons not accus-
tomed to it, it induces a craving for whiskey." Now,
as alcohol is considered by many to be injurious in
rheumatic affections, it would surely seem too bad if
the water in its cure brought forth the habit of indul-
gence in strong drink, which, in turn, would lead to
recurrences of the original evil.
It is probable that treatment will again undergo a
modification, as the toxin theory, or the chemico-toxic,
or the miasmatic theory of its causation becomes rec-
ognized. Many already believe that there is a germ
infection to account for the genesis of the affection.
Until some radical change in treatment becomes es-
tablished upon a foundation of plausible theory, we
can do no better, it would seem, than to stick to salicy-
late of sodium or oil of wintergreen as the main remedy
for those who can take them without injur)', to which
may be added, especially for the latter class of pa-
tients, such alkalies as the salts of sodium, potassium,
ammonium, and lithium furnish, and to which may be
further added colchicum for certain cases.
Washing out the tissues by causing the patient to
drink large quantities of pure spring water can but
be beneficial within certain definite limits, and the
scientific use of water externally applied surely has a
field of usefulness which has as yet not been ex-
hausted.
THE BUTCHERY OF THE SICK AND
WOUNDED.
The revolution in Cuba furnishes to the world an ex-
ample of the logic of war, which we could wish might
serve as a deterrent to the jingoes of all nations, but
which, of course, will not. A war which is waged be-
tween two peoples for the attainment of a specific ob-
ject will naturally not cease until one or the other
side becomes too weak longer to contend. To be
consistent, therefore, each side should strive, by what-
ever means in its power — bullets, dynamite, poison,
famine — to destroy as many of the enemy as possible.
If any of these chance to be sick or wounded, so much
the better, for they are then an easier prey. It is on
this principle that the war in Cuba is now being
waged, by Spain at least, and, if we can trust the
Spanish accounts, by the revolutionists as well. Con-
cerning the cruelty of the Spaniards we have abun-
dant testimony of the Cubans, of Americans, and of
the Spaniards themselves; and although we have
only Spanish accounts of the murder of the sick by the
Cubans, it is not unlikely that they are in the main
correct, although probably somewhat exaggerated.
The latest evidence of Spain's determination to
crush the rebellion by waging war on the sick is fur-
nished us by a correspondent in Havana, who sends
a copy of the Gaceta Oficial of that city, containing a
decree of the governor-general of the island concern-
ing the sending of medicines from the capital to pro-
vincial towns. After formulating the conditions under
594
MEDICAL RECORD.
[October 24, 1896
which pharmacists are permitted to sell drugs, Gen-
eral VVeyler says that all who disobey these provisions
will be regarded as aiders and abetters of the rebel-
lion, and will be " tried by court martial," which is
euphemy for " executed for the crime of rebellion.'"
Not long ago a physician and his wife were ar-
rested and thrown into prison in Havana for the crime
of having bandaged the wounds of some of the rebels.
Soon after that a body of Spanish soldiers discovered
a hospital near Ininones, and on the order of their
commander put to death with the machete the resident
surgeon and all the sick and wounded inmates, more
than twenty in number, and then burned their bodies,
with the house and outbuildings.
A newspaper in Madrid recently contained an ac-
count of the murder of a Spanish surgeon, who had
been captured by a body of insurgents, after he had
been forced to dress the wounds of some of the party;
and official telegrams from Havana occasionally con-
tain reports of attacks by the revolutionists upon hos-
pitals. We doubt not that some of these reports are
true, for the Cubans can hardly be expected to abstain
from reprisals when they have seen their helpless
comrades butchered. And, moreover, they are logical.
Theorists have sought to establish humane rules for
the carrying on of war, to formulate an ethical code
for the guidance of men engaged in slaughtering each
other; but their efforts are vain. War has been sung
by poets and blessed by the Church, but it is hellish.
THE PROPOSED CONGRESS OF LEPROLOGY.
From replies received by Dr. Albert S. Ashmead, of
this city, to letters addressed by him to many of the
leading leprologists of the world, tlie proposed inter-
national congress of leprology would appear to be an
assured fact. The only questions that remain to be
decided are where the congress will assemble and
when. It was suggested that it meet in Moscow in
August of next year, during tlie session of tlie Inter-
national Medical Congress; but objection has very
properly been raised that the greater would absorb the
lesser, and that the work of tlie leprologists would be
buried beneath the overwhelming mass of papers and
discussions at the general meeting. If it is worlii
while at all for students of leprosy to come together
from all parts of the world to discuss measures for the
suppression of this disease, the assembly ought cer-
tainly to enjoy the dignity of an independent congress.
The necessity of a special congress being conceded,
it was thought best to meet just before the Moscow
congress, so tliat those who wished to attend both
could do .so; and it was furtlier proposed to meet in
Bergen, the home of Dr. Hansen, in honor of the dis-
coverer of the lepra bacillus. Dr. Hansen, however,
recognizing the convenience of a more central point
for the meeting, has expressed his wish that the con-
gress be held in London ; and that seems also to be
the choice of most of those actively interested in the
project. London would certainly appear to be the
place best suited for a meeting of this kind, and we
doubt not it will be finally selected by the promotors
of the congress.
HOT-WATER BOTTLE BURNS.
Less than two years ago attention was directed, in the
editorial colunms of the Medical Record, to the pos-
sibility of most serious injury to patients, especially
during recovery from anjesthesia, from the application
to the body's surface of the ordinary rubber water bag,
even when the water it contained is not excessively
hot. Little had been written till then upon the sub-
ject, and little has been written since. It is bad
enough for a man to have such an unfortunate acci-
dent in his practice, without being called upon to pub-
lish his mishap broadcast.
The question has, however, been widely discussed
in medical gatherings, and since the publication of
our warning at least three large hospitals in this city
have established the rule that the nurse shall remove
the bottle from the bed when the patient is put back
into it from the oj^erating-table.
This is an excellent rule, it seems to us, and one
which might well be established in every hospital in
the land. No harm can come to the patient from heat-
ing the bed, and the precaution would act as a con-
stant reminder to the nurse and internes of the ele-
ment of danger, and would induce watchfulness when
in emergencies it becomes necessar)' to apply heat in
this way to other than operative cases. The fre-
quency with which extensive burns have occurred in
the past was well illustrated in a recent discussion at
the Lenox Medical Society, the members present hav-
ing, with scarcely an exception, instances to relate of
such accidents which had fallen under their observa-
tion, or of which they had direct knowledge. Feeling
that our previous notice of the matter has not been un-
rewarded, we do not hesitate again to call attention to
it, in the hope that it may save some one from an un-
pleasant and unprofitable experience, to say nothing
of the patient.
Bi-niis of the ^^ecU.
Hebrew Physicians at Moscow. — We have re-
cei\ed llie following from the executive committee of
the Twelfth International Congress: " In reply to nu-
merous inquiries in regard to the conditions under
which Israelites may take part in the XII. Interna-
tional Medical Congress, the executive committee
hastens to inform those interested that the minister of
the interior, with the approval H. I. H. the Grand
Duke Sergius Ale.\androvitch, has judged it possible
to authorize the arrival at Moscow, for the congress,
of foreign Hebrew scientists on the same conditions
of other foreigners. They will be obliged, therefore,
the same as the latter, to liave their passports vis^d
by the Russian consul where they reside. Orders
have consequently been given by the minister of for-
eign affairs to the Russian consuls and ministers in
foreign countries, to the effect that the passports of all
persons going to the XH. International Congress of
Moscow must be vise'd without regard to the religious
beliefs of these persons." We trust our Hebrew con-
October 24, 1896]
MEDICAL RECORD.
595
frferes will be duly grateful to His Imperial Highness
Nicholas Alexandrovitch for this gracious permission
to visit one city in his dominions.
The Marine Hospital Service — There will be
held in Washington, D. C, on February 3, 1897, a
competitive examination of candidates for appoint-
ment to the position of assistant surgeon in the Unit-
ed States Marine Hospital service. Candidates are
required to be not less than twenty-one years of age, and
no appointment will be made of any candidate over
thirty years of age. They must be graduates of a rep-
utable medical college and furnish testimonials as to
character. Successful candidates, having made the
required grade, are appointed in order of merit, as va-
cancies arise during the succeeding year. A success-
ful candidate, when recommended for appointment, is
commissioned by the President of the United States
as an assistant surgeon. After four years of service
and a second examination he is entitled to promotion
to the grade of passed assistant surgeon, and to the
rank of surgeon after a third examination, according
to priority, on the occurrence of vacancies in that
grade. The salary of an assistant surgeon is $1,600
per annum, together with furnished quarters, light,
and fuel; that of a passed assistant surgeon, 5i,8oo
per annum; and that of a surgeon, $2,500 per annum.
In addition to these salaries, after five years' service
an additional compensation of ten per cent, of the
annual salary for each five years of service is allowed
medical officers above the rank of assistant surgeon,
the maximum rate, however, not to exceed forty per
cent. When an officer is on duty at a station where
there are no quarters furnished by the government,
commutation of quarters is allowed at the rate of $30
a month for an assistant surgeon, $40 for a passed as-
sistant surgeon, and $50 for a surgeon. The success-
ful candidates, after receiving appointments, are usu-
ally ordered to one of the larger stations for training
in their duties. Full information may be obtained by
addressing the surgeon-general of the Marine Hospi-
tal service, Washington, D. C.
Alvarenga Prize of the College of Physicians of
Philadelphia. — The College of Physicians of Phila-
delphia announces that the next award of the Alva-
renga prize, being the income for one year of the be-
quest of the late Sehor Alvarenga, and amounting to
about $180, will be made on July 14, 1897, provided
that an essay deemed by the committee of award to be
worthy of the prize shall have been offered. Essays
intended for competition may be upon any subject in
medicine, but cannot have been published, and must
be received by the secretary of the college on or be-
fore May I, 1897. Each essay must be sent without
signature, but must be plainly marked with a motto
and be accompanied by a sealed envelope having on
its outside the motto of the paper and within the name
and address of the author. It is a condition of com-
petition that the successful essay or a copy of it shall
remain in possession of the college; other essays will
be returned upon application within three months after
the award. The Alvarenga prize for 1896 was not
awarded.
The Late Dr. Edward S. Farrington. — At a meet-
ing of the West End Medical Society, on October 3,
1896, the following minute was adopted:
" It is with deep regret that we learn, at this our
first meeting of the year, of the death of our esteemed
fellow-member. Dr. Edward S. Farrington, who died
on September 7th, of typhoid fever. He was a man of
fine character, scholarly attainments, and attractive
personality, and was held in high esteem by all who
knew him. We feel that by his death both the society
and the individual members thereof have lost a valu-
able associate and a good and loyal friend.
" We hereby resolve that these, our expressions of
regret and appreciation of our loss, be spread upon
the minutes of this society, and that copies thereof be
transmitted to his family and to the current medical
journals.
"Cyrus J. Strong, M.D.,
" Howard Gillespie Myers, M.D.,
"Charles Good, M.D.,
" Edward L. Williamson, M.D.,
" Committee."
The Late Dr. William Remsen Taylor.— At a
special meeting of the medical board of the Astoria
Hospital, held October 6, 1896, action was taken as
follows:
" The medical board desires to pay tribute to the
memory of William Remsen Taylor, M.D., late presi-
dent of this institution.
" Whereas, The medical board, in the death of Dr.
Taylor, has lost its first executive officer and long-
tried friend ; therefore be it
" Resolved, That the board causes to be spread upon
the minutes of its records these resolutions of appre-
ciation and sorrow.
" Resolved, Further, that the sympathy of the board
be extended to the members of his family; also that
a copy of these resolutions be forwarded to them and
be published.
"Neil A. Fitch, M.D.,
"James D. Trask, M.D.,
" Clarence N. Platt, M.D.,
" Comynittee."
Physician Sued for Pits A novel suit has been
begun against Dr. Feeney, of Staten Island, by an un-
dertaker, who claims $5,000 damages for the marring
of his facial beauty by small-pox. It is charged that
the physician diagnosticated as chicken-pox certain
cases which the undertaker took charge of after death,
and from which he contracted variola. It is reported
that when his lawyer presented in evidence the under-
taker's face the judge ordered it to be marked " Ex-
hibit No. I," to which the objection was raised that it
had been too much marked already. This is an in-
stance in which the undertaker did not prove the tra-
ditional best friend of the physician, who covers up
the latter's mistakes. The unusual scene presented by
a suit at law being brought by a member of one pro-
fession against that of another upon which it feeds,
can be accounted for by the fact that the plaintiff
combined the function of coroner with that of his
other undertakings.
596
MEDICAL RECORD.
[October 24, 1896
The Modesty of Englishmen offers an obstacle to
science which is deplorcible. Mr. Jonathan Hutchin-
son has been giving clinical lectures which were, of
course, very popular, and were attended by many wo-
men practitioners as well as by those of the sterner
sex. It is now announced, however, that only men
will hereafter be permitted to attend the clinics, as
the male patients express an unwillingness to disrobe
and display their lesions in the presence of the ladies.
A Welcome. — Drs. Leith Napier and Ramsay
Smith, who were picked up in London by the govern-
ment of South Australia to take charge of the Adelaide
Hospital, from which the regular staff had been driven
by ^he action of the lay authorities, have arrived at
their posts. At a special meeting of the Victorian
Branch of the British Medical Association, called to
discuss the new arrivals, the following resolution was
adopted :
"That the Victorian Branch of the British Medical
Association desires to place on record its strong dis-
approval of the disloyal action of those medical prac-
titioners who recently accepted appointments at the
Adelaide Hospital in defiance of the protests of the
South Australian Branch.'"
The Water Supply of Philadelphia. — In an arti-
cle in the Dittetic and Hygienic Gazette, on "Typhoid
Fever in Philadelphia," Dr. Henry Leffmann shows
by statistics and topographical data that the high ty-
phoid death rate in that city is, for the most part, di-
rectly due to the use of polluted water, and there is
every reason, he says, to believe that if the present
water supply of tiie city were subjected to filtration
an immediate fall in the typhoid rate would be shown,
and under such circumstances the sanitary condition
of the city would be in the front rank of the large
cities of the world. During the year 1S95 there were
four hundred and sixty-nine deaths from typhoid fever
in Philadelphia, and, estimating the cost of each one
at $100 — a low figure — there was a total expense of
$469,000, "the interest on a sum quite sufficient to
filter all the water." If to that is added the cost for
the cases which terminated in recovery, there would
be a large sum to help pay the first cost of construc-
tion of the filtering plant.
Antitoxin Treatment of Diphtheria in Austria.
— Professor Paltauf has publislied statistics of 1,103
cases of diphtheria in which antitoxin was employed,
with the result of 970 recoveries and 133 deaths,
equivalent to a mortality of 12.5 per cent. He lays
much stress upon the early application of the serum,
for in the case of injections made on the second day
of the disease the mortality amounted to 6.7 per cent.,
whereas in those made on the third day it amounted
to 19 per cent., in those on the fourth to 23 per cent.,
in those on the fifth to 31 per cent., and in those on
and after the sixth to 33.3 per cent. Professor Pal-
tauf makes mention of the epidemic of diphtheria in
Ischl, where in December, 1895, all those children
died who had not received the antitoxin treatment;
whereas in January, 1896, in the cases of 16 children
attacked with the disease and treated with antitoxin
the result was in every way successful. — The Lancet.
Dr. John B. Hamilton, editor of Xtve. Journal of the
Ante r icon Medical Association, lias resigned from the
Marine Hospital service, in order to devote himself to
his editorial duties and the demands of private prac-
tice.
Professor Koch Studying Leprosy. — Dr. Robert
Koch has been sent by the Prussian health depart-
ment to Memel, in Eastern Prussia, in order to study
leprosy and the means by which it is spread, and to
devise measures by which further spread of the dis-
ease in that region may be prevented.
Dr. Irwin, Li Hung Chang's physician, is a genial
and talented Irishman. Just as he left Netley eigh-
teen years ago he heard of a good opening for a doctor
at Tein-Tsin, so he turned him cheerily to the Flow-
ery Land. In 1879 he was called in to attend a
serious case in the imperial yamen. His patient
recovered, he was appointed chief physician to the
viceroy and the viceroy's family, and ever since his
lot has been a happy and prosperous one. — The Can-
ada Lancet.
The Doctor's Debts. — .\ Vienna physician was re-
cently sued for the amount of a bill which he refused
to pay. He claimed, and in this was sustained by the
court, that the practice of medicine was a privileged
profession and not a trade, and that a physician's
property could not be seized for the payment of his
debts. The case was carried from one court to an-
other until it reached the court of appeals, and in all
the decisions were to the same effect, and the creditor
lost his money.
Consecration of St. Luke's Hospital — The new
buildings and chapel of St. Luke's Hospital, at One
Hundred and Thirteenth Street and Morningside
Heights, now nearing completion, were consecrated on
October 17th by Bishops Potter of New York, Little-
john of Long Island, and Huntington of Central New
York, assisted by the archdeacon of the Episcopal
diocese of New York and the clergy of the city. The
board of managers of the hospital, the members of the
medical .staff, and a few of the patrons of the institu-
tion assisted in the ceremonies.
Sir George Murray Humphry, of c:ambridge,
England, died at his home on the evening of Septem-
ber 24th. He was born on July 18, 1820, and at the
age of nineteen entered St. Bartholomew's Hospital,
and immediately upon obtaining his qualification to
practise, when but twenty-two years old, was ap-
pointed surgeon to .Addenbrooke's Hospital, Cam-
bridge. He was a frequent contributor to periodical
literature, and published several works on anatomical
subject. He was chairman of the general committee on
collective investigation of the British Medical Associa-
tion, and himself made and published the results of
the investigation on old age. He was among the first
to call attention to the fact, which has since come to be
very generally recognized, that the aged bear the shock
of injuries and surgical operations wonderfully well
and that their power of resistance to disease is often
as great as that of younger persons. He received the
honor of knighthood in 1891.
October 24, 1896]
MEDICAL RECORD.
597
Helium, one of the new ly discovered constituents of
the atmosphere, has been divided by Professor Ram-
say into two portions, one of which is lighter than the
other, althougli both give the same spectrum.
Dr. B. Meade Bolton, chief of the department of
pathology and bacteriology of the Philadelphia board
of health, has been tendered the chair of bacteriology
in the University of Missouri, and will probably accept
the offer.
Gifts to a Hospital. — .A number of the summer
residents of Long Branch, before returning to their
homes recently, started a subscription list for the ben-
efit of the Monmouth County Hospital, and collected
a considerable sum for the institution.
A Home for Blind Women. — The Church Charity
Foundation of the Long Island Episcopal diocese has
made arrangements to open a home for blind women
in Maspeth, on November ist. The building is sur-
rounded by five acres of land, which have been deeded
to the diocese. It is stated that there are twelve hun-
dred blind persons in Brooklyn and vicinity, and that
only a small percentage of them is cared for in char-
itable institutions.
" Charaka-Samhita. " — The fifteenth fasciculus of
the translation, by Avinash Chandra Kaviratna, of this
quaint old medical treatise, deals with the properties
of various articles of diet and with the perversions of
appetite. The physiology of alimentation is consid-
ered in a primitive fashion, and the consequences of
gluttony are vividly portrayed. The final portions are
concerned with epidemics and their origin in the vi-
tiation of tiie air, soil, and water.
The Hope Hospital in Langholm, Scotland. — A
correspondent of The Lancet writes that the cornc
stone of this hospital was laid, on September 21st, by
Miss Hope, of New York. The hospital is one of
the results of a sum of _^i 00,000 left by the late Mr.
Thomas Hope, of New York, to Langholm, as his na-
tive place, the capital to be administered by trustees
for the benefit of the inhabitants. The building is to
be a very handsome one, and the plans are in every
respect drawn on a most liberal scale. The cost is
estimated at ^17,000.
The Proper Pronunciation of Greek. — The Octo-
ber number of Ediiaitioii contains an interesting
article with this title, by Dr. A. Rose, of New York.
It is a paper which was read by him before an inter-
ested audience in the hall of the Academy of Medicine
in June last. The same number contains the remarks
delivered at the time of the lecture by Professor Orris,
of Princeton, and Mr. Botassi, the Greek consul at
New York. The arguments .advanced against the
Erasmian pronunciation are very strong, and should
be read by all Greek professors who adhere obstinately
to this artificial and indefensible system. Russia and
France have, we understand, adopted the correct pro-
nunciation; and if Germany, England, and .\merica
could be induced to follow suit, the dream of the adop-
tion of Greek as the international tongue would seem
to be nearer realization.
Philadelphia Hospital. — Dr. E. B. Sangree has
resigned the position of pathologist to the Philadelphia
Hospital, in consequence of the assumption of the du-
ties of the chair of pathology and bacteriology in the
Vanderbilt University at Nashville, Tenn.
Slumber Sound in Philadelphia. — The current be-
lief that insomnia is unknown in Philadelphia will be
strengthened by an incident related by the correspon-
dent in that city of The Lancet. He writes that a hyp-
notist had been giving exhibitions in one of the thea-
tres, and as a " special feature" he put a victim into a
sleep that was to last seventy-two hours, placed him in
a store window in a prominent thoroughfare, and
offered $roo to any one who could rouse the sleeper be-
fore the time named. One man, an.xious to earn the
money, failing to make any impression on the victim
by tickling, prodding, etc., became desperate and
struck him some heavy blows with his fists, without
accomplishing his object, however, but injuring him
severely. Just at this juncture the "professor" ar-
rived. He was ordered to arouse the man, which he
did, when it was found necessary to remove him to a
hospital.
Philadelphia County Medical Society. — At a meet-
ing of the Philadelphia County Medical Society, on
October 14th, Dr. F. W. Talley read a paper entitled
"The Proper Position of Coeliohysteropexy in Gyne-
cology;" Dr. A. O. J. Kelly read a paper on "Essen-
tial Paroxysmal Tachycardia, with a Report of Four
Cases;" Dr. C. \V. Burr read a paper on "The Rela-
tion of Anajmia to Chorea," in which, as a result of
observations made in thirty-six cases, he came to the
conclusion that ana;mia is not an exciting cause and
not commonly a predisposing cause of chorea: but in
many cases it is secondary to the chorea.
College of Physicians of Philadelphia. — At a
meeting of the surgical section of the College of Phy-
sicians of Philadelphia, on October i5tb. Dr. Spren-
kle, by invitation of the executive committee, read a
paper on ■' Prolonged Pregnancy," in which he pointed
out the dangers to which this condition might give rise,
and advised the induction of artificial labor if gesta-
tion be prolonged two weeks beyond the normal. Dr.
C. B. Penrose read a communication, entitled " Hys-
terectomy by Combined Operation through Abdomen
and Vagina," in which he advocated, in place of fol-
lowing the procedure commonly employed, that the
abdominal section be made first and the vaginal
manipulations be proceeded with afterward.
Vital Statistics of Philadelphia. — For the week
ending October loth, there occurred in -the city of
Philadelphia 357 deaths — 44 less than during the pre-
ceding week. Of the whole number, 104 were in chil-
dren under five years of age. The following causes
were assigned for the largest number of deaths: Pul-
monary tuberculosis, 39 ; heart disease, 24 : carcino-
ma, 21; marasmus, 21; apoplexy, 17; nephritis, 15;
pneumonia, 14; inflammation of the brain and its
membranes, 14; diphtheria, 14. There were repiorted
during the week 73 cases of diphtheria, 28 of typhoid
fever, and t6 of scarlet fever.
598
MEDICAL RECORD.
[October 24, 1S96
J>ociety Reports.
NEW VURK STATE MEDICAL
TION.
ASSOCIA-
Thirleenth Annual Meeting, Held in New York, Oc-
tober /J, 14, and /J, i8g6.
Dakwix Colvin, M.D., President.
The President called the meeting to order at 10 a.m.,
October 13th, and expressed pleasure at ^eing called
to preside over so important a body.
Report of Committee of Arrangements. — Dr.
John G. Truax made a verbal report, in lieu of the
written one left at home, and heartily welcomed mem-
bers of the association to New York and this annual
meeting.
Report of the Council. — Dr. E. D. Ferguson read
the report. The library now contained ninety-five
hundred and thirty-eight volumes, having been in-
creased by thirty-live volumes during the past year.
The total sum in the treasury at the beginning of the
year was $5,330; total disbursements, $1,992; total
amount remaining, $6,258. A resolution was adopted
by the council, and later accepted by the association,
in opposition to restriction of vivisection by Congress.
In the matter relating to removal of physicians from
the Harlem Hospital without cause, brought up bv Dr.
Manley, the chairman of the council to which it was
referred reported that it was a local matter, and he
thought the association should not interfere with local
matters.
Dr. Manlev could not agree with the report that
the discharge of physicians from the hospitals without
cause was a local matter. In the present instance it
was done at the urgency of the medical colleges, and
the action of the faculties of those colleges was in vio-
lation of all ethical rules. Dr. Manley moved that the
matter be referred back to the council, which should
report by the last session.
Drs. J. G. Truax, Fercison, and others made a
few remarks, and the matter was referred as called for
in Dr. Mauley's motion.
Dr. J. B. Hamilton — On motion of Dr. Manlev,
the following resolution was adopted:
" To the Surgeon- General of the Marine I]osf>ital Serrice
of the United States.
" Whereas, Dr. John B. Hamilton, of Chicago, 111.,
surgeon to the Marine Hospital of that city, professor
of surgery in Rush Medical College, and editor of the
Journal of the American Medical Association, has been
ordered to vacate his present position and report for
duty at San Franci.sco; and
" Whereas, Dr. Hamilton, a native of Illinois and
graduate of Rush Medical College, occupies the re-
sponsible position of editor of the leading medical or-
gan and exponent of medical science in this country;
for the great success of which of late years, its en-
larged circulation and unparalleled prosperity, for
widening the inlUience of and extending the benefits
of the American Medical Association, all must admit,
we are chiefly indebted to Dr. Hamilton;
" Whereas, The removal of Dr. Hamilton from Chi-
cago and his withdrawal from the the editorship of the
Journal of the America 1 Medical Association would be
a great loss to the entire profession (medical) of the
United States; therefore be it
'■ Resolved, That the .Medical .Association of the State
of New York, appreciating the rare qualities of Dr.
Hamilton as a scholar, a teacher, and a fearless editor,
and his labors in the past in the defence of non-secta-
rian medicine and his efforts to raise the standard of
the medical profession in the United States of .Amer-
ica, respectfully petition the President of the United
States and the surgeon-general of the Marine Hospital
service to reconsider or rescind the above-named or-
der, and permit Dr. Hamilton to continue in Chicago
at his post, believing that by so doing the interests of
the Marine Hospital service v.ill not be neglected and
those of the medical profession best protected."
Functionless Organs. Are There Any ? The Use
and Disease of the Vermiform Appendix. — Dr.
Nelsu.n L. Norih, of Drooklyn, read the first scien-
tific paper. "While thinking how best to present my
thoughts in favor of what I supposed to be about the
real truth, that the human organism, in its normal con-
dition, was pretty nearly perfect in all its parts, and
that all its parts were each peculiarly and specially
adapted to accomplish its own portion in the economy
of the completed whole, I opened the Medical Record
and read, under the head 'Rudimentary Organs,' by
Cora H. Flagg, M.D., as follows: 'In all of the higher
animals we find a large number of structures which
are either absolutely useless or of such slight service
as to bear little or no relation to the existing life or
wants of the animal." Evolution in the article quoted
from has certainly an enthusiastic advocate, and the
prize essay of the author is very pleasant Darwinian
reading; only we are inclined to think, in running
over man's 'rudimentary organs,' that man is, after all,
'a kind of nature's patchwork,' and a great way from a
perfect or completed organism, and we are also in-
clined to exclaim with Shakespeare, though in the
deepest irony :
" \Vli.it a piece of work is man! '
To continue the parody:
" How ignoble in origin!
How infinite in rudiments!
In form and moving
How lil<e his prototype!
In action like an animal!
In apprehension how like a (heathen) god!
The fag end of creation !
The continuation of the (lower) animals!
"We have not to go far back in medical literature
for statements to the efTect that so important an organ
in the digestive and blood-making process as the
spleen is utterly functionless except as a possible
resen-oir for the blood during congestive conditions.
.Also with several other of the glandular organs here-
tofore supposed to be wholly functionless, it is coming
to be well understood that, in.stead, they are hamato-
poietic, and hence of singular importance in the as-
similative process of tissue building.'"
Dr. North cited the thyroid and thymus glands as
examples: "Even the tonsils, the glandular organs
which have borne all sorts of abuse from cauteriza-
tions, incisions, and excisions, are beginning to be
looked upon as 'guardians of the fauces,' arresting in
their follicles marauding bacilli or overtaking them
with germicidal secretions, or else bearing in their
own bodies the force of the toxins which would other-
wise get deeper and attack the citadel of life's forces.
So it may be that the poor appendix vermiformis, so
often referred to during the last few years as the death-
inviting, functionless rudiment of a former existence,
may be found to have been created or evoluted for a
purpose, and not intended to be sacrificed to the sur-
geon's knife without mercy whenever found in sight or
within reach, whether guilty or not guilty of diseased
action. It is fairly supposahle that, whether man
was created instantly by the fiat of God or by the slow
process of evolution, the design was to make a perfect
being: and it is not fair to suppose — conceding even
that the origin dates from the very lowest and first con-
ditions of life — that all through the extended process
October 24, 1896]
MEDICAL RECORD.
599
of evolution there should be of necessity traces of the
changes in the multitudinous rudiments of former con-
ditions, useless for the life that now is and dangerous
to that life, in that they so easily take on diseased ac-
tion and become only 'pathological in their signifi-
cance.' Rather let us suppose that an almighty God
— or the conservative all-powerful force of nature —
would have improved at each turn of the evolution
processes ; and so we sliould discover that every
part of the human organism, however apparentits in-
significance, has a use, and should not be sacrificed
without good and sufficient reason therefor. The
numerous follicles or glandular structures of the ap-
pendix show evident secretive or secernent action, and
it is quite possible that from these, as from glandular
bodies of a like character in the lower portions of the
ileum, secretions are thrown out which guard this ileo-
cecal valve, and perhaps hinder the passage of the
colon bacteria and so tend to preserve the normal
condition of the parts. Of course, in a diseased con-
dition, as in appendicitis, all this is changed. Then,
again, a careful study of the form, location, bearing,
and action of the appendi.x would indicate its primal
use or function as an automatic closer or 'drawstring'
to the ileo-Cffical valve; its cavity being filled with
gas, it naturally rides upward like the ball valve used
by plumbers and so draws the mucous folds of that
valve in coaptation — thereby preventing the foul gases
•of the colon from passing upward. While this valve
would prevent regurgitation of gases from the colon, it
would not prevent the passage of fasces into the
colon."
While looking up the subject of the appendix vermi-
formis, Dr. North had been startled by the number
of cases of appendicitis reported and referred to. In
seeking the explanation, he had visited the health
office of Brooklyn and studied the relative number of
deaths for the several years since 1880, from perito-
nitis, perityphlitis, typhlitis, appendicitis, intussus-
ception, obstruction of tiie bowels, colic, perforation
of intestine, ulceration of bowels, perforation of ap-
pendix, and constipation. The percentage of deaths
from these combined causes had been, in 1880, i ; in
1888, i:^; and for the successive years to 1895 it had
been i J-, i -|'^, i '-, i ^, i i-, i^. It was obvious that
since there were more deaths from these causes there
must be more cases in the aggregate, or else the treat-
ment was faulty. It was not likely surgical technique
would much further diminish the death rate from op-
erative interference, and Dr. North thought the diffi-
culty lay in practitioners giving up as soon as a pa-
tient complained of pain in the right side and calling
in a surgeon, instead of resorting to early local anti-
phlogistic and internal remedies. Among the remedies
which Dr. North had found valuable in the class of
diseases named were opium (which was often curative
in peritonitis), leeches, ice bag, or poultices, mild ca-
thartics, and rectal injections.
Dr. John Cronin had seen many cases of what
formerly had been called ileus, then typhlitis, peri-
typhlitis, paratyphlitis, appendicitis, recover under
local applications and medical treatment. Leeches,
ice bag, and poultices were among the remedies — ice
bag in the acute stage and poultices later.
Dr. W. M. IJe.mi's found, in addition to the opium
treatment and the ice bag, benefit from rectal injections
of cold water.
Dr. Henry D. Did.a.ma remarked that the thyroid
gland was once considered useless, but now as a rem-
edy it was taken by the fat man to reduce his weight,
it was regarded as a cure of cretinism, etc. Even the
suprarenal capsules were put to service — at least he un-
derstood such a report came from St. Louis, where most
of our things come from. So the appendix vermiformis
might be found to have some use — he hoped it would.
A surgeon in the State had told him that he had often
been called by physicians to cases of supposed appen-
dicitis, had operated, had often found the appendix all
right, closed the wound, and — received his pay
The President's Address. — Dr. Darwin Colvin
then read his annual address, on "Medical Expert
Testimony." It will be published later in full. Some
experience was given, showing that the present method
of obtaining expert testimony was extremely faulty; in
every case so-called experts could be secured for a fee
to give entirely conflicting testimony. He favored
such change as would make the expert as free from in-
fluence by the opposing parties as were the jurors or
the judge.
Report of the Committee on Criminology Dr.
Austin Flint read the report. The committee had
been appointed at the last meeting to confer with a
committee appointed by the Prison Association of
New York, to report on criminology. The two com-
mittees met with the executive committee of the Pris-
on Association, December 10, 1895. The chief sub-
ject of discussion at this meeting was the question
of the amendment to the constitution of the State,
prohibiting productive prison labor. The injurious
results of such an amendment, enforcing idleness on
prisoners, were pointed out during the discussion
and in a letter sent by the committee to members
of the association. The committee recommended to
the president of the State commission of prisons the
adoption of the Bertillon system of identification of
prisoners. The system was not only useful in the
identification of prisoners, but was also of the greatest
scientific value, in connection wdth the study of crimi-
nology and anthropology and related questions. The
report was signed by the members of the committee,
Drs. Flint, Gouley, and W. A. White, on motion was
accepted, and the committee was continued.
Prostatic Enlargement — Dr. J. W. S. Gouley
opened the discussion on this subject with a paper in
which he propounded the four following questions:
1. What is the nature of prostatic enlargement?
2. How is prostatic enlargement recognized? 3. What
are the effects, and how may they be counteracted?
4. When is operative interference indicated, and what
operations may be safely performed for prostatic en-
largement? (See p. 57 7. j
Prostatectomy. — Dr. S,\muel Alexander's paper
on this subject will be published in a future issue.
Dr. W. G. BROWN.st)X, of Connecticut, spoke to one
point, catheterization in old men w-ith enlargement of
the prostate. By carrying this out systematically and
irrigating the bladder when necessary, he had made
many old soldiers comfortable and prevented the de-
velopment of vesical and renal symptoms. The solu-
tions were carbolic acid and glycerin (carbolic acid,
two per cent.), boric acid.
The Effects of Prostatic Enlargement and How
They may be Counteracted. — Dr. Doura.AS Avers
read a paper on this subject. He said that, although
the prostate had been spoken of as a gland, it might
be called a muscle, since so small a portion of it was
glandular. The first effect of enlargement was change
in the capacity and course of the urethra, followed by
obstruction to the flow of urine. Complete retention
of urine might occur early, but usually it was one of
the latest symptoms. Persons approaching the age at
which pro.static hypertrophy was likely to develop
ought to be warned by the physician, who should see
that the bowels moved daily, that the body was pro-
tected by suitable clothing, that the patient partook of
suitable food or that which was plain, nutritious, ea-
sily digested, not highly seasoned, and took moderate
exercise. The amount of residual urine should be
early learned and the catheter called into timely requi-
sition. No. 9 or No. 10 of the .\merican scale soft-
6oo
MEDICAL RECORD.
[October 24, 1896
rubber catheter would answer in the majority of cases.
When the uriiie became turbid or offensive resort to
vesical irrigation should be had. As to medicines,
such as the physician's experience had taught him
would give the best results should be used. While
acknowledging our lack of power to prevent the cause
of prostatic hypertrophy, we should employ such means
as would lessen the effects and make more comfortable
the decline of life.
Method of Retaining the Drainage Tube. — Dr.
E. D. Ferguson had found the best method of retain-
ing a drainage tube inserted into wounds or cavities
to consist in stitching it to the integument.
Dr. H. O. Makcv e.xpressed his pleasure at hearing
the very complete and excellent papers read by Dr.
(iouley and Dr. Alexander. He recommended to the
consideration of the readers an excellent paper on the
subject written at his suggestion by his friend. Dr.
White, of Boston, in 1887. Dr. Marcy had found vision
much aided in one case of prostatectomy performed
by him by placing the patient in Trendelenburg's
posture. He thought we would come to do away with
suprapubic drainage in this operation and rely entirely
upon perineal drainage. Alexander's operation was
destined to have a wide field of usefulness.
Dr. Gouley, in some closing remarks, said residu.il
urine in enlargement of the prostate was not due to
want of expulsive power on the part of the bladder,
but to closure of the urethra, which took place long
before there was loss of expulsive power. One ounce
of residual urine was sufficient to do mischief, and it
was not wise to wait until there was more before be-
ginning the use of the catheter. Catheterization, when
properly performed, did no harm whatever. In enucle-
ating the prostate he strongly commended the use of
the finger instead of sharp instruments in order to
diminish hemorrhage. If the proper drainage tube
were employed it would not come out, and there would
be no necessity for stitching it to the skin. Trende-
lenburg's posture was the worst of all in prostatec-
tomy, for it was desirable that gravity should act away
from the body.
The Treatment of Fecal Fistula, with Report
of Cases. — Dr. F. H. Wkkhn, of New York, read a
paper on this subject (see page 586).
Irritable Stump.— Dr. Joseph D. Bry.\nt, of New
York, in this paper gave statistics of the late war
bearing on the nature" of the stump following amputa-
tions, the opinions of instrument makers on the sul)-
ject of irritable stump, and then described a method
of amputation in the lower third of the leg wdiich he
had employed in a number of cases. The military sta-
tistics showed a large percentage of cases with either
an unhealed or an irritable stump some. months after
amputation. He had been unable to secure statistics
from surgery in civil life. A visit to a number of
artificial limb makers in the city had not resulted in
securing all the information which he had desired, but
it was learned that irritable stump was recognized by
each of them, one manufacturer .stating that about ten
per cent, of all ca.ses were of that nature. Some were
of the opinion that the owners of the stumps were as
much at fault as the surgeon. The length of the flap
was recognized as important in efforts to secure a use-
ful stump.
Dr. Bryant then gave the history of the first case,
that of a military man, which had led him to employ
t!ie mode of amputating and described the llap which he
had found gave the most serviceable stump, especially
in the lower extremity, where he had most frequently
applied the method. .All told, he had operated in this
manner in fourteen cases, and in eleven the stump
had been in every way satisfactory. In his conclu-
sions he said: i. The flap of all pressure-bearing
stumps should be equal in length to rather more than
one-fourth of the circumference of the part where am-
putated. 2. Irregularly formed flaps should be con-
structed on the same basis, one portion of the flap
making up for the deficiency in length of the other.
3. Periosteal covering of the divided end of bone
should be made if possible, and when possible the
periosteum should be raised apposed to the overlying
soft parts. 4. This method of procedure secured the
most serviceable stump in amputation of the lower
third of the leg.
Dr. H. O. M.arcv, of Boston, said that many years
ago, when he was a medical student, he asked Dr. Bow-
ditch what would be the effect of covering the end of
the amputated bone with the lifted periosteum, and
the reply was that it would probably produce a lump
of bone and cause trouble. Dr. Marcy said further
that he was in tiie habit of suturing the several tissues
to their kind and of sealing the wound with iodoform
collodion, not employing drainage, and he thought
stumps so treated gave less trouble.
Dr. Did.\.m.a thought the point made by the author,
not to separate the periosteum from the superincum-
bent tissues, was an important one.
Hindrances to the Successful Treatment of Dis-
eases of Infancy and Childhood. — Dr. J. Lewis
.Smith road tire paper. The first hindrance was the
disinclination of mothers to nurse their own children.
The next was the difficulty of getting a healthy and
reliable wetnurse. Before the New York foundling
asylum was established about all the babies under city
care died. .\ watch had to be kept at the foundling
asylum to-day to prevent mothers leaving their infants
at the door and going off without making their identity
known. Medical colleges did not give sufficient in-
struction to undergraduates in the diseases of children,
and this want had been only partly met by the post-
graduate schools. The habit of attributing all ills to
painful dentition, for which, formerly at least, physi-
cians lanced the gums, was a serious fault. Rheu-
matism was often called growing pains, consequent!)
proper treatment was not adopted and the number of
cases of heart disease was greater than it shoidd be.
The questions of alimentation, spreading disease at
school, and some others had recently been discussed in
paediatric literature, and were therefore passed by.
The Practical Uses of Roentgen's Discovery as
Applied to Surgery ; with Illustrations.— Dr. Rec-
iN.M.i) S.^VRE, of New York, gave a brief review of the
discovery and principles of the .v-ray and then pro-
jected on the .screen a number of photographs so taken
of orthopaedic cases. It was evident from the demon-
stration that the .v-ray was of value in the location of
fractures; in determining whether there had been
proper reduction, which could be done without remov-
ing the dressings; in locating sequestra and perhaps
abscess of bone, in determining whether di.sease had
invaded the joint, and whether there was bony or
fibrous ankylosis. It was of less use than might have
been supposed in clubfoot of children, for the cartilage
was so extensive as to cast a light shadow throughout
most of tiie space. l!ut this fact showed the foolish-
ness of removing tissue by the knife in such cases,
since mechanical appliances would readily bring the
parts into place. Among the illustrations were some
of bandylegs, clubfoot, dislocation at the hip, bonv
and fibrous ankylosis, fracture, etc.
The Treatment of Otorrhoea and Its Importance.
— By Dr. Kdward B. Dench, of New York. The term
otorrhoea was used collectively to avoid technicality. In
a given case the physician should inquire how long the
discharge had been present; had it been preceded or
accompanied by pain: was there a history of previ-
ous disease of the ear; had the discharge been con-
tinuous or intermittent; had there been any sudden
diminution of the quantity of the discharge. If so, had
October 24, 1896]
MEDICAL RECORD.
601
it been accompanied or preceded b)- pain. He should
observe the character of the discharge— whether serous,
sero-mucous, or purulent, whether large or small in
amount. A chronic discharge lasting a month, puru-
lent in character, must come from the middle ear, and
naturally the membrana t)'mpiini must present some
opening. A recent purulent discharge might be from
the external ear, as in furuncle. Sero-mucous dis-
charge came from the middle ear. Pressure in front
of the tragus or traction on the auricle would cause
pain if the external ear were involved, and in adults
this was a sign of considerable importance; but in
children the bones of the ear were not yet formed and
the traction would cause pain, as also in inflammation
of the middle ear. In many cases patients had a series
of attacks, usually following colds, and between the
attacks there was no discharge. Here there was either
a simple catarrhal inflammation of the middle ear
with slight serous discharge, or there had been a puru-
lent discharge with destruction of most of the mem-
brana tympani, the lining membrane being left exposed
over a large area, from which serum flowed during con-
gestion. When the membrana tympani was intact
pain preceded the discharge, hut when it was perfo-
rated there was absence of pain. As to furuncles,
they were rare in infants, more frequent in adults.
Most of the paper was devoted to inflammation of the
middle ear.
In simple earache with serous exudate, when the
tension became great enough it ruptured the mem-
brane, some fluid escaped, pain was relieved, the pro-
cess healed spontaneously unless infection took place,
and the membrane closed. When suppuration existed
it always implied destruction of tissue, and in the mid-
dle ear both the soft structures and the bony walls
might be invohed. The discharge would cease as
soon as the necrotic tissue had been separated, but
often drainage was not perfect. The first object of
treatment was to keep the canal free of discharge, the
second was to secure an aseptic condition of the
meatus. While much had been said of drainage by
iodoform gauze, his own experience had been so un-
satisfactory that he no longer employed it. He fa-
vored the older method of syringing as often as was
necessary to keep the ear free from secretion. Under
no circumstances would he stop the ear with cotton,
nor should powders be used, such as borax, As an an-
tiseptic douche he preferred bichloride, i to 3,000 or i
to 5,000. Dr. Dench then described two methods of
removing necrosed bone when this was present. He
preferred curettage through the canal.
The Relation of Affections of the Upper Air
Passages to Diseases of the Ears. — Dr. Prank S.
MiLiiURY, of lirooklyn, pointed out in the first part of
this paper what he believed to be the frequent connec-
tion between some abnormal condition of the anterior
nares and postnasal altections which were commonlv
recognized as the cause of much middle-ear disease.
In his opinion in every case of adenoids the Kusta-
chian tubes were involved. The adenoids should be
removed and thereby humanity saved much suffering in
connection with the ear as well as with the naso-
pharynx.
The Technique of Intubation in Children ; Some
Remarks on the Time for Operation and on the
After-Treatment. — Dr. Thum.as J. Hii.i.is, of New
York, read a paper with tiie above title. Success de-
pended a great deal upon experience, attention to little
points, and on proper nursing of the patient by the
parents or friends.
Temperature as an Element in Prognosis Dr.
John Shradv, of New York, read a very practical
paper on this subject, which will appear later.
The Medical Treatment of Inebriety Dr. T. D.
Crothlks, of Hartford, Conn., read this paper. In-
ebriety, he said, was a more complex disease than
insanity. Its progressive degeneration often dated
back to ancestors, to defects of growth, to retarded de
velopment, or to early physical and psychical injuries.
Later the poison of alcohol, by its ana;sthetic and
paralj'zing action, developed more complex states of
degeneration, the form and direction of which were
very largely dependent on conditions of li\ ing and on
surroundings. The psychical symptoms showed pro-
gressive disease of the higher brain centres, with
degrees of palsy and lowered \itality. The medical
treatment must be based on some clear idea of what
constituted the nature of inebriety and the conditions
present in the case to be treated. This required a
careful clinical study of the symptoms, tracing them
back to causes, and'all the varied conditions foimative
in the progress of the case. Heredit_\- was the most
frequent predisposing cause. A second class of cases
was due to physical and mental strains or to drains and
injuries. The second part of the clinical study was
the effect of alcohol. What injury had it caused?
How far had it intensified all previous degenerations
and formed new pathological conditions and sources
of dissolution? What organs had been most affected,
and, most important of all, how far was the use of alco-
hol a symptom or an active cause? Having ascer-
tained these facts, the medical treatment was the same
as in other diseases — the removal of the exciting and
predisposing causes and building up the body.
The first question was the sudden or rapid removal
of alcohol. If the patient was alarmed and intensely
in earnest to abstain, he would consent to have the
spirits removed at once. If he was uncertain and had
delusions as to the power of alcohol to sustain life, the
withdrawal would depend on circumstances. The re-
moval of all spirits at the beginning of the treatment
was always followed by tlie best results. The reaction
which followed could usually be neutralized by nitrate
of strychnine, one-twentieth of a grain every four hours,
combined with some acid preparation. Sodium brom-
ide in fifty or one-hundred grain doses every three or
four hours would break up the insomnia and cause
sleep the first two nights.
The w ithdrawal of spirits should always be followed
by a calomel or saline purge, and a prolonged hot-air
or hot-water bath, followed by vigorous massage.
Hot milk, hot beef tea, and in some cases hot coffee
were very eftectual. If the patient persisted in a
gradual withdrawal of the spirits, strjxhnine. one-twen-
tieth of a grain, should be given every two hours, and
the purge and hot bath should be given every day
while the spirits were continued. The form of spirits
should be changed from the stronger liquors to wines
and beers. Some of the medicated wines were useful
at this time, or spirits served up in hot milk. The
two conditions to be treated were poisoning and starva-
tion. Food and tonics were indicated for the second
condition, calomel purges and baths for the first.
Dementia, melancholia, paresis, tuberculosis, rheu-
matism, and neuritis were forms of disease which fre-
quently appeared after the withdrawal of alcohol, and
whether they had existed concealed by the anarsthetic
action of alcohol, or had started up from the favoring
conditions of degeneration caused bv spirits, was not
known. The therapeutic requirements must reach out
to meet all these unsuspected diseases, which might
appear at any time.
While the ostensible object of medication was to
stop the drink craze, this was as far from being cura-
tive as the suppression of pain by a dose of opium.
Conditions which caused the disordered nerve force
to concentrate in cravings for the anasthesia of spirits
had to be neutralized and prevented before a cure
could be expected. The use of narcotics and drugs to
check the desire for spirits at the beginning was tern-
602
MEDICAL RECORD.
[October 24, 1896
porary and always uncertain. Opium, cliloral, and
cocaine given freely at this time often simply changed
the drink craze into a craving for these drugs, which
were used in the place of spirits ever after.
Premonitory symptoms of a drink storm could, ac-
cording to the case, be met with calomel and saline
cathartics, prolonged baths, rest or exercise, cinchona
and iron tonics free from spirits, or some of the coca
compounds. Tinctures of any form were dangerous.
The masked character of inebriety made it dangerous
to use narcotics beyond a certain narrow limit. Per-
sons who had been subjected to active drug treatment
to suppress the desire for spirits were feebler and more
debilitated than others. Those who had taken the
so-called specifics were marked examples, and, whether
they used spirits again or not, they were always en-
feebled and pronounced neurotics.
The present empirical stage of treatment should
rouse a greater interest and bring the medical treat-
ment of inebriety into every-day practice. Then the
family physician, and not the clergyman or quack,
should be called in to advise. A new realm of medi-
cal practice was at our doors, only awaiting medical
study above all theory and exclusixely from the scien-
tific side.
The Surgical Relief of Obstruction of the Com-
mon Biliary Duct by Calculi. — Dr. H. O. M.'^rcy,
of Boston, in this paper related the circumstances
which led up to his operating in 1884 for the first time
for calculous obstruction of the common duct. Prior
to that time operation on the common duct had been
regarded as impractical. Having attended about three
cases before that date which had resulted in death, he
made up his mind to operate should another case come
under his observation, and this occurred in 1884.
However, he was unable in that instance to dislodge
the stone in the common duct, and predicted that the
patient would some time have another and fatal attack
of complete obstruction, although the symptoms were
relieved on this occasion; and so it proved. His first
entirely successful case was in 1889 — a calculus
weighing fifty-nine grains was removed, and the wo-
man was living and well to-day. The operation was
now regarded as not only admissible but as mandatory.
A New Microtome.- — Dr. Sidney Y.ankauer, of
New V'ork, described a new microtome, which could
be sold for between $5 and J 10, whereas those on the
market cost as much as $50. He also showed a plas-
ter-of- Paris bandage cutter, and explained on mechan-
ical principles the inefficiency of the knife and scis-
sors.
The Physiological Deductions Regarding the Use-
fulness of So-Called Animal Extracts. — Dr. H. A.
Haubold, of New York, in a brief paper considered
the possible physiological action of the animal extracts,
prefacing his remarks with the statement that their use
was not new, for Pliny asserted that the Greeks and
Romans ate the testicle of the donkey as a remedy for
impotence. The conclusion arrived at by the author
was that the animal extracts acted as medicines and
not as foods; they, including nucleins and protonu-
cleins, did not furnish the blood with elements from
which the tissues could be more readily built up than
from elements in ordinary diet. They certainly were
not deposited in the system, where they obtained root
and grew, unless they were taken through the digestive
tract and blood. If not .so taken, their action was as
that of a foreign material, of which the system tried
to rid itself.
One Point in the Treatment of Endometritis. —
Dr. W. H. R<ir.n passed hastily over the anatomy of
the uterus and then arrived at the object of his paper,
which was to direct attention to the value of nitrate of
silver in the treatment of endometritis. This was not
new, but the remedy had fallen largely into disuse.
He did not wish to be understood as advocating it in
all cases or as the sole remedy. Each case must be
treated according to its merits. Weak solutions were
sufficient in tiie early stage and in mild cases, while
the solid caustic was reserved for chronic granular
conditions.
Dr. Brdoks said that to his mind there was no fal-
lacy greater than the cure of endometritis with nitrate
of silver, particularly with the stronger applications.
There might be a temporary result which looked like
cure or improvement, but the after-result was likely to
be worse than the original condition, as had been
pointed out by an eminent gynecologist under whom
he had studied.
Dr. J. H. Cai.ki", of Connecticut, had made it a cus-
tom to examine the secretions b.tcteriologically in
endometritis, and had found that the congested and
thickened lining membrane, with its secretions, made
a good culture bed for various germs. A great many
of the germs were killed by even a weak solution of
nitrate of silver, say i to 1,000 or 3 to 1,000.
Dr. W. M. Bemus had found the galvanic current
valuable in dissolving the mucus adhering to the en-
dometrium in the catarrhal condition, thus enabling
him to remove it. Peroxide of hydrogen also aided.
Dr. John Croxyn approved of the use of nitrate of
silver in some cases, and had not understood that the
author made use of it in all. Curetting was a fearfully
abused operation.
A Class of Fatal Cases, Presumably Due to In-
testinal Ptomains. — Dr. E. D. Fkrcu.son, of Troy,
read the paper. It will appear in a future issue of
the Medical Record.
Address on Surgery. — Dr. Charles Phelps, of
New \ork. '" h is proper that we should celebrate with
form of words the splendid achievements of our imme-
diate predecessors and of our contemporaries; it is
pardonable if our exaltation has been sometimes voiced
in too magniloquent and resounding phrase, and not
always tempered by a generous remembrance of the
struggles and succcs.ses of a remoter time. The pres-
ent supposed renaissance of medical art is but a some-
what sudden increase in the energy of an irregular but
ceaseless de\elopment. It is unimportant to the pres-
ent consideration of medical or surgical art to disen-
tangle its history from early fable and mythological
romance, to determine to what extent it existed in an
epoch of barbarism or in a subsequent era of media-val
superstition, or even to define the period in which it
may be deemed to have acquired a scientific basis.
From the .seventeenth century, at lea.st, the inclusion
of medicine in the field of positive, if not exact, sci-
ences is beyond question, and its continued advance-
ment a matter of record. The successive disco\eries
of the circulation of the blood, of the efficacy of vac-
cination, and of the possible annihilation of pain by
anaesthesia are imposing landmarks along the path
which has been travelled. And all through this time
the gradual evolution of a rational system of treatment
of disease and a progressive improvement of methods
of surgical interference are sufficient evidence that the
advance has been fairly uninterrupted. In American
colleges and universities, even of the higher grades,
the extent of classical and rhetorical study demanded
has been more and more circumscribed, until under-
graduates are now practically ]:)ermitted to pursue such
exclusive lines of work as in their unguided opinion
I^ertain directly to their future occupation. The sur-
rounding condition of mental action, and perhaps the
contemporaneous mental constitution, incite to scien-
tific investigation rather than to endeavor in the higher
planes of literature. It follows that the arts most
sedulouslv wrought and scientifically developed have
been meclianical, industrial, or in some sort utilitarian,
rather than aesthetic. The gentler arts of oratory and
October 24, 1896]
MEDICAL RECORD.
603
poe^y and of letters have not only failed of advance-
ment, but have suffered decadence. It is not only
natural, but inevitable, in an age characteristically
occupied with an improvement of physical conditions,
that the art most directly concerned witii the integrity
and prolongation of life, without which all other ma-
terial advantage is naught, should coniinand great
attention, make great progress, and receive great
honor."
The progress of surgery in times of war was then
mentioned. The work of bacteriologists since Pas-
teur's discovery twenty-five years ago had been de-
voted largely to establishing the dependence of various
diseases upon the action of specific germs. " It is evi-
dent," tlie author said, " that the present disposition to
direct medical and surgical investigation straight to
its ultimate ol)ject, the cure of disease, while it has
grown out of the mental attitude characteristic of the
time, has been greatly strengthened by the fact that
the conditions have been made favorable by work pre-
viously accomplished. Clinicians and pathologists
have so strongly established premises that the time
has been rife for conclusions. The present system of
aseptic surgery has resolved itself into an attempt to
reach an ideal condition of cleanliness by the employ-
ment of specific agencies. The discovery of facts
which have reduced sanitation and public hygiene to
an almost exact science, and of the laws which govern
the inception and development of irifectious diseases,
have in themselves alone effected a greater saving of
human life than have all other recent advances in
medicine combined; but an estimate of the progress
of therapeusis would be inadequate which failed to
recognize the services which have been rendered in
other ways, and which are to be accounted only by com-
parison." In this connection, the author mentioned
such measures as the use of Murphy's button, Maun-
sell's method of circular enterorrhaphy, laboratory
and special work.
" The e.xtension of medical knowledge and the perfec-
tion of medical art may not now demand the forces of
originality or the use of the highest forms of intellec-
tual power, but the vast progress made is not less
worthy because the field is open. The conditions of
progress are still unchanged. The knowledge gained
in the past has not yet been entirely utilized for the
purposes of the present, and methods of investigation
and of procedure for practical realization of its results
which still obtain promise to be sufficient for the im-
mediate future. It is possible that entirely new de-
partures may be taken for incursion into the realms of
disease, but the branching of the ways is not yet in
view."
About half of the paper related to business methods
and ethics of the present age. " The ethical side of the
profession is less admirable," the author said, " and less
satisfactory as a subject for observation. It is not
only the methods and purposes of scientific investiga-
tion which reflects the charateristics of the age, but no
less the manners and morals of the professional men.
The age is pre-eminently commercial, and all phases
of life assume a corresponding tinge, especially in
America, where manners and modes of thought have
remained in an exceedingly impressionable condition.
The indispensable condition to business success is to
'hustle,' and it has been largely adopted as a rule of
action in the pursuit of medical practice.
"The medical art, when inspired by sympathy and
guided by a full sense of its serious responsibilities in
the relief of suffering and in the preservation of hu-
man life, yields precedence in the sacredness of its
mission only to the ministrations of the Church, and
is worthy of the chivalric regard of the best of men ;
but practised as a simple business occupation, and de-
generated to a vulgar scramble for the gain it brings.
it is but a carrion trade, and they who practise it are
no longer ministers of mercy, but prowlers in the
shadow of the tomb, who find their profit in disease
and death and fatten on decay.'"
Two Interesting Cases of Surgery of the Kidney.
— Dr. Joseph E. Janvrin, of New York, read the his-
tories of the cases. He said one brought up the ques-
tion of the proper treatment of pyelitis and abscess of
the kidney when the organ was diseased throughout.
The first case was one of multiple abscess of the left
kidney complicated by Bright's disease with septic
symptoms, in which he removed that kidney, but the
patient died from sepsis and ura;mic poisoning si.x
days after the operation. The case was in a woman
who was paralyzed from myelitis and had cystitis.
The only question which could arise as to the treat-
ment was whether he ought to have simply drained
the kidney after cutting down upon it, or remove it,
and to his mind its removal was absolutely demanded.
The second case was one of fibro-lipoma which had
developed from the capsule of the left kidney, the kid-
ney itself not being damaged. The patient made a
good recovery after removal of the tumor, the kidney
being left.
The Palliative Treatment of Cancer of the Cer-
vix and Bladder in Women.— Dr. Nathan G. Boze-
MAN', of New York, in this paper confined his remarks
to the treatment of cancer of the cervix and bladder in
the stage of the disease when an operation could not
be considered and any treatment resorted to could
only be for the alleviation of suffering. These women
complained most of hemorrhage and foul discharge
from the vagina. Digital examination frequently
caused excessive bleeding. It could be controlled by
putting the patient in the knee-chest position and pack-
ing with gauze containing an antiseptic powder. This
was to be renewed three times a week, and the douche
was to be employed for cleanliness. The most difficult
cases to manage were those in which the bladder was
involved. The first manifestations were severe cys-
titis,excessive vesical tenesmus, and frequent urination,
but when perforation took place the urine found a free
outlet, the bladder was given physiological rest, and
the painful symptoms disappeared. For these cases
Dr. Bozeman had had an apparatus constructed for
continuous drainage and irrigation of the bladder.
With the catheter introduced through the fistula he
connected a rubber tube through which there was a
constant (or intermittent) but slow flow of water from
a gallon bottle, the tube always being full of water.
Summing up, he said there were three points to be
observed: i. Keep the seat of disease in an aseptic
condition. 2. Counteract narrowing of the vagina in
front of the disease. 3. V\'hen the bladder was per-
forated, use an efficient method of irrigation and drain-
age. He used distilled water, and to this one could
add, if he wished, some disinfectant.
Dr. Janvrin discussed this paper.
Bromides as a Cure in Diphtheria Dr. Robert
Abkkdein gave personal experience with bromides in
the treatment of diphtheria, he having begun their use
in that disease in 1888. .Speaking of one case, he
said he prescribed two drachms of bromide of ammo-
nium in four ounces of water, directed that the mouth be
washed out with warm w^ater, and then w ith a teaspoon-
ful of the bromide solution, after which a teaspoonful
should be swallowed. This was repeated every two
hours, and a piece of salt pork was put on the throat
from ear to ear. Out of thirty-six cases treated with
the bromide he had lost only two, and in the two cases
he did not attribute death to diphtheria, as it occurred
suddenly and in syncope after the throat had cleared
up. He regarded the remedy as almost a specific, and
had not found it necessary to resort to antitoxin, al-
though he was not prejudiced against this agent.
6o4
MEDICAL RECORD.
[October 24, 1896
Recent Investigations Concerning Eclampsia.—
Dr. \\'illiam T. Lu.sk made some verbal remarks
upon this subject. His recollection was that lie had
read a paper composed by a gentleman in the city
stating that by watching the urine and the symptoms
it was possible to anticipate every case of eclampsia,
and possible with this preparation to prevent any wo-
man having a convulsive attack. It was stated that if
the urea fell below a certain percentage, premature
labor should at once be induced and convulsions would
thus be avoid. Dr. Lu.sk had seen a patient who had
had convulsions in a previous pregnancy. In the
present pregnancy she went along four months; then
a little albumin api:)eared in the urine, and in view of
past experience it was thought advisable by her physi-
cian to bring on premature labor. Digital dilatation
was employed, then rapid dilatation according to what
he believed was now termed surgical methods in ob-
stetrics. The foetus and placental membranes were
removed and the uterus was packed with gauze. Then
Dr. Lusk was called to see her because she had most
profuse hemorrhage. She survived, but for twenty-
four hours it did not seem possible that she could live.
This was a case in which there was a little albumin
in the urine, but not a single symptom, and Dr. Lusk
thought it would have been wise had the physician
clung to the old method and left the pregnancy undis-
turbed.
He had seen a case in which tliere was a trace of
albumin in the urine and was told the urea was two
and a half per cent. In the old physiology this
amount and upward was a normal average of urea, and
the pregnant woman was passing a large quantity of
water. But he understood that this patient must have
abortion produced, otherwise she would with this per-
centage of urea finally suffer into.\ication, and the
wary man always anticipiated these things and brought
on abortion. But Dr. Lusk did not quite concur; the
pregnancy went on, a baby was born at term, and the
woman did not have a symptom of any kind.
After relating another somewhat similar case, Dr.
Lusk said there were certain things to be borne in
mind. First, there were a great many ca.ses of albu-
minuria which did not have eclampsia. There were a
great many cases of eclampsia which did not have
anything in the urine. Urea could be injected in
quantities without producing convulsions. There were
a great many poisons the result of tissue changes, and
they were produced in greater quantities in pregnant
women, and a small quantity retained in the system
might produce serious results. These poisons seemed
largely to defy chemical analysis.
Dr. Lusk still preferred the use of Barnes' bags in
inducing labor. He had not tried veratrum viride in
the treatment of convulsions, but thought he would,
especially as it received a great deal of consideration
at the recent gynecological congress at Geneva, the
Italian and also the French physicians having taken
it up with much enthusiasm.
Dr. Snrnui discussed the action of veratrum viride,
saying that it, like blood-letting, reduced the arterial
tension, and a recent article attributed to high tension
alone, even aside from the presence of poisons in the
blood, tendency to cause convulsions. He said there
was a marked difference between veratrum viride and
veratrum alba, the latter being the drug used in F-urope,
while the former was found and used in .America.
The use of veratrum viride in eclampsia started with
Dr. French, in Brooklyn, and the greatest trouble
which had come from its popularity was its adminis-
tration in too great doses. Five to ten minims of the
officinal extract was large enough a do.se, to be repeated
in ten or fifteen minutes, if necessary, and in less
amount at subsequent doses.
Dr. French said there were three brothers of them
at the time veratrum viride was first used, and they
employed a tincture which they made from the fresh
root dug late in the fall or early in the spring, when
the root contained a minimum of water. He emploved
this agent and blood-letting, and should continue to
do so as long as he never lost a patient. But he was
never called to a case without fearing that he might
lose it.
The Duty of the Public to the Physician Dr.
WiLLi.AM M. Bemus gave in this pajxir a review of the
facts of the common law bearing on the responsibility
of the physician and a part of the statute laws relating
to the subject. His attention had been directed in
this line by a suit brought against him for a CoUes
fracture by a charity patient urged to do so by a law-
yer who first thought she could sue the city but found
suit barred by the expiration of the statutory time.
After the plaintiff had produced her witnesses, the
judge deemed it unnecessary to hear the defence and
directed the jury to find for the defendant. But the
patient had no money to pay the costs.
Dk. D!i)AM.\ called attention to the fact that at pres-
ent the plaintiff was required to furnish bonds to pay
costs in case the verdict was against him. Dr. Fkk-
GUSo.N', Dr. Harrixi;ton, and other gentlemen made
some remarks.
A Plea for the General Use of Measures to Pre-
vent Ophthalmia Neonatorum. — Dr. A. A. Hukbell,
of Buft'alo, in this paper reviewed statistics on blind-
ness in various countries, showing that a large per-
centage of the cases originated in purulent o))hthalmia
of the newly born; mentioned the efficacy of its ]3re-
vention by different methods, especially C'rede's, when
employed in maternities and in private practice; re-
ferred to laws compelling the use of the Crede method
under certain circumstances in this country, and urged
its universal use, or the use of some method found by
experience to be efficient. In Paris certain doctors
had employed insufflation of iodoform powder into the
eye of the newly born with, they claimed, better results
than with the Crede or nitrate-of-silver method. 'J"he
latter consisted in dropping one drop of a two-per-
cent, solution of nitrate of silver into each eye of the
baby just after birth.
Supplementary Notes upon Tendon Grafting and
Muscle Transplantation for Deformities Following
Infantile Paralysis. — Dr. S. 1'.. Mili,ik.en, of New
York, read the paper, which will appear in a future
issue of the Mkdical Record.
Auscultatory Percussion. — Dr. Louis L. Sea.man,
of New York, read a paper supplementary to one
which he had read before the Academy of Medicine
some years ago, describing an instrument for ausculta-
tory percussion, more esixfcially for use over the chest,
but also over the abdomen. It consisted of a hammer,
which made the stroke by action of a spring. It was
placed within the cylinder, to which an F.di.son phono-
graph .sound magnifier was attached. The latter could
be used alone, and was being much employed in Eu-
rope inde|)endently of ])ercv'ssion.
Neuralgia of the Peripheral Nerves, with Special
Reference to That Dependent on Trauma or Degen-
erative Changes. — Dr. rnciMA> H. Mani.i-.v, of New
York. " .At the very threshold of this study it becomes
necessary that some sort of comprehensive definition
be given of neuralgia, in order to demonstrate that
such a pathological entity exists at all. F'rom the
standpoint of pathology it may be open to considera-
ble doubt, as the groundwork of our views on this mal-
ady, which manifests itself through the nervous .system,
rests rather on clinical phenomena than on anatomical
changes of the molecular or corpuscular elements in
the cerebro-spinal axis. It therefore follows that as
the histopathology of that condition recognized under
the name of 'neuralgia' is still involved in great ob-
October 24, 1896]
MEDICAL RECORD.
605
scurity, anything like a scientific classification of its
various pathologic divisions dependent on cellular
changes is quite impossible. 'I'his difficulty was ap-
preciated when the present contribution w'as under-
taken. My aim has been rather to record clinical ob-
servations and curious phenomena than to branch off
at length into the domain of speculation or hypothesis.
'■ Nerve trauma : It has always been an interesting
question to me what share of disorganization a nerve
sustains in severe trauma, in injuries especially of the
major articulations or the members, in entasis, sprain,
dislocation, or fracture; what the degenerative power
of a damaged nerve is; and what the remote effects on
it are which may at an ultimate date follow.
" Nerve degeneration through vascular changes, de-
pendent on tension or compression of the nerve trunks :
A large nerve trunk is not a highly vascularized struc-
ture ; and hence atrophic changes follow rather as a
consecutive condition dependent on the vascular ele-
ments in the ganglionic centres or the peripheral ter-
minals. But are the nerves alone the media of the
transmission of vitalizing influences, of sensation and
motion, and of all other vital phenomena connecting the
centres of life — the brain and heart — with the extrem-
ities and the organs.' Or do not the ventricular or
meningeal fluids of the brain, with the moving blood
current, participate actively in the function of animal
magnetism, in the efferent transmission of impulse or
sensation ? During the past fifteen months in m\' own
researches and experiments on the hajmic elements in
the living animal I witnessed such evident influence
of the corpuscular elements as to leave no doubt in
my mind that a vital nerve must be animated by living
blood.
"Anatomy of the nerve trunks: A complete nerve,
functionally considered, consists of a root and gang-
lion— the central source; a shaft, or conductor; and
the terminal filaments, or ramifications. All the cere-
bro-spinal nen-es, as they pass out through passages
of the cranio-rachidian cavity, occupy openings in the
base of the skull and the jointed borders of the verte-
bral apophyses. All the larger primitive meduUated
nerve trunks are very rich in a reticulated fibrous
stroma. The resistance of these nerve trunks is some-
thing quite extraordinary ; which goes to show that the
generally accepted notion, that nerve tissue is brittle
and fragile, is a fallacy.
•■ Neurectasia, or nerve-stretching, is a very ancient
device for the relief of severe neuralgia; but Tillaux
and Trombetta have employed it to determine the rel-
ative resisting power of the larger nerve trunks.
'I'rombetta's experiments were all made on the living
subject. Tabulating his experiments on this topic, he
found that it required an average of eighty-four kilo-
grams—two hundred and thirty pounds — to rupture the
sciatic nerve. The tough, resisting characters of the
nerves are what tend to impart to them their marvel-
lous physical tolerance and enables them to survive
the longest after the violent injury of a limb, the nerve
being the last to perish. The experienced surgeon,
familiar with this fact, well knows that, however hope-
ful other signs may be, when total abeyance of all
neural phenomena is present, the crushed or mangled
limb is irretrievably domed and must be sacrificed.
"Neuralgia of the periphery dependent on senile
degenerative changes or structural alteration concom-
itant with advancing age: The physiological anatomy
of the body, from its earliest development to the end
of life, embraces evolution and involution, the raising
up and pulling down of developmental structures.
The infant is born hairless and toothless, probably
sightless and deaf, able to digest liquids only, and is
guided in movement quite entirely by instinct. During
the period of growth, the shape, the relations, the re-
sistance, and the volume of various structures and or-
gans undergo the most radical changes. After maturity
the onward course of structural changes varies widely
in different individuals, depending on heredity, envi-
ronment, habit, climate, and occupation. From the
twenty-fifth to the forty-fifth year no very marked gross
changes are noted in the body; howe\'er, degenerative
and senile changes are subservient to no unchanging
laws, and hence years are not always a criterion of age.
The first of the tissues to show signs of atrophic waste
are the areolar, the adipose tissue, and muscle; then
the bones shorten and harden, the capillary openings
betw-een the diploic system and the pericranial plexus
of veins are entirely obliterated, the cavernous pas-
sages in the bones and all the foramina through which
the nerves emerge become contracted and greatly nar-
rowed. This is notably the case in the bones of the
head and spine. It is now interesting to inquire what
share this reduction, condensation, and distortion may
have as a factor in degenerative changes, by a continu-
ous and ever-increasing pressure on the nerve roots.
Is it a prominent etiological factor in many of those
severe neuralgic seizures? It will hardly do to in-
voke neuritis as a cause, inasmuch as a primary in-
flammation of ner\-e substance is denied by many
prominent pathologists. There can scarcely be a
doubt but this senile shrinkage, in embarrassing the
vascular current and compressing the nerve elements,
leads to other ultimate degenerative changes and well-
marked functional disorders; in fact, it requires no
stretch of the imagination to comprehend the relations
of cause and effect in the degenerative changes here
enumerated. After middle life, reversion of outline
with a progressive diminution in length of the spine
is obvious, when it is commonly said that the individ-
ual has "grown smaller." At this period the human
machinery begins to show signs of wear, and the whole
nerve structure suffers.
" In the above brief notes my purpose has been to re-
vive an interest in the study of the peripheral neural-
gias. The subject is attended with great difficulties,
because the physiology of the complex nerve functions
is yet in many important particulars unsettled. In
the types of neuralgia here considered, the degenera-
tive or senile theory enunciated may account for at
least one important etiological factor, emanating from
mutations attending the process of involution. It
affords a material basis for inductive reasoning, which
may open the way for a more rational therapv.''
Temperature an Element in Prognosis.— Dr. John
Shradv read a paper entitled " 'I'emperature as an
Element in Prognosis," in which he discussed some-
what at length the various phases of heat phenomena,
particularly in relation to the attribute of force. He
drew attention to the interchangeability of the terms
applicable to electricity, motion, and last, not least,
chemical affinity. He regarded man as a walking
laboratory — which, indeed, was by no means an origi-
nal view — since his functions would be inoperative
without elementary changes, the outward registry of
which was justly entrusted to the thermometer. It
could not be gainsaid that every phenomenon, both
organic and inorganic, was governed by fixed laws, the
operation of which was often misconceived, although
the analogies of heat, light, and electricity aided
somewhat by the present vogue of their study. The
only trouble, as pointed out by Paget, was that we be-
came embarrassed by numerous exceptions, through
failure of making the law sufficientlv comprehensive.
Much yet was to be learned in the language of temper-
ature, and such language could be gained only in the
comparative school in connection with other branches
of science. F"or this reason, all on account of the im-
challenged appeals to the eye, he could do nothing
else but accept the thermometer as the greatest of the
instruments of precision. What is called science is
6o6
MEDICAL RECORD.
[October 24, 1896
the court of .last resort, and it will adjudicate between
the claims of the organic and inorganic, on the basis
of a compromise between force and resistance. In all
these cases of disputed sovereignty, heat more than
rhetorically represents the fury of the battle. At all
events, thus far observers and experimenters have won
glory as strategists of the campaign, without founding
a new empire. The same immutable laws prevail,
notwithstanding their unsatisfactory interpretation and
application. Yet, because investigation has been
without very material result, should it therefore be
abandoned? The phenomena of heat, therefore,
should be studied on the basis of the laws which gov-
ern material force. He quoted from trustworthy au-
thorities many high temperatures in acute diseases,
and corroborated in the main the view that in them-
selves they were not especially fraught with danger or
in general portentous of evil. The involvement of
special nerve centres, or, as Musser has been pleased
to style it, the thermo-toxic apparatus, does not bring
much hope or consolation, nor give much time for
any but reminiscent measurement. The temperature
peaks, sharp and precipitous, explode at a very high
apex with a dismal chasm at the end of the range. In
many and by far the most numerous cases, the gauge
marked intensity only. It was the brisk, crackling
fire, and not the low, smouldering one, on point of ex-
tinguishment through abstraction or loss of material,
which gives the glow of comfort. In these last cases
of the subnormal, care should be taken to observe
both the central and the peripheral temperatures, for
even a chill may be misleading, as many have been
surprised by the per-rectum test with readings of 107°
or :o8'' F., recovery not therefore on that account to
be unhoped for. It is the subnormal temperatures
which are really alarming, those, in fact, obtained after
the precautionary shakedown of the thermometer, at
least, say, to 95^ F. ; the normal thin red line will not
answer. The extreme ranges, zigzag and with short
curves, constitute the stenographic writing upon the
walls. Of course, the respiration and circulation are
not to be unstudied, nor conditions, environments, and
the teachings of bacteriology; but as careful engineers
it behooves all to watch well the heat-gauge, or, at
least, the stop signal of the track walker, for the ther-
mometer does not well brook contempt. It has its
revenge in uncanny dooms. Above all, let not the
prophet entirely despise the honors which may be his
due.
Officers Elected President, Dr. Charles Phelps,
of New York; Vice-Presidents and Members of the
Council by Districts : i. Dr. R. N. Cooley and Dr. John
P. Shearer; 2. Dr. E. M. Lyon and Dr. T. H. Han-
non : 3, Dr. Robert Aberdein and Dr. L J. Brooks;
4, Dr. .\. A. Hubbell and Dr. \V. M. Bemus: 5, Dr.
C E. Denison.
Correction By a mechanical transposition a por-
tion of the proceedings of the section on surgery of
the College of Physicians of Philadelphia in the
Medical Record of October 17th, p. 560, was in-
cluded in the report of the meeting of the Schuylkill
<"ounty (Pa.) Medical Society.
Rise in Temperature after Labor. — Dr. Machure
(Tlie Canadian Practitioner, August, 1896) says: " For
twenty-four or thirty-six hours after labor the tem-
perature may be elevated as the result of fatigue, but
if the subsequent temperature should be above 99' F.,
its cause should always be promptly investigated. It
may be due to (i) constipation, (2) mammary disturb-
ances, (3) intercurrent non-obstetric disease, or (4)
isepsis."
NEW YORK NEUROLOGICAL SOCIETY.
Stated Meeting, October 6, iSg6.
B. S.\CHS, M.D., President.
A Contribution to the Study of Motor Aphasia. —
Dr. B. ()NrF read a paper with this title. He said
that diiri:ii; the last few years the writings of various
authors had shown the necessity of harmonizing the
conclusions of the two principal methods of studying
language. He was of the opinion that the strictly
anatomical and psychological theories must be blended
with one another. The following case of cortical
motor aphasia was then reported :
Mrs. S. D , twenty-three years of age, had an
attack of acute articular rheumatism three years ago,
during which she probably acquired an endocarditis
with valvular lesions of the heart. On June 7th, after
a miscarriage, she had an attack of embolism, followed
by hemiplegia of the right side and involving the
right arm, and particularly the hand and fingers. She
said that the understanding of spoken language was
unimpaired, but this statement should be taken with
some allowance. He had first seen her on April 3d.
At that time there was slight disturbance of motor
speech — i.e., slight difficulty in finding the words, and
an occasional misuse of words, or an improper con-
struction of sentences. She had difficulty in giving
the name of common objects presented to her. Aside
from these disturbances there was marked defect of
the faculty of reading and writing, individual letters
of the alphabet being frequently mistaken. She found
it, as a rule, easier to read the word in toto than to
spell it. The word "one," for example, was pro-
nounced correctly, but spelt '" won.'" In the writing,
which was done with the left hand, the patient used
printed characters, both in copying and writing from
dictation. The auditory impressions received from
loud reading undoubtedly helped her understanding,
and enabled her to read words which she could not
otherwise. There were absolutely no visual disturb-,
ances — no hemianopsia and no narrowing of the vis-
ual fields, .•\pparently there were no gross lesions of
memory.
The author then referred to the researches of Bian-
chi on the removal of the frontal lobes of monkeys.
He concluded that the frontal lobes were, so to speak,
the centre for intelligence and constituted the organ
in which the various sensory and motor images became
co-ordinated and fused. The destruction of this por-
tion of the brain results in the destruction of the ana-
tomical basis upon which judgment and the reasoning
faculties reside. Until recently, Broca's centre had
always been considered, he said, as motor, and its
anatomical position would not contradict such a view;
but, on the other hand, the function of this centre is
so much more complex than that of the parts compos-
ing the motor district proper that one hesitates to
place it under this head. Broca's centre, the reader
said, is a centre of the higher order, presiding over
the functions of the larynx, tongue, and lower part of
the face, and probably also has at the same time the
function of fusing sensory and motor elements, and
must be considered as a part of the frontal lobe in the
sense of Bianchi's definition. This view found fur-
ther support in his own observ'ations. He reported
a case of a man whose speech had been suddenly
affected, so that he spoke very thickly and could
hardly be understood. There was no real aphasia, for
he knew what he was going to say, and always suc-
ceeded in saying it, but the words were very much
blurred. Five days later he died with symptoms of
congestion of the lungs. On post-mortem examina-
tion, a blood clot was found at the level of the lower
part of the ascending frontal and ascending parietal
October 24, 1896]
MEDICAL RECORD.
607
convolutions of the left hemisphere. Almost all the
cortical substance of these convolutions had been de-
stroyed, but tlie third frontal convolution had been
left intact.
With the exception of the old theory of Wernicke,
of the existence of a special speech tract connecting
the speech centre directly with the nuclei of the
medulla, a pure type of subcortical aphasia could not
be conceived. Wernicke had himself abandoned this
theory. He compared the process of acquiring speech
to a reflex process, but the part which visual, tactile,
or muscular sensations might play in the acquisition
of speech were not at all considered by this author.
Careful analysis, however, showed that the tactile and
muscular elements had a much more direct influence
than the visual. The acquisition of such sounds as
could be learned by watching the motion of the lips
was the easiest of all. The auditory element informs
the speaker as to whether the utterance is what was
intended, while the tactile elements help to make such
utterances possible and more and more correct. It
must be assumed that Broca's centre takes part also in
this process. Each innervation of Broca's centre is
conveyed to the centre of the auditory word images,
but each innervation of the auditory centre is not
necessarily carried to Broca's centre. The child is
taught to associate a certain letter with an effort
necessary to enunciate the proper sound. A direct
association between the auditory and visual image is
not absolutely necessary for the mental act of reading;
it is very probable, on the other hand, that a direct
association forms between the visual and the psycho-
motor image, which latter innervates the auditory
image. When we read, we have a distinct impression
that the psycho-motor images are first aroused. The
faculty of reading depends upon the intactness of
Broca's area equally with the intactness of the centre
of auditory word images; hence, a lesion of Broca's
centre must cause not only motor aphasia but alexia.
On the contrary, subcortical motor aphasia leaves in-
ternal language and the faculty of mental reading
intact. The motor conceptions can be acquired with-
out any association with the speech organism. The
writing of a word implies the ability to spell it. Only
for the writing of single letters at dictation the possi-
bility remains that the auditory image affects directly
the graphic concept. Cortical motor aphasia implies
not only alexia but also agraphia. Bastian distin-
guishes three states of lessened excitability of the cen-
tre, viz. : (i) That in which it does not respond to
volitional excitation, but can be excited by association
from one centre to another; (2) that in which the
centre responds only to direct sensory stimuli; and
(3) that in which even these direct sensory stimuli fail
to excite the centre to activity. If there were a con-
tiguous and continuous zone of language, as some have
thought, then any lesion within this centre ought to
cause actual aphasia. The fact that a lesion within
the centre of language causes no aphasic disturbances
speaks against the continuity of this zone.
In the case reported in the paper it was easy to
understand, Dr. Onuff said, the occurrence of motor
aphasia with alexia and agraphia, if we supposed that
Broca's centre was involved. This view found further
support in the fact that many cases of motor aphasia
with alexia had been reported in which the aphasia
had been almost entirely recovered from, while the
alexia had remained. He could not answer, however,
the question, why in this and many other cases the
aphasia was recovered from sooner than the alexia. The
observations in this case would go to show that most
of the wortls are read as a whole, and not by spelling.
It was certainly not possible in the English language,
because of the variety of ways in which certain groups
of letters are pronounced in different groups. In
learning Russian he had himself begun to read before
he had been entirely familiar with the letters of the
alphabet. Although to a certain degree he had to read
the language " spellingwise," he still recognized many
words by familiar combinations of letters and by the
sense. He believed that the reason his patient used
printed characters solely was that there was a loss of
motorgraphic memories. The visual memories for
printed signs are usually much better established than
those for script, for the reason that reading is chiefly
done from printed characters. That muscular sensa-
tions play a very important part is shown by the fact
that we can write with the eyes shut. If we are war-
ranted in speaking of a motor speech centre, we must
be justified in speaking of a physiological apparatus
in which muscular graphic memories are stored. Loss
of these memories does not imply absolute impossi-
bility to write, as visual memories may supply the
deficiency. It is not supposed that the lesion may
destroy the motorgraphic memories only and leave
intact the other motor faculties connected with the
hand and finger muscles. A patient with a lesion of
Broca's centre can understand what is said to him, but
he has lost the power of inwardly repeating what has
been said. The motor speech centre forms such an im-
portant factor in the evolution of the higher mental pro-
cesses that its lesion cannot remain without damaging
influence on the mental activity.
Discussion. — Dr. Joseph Collins said that he
agreed for the most part with the views expressed by
the reader of the paper. Certainly the paper served
still further to confirm the views expressed by Bian-
chi. Personally, it seemed to him tliat all that a
study of aphasia could do was to help the pedologist.
We could do a great deal for psychology by working
in the field of aphasic disturbances. He could not
agree with Dr. Onuf that a person having pure motor
aphasia had complete inability to read. It did not
seem to him that it was necessary in order to read to
translate what we read into articulated words, and he
thought he had one or two cases under observation at
present which would abundantly substantiate this
statement. One patient was completely aphasic, yet
he could write prolifically, and was able to read
understandingly both his own writings and those of
others. He certainly both read and understood these
writings; hence, the speaker said, he could not believe
that with pure and complete motor aphasia there is
necessarily alexia. He did not think there was any
objection to subdividing the motor speech centre into
an articulo-motor centre and placing adjacent to it
the centres for phonation, labial movements, and buc-
cal movements.
The President said that his individual experience
with aphasia had been a rather curious one. At first,
he had been impressed with the writings of Jackson
and Bastian. Then had come the German school with
all sorts of mechanical theories, and now we all felt
the need for returning to a mixture of the psychologi-
cal and the mechanical theories. On the whole, he
was in entire agreement with the views expressed by
the reader of the paper. Recently he had observed
the progre'ss of a case in which aphasia was the sole
symptom of a cortical tumor. The manner in which
it progressed would seem to justify fully the subdivi-
sion of the motor speech centre, and also to show that
speech is not the function of any one centre or any
series of centres, but that it is really the result of a
very close union of these centres by distinct associa-
tion tracts. If this were not so, a relatively small
lesion could not explain the variety of symptoms ob-
served in a single case. The case referred to was
that of a lady who had been carefully observed by her
brother, who was a physician. The first thing noticed
was an apparently slight apathy, but this was really
6o8
MEDICAL RECORD.
[October 24, 1896
due to a difficulty in speech. When first seen by Dr.
Sachs, about three months after this, it was found that
she had lost the faculty of using nouns, so that she
could not give the names of those persons best known
to her. .\fier a while the ditticulty of speech became
more distinct: there was great difficulty in finding
words. Toward the end only was there a distinct
deficiency in the understanding of language. From
the very first her brother had noticed a distinct diffi-
culty in reading, and a still greater difficulty in writ-
ing. He had never seen a patient able to speak so
much and yet be unable to name or even to copy single
letters. She could, however, write a w^hole name
fairly well. Such a case seemed to show the necessity
for a further subdivision of the motor area. The
paper of the evening was of value as a corroboration
of Bianchi's views. It showed that we were gradually
turning to larger divisions rather than to the small
localization areas which we employed as a result of
the teachings of Ferrier.
Dr. Onuf, in closing the discussion, said that he
distinguished two forms of aphasia — cortical and sub-
cortical motor aphasia. The latter was also called
pure motor aphasia. In cortical motor aphasia it was
assumed that the cortex where psycho-motor images
of speech are deposited is affected. Subcortical
aphasia is one in which there is an impossibility of
loud speech, but internal language remains intact:
hence such persons can read and write perfectly. He
believed the cases referred to by Dr. Collins were
examples of subcortical motor aphasia.
The Commitment of Patients and the New In-
sanity Law Dr. G. W. Jacohv read a paper on this
subject. He said that under the name of " the insanity
law" there went into effect a new law in July of this
year. In his opinion the framers of the law had
totally failed to unite the postulates of jurisprudence
with those of medicine — indeed it would seem that
they had intentionally ignored, as far as possible, the
medical side of the subject. The medical certificate
no longer serves for the temporary detention of the
patient for five days. The responsibility for the com-
mitment has been removed from the shoulders of the
physicians to those of the judge, and a matter which
is essentially medical has been transformed into one
chiefly legal. This law also provides that at least one
day before the physician presents his application to
the judge the patient is to be informed of the pro-
ceedings. This personal service can be omitted under
certain circumstances, according to the discretion of
the judge. After all the necessary legal preliminaries
have been taken, the superintendent of the institution
to which tile patient is committed may refuse to ac-
cept the patient on the ground that he does not con-
sider the person insane, or that the papers are not
made out properly. There is also a provision for an
appeal from the decision of the judge and a trial by
jury. The old law was much better, particularly on
account of its provision for temporary detention. The
provision which takes away every method of procedure
except appeal, when the application is refused, is a
particularly objectionable feature. Personally, he
would not be satisfied with an insanity law which
would not allow of the temporary commitment of the
person on the strength of medical certificates by two
qualified physicians, one of whom should hav<,' special
psychiatric qualifications.
Dr. Carlo.s F. Macdon.ald said that he wished at
the outset to disclaim any responsibility for the fram-
ing of the new law. It had its origin with a member
of the statutory committee of revision. He was the
only physician in this State who had opposed the bill
before the legislature. During the past .seven years,
as commissioner in lunacy, he had examined thousands
of cases of alleged illegal commitment, and he had
yet to learn of a single case of a sane person being
committed through corrupt collusion or through in-
tent, although he had occasionally known of instances
of mistaken diagnosis, such as might occur in connec-
tion with any disease. He thought that as a rule
judges would waive the notice of personal service upon
the patient or friend, and it seemed to him a distinct
advantage to make the commitment a judicial order
rather than a judicial approval, as in this way it re-
lieved the medical profession of much responsibility
and the danger of suits for damages. In his judg-
ment, the weakest point was the absence of any pro-
vision for temporary detention. A detenu ined effort
should be made this winter by the medical profession
to amend the law in that respect. Curiously enough,
laymen consider themselves fully as qualified as
physicians to diagnosticate insanity, and this new law
is an outgrowth of that feeling.
Dr. C. L. D.anw said that his views were entirely
in harmony with those of the reader of the paper, and
the society should make it clear that it appreciated the
absurdities and many faults of the new law. It had
caused an infinite amount of trouble to the city phy-
sicians, and the ordinary process of commitment had in
consequence become tedious and expensive — so much
so that physicians had found it advisable to commit
insane [persons, as far as possible, to institutions out-
side of tills State.
Dr. V. Peter.sox said that the new law was objec-
tionable in that the paper must be fully made out and
approved by the judge before the patient could be sent
to an asylum, and because of the possibility of other
difficulties arising in practice, such as had been men-
tioned. In his own experience, however, the judge
had in every instance dispensed with the personal
service.
Dr. Gr.\eme M. H.am.mond said that he agreed with
the views presented in the paper, and now^ that the
evils had been pointed out it was our duty to consider
the best remedy. He hoped the society would take
an active interest — for instance, by appointing a com-
mittee charged with the duty of urging proper amend-
ments.
Dr. L. C. Grav said that he thought the law was
not only absurd but an outrage. It was ridiculous
that physicians should submit to lawyers about a matter
involving the question of a cli.sease of the brain.
Dr. Collins said that according to the new law
the physicians certified to the insanity of the person,
and the judge committed him. This was no infringe-
ment upon the rights of the medical profession. He
did not think that the gloomy view and the objections
presented in the paper were well founded. It was
true there were some objectionable features, but they
did not appear to him to be of vital importance. The
new law otTered unusual opportunities for a trial of
the home treatment of the insane, so strenuously advo-
cated by some.
Dr. L. F. Bishop said that the new law had given
him less trouble than the old law.
Dr. Hirsch said that this law had no counterpart
in any other country, for not only the disposal of the
lunatic, but the decision as to his insanity was made
by the judge, the physicians only giving their testi-
mony. This testimony was given on special blanks
which made it far from scientific. It was remarkable
that a judge must tell us whether a patient is fit to
live with his family, or must be deprived of his liberty
because of his being insane and a menace to society.
Persons having small-pox or cholera were often for-
cibly removed from their homes, but in these instances
the decision was made by a physician, as it should be,
and not by a judge. He thought that the personal
service provision was objectionable, and sometimes
produced a bad mental impression on the patient.
October 24, 1896]
MEDICAL RECORD.
6og
Dr. M. Allen Starr said that according to the
new law the judge acted entirely upon the testimony
given by the two physicians — the physicians' rights
were more fully protected than by the old law. He
urged that the society should not take an extreme
view, but should simply ask that one or two features,
which were generally admitted to be particularly ob-
jectionable, should be amended.
The President said that the worst feature was tlie
lack of provision for temporarily detaining acute cases.
One result of the- new law would probably be the es-
tablishment of many private institutions for the care
of the insane, which would not be under the control
of the State. He had found that it took about four
hours to have a certificate signed in this city.
IJr. Jacohv, in closing the discussion, said that he
did not look upon the new insanity law as an unmiti-
gated nuisance. The judges now take the certificates
of the physician simply as testimony additional to
that of the petitioner. If an appeal should be taken
from the decision of the judge, it was not clear that
adequate provision would be made for the patient.
Dr. Hammoxd then offered the following resolu-
tion, which was unanimously adopted:
" Resolviui, That the president appoint a committee
of five to report to the society such measures as it
may deem expedient for securing the amendment of
the present lunacy law governing the commitment of
the insane."
OUR LONDON LETTER.
(From our Special Correspondent.)
OPENING OF WINTER SESSION INTRODUCTORY LEC-
TURES—DEATHS OF SIR G. HUMPHRY AND DEAN
COPEMAN A DANGER FOR SANITARY BOARDS JUBI-
LEE OF AN/ESTHESIA — MALE PATIENTS AND FEMALE
PHYSICIANS.
London, October 2, 1896.
The winter session of our medical schools opened yes-
terday. In some the time-honored addresses were
omitted, as has been the case for several years; in the
others the old custom was observed. The addresses
were certainly worth listening to by practitioners as
well as students, far more so, in fact, than the after-
dinner speeches that in some instances have sup-
jjlanted them. The dinner which was to have been
held by the alumni of University College was omitted,
in consequence of the death of Sir J- Erichsen. But
there was an address by Prof. S. Martin, who expressed
satisfaction at the rate of progress of scientific medi-
cine, and that we have passed from the darkness of the
sorcerer and herbalist into a clearer knowledge of the
processes of disease, and, therefore, the means of coun-
teracting tiiem. The great change that has taken place
has been from the speculative to the real, he said, and
added that in not a few cases treatment is an experi-
ment— intended, it is true, to benefit the patient, but
still an experiment, since all the conditions present in
the body are not known, and we watch the result to
ascertain new facts. Much treatment is empirical, but
not to be despised, since it often gives a clew to the
experimental investigation of the morbid process.
The lecturer then spoke of bacteriology, which, he said,
has taught us the cause of tuberculosis: and he saw no
reason wliy, as knowledge advanced, we should not de-
stroy the sources of infection and deliver mankind
from the scourge of centuries. So, too, there is hope
that in time cholera also may cease to be a scourge to
the race.
.\t St. George's Hospital, Mr. A. Frost regretted
that a number of men commenced medical study who
were really unfit for the profession, and he thought the
standard of preliminary education should be raised.
Then, as to surgery, some men had no manual dexter-
ity, whereas they should in many cases be ambidex-
trous. Much clumsiness is due to the ridiculous cus-
tom of teaching children to do everything with the right
hand — a relic of pagan superstition. The lecturer
then passed to the subject of vaccination. Students,
he said, should remember that Edward Jenner was a
pupil of St. George's. His discovery had saved mil-
lions of lives, had stood the test of a century, and its
value was admitted by all who were capable of weigh-
ing evidence. But its opponents had added the proof
of a gigantic experiment upon human li\es, with a re-
sult so appalling tiiat it should not be forgotten; and,
curiously, this experiment was conducted in Jenner's
own county, Gloucester — an illustration of the proverb,
■■ A prophet hath no honor in his own country." The
royal commission had reported, and although they
could not agree whether they should compel people to
protect their children from small-pox, or should ask
them not to increase the prevalence of small -pox unless
conscientious scruples led them to do so, or whether
they should have as absolute control of their children's
lives as over their chattels, all sections of the commis-
sion agreed that vaccination is a preventive. The
road indicated by Jenner had been followed by Pas-
teur, Lister, Koch, and others, and it now remained
for students to discover whither it led.
Mr. Morton Smale was the lecturer at St. Mary's
Hospital, and a marked feature of his address was an
exposure of so-called "patent medicines," on which
the British public squanders two and one-half millions
of pounds a year. He thought the governmental stamp
misled many ignorant persons to believe in these nos-
trums, and therefore should be abolished, while drugs
should be supplied only by qualified pharmaceutical
chemists, and no combination of drugs should be sold
or dispensed even by such pharmacists except on the
prescription of a qualified practitioner.
At the Middlesex Hospital Dr. Essex Wynter first
reviewed the course of study, and asked his hearers to
think over the important period of their lives in which
their studies were to be carried on — a period which
covered the transition from dependence on others'
guidance to freedom and the assumption of more than
ordinary responsibility, including the chief period of
physical, intellectual, and moral growth, and of great
inliuence on their future social standing. They must
develop their senses, acquire manipulative skill, culti-
vate capacity for deliberation and prompt action in
most disturbing circumstances, and, above all, the
habit of patience, kindness, and tact, remembering
that
" We are not ourselves
When nature, being oppressed, commands the mind
To suffer with the body."
One after another our friends are passing over to the
majority. Just after 1 had dispatched my last letter,
telling you of Erichsen's death, I received the news
that surgery had lost another veteran, viz., Sir George
M. Humphry, the Cambridge professor who did so
much to raise the medical school of Cambridge that
he was sometimes spoken of as having created it. He
represented the university in the General Medical
Council from 1869 to 1889. George Murray Humphry
was the son of a barrister and was born in 1820. He
was one of the elected fellows of the Royal College of
Surgeons in 1844, and practised at Norwich before he
went to Cambridge to become surgeon to the hospital
and professor in the university, of which he took the
M.B. in 1852, and M.l). in 1859. Among the nmrer-
ous honors he received may be named tlie honorary
membership of various societier, British and foreign.
6io
MEDICAL RECORD.
[October 24, 1896
the degrees of LL.D. and D.Sc, the presidency of the
anatomical and pathological societies, and the much
prized F.R.S. He was knighted in 1889. Perhaps
his most esteemed work was that "On the Human
Foot and the Human Hand," but his "Treatise on the
Human Skeleton" runs it a close second. Besides
" Lectures on Surgery" and numerous contributions to
societies and journals, he was the author of '" Observa-
tions in Myology," "Observations on the Limbs of
Vertebrate Animals," and an essay on "The Coagula-
tion of the Blood in the Venous System during Life."
Besides these and other works, you will remember his
Hunterian oration of 1879, " On Old Age and Changes
Incidental to It," which created no small interest in a
subject which the distinguished orator was known to
have carefully studied.
Another notable death is that of the Rev. A. C.
Copeman, honorable canon of Norwich, where, like Sir
George Humphry, he practised in his earlier career as
a surgeon. He was a member of the College of Sur-
geons in 1845, ^"d ^l-^. of the London University in
1848. He became a clergyman and was promoted to
various offices in the Church, and continued at Nor-
wich until his death last Sunday. Though he left the
profession he retained much interest in it, and on the
hospital committee, as well as chairman of the board of
guardians and in other positions, gave much attention
to the welfare of the sick and the poor. He was in his
seventy-fourth year, and the oldest of the beneficed
clergy in Norwich except one.
A sum of ^"2,875 has been awarded by a jury as
damages to the representatives of a gentleman who
was alleged to have died through the escape of sewer
gas into his house, from a flue in the chimney stack
erected under the superintendence of the surveyor.
This method of ventilating the sewers must necessarily
be risky, and as the local sanitaiy authority has to
pay these heavy damages, to say nothing as to costs,
other boards will doubtless adopt better methods and
forbid their officers to permit this dangerous one.
The Society of Anaesthetists have initialed a move-
ment for the celebration of the jubilee of anaesthesia,
and, of course, invite the co-operation of the profes-
sion at large.
In consequence of the objections of patients to un-
dressing before women, Mr. Hutchinson has been
obliged to exclude female physicians from the demon-
strations at his museum. Of course, the attendance
of patients is voluntary, and their objections must be
respected or their cases could not be exhibited.
DISEASES OF THE AGED— A SPECIALTV.
To THE Editor op the Medical Record.
Sir : Now that childhood has been fenced off as a pos-
sible specialty and is being prospected by careful ob-
servers as to its probable yield to one who works it
faithfully, it is time that we should turn to the other
extreme of life, and consider whether it, too. may not
be worthy of intensive cultivation.
The physiological processes of old age and its path-
ological changes are certainly deserving of more thor-
ough study than they have j'et received. The senile
heart has been the theme of some very able essays and
even volumes. The digestion of the aged would be
an interesting subject for observation and analysis.
The brain changes of age — their nature, their causes,
their possible prevention — would, when understood,
form a very valuable contribution to that store of
knowledge upon which the wise therapeutist bases his
remedial efforts.
The food, clothing, exercise, sleep, and occupation
of old age must be thoroughly comprehended, not in
a faddish way, but as a part of the education of every
physician, if our race is to advance in longevity as in
culture and comfort.
If this is true, it is not difficult to believe that in
future the practitioner who wishes to bring his patient
who has already passed seventy safely and happily to
the eightieth, ninetieth, and even one hundredth mile-
stone of his earthly journey, may be glad to turn for
counsel and consultation to one who has made the care
of the aged a special study.
Why do old people die? How do the changes oc-
cur, and in what organs or functions are the subtle
processes located which cause so many aged persons
to detach themselves painlessly, quietly, without evi-
dent disease, sometimes apparently by a simple exer-
cise of the will, from the parent tree of humanity.'
An author tells us that it is failure of nutrition which
gradually extinguishes the life flame of such persons.
If so, how necessary is it that the nutrition of the lat-
ter half of life should be minutely studied! And how
dangerous an experiment it must be, unless for grave
reasons, to tinker with the diet and digestive habits of
the aged! Then the promotion of nutrition must be
the ultimate goal of eveiy therapeutic effort. All
progress in this direction is gain: all disorder of nu-
trition, by however excellent a drug, is perhaps irre-
coverable loss.
So, as the patient gradually passes farther and far-
ther on the way whose distant stretches so few of us
may hope to tread, the wise physician should, for or-
dinary ailments, steadily lesssen the doses of the more
powerful remedies, drop the dangerous drugs and those
which are trying to the stomacii, and place his reliance
more on rest in bed, with simple and abundant food.
Even aperients are sparingly administered, the bowels
being coaxed rather than compelled to their duty.
Yet even tlie most experienced general practitioner,
as he stands in an attitude of respect before that aged
frame which has weathered the storms of nearly a cen-
tury, must at times, dreading lest his well-meant efforts
should add to its perils, long for the counsel of a pro-
fessional brother who, to his own long acquaintance
with his patient's peculiar needs, might contribute a
deeper scientific knowledge of the processes of age, its
pathology, and its therapeutics.
A study of the tliought processes of extreme age
would be no insignificant portion of the training of
such a specialist. Why is it that the mental faculties
of some persons deteroriate with the onset of advanced
age, while those of others, apparently no more healthy,
are preserved clear and alert, though of course not so
hardy as in middle life? Is this preservation depen-
dent upon bodily nutrition? or is it the reward, as
some would have it, of the habitual ingestion of
healthful, pure mental food throughout life? Does
the brain cell thus fed on the best of social intercourse
and literary pabulum win the reward of intellectual
longevity? What would the specialist on old age
have to say upon this point?
Apart from the gradual brain deterioration which
affects so many among the aged, there are numerous
disturbances of its mentality which call for study. Is
there not a melancholy which is the result of age
changes? If so, what is its cause? Has it to do with
digestive errors? Or is it the result of a failure of
excretion, as by the kidneys? Sometimes it seems,
due to insufficient sleep, and occurs in otherwise
healthy individuals.
Shall old age have its specialists and its special
journals? Or can it be merged with pa-diatrics into a.
specialty which embraces both extremes of life? A
startling suggestion, yet one which is not destitute of
reason. Both extremes of life involve frailty of organ-
ization, and demand wise super\ision of diet, clothing,,
and exercise. Both call for lessening of drug medica-
tion. In both the main reliance must be placed on-.
October 24, 1896]
MEDICAL RECORD.
611
the power of the body to right itself, time being a
cheap commodity. Both need for their medical guid-
ance the same type of physician. He must be thor-
oughly equipped with professional lore, )-et must add
to this extraordinary patience and gentleness, and a
love for philosophical reflection which shall ensure
deep insight and great breadth of view.
There are many men of this type and capability,
failures in the fierce elbowings of ordinary practice of
medicine or surgery, who might find a congenial and
profitable field in these departments of " inner medi-
cine," both of which contain rich mines of research,
awaiting development by a master worker.
.A.. K. Bond, M.D.
Baltimore, Md.
TUBERCULOSIS AND BACTERIAPHOBIA.
To THE Editor of the Medical Record.
Sir: Some five or si.x years ago, when Dr. Koch first
brought out his tuberculin claim, I wrote you a brief
note which was published in the Medical Record,
stating that " tuberculosis is a disease of malnutrition,
the result of a defective organization, either hereditary
or acquired; and hence is incurable when once fully
established in the pulmonary organs."
In that brief article I also warned the profession
against what appeared to be the coming craze named
as the latter part of the title to this article. Since
that time, in spite of the bacteriaphobia which seems
to have seized upon the great and learned medical
men of the whole earth, I am more than ever confirmed
in the truth of that statement. That this form of dis-
ease is the result of malnutrition, its own common
English name clearly indicates. It is a consumption,
a wasting away. Why do its victims waste away?
There is but one answer to this question ; they waste
away because they are badly nourished. Nutrition is
defective. Does this grow out of the condition of the
lungs? Are the lungs the primary organs of nutri-
tion? Do the lungs make blood? The truth is that
pulmonary tuberculosis is not the primary, but the
secondary condition. So also are all the local mani-
festations of the disease. The primary condition is
found in the blood-making organs. The organization
fails to make a full supply of pure and perfect blood
for its own absolute needs, and the result is a dyscra-
sia : bad blood, defective blood, autotoxiemia. Such
blood contaminates the whole organism and specially
the lungs, and more especially the upper lobes of the
lungs, because the whole blood stream courses through
these organs and the toxins entangled in the lung cells
are retained there and become the foci of pulmonary
irritation, inflammation, and ulceration ; '" more espe-
cially in the upper lobes," first, because there the
circulation is weaker and more easily obstructed.
The real seat of the disease is in the chylopoietic
viscera and is organic; that is, it has its origin in
defective digesting and assimilating organs. They
fail to convert the food into healthy blood in sufficient
quantity to maintain a normal physiological con-
dition. This is the root of the disease, and what is
called the tuberculous bacilli are the outgrowth of it
after it becomes seated in the lungs, where the atmos-
phere has access to the deposit and comes in contact
with it. These are from without and not from within.
The first symptoms of the disease are connected
with the abdominal organs and are manifested in the
form of indigestion, constipation, congestion, eructa-
tion, borborygmus, etc., followed by headache, a slight
intermitting fever, and finally by cough, etc. Some-
times the first suspicion of the disease is aroused by a
pulmonary hemorrhage bursting forth from heavily
congested lungs, the result of the dyscrasia which has
been gradually creeping upon the patient so insidi-
ously that it is not suspected. There had been no
thought of tubercle, but only of a general malaise
attributed to want of exercise, or indigestion, or some
of the other premonitory symptoms. During this
premonitory period, this malaise stage, a careful in-
spection will manifest a periodicity of action in the
system, with temperature normal or subnormal at some
period between midnight and midday and above nor-
mal at some part of the period between midday and
midnight. This periodicity generally continues and
increases to the end; unless indeed the disease is sub-
dued or greatly mitigated. Fistula in ano and appen-
dicitis are both indications of an organic predisposition
to tuberculosis; so also is typhoid fever, but when it
is successfully passed through, it seems, for a time at
least, and perhaps forever in some cases, to immunize
the organization against any further tendency to tuber-
culous deposition. The root of this fever we all know
to be enteric. The same may, in some measure, also
be true of appendicitis, fistula, and tuberculous joint.
If the above intimated theory of tliis dreadful enemy
of the human race be true, or chiefiy so, the practical
uselessness of all prevailing modes of treatment will
be manifest, and specially those founded upon the
bacteriological theory. Tuberculin injections have
been demonstrated a failure; so also has the creosote
treatment, and indeed all methods may be said to have
come to naught. Now let us do better. How?
.\bandon all bacteriaphobia and come down to a
rational method of treatment. Let all high-flier theo-
ries like bacteriolog}', specific medication, and all
such foolishness go, and come down to rationalism,
which is the only scientific and successful form of
medication known to man. Rational medication is the
outcome of man's highest faculties. It results from
the ability in all cases to trace the symptoms mani-
fested back to their origin, the cause of the disease,
and the present systemic condition resulting from that
cause. To this end the successful physician must not
only understand the significance of all manifested
symptoms, but be able by his learning to trace them
back to their origin in the organization. If the patient
has a fever he must be able to rea h the cause of that
fever and remove it, if possible, or, if not possible,
then to conduct or aid the natural forces of the organ-
ism in their struggle to restore the lost physiological
condition. I have sometimes said that physicians
know everything that can be known, except how to
cure disease. The reason for such a remark grows
out of the fact that their remedies are not well directed
to this end. They are too often impelled by the
thought that something must be done, and something
too that must produce clearly manifested results,
whether these results are toward the normal or the
abnormal. Homoeopathy should have taught us long
ago to beware of too clearly manifested results, unless
we are absolutely sure that they are in the physiologi-
cal and not the pathological direction. I knew of
a case that occurred in your great city of New York,
where a very prominent gentleman, like most city
gentlemen a high liver and of very full habit, though
only forty-four years of age and of strong constitution
after dining out in the evening, was taken in the mid-
dle of the night with a bad fit of indigestion and a
"big doctor" was called in to relieve him. The pa-
tient's heart was dreadfully oppressed from plethora
and general stagnation of the circulation, accompa-
nied by abdominal pain. The doctor injected hypo-
dermically one-half grain of morphine, which soon
relieved the patient, who fell asleep and never awoke
any more to the things of this world! This was a case
of irrational medication, and well illustrates by con-
trast what I mean by rational medicine.
All cases of irrational medication are not so clear
6l2
MEDICAL RECORD.
[October 24, 1896
as this one was, but the antiseptic treatment of tuber-
culosis is almost or quite as much so, because the rem-
edies are irrationally applied. They are applied to
an effect of the disease and not to its cause. The
pause is malnutrition, and is usually the result of a
defective organization, either inherited or acquired by
bad habits of living. .\11 our efforts should be di-
rected to restoring the lost functions of the blood-
making organs. This is the direction in which now
all our efforts at cure should be directed. Everything
that we now know to be beneficial in these cases is in
this direction — best climatic conditions, exercise out
of doors, tent life in suitable climates, proper food
suitably prepared, and every other means that operates
to promote healthy blood-making in the organization.
J. S. PRETTY^rA^-, M.D.
MiLFOKD, Del., September 8, 1896
pXecUcal Jtcins.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending October 17, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
.Smallpox
Cases.
Deaths.
17
S5
33
15
53
I
0
3
3S
2
57
17
0
0
The Society of Medical Phonographers of England
now has over two hundred and fifty members.
Intestinal Fermentation In a study of the vari-
ous foods as to llieir ]jutrefactive tendencies, Gilbert
and Dominici are quoted in the Texas Medical Ne7vs
as e.xperimenting with milk upon a healthy man. Two
and five-tenths litres of milk were given daily for
five days. Before beginning with the milk diet the
fa;ces showed sixty-seven thousand bacteria per milli-
gram. On the second day of the milk diet the faeces
showed fourteen thousand bacteria; on the fifth day,
twenty-five hundred. By the use of sterilized milk
the number was still further reduced. From this the
inference is drawn that milk is the ideal diet in
typhoid fever and other enteric diseases, it being less
fermentative than meat and other albuminous mate-
rials.
Dangers of " Scorching."— .\ patient whose case
illustrates the subjective dangers of "scorching" was
recently under the treatment of Dr. Hansell in the
hospital. A young man, who had imperfectly conva-
lesced from a severe attack of typhoid fever, exercised
violently on his bicycle for two or three successive
days in direct opposition to the advice of his phy-
sician. -Vftcr his last run, he noticed a defect in his
visual field. It was found that he had sustained a
circumscribed local detachment of the retina from
hemorrhage into the choroid. A somewhat similar
case was recently reported by an English ophthalmic
surgeon. In his patient the hemorrhage was due to
the rupture of a retinal vessel. Another accident, oc-
curring in the person of the writer, is thus far unique
in the literature of bicycling. After a hard and hilly
ride over stones and ruts the contents of the bladder
were found to be, in large measure, blood. In the
next micturition but little difference was noted and in
twelve hours the urine had regained its normal color.
Examination of urine subsequently passed showed the
presence of large numbers of blood cells and some
bladder epithelium. The hemorrhage was therefore
probably from a small vein in the bladder wall. Ac-'
cidents of this and like nature should be widely re-
ported, in order that bicyclers, who constitute so large
a proportion of the young and middle-aged, may regu-
late their exercise according to their physical powers
and endurance, and they should accept these instances
of threatened blindness as warnings against immodera-
tion.— r/iihiclclphia Folydink.
The Weaning of Infants — Dr. Louis Fischer
{Pcliatrks, July i ^, 1896) says that when a child
reaches the age of six months it is well to think of
weaning. Gradual weaning is usually very success-
ful. Begin by feeding from six to eight ounces once
during twenty-four hours. Each succeeding month
withdraw one breast feeding and substitute an artifi-
cial feeding, so that by the ninth month the infant is
weaned. Complete weaning should take place about
the tenth month, unless it is midsummer or there ex-
ists some other special condition. For artificial feed-
ing, Dr. I'ischer recommts.ds three ounces of cow's
milk, and if the bowels are regular, three ounces of
barley gruel, and about ten-fifteenths of a grain of
ordinary table salt nnd half a lump of cane sugar. He
says that if the increase in weight is not five or six
ounces weekly, a careful chemical and microsccpical
examination of the breast milk should be made.
Subcutaneous Alimentation. — In a communication
to the AJii/h/u-tii-r mcif. U'oc/i., August ^tli, Fritz Voit
reports some experiments with subcutaneous alimenta-
tion. Leube had before injected melted butter in the
dog, made lean by restricted diet, and at exploratory
laparotomy found that it had been laid up in the form
of fat. This fat in states of the system with insuffi-
cient heat was completely used by the economy, thus
sparing the albuminoids. Leube had no success,
howe\er, with sugar in large amounts, but Voit, ob-
serving that animals and man did not react alike,
injected grape sugar in the latter with success. Of a
ten-per-cent. solution used with clue antiseptic precau-
tions, he found that he could inject subcutaneously
(in the thigh) ten, one hundred, or one thousand cubic
centimetres without inconvenience. As much as sixty
grams of grape sugar could be injected \\ithout a trace
of it being found in the urine subsequently. Levrose
and galactose could be used as well as dextrose, but
lactose and cane sugar reappeared almost entirely in
the urine. .Sugar could not be used for alimentary
purposes by direct injection into the veins of animals,
as it was excreted at once \\ith the urine.
Physiological Albuminuria.— Dr. Zeehuisek (Cai-
tralblatt fur iruiere Aledicin, January 11, 1896) has
examined the urine of one hundred and forty-four
supposedly healthy individuals. His examinations
were made from the standpoint of the clinician and
only that substance was regarded as albumin that was
coagulable through iieat. He concludes as follows:
(i) Many cases of alijuniinuria in young people (five
per cent, in the one hundred and forty-four) are caused
by affections of the renal parenchyma. (2) In an-
other series of cases the albuminuria in the young is
of extra-renal origin, i.e., accidental (red blood cor-
puscles, leucocytes, speiTnatozoa, etc.). (3) Func-
tional albuminuria was not observed in the one
hundred and forty-four cases examined. (4) In the
persons examined, no trace of a "physiological albu-
minuria" was discovered. (In 71.5 per cent, of the
one hundred and fortv-four cases the most delicate
reagents failed to disclose the faintest trace of albu-
min.)
Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 50, No. 18.
Whole No. 1356.
New York, October
"> I
1S96.
$5.00 Per Annum.
Single Copies, loc.
MYXCEDEMA: A CASE TREATED BY THV-
ROIU EXTRACT.
By JOHN WOODMAN, M.D..
NEW VORK CITV.
It seems advisable, on account of its advanced char-
acter, to report the following case, so wonderfully and
quickly relieved by small doses of thyroid extract,
aided by the ingestion of large quantities of water :
Mrs. F , aged thirty-eight, married. She has
six children, the last of which was born in 1893.
Family history good. She had always been well.
She menstruated at fourteen years; the flow was al-
ways profuse. She w'as constipated all her life. Her
present illness began nearly eight years ago. She
first noticed that the left side of her face and the left
eyelid were swelling slowly. Soon the swelling ex-
tended to the other side of her face, and then slowly
involved the entire body, it being most marked about
Ihe upper eyelids, scalp, and supraclavicular spaces.
The eyes could scarcely be opened. With the swell-
ing a gradual weakness developed and a general ma-
laise. The face became very broad and the nose
markedly flattened. The lips were swollen, pale (at
times bluish), and the lower one especially tended to
be everted. The tongue was much swollen and pro-
truded, making it difficult for her to shut the mouth;
it was also very dry, so that swallowing was difficult
and accompanied by a gurgling sound. The arms,
wrists, and hands were swollen, so that the hands
could not be tightly closed. The abdomen became
ver)' large. The feet were swollen, especially at the
inner and the outer arches and on the dorsal surfaces.
She wore No. 3 shoes eight years ago, and in January,
1895, she wore Xo. 7. The feet also became very ten-
der. There was no pitting of the oedema on pressure
until in December, 1894. The tumefaction was not
evenly distributed, but seemed to be in rolls between
the muscles. It was spongy and elastic to the touch.
Her head fell forward, probably on account of weak-
ness in the posterior cervical muscles. Her weight
increased from one hundred and twenty pounds to two
hundred and forty pounds. She had not sweated since
she began to notice the swelling. The skin was hard
and dry. In 1892 sheJiad an attack which was diag-
nosed as jaundice. The conjunctivas and skin were
very yellow. This discoloration lasted about three
weeks, when the conjunctivae became normal. The
skin never returned to its normal color, but turned a
darker yellow, then brown, and finally almost black.
There was pigmentation all over the body, especially
on the exposed parts and on the neck and chest. The
skin became harder and more indurated after that at-
tack, and seemed adiierent to the underlying struc-
tures. There were deep wrinkles all overtheface, es-
pecially on the forehead and about the mouth. A fine
scaly desquamation was present over the entire body.
The hair fell out entirely from the axilla; and pubes,
but not very much fell from the scalp, though the hair
there became very coarse, dry, and brittle. The nails
on the hands did not change, but on the feet they were
thickened, brittle, and deeply striated. Different joints
would swell and become painful, and then the swelling
would disappear, leaving stiffness.
The gums were swollen, spongy, and sore, and
nearly all the teeth fell out. There was marked lacry-
niation. There was dribbling of saliva at night, but
the mouth was dry during the day. The breath was
foul and the tongue often coated. The appetite was
poor; she wanted to eat only certain articles of diet.
She had more or less nausea all the time, and she often
vomited. She was constipated nearly all the time.
She had a cough all the time, but it was much worse
during the winter, with expectoration of whitish sputa.
She could not breathe through the nose, so the mouth
was open all the time. She snofed at night. There
was also great dyspncea at night. She could not lie on
the left side, and often had to sit up to breathe. She
had marked dyspnoea at all times on exertion, and on
account of the dyspnoea and extreme swelling of the
tongue and lips she could speak only in monosylla-
FiG. I. — Mrs. F., January 4, 1895.
bles, and the speech was hesitating and muffled.
There was palpitation of the heart, at first at night
and then marked on the least exertion. Often she
had syncopal attacks. The heart upon examination
was found enlarged to the left and downward, with a
systolic murmur at the apex, which was transmitted to
the axilla but was not heard in the back.
She noticed, soon after the appearance of the swell-
ing, that she did not pass as much urine as formerly.
Sometimes she had severe pain after micturition, and
at other times she would pass urine unconsciously.
The urine was repeatedly examined and was always
found to be acid; the average specific gravity was
1.020; albumin varied from a mere trace to as high
as twelve per cent., and was always present. There
were no sugar and no tube casts.
614
MEDICAL RECORD.
[October 31, 1896
She never had headache, but would have vague
neuralgic pains in the lumbar region, radiating to the
lower extremities and around the scapula. She had
cramps in her leg frequently. Her disposition com-
pletely changed. She was apathetic, and no longer felt
any interest in life around her or in her family. She
FiC. 2.— Mrs. F., February i. 1895.
felt as if she could not cry, but wanted to be alone all
the time. She was content to be alone and to sleep
all day in a chair; she often had bad dreams, and
would get frightened in her sleep. Within the first
year of her illness she began to have hallucinations.
She would see rows of people's faces, and would think
she was being followed as she walked about her
house. She never thought she would be harmed, but
felt as though some one was always near her. She
would not leave the house alone, for fear of getting
lost. She had some inco-ordination of her feet, and
it would seem to her as if she was walking on slip-
pery ice. Memory failed, and she could not recall
events of two weeks before. The eyeS became very
weak, and finally she could scarcely see. Marked
deafness developed on the left side. There were
marked mental slowness and dulness of comprehen-
sion. She was always cold. Slie felt more comfor-
table in summer than in w inter, but even in the hottest
weather she felt uncomfortably cold.
Three children were born during the eight years,
and during the pregnancies all the symptoms were
much e.xaggerated. The children were bom healthy
and were breast fed. The first, born about a year
after her pronounced symptoms apjjeared, is now
strong and well. The second died of erysipelas at
four months. The third is now two years old, and
seems bright and intelligent; but six months ago it
had a convulsion, after which a hemiplegia developed,
vhicli has continued to the present time. A ventral
hernia developed during one of the pregnancies.
During the eight years she was treated, at different
times, for Bright's disease and for dyspnotaand palpi-
tation, with apparently good results each time, but
with no permanent improvement. The treatment by
thyroid extract was begun on January 4, 1895, and five
grains daily were given at first. Later the dose was
increased to ten grains daily, but it produced so much
dyspncxa and palpitation and such a rise in temperature
that it was reduced to the original amount and was
continued at five grains daily until she regained her
normal condition. While taking the thyroid extract
she drank large quantities of water. Within the first
week of treatment the symptoms began to ameliorate,
and there was a steady improvement up to the time of
her recovery. The oedema began to disappear almost
immediately, the fulness in the eyelids, face, scalp,
and upper extremities disappearing first, the cedenia in
the lower extremities being the last to disappear. The
tongue, lips, and gums became normal, and she could
soon speak perfectly well without dyspnoea. She
could walk up and down stairs, and sleep on either
side without discomfort. Her appetite improved, and
she no longer had palpitation.
February 12, 1895, she began to perspire, and the
skin after that time began to resume its normal char-
acter. Desquamation took place in large scales.
Flakes could be stripped off, leaving normally smooth
skin beneath; and the pigmentation was removed with
the superficial layer of epidermis which desquamated.
The skin was no longer thickened and adherent, but
soft and smooth. The hair in the axillae and on the
pubes began to grow, and the hair on the .scalp became
much softer.
The symptoms of diminished urine and incontinence
disappeared, and albumin was not found in the urine
after the middle of February. The apathy disap-
peared, and she became bright and cheerful. She had
no hallucinations of any kind and slept well at night,
but had not the great tendency to sleep that she had
formerly. Her memory became perfectly clear, and
her eyes and ears regained their former acuteness.
March I, 1895, she had lost thirty-one pounds, and
about May ist her weight had been reduced from two
hundred and forty pounds to one hundred and eighty.
The thyroid extract has evidently supplied the sub-
FiG. ^. — -Mri. 1'., M.irLh i, 1:^5.
Stance from lack of which so many serious symptoms
developed, and she has continued to take the extract
in five-grain doses every other day since her recovery
to normal condition. She will undoubtedlv have to
October 31, 1896]
MEDICAL RECORD.
615
continue supplying tlie lost substance by means of the
thyroid-extract preparations, for, since the great swell-
ing about the neck has disappeared, it can be plainly
seen that the thyroid gland is completely atrophied.
She coiTtinues well to the present date.
I am indebted to Dr. M. Allen Starr for seeing the
case in consultation, and to Dr. Elizabeth D. Dixon
for assistance in arranging the history for publication.
:z3 East Twentv-Fifth Street, October i, 1896.
THE BICYCLE FOR SCOLIOSIS.
By otto G. T. KILI.\NI, M.D.,
NEW VOKK,
INSTRUCTOR OF CLINICAL SURGERY IN THE POST-GRADUATE MEDICAL SCHOOL
AND HOSPITAL.
Since the etiology of scoliosis and the static laws
governing the same have been studied more closely,
both the prophylaxis and tlie treatment of lateral cur-
vature of the spine have progressed considerably in
this country as well as abroad. The former is still
If our therapeutic efforts should enable us to correct
these three cardinal points, or, still better, to over-
correct the position by transforming the scoliotic cur-
vature into the opposite curve, when the static laws
would exert their influence upon the vertebra; in the
reverse sense, and if, finally, we could keep the verte-
bral column in this corrected or over-corrected posi-
tion for any length of time, we would be able to cure
a scoliosis just as well as the severest cases of club-
foot, as Hoffa sets forth so ably in his " Lehrbuch der
orthopiidischen Chirurgie." But as yet we are far
from having achieved anything of the kind.
First of all, we have to strengthen the general con-
stitution of scoliotic children, and especially their
weak muscles.
Then we have to reduce the contraction of the col-
umn by mobilizing the spine.
I do not intend to enumerate all the different meth-
ods by which we strive to achieve this end, but presume
that they are known and selected for the case in ques-
tion according to the predilection and personal experi-
ence of the physician or orthopaedist in charge.
Fig. I. — Artificial curvature of normal spine,
caused by handlebar lowered on riyht side.
Fig. 2. — D. F. , scoliosis, age 13, standing.
Fig. 3. — D. K., sitting on an ordinary bicycle.
somewhat neglected here, as all the public schools
and a great many of the private schools fail to furnish
benches answering the requirements for preventing
the development of scoliosis in children. The in-
correct position of the pupils is partly the direct re-
sult of the method of writing, and we sincerely hope
that the inclined handwriting will shortly disappear
entirely from our schools.
In well-developed habitual scoliosis of the usual
kind, with dorsal convexity to the right and lumbar
convexity to the left, we find in the so-called second
stage the following symptoms:
1. The vertebral column is shortened.
2. The whole spine is displaced to the right.
3. Besides the angular deformity of the ribs, the
spine is twisted, so to speak, around its longitudinal
axis, so that the right side of the thorax stands con-
siderably farther back than the left.
If my impression is correct, a good many of the
physicians treating scoliosis have given up to a great
extent the apparatus in the form of plaster-of-Paris
corsets and braces, intended for correcting the abnor-
mal curvature of the spine and keeping the same in
this corrected position.
My personal opinion is, that all modern treatment
for scoliosis should culminate in the endeavor to cor-
rect the curvature as much as possible, and then, in-
stead of trying simply to keep it in this jDosition, to
exercise the muscles in this corrected position, so that
they will be able to hold the spine in it, if the altered
anatomical conditions will permit.
Before describing my new device to achieve this
purpose, it seems hardly necessary to state that I con-
sider it only one link in the long chain of therapeutic
efforts, and nothing would be more wrong than to rely
solely upon the one in question.
6i6
MEDICAL RECORD.
[October 31, 1896
Fig. 4. — D. F., treading on modified bicycle, with Fig. 5. — D. F., treading on modified bicycle, hori-
left pedal high. zontal pedals, left foot forward.
Fig. 6.— D. F., treading on modified bicycle, right
pedal high. Spine practically straight.
Fig. 7.— D. F., in same position, on bicycle with Fig. 8.-1). F., treading on modified bicycle, with Fig. 9.— D. K., combination of inclined scat with
ordinary handlebar. horizontal pedal, right foot forward. modified handlebar.
Bicycle exercise constitutes such a perfect combina-
tion of active and passive motion, by means of an
exactly constructed machine that it suggested itself
to me to make use of it in the treatment of scoliosis.
The oft-repeated accusation that the bicycle tends to
develop forward curvature of the spine (kyphosis)
was, of course, of no weight, and, if so, it would rather
have induced nie to make use of this quality.
I shall now endeavor to describe the photographs
published with this paper, and thus lay the question
before the profession for its judgment.
No. I shows a sculptor's professional female model.
October 31,
1S96]
MEDICAL RECORD.
6r
whom we may consider of perfect figure, even lacking
the otherwise normal slight scoliosis brought about by
tlie use of the right arm in manual work. She is
seated on an ordinary ladies' bicycle held fast in a
home-training machine, which enables the rider to
practise at home, while the machine stands still. The
saddle is raised a little more than is customary with
women riders, to bring the weight of the body partly
on the handlebar. The latter is arranged in a way
to be described later, which allows either half to be
raised or lowered to any degree desired.
In our pictures the right handlebar is lowered to
some extent, as is clearly sliown by the position of the
1 1.,. u.-MudilKd Ilamilcb.ii
two hands. The line of the spinous processes is
painted on the skin with a dermatographic blue
pencil.
It is immediately apparent that the woman shows a
left conve.x dorsal and a right convex lumbar scoliosis
of noticeable degree. Any one who will repeat the ex-
periment can convince himself of the conditions to
be named: first, the line of processus spinosi shows
clearly the bending or lateral curvature of the spine.
This line is in cases of true scoliosis very often mis-
leading, as is well known, and should not be relied
upon too much. Secondly, the thorax is decidedly
twisted, so to speak, around its longitudinal axis in
an ascending spiral from left to right; the right shoul-
der is lowered, the median edge of the left scapula
stands out; the cur\e of the ribs of the right side is
flattened; in short, we have the position we try to pro-
duce in a case of common habitual scoliosis (with
dorsal convexity to the right).
If it is possible to influence the normal body in the
manner described by the use of a handlebar lowered
on one side, it will be interesting to see how a case of
scoliosis will be altered.
Fig. 2 shows a little patient of mine, thirteen years
of age, in standing position, with a scoliosis which
needs no comment.
Fig. 3 shows the same patient seated on an ordi-
nary ladies' bicycle, with arms hanging straight down.
Here the scoliosis is still more marked than in stand-
ing, as the weight of the body comes into play. The
right dorsal curvature is just as plain as the left lum-
bar curvature. Now we put on the handlebar, lowered
on the right side, and go through the difTerent motions
and positions in the revolution of the wheel.
In Fig. 4 we begin with the left thigh in flexion,
the left pedal high. We have to consider the spine
fixed at about the first lumbar vertebra; the dorsal
and cer\-ical parts of the spine are pulled down and
bent to the right, with the natural result that the
spine is straightened out.
Fig. 5. — The left leg begins to go down till the
pedals form a horizontal line, with the left foot for-
ward. The spine is nearly straight, the scapula; show-
ing clearly the intiuence of the position on the thorax.
Fig. 6. — The left leg goes still farther down and
brings the right thigh correspondingly in flexion.
The patient's spine is almost straight, the angular
deformity of the ribs is straightened out considera-
bly, and the position is as nearly as possible the ideal
one.
For comparison, we show in Fig. 7 the same patient
on a bicycle with the usual handlebar, in the same
position, namely, the right pedal up.
Finally, Fig. 8 shows her with the right foot com-
ing down to the line of horizontal pedals. This con-
stitutes one revolution of the pedals, and
treading begins anew.
It seems evident that muscular action
in this corrected position, achieved by such
simple means, ought to be beneficial. For
any one conversant with the treatment of
scoliosis it is needless to say that I cannot
speak yet of any results produced by this
treatment, although I have at present four
patients, two boys and two girls, using my
adapted bicycle. I would not venture to utter
until several years have elapsed any definite
judgment on its possible value, but rely on
the apparent rationality of the idea, and hope
that other physicians may give it a trial.
Another important feature is that, with
the untwisting, so to speak, of the spine by
the position of the arms, we can add the
inclined seat, by raising one-half of the
saddle upon the proper side, as shown
in a primitive way in Fig. 9. Any of the saddles in
the market with separate lateral sections tliat can be
]iadded higher on one side, answer the purpose well.
In one of these there is a contrivance by which one
side may be raised by means of a screw which acts
on a steel plate upon which the cushion rests. This
of course would answer only for training at home, as
balancing would be seriously impaired by the inclined
seat. The lowered handlebar alone does not inter-
fere with it at all, as I know by personal experience in
riding on such a bicycle myself for the sake of trial.
Conceded that the ideas set forth in this paper are
right, we only have to mention briefly the advantages
of the treatment. First, a good many of the patients
to be treated are in possession of a bicycle. Even for
those who do not own one, the expense is relatively
slight in comparison with tliat of other orthopsedic
apparatuses. Secondly, it aiTords a physical exercise
to which the patients will take kindly and which they
will therefore carry out faithfully. This is a decided
point of advantage, as the execution of g)-mnastic ex-
ercises always demands an unusual amount of patience
and perseverance on the part of both patient and
physician.
Finally, it only remains to describe the simple de-
vice by which either handlebar can be adjusted in
any desired position. The handlebar used by me (as
shown in Fig. 10) is sawed apart in the middle, and
the two parts are adjusted by means of a screw and
thread, fitting one into the other (the two necessary
pieces having been soldered into the tubes). The
circumference of the two pieces is grooved and held
in place by a wedge with corresponding teeth, the lat-
ter being tightened by a screw with nut, fastening the
jaws of the head, pointing toward the rider. The
thread mentioned will allow the lowering of either side
of the handlebar to any degree desired, while the two
halves of the handlebar will still be held firmly to-
gether. The wedge with its corresponding teeth will
hold all the parts absolutely firm when pressed in
against the handlebar by the tightening screw and nut.
.■\ny skilled mechanic will be able to alter any han-
6i8
MEDICAL RECORD.
[October 31, 1896
dlebar in the desired way. I personally am indebted
to Robert Linder for faithfully carrying out my in-
tentions.
133 East Fifty-Seventh Street, New York Crrv.
DIPHTHERIA OF THE NASO-PHARYNX.*
By WALTER J. FREEMAN, M.D.,
PROFESSOR OF LARYNGOLOGY, PHILADELPHIA POLYCLINIC; LARVNGOLOGIST
TO THE ORTHOPEDIC AND CHILDREN'S HOSPITALS; CONSULTING LARYN-
COLOGIST TO THE PENNSYLVANIA INSTITUTION FOR THE DEAF AND
DUMB, ETC.
Although we find brief mention here and there of the
occurrence of diphtheria in the naso-pharynx, its im-
portance in this position has by no means received the
recognition it deserves. Guthrie' says that '"nasal
diphtheria is very common in children, and may often
escape recognition, for membrane . . . may be found
above the soft palate and in the posterior nares."
Moritz Schmidt^ says that the formation of membrane
in the vault must take place very frequently, but dwells
upon it more in its aspect of causing destructive action
in the ears. Seibert,'' Rosenburg,' and many others
regard it simply as an extension from a faucial diph-
theria, overlooking apparently the fact that the recog-
nized tendency of this process is to extend downward.
Bosworth,' likewise, calls attention to the fact that
" the primary deposit occurs at times in the phaiyngeal
vault or some other portion of the upper air tract,"
but he does not take the position that this is a very
frequent seat, for he states in another paragraph that
"the diphtheritic membrane primarily makes its ap-
pearance, in the very large majority of cases, on the
face of the faucial tonsil, where it is open to direct
ins|)ection. ... In rare instances," he goes on to
say, '• it makes its appearance on the pharyngeal ton-
sil, where it can be inspected only by the rhinoscopic
mirror," adding that "this last resource is unavailing
in most cases in children." In my opinion, however,
it is a mistake to assume that the disease first makes
its appearance on the faucial tonsil simply because it
is first recognized there, and also to state that the
vault can be examined only by means of the rhino-
scopic mirror, and that this is unavailing in most
cases in children.
The period of incubation of diphtheria is given by
the majority of writers as about four da\s. When,
however, the disease has been surely traced to infec-
tion, as in the not uncommon instance of a physician's
receiving the expectoration directly in the face while
examining a patient, the incubation is found to be but
twelve to thirty-six hours. This, as has been experi-
mentally determined by the inoculation of the ptomain
in the lower animals, is probably the true period of
incubation. It is, therefore, reasonable to believe
that, in those cases in which the period of incubation
has been extended for days or even weeks, the infec-
tion has been less in amount or less virulent, and has
needed time to develop. Nowhere could this more
easily take place than in the nose, or in the crypts and
folds of the various tonsil groups, especially those of
the naso-pharynx, where no mechanical cleansing
takes place as in eating and drinking.
The literature of the subject of diphtheria is vast,
and I shall not enter into a detailed account of the
history of the disease. I feel, however, that a brief
synopsis is not amiss, that a more perfect understand-
ing of the points to be discussed in the paper may
obtain. The microbic origin of dipluheria was first
recognized in 1S68 by Oertel," who thought that in a
micrococcus he had found the specific germ. It was
not, however, until sixteen years later that Klebs ' an-
nounced the discovery of the true bacillus of diph-
* Read by title before the American Larj-ngological, Rhinolog-
ical, and Otological Society, New York, April iS, 1S96.
theria, which has since that time been called conjointly
by his name and by that of Loeffler," who a year later
first proved that the bacillus was pathogenic and
obtained cultures. The Klebs-Loeffier bacillus is of
about the same length as the tubercle bacillus, but is
much thicker and is somewhat bent or curved. It is
irregular in outline, due to its beaded or granular ap-
pearance, and is motionless. Its chief characteristics
are the rapidity and peculiar appearance of its growth
on culture media, which, according to Park,'' distinctly
differs from that of any other mouth bacteria, except
— notice this — the so-called pseudo-diphtheria bacil-
lus, and in its taking the stain in a pecular way, the
granules and the ends, one or both of which are
clubbed, being more deeply colored. But it must be
remembered that many circum.stances, such as differ-
ent culture media and other influences in growing,
alter the shape of the germs very markedly, so that,
for instance, instead of having the club-shaped ends,
these may even be pointed. The theory that the
Klebs-Loeftler bacillus is the cause of diphtheria is
now firmly established, as firmly as in the case of any
of the germ diseases, but we also recognize that
pseudo-membrane may be formed by other germs and
possibly even by inflammations not microbic in origin.
Loeffler '° in 1887 announced that a bacillus closely
resembling that of typical diphtheria existed in ap-
parently harmless pseudo-membranous inflammations,
which from their mild clinical course could not be dis-
tinctly classed with true diphtheria. Its chief points
of difference, he says, are that it is not pathogenic,
that its ends are not so often club-shaped, and that it
does not grow so characteristically. The life of the
so-called pseudo-diphtheria bacillus is extremeh-
short, and in this corresponds with the degenerated
form of the bacillus of true diphtheria found in mem-
branous rhinitis and other cases of mild diphtheria.
The vitality of the Klebs-Loeftler bacillus, on the
other hand, is very great. Park states that some
membrane on cloth still gave cultures after six months.
Von Hoffmann " has isolated a bacillus which, except
for its non-pathogenic properties, cannot be distin-
guished from the bacillus diphtheria;. This he found
also on apparently healthy mucous membranes.
In view of these facts, it is not surprising that so
much doubt and confusion should arise as to the
differential diagnosis between diseases exhibiting
pseudo-membrane as their earliest and most pro-
nounced symptom. Since such diseases exist, so alike
in their most prominent symptoms, the one very fatal,
the other apparently innocent, it is of the utmost im-
portance th.-it the most searching analyses and every
means of diagnosis at our command should be em-
ployed to enable us to arrive at a correct diagnosis.
Roux and Yersin,'' and Abbott,'" have asserted, and
as I think on good groimds, that the pseudo-bacillus
above mentioned is but an attenuated form of the
Klebs-Loefrter bacillus, and may under certain con-
ditions recover its virulency. While the so-called
pseudo-bacillus gives rise to symptoms differing clin-
ically from the Klebs-Loeffler bacillus, the difference
is more in degree than in kind, and Abbott " has
found that the same pathological changes follow,
though in less degree. The characteristic symptoms
produced by typical diphtheria arise too late in the
course of the disease to serve a practical purpose in
affording us means to differentiate the two. Often
the occurrence of diphtheritic paralyses or of albumi-
nuria has been our only means of knowing that the
patient has had true diphtheria, the course has been
so mild, resembling in so many ways that of pseudo-
diphtheria. Hardly one of us but has seen cases of
true diphtheria, proved such by the typical sequelae
above mentioned, run their course with hardly a con-
stitutional symptom, and again we have all had most
October 31, 1896]
MEDICAL RECORD.
619
threatening cases, causing us no end of anxiety and
doubt, recover in a few days. \\'hen we think of the
mild cases, even simulating simple lacunar tonsillitis,
which give rise, as has been proven by reliable au-
thorities, to diphtheria of fatal termination and also to
infection to others, we begin to appreciate the respon-
sibility resting upon us, and are taught to regard with
a certain amount of gravit}' all pseudo-membranous
exudate wherever formed. This was brought most
forcibly to my mind during the years 1893 and 1894,
when Abbott and Ravenel were carrying on their bac-
teriological investigations in membranous rhinitis,
upon the results of which they based their brochures
and presented the largest summary of cases published
up to the year 1895. Of the thirteen new cases Ab-
bott " and Ravenel " reported, in all of which Klebs-
Loeffler bacilli were found, nine had been reported
from my clinics at the Children's and Polyclinic hos-
pitals. Until that time such cases had been treated
as are those of dispensary patients and seldom sub-
mitted to bacteriological examination, because there
were so few constitutional symptoms to cause any sus-
picion of gravity. Finding that several cases of in-
fection undoubtedly arose from these, no more cases
of this disease have been permitted more than the one
visit to the dispensaries, and have been immediately
reported to the board of health as cases of nasal diph-
theria.
Although the anterior nares are so easily examined,
such a location for diphtheria has been recognized
only for a few years, and no one can doubt that the
naso-pharynx, although hitherto examined even less
frequently for diphtheria, forms a much more likely
field for the lodgment and growth of such pathogenic
micro-organisms. The recognition of pathological
processes here, although at times attended with much
difficulty and requiring much patience, will amply
repay the pains taken, as it is an axiom that the earlier
the diagnosis of a disease the better the prognosis.
Notwithstanding Bosworth's statement to the con-
trary, I feel convinced that in a large majority of chil-
dren it is possible to examine the naso-pharynx. In
those cases in which the examination with the rhino-
scopic mirror cannot be made successfully, there still
remain to us other methods of examining this region,
namely: (i) inspection through the anterior nares, and
(2) bacteriological culture from the vault, with one of
which we can ordinarily attain our end. Thus, of
three hundred and eighty dispensary patients between
two and twelve years of age, I could study the vault in
two hundred and thirty-four, in many only through
the anterior nares. I acknowledge that in many sub-
jects suffering from diphtheria the examination would
be more difficult, but not if undertaken early. The ac-
companying cut, taken from an article in the Polyclinic
Journal,^'' shows an easy method I have used for hold-
ing children for throat and nose examination, though
in most cases of severe diphtheria any forcible meth-
ods are unadvisable.
No one will deny at this date that diphtheria is a
local affection, and gives rise only secondarily to con-
stitutional symptoms by the absorption of the tox-
albumins generated by the bacillus. It has been
proven that the membrane deprived of its germs pro-
duces the diphtheria by the action of its ptomain, a
ptomain so poisonous that "one-three hundredth of a
grain is fatal to a full-grown guinea-pig." If we can,
therefore, detect the disease clinically at the point
where the infection is just taking place, that is to say,
at its strictly primary seat, where the thin smoky film
of fibrous exudate is only beginning to form, and slight
constitutional symptoms exist, much can be done to
arrest its progress. For " we may hope," as Bosworth
says, " by the first application to rob the local prog-
ress of much of its infective potency and limit its
capacity for extension." Recognizing this, we should
examine with the most thorough scrutiny not simply
the pharynx and larynx, as is usually done, but also
the nares and naso-pharynx, and not merely in cases
of suspected diphtheria, but in all our patients, even
those in whom some evident cause of sickness exists.
The procedures are so easy of accomplishment in a
large number of instances that it should be a riile for
general practitioners also to adopt them as one of their
routine methods of physical diagnosis. We would
then seldom have the statement that the disease is
constitutional " because the symptoms precede the
local manifestations."
The Easy -Method for Holding Children for Throat and Nose Examination.
As the whole course of diphtheria is only a few
days, if we can gain even a few hours in the recog-
nition of the disease the balance will probably turn
in our favor. Bacteriology has done much in enabling
us to tell whether the pathological process is diph-
theritic. Time gained in controlling the disease is,
however, only to be obtained by discovery of the pri-
mary seat or true origin before the pseudo-membrane
is well formed, and therefore before absorption lead-
ing to symptoms of toxa.-mia has begun to take place.
Diphtheria is a disease which overwhelms patients so
suddenly that, except at the very beginning or when
it is quite mild, cases of it comparatively rarely come
to the dispensaries. They are struck down and feel
so ill that the throat symptoms sink into insignificance
and the general practitioner is called, so that, although
the larnygologist may be called upon to exercise his
peculiar skill in diagnosis or treatment, it is, unfortu-
nately, not until the disease has made considerable
progress. Thus it is that our dispensary cases of
diphtheria are mostly made up of membranous rhi-
nitis or of diphtheria just commencing in the naso-
pharj'nx, fauces, or larynx, in which there are few and
620
MEDICAL RECORD.
[October 31, 1896
light constitutional symptoms, and the patient comes
because of some merely local discomfort.
Case I. — Aged nine years. Taken sick November
25, 1893. Pseudo-membrane in naso-pharyn.\ and
covering both Eustachian prominences. Klebs-Loef-
fler bacilli found. Pseudo-membrane disappeared
December i, 1893. Only sequela was a slow pulse
(50), thus showing the unmistakable diphtheritic tox-
aemia. At no time was the psoudo-mcmbrane else-
where than in the vault.
Case II. — Physician, who for two weeks had been
treating a case of diphtheria in a child, with Klebs-
Loeffler bacilli present, and albuminuria, ciliary and
other pareses. The ph3"sician developed sore throat
with headache on November 21, 1895. Hxamination
showed slight exudate in the naso-pharynx. Next
day, in spite of all antiseptic measures, there was in-
crease of pseudo-membrane in the vault. Dr. Harri-
son Allen was called in consultation ; decision, prob-
able diphtheria. Antitoxin injection November 22d.
False membrane absent November 26th. Isolation,
however, continued, because of persistent presence of
Klebs-Loeffler bacilli. Recovery uneventful ; no se-
quelae. At no time was the pseudo-membrane present
elsewhere than in the naso-phar}nx.
Case III. — J. C , aged eleven years. March 24,
1896, vault simply lined with pseudo-membrane.
None elsewhere. Clinical diagnosis, diphtheria.
Culture taken and examined, with report "contains
some doubtful bacilli." Second day merest trace of
membrane on left Eustachian prominence. I consid-
ered the patient practically well, and the diagnosis a
mistake, but he returned to the clinic March 28, 1896,
after having been sick two days. Vomited, and on the
third day had acute otitis media sinistra. Examina-
tion of the vault showed the pseudo-membrane still
present on left Eustachian prominence. Another cul-
ture taken April 3, 1896, and answer returned April 6,
1896, "Case is one of true diphtheria.'' House
quarantined and patient sent to Municipal Hospital.
No pseudo-membrane at any time elsewhere than in
the vault.
Cases IV. and V. — M. N , aged four and a half
years. July 20, 1893. Apparently simple rhinitis.
One week later membranous rhinitis and pseudo-
membrane in the fauces. R. N , her brother, aged
eiglit and a half years, at the same time had pseudo-
membrane only in the naso-pharynx.
I hav'e observed numerous other cases of pseudo-
membranous deposit in the vault, which, however, I
have not been able to follow.
It is of importance to call attention also to two in-
teresting cases reported by Holt.''
(1) Rachitic child, aged two years. Januarj- 7,
1890, had profuse nasal discharge No pseudo-mem-
brane visible for two weeks, then a minute spot on
one tonsil and four days later on the other. Death
finally resulted.
(2) An infant, six montlis old, exposed to this
one, had nasal discharge of mucus and blood for
twenty-nine days without other symptoms of diph-
theria. Then tedema of the extremities occurred, fol-
lowed by death on the thirtieth day as a result of
nephritis. There was no visible membrane at any
time. Autopsy showed a patch of diphtheritic mem-
brane one inch in diameter in the naso-pharynx, and
a smaller one in the pharynx near the epiglottis. No
bacteriological examination was made.
In presenting these cases, although they are few in
number, we take into account the infrequency with
which, for the reasons mentioned above, we see diph-
theria in the dispensaries. I regard them as sufficient
in number and importance to warrant the claim that
the naso-pharynx is very frequently the starting-point
of the disease. That there was no extension of the
pseudo-membrane, and that the cases ran such a short
mild course, are due, I believe, to the early and thor-
ough methods of cleansing the naso-pharynx.
lilBI.IOGR.M'HV.
1. Guthrie: I.ancet (London), 1S94, p. 1,02;.
2. .Moritz Schmidt: Die Krankheiten der oberea I.uftwege,
iSo4, p. 377.
3. Seibert: Journal of the American Medical Association,
February 22, 1S96.
4. Rosenburjj; Die Krankheiten dcr Mundhiihle, etc., 1893,
p. llS.
5. Bosworth: Diseases of the Nose and Throat, vol, ii
6. Oertel: Studien liber Diphtheric. Aerztlich. Intelligenzbl.,
MUnchen, 186S. Nr. 31.
7. Klebs: Corref. in den Verhandlungen des II. Congresses
fiir innere Medicin, 1SS3, S. 141.
8. Loefiler: Mittheilungen des Kais. Gesundheitsanites. Band
ii., 18S4, S. 425.
9. Park: Diphtheriaand Allied Pseudo-Membranous Inflamma-
tions. Medical Record, July 30 and August 6, 1S92.
10. Loeffler: Cenlralbl. /lir I'.acteriol., 1SS7, Band ii.
11. Von Hoffmann; Wiener med. Wochensch., No. 344, 188S.
12. Rou.\ and Versin: Annates de I'lnstitut Pasteur, 1890,
tome iv. , p. 409.
13. Abbott; A Review of Some of the Disputed Points, etc.
Medical News, November 17, 1S94.
14. Abbott: The Etiology of >[embranous Diphtheria.
Transactions of the College of Physicians of Philadelphia, vol.
.XV., p. 122, 1S93.
15. Ravenel: A Contribution to the .Study of the Etiologj- of
Membranous Diphtheria. Medical News, >I.iy 18 and 25, 1S95.
16. Polyclinic Journal, vol. iv.. No. 12, March 23, 1895.
17. Holt: New York Medical Journal, May 31, 1890, p. 605.
A CLASS OF FATAL CASES PRESUMABLY
DUE TO INTESTINAL PTOMAINS.'
Bv K. D. FERGUSON, M.D.,
TROV, N. V.
Something over twenty years ago a case occurred
under my observation that created in me a profound
interest and became the subject of considerable
thought and reading. The patient, a man about forty
years of age, had the appearance and history of robust
health. I had known him for several years and iiis
sturdy figure had impressed me with a favorable view
as to his ability to resist disease and his chance for
many years of life. He was taken quite suddenly
with abdominal pain and became rapidly very ill, so
that on the second day I saw him in consultation.
From the condition and clinical history, we could
fairly exclude intestinal obstruction and peritonitis,
but vomiting, which had begun early in tlie trouble,
had continued, and instead of becoming offensive in
odor, as would have been expected in obstruction, was
of a watery material which later showed small brown-
ish flakes wliich gradually grew darker. The vomit-
ing was frequent but not violent, and at times was
rather a regurgitation than a vomiting. His pulse
was rapid, the countenance anxious, the complexion
somewhat " muddy," although he had naturally a dark
skin, and the sclerotic lost its j^early clearness, al-
though not to a degree to lead me to pronounce it
colored with bile. The movements of the bowels did
not throw much light upon the case, but the color,
though dark, was not a healtiiy brown, neither was it
a green or a black. There was quite a degree of tym-
panites, but no notable tenderness.
The man was evidently "sick unto death," though
he retained his mental faculties in a fair state during
the greater part of his illness. The vomited material
grew darker, finally almost a "black vomit;'" his pulse
became very rapid, and just before death the temper-
ature rose to a very high point — over 105' F. No
post-mortem examination was made, nor do I now
think that any positive result could have been obtained
' Read at the annual meeting of the New York State Medical
Association, on October 14, 1S96.
October 31, 1896]
MEDICAL RECORD.
621
from one, in view of the limited Icnowledge of patliol-
ogy tiien in our possession.
Here was a case that I was unable to classify.
That it was not a common disease was evident; nor
could I assign it to any of the recognized forms of
fever or local inflammations. That it was to.xic in its
origin seemed the only rational explanation, but none
of the mineral or alkaloidal poisons would furnish a
similar clinical history. The animal poisons seemed
the more probable basis of explanation, and I recall
my disappointment, when, some few years thereafter, I
read Boehm's article on sausage, fish, and cheese
poisoning, in Ziemssen's " Cyclopa;dia," without secur-
ing definite aid in unravelling the tangle. I had
awaited the appearance of that volume with this case
in mind, and, though disappointed in the hope of defi-
nite aid, my opinion that I had seen the work of
some animal poison was strengthened in a general
way.
However, I had been unable to secure evidence that
the patient had taken any food likely to cause the
trouble, or different from that taken by other members
of the family. Hence I finally evolved the idea that
his was a case of auto-infection, though the conclusion
was based upon a process of exclusion rather than any
reliable evidence from pathological investigations.
About ten years thereafter I witnessed a similar
course of events in a girl about ten or twelve years of
age. The onset was sudden, there being considerable
abdominal pain, fever, and vomiting, with rapid fail-
ure in the vital forces. The vomiting was possibly
more regurgitative in character than that of the first
case, but the colored and finally " coffee-ground" ap-
pearance of the material from the stomach recalled
the former case and led me to anticipate the fatal issue,
which occurred in slightly less than three days from
the time of onset. By this time some progress had
been made in the chemistry of decomposition. Alka-
loids had been secured from animal tissues, and a
presumption was beginning to take reasonable grounds
in favor of the intervention of bacteria in the process.
The work of Selmi, of Bologna; Gautier, of Paris; and
Brieger, of Berlin, had begun to throw a degree of val-
uable light upon this somewhat obscure field, so that
rather definite notions were possible, and I began to
speculate somewhat on the various links in the chain
represented by my two cases. The dark or coffee-
ground vomit had impressed me as an important ele-
ment in the evidence, for I felt that I could exclude
upon reasonably good grounds the presence of gastric
ulcer in any of its forms as the source of the hajma-
temesis. In piecing together the more prominent signs
and symptoms as I Iiave related them, I came to the
conclusion that the first step was due to the presence
and functional activity of some micro-organism in the
intestinal canal; that thence resulted some ptomain or
toxin which was absorbed into the intestinal veins and
reached the liver, where it induced a rapidly progres-
sive and diffuse parenchymatous hepatitis with its
attendant systemic and local phenomena, among which
was the hx-matemesis. To a certain extent, the pro-
cess seemed analogous to acute yellow atrophy of the
liver, or even yellow fever, though the cases did not
show notable icterus. The analogy was sufficient,
however, to induce the opinion that when another case
occurred an autopsy would show profound hepatic
changes.
Not very long after the second case I was requested
to see a child about four years of age, which was
thought to be suffering from peritonitis, with a view to
opening the abdomen in the hope of finding the cause
and removing the same. Though the child's abdomen
was somewhat tympanitic, the evidence of peritonitis
did not seem clear enough to warrant a surgical pro-
cedure, and the fact that regurgitation of a watery
mucus with small brownish flakes had recently oc-
curred, together with the rapid development of the
symptoms, led me to conclude that the case was simi-
lar to those just related, and that " black vomit'' would
occur and death follow. Such proved to be the case,
the patient perishing after about three da3s of illness.
The autopsy showed no peritonitis. The bowels were
distended with gas, were quite hyperamic, and con-
tained a rather dark and somewhat grumous material.
The liver had undergone notable changes; a portion
being somewhat swollen, rather nutmeg-like, with
brown and yellow mottling on section and softened in
consistence, while the remainder was shrunken, the
capsule was wrinkled, rather yellow in color, and was
flexible with a rather leathery feel while handling
without breaking the capsule.
A year or so after this case I saw a man, about
forty-five years of age, v^ho was also supposed to be
suft'ering from peritonitis. The history showed ab-
dominal pain, not localized, though apparently in-
testinal; very moderate distention with gas; rapid
development of symptoms of exhaustion; rising fever;
vomiting of a glairy, rather watery fluid; and slight
icteroid tinge of the sclera. I ventured the opinion
that the patient would have '" black vomit" and would
perish within a short time, which proved to be the
case, for he died on the following day. A post-mor-
tem examination showed the same condition of the
abdominal organs that was found in the case of the
child, the remaining organs of the body showing no
evidence of disease.
So far I had encountered only cases of spontaneous
origin, though they were not the only ones I had seen
in which I had believed the same or a similar morbid
process existed, yet they presented a more pronounced
and typical course.
I now turn to a series of cases having a relation-
ship that rendered them of even greater importance,
for from them it seems reasonable that some practical
conclusions may be deduced.
One evening three or four years ago, I was requested
to see a young man who had just been shot in the ab-
domen. The bullet was believed to have penetrated
the abdominal cavity. There was sufficient shock to
justify a presumption that visceral injury had occurred.
The usual preparations were made, and as early in the
following day as the light would allow the abdomen
was opened and a wound of the intestinal canal was
found and closed. The patient progressed without
serious symptoms for about two days, when he began
to have abdominal pain and regurgitation of a waterv
material, which finally began to show brown specks
but was not offensive. I felt that we were dealing
with another case of poisoning by intestinal ptomains,
and that a fatal issue would soon supervene. This
proved to be the case, and the autopsy showed an ab-
sence of peritonitis aside from the adhesive peritonitis
that was connected with the Lembert stitches and
which had progressed only to the conservative degree
that had resulted in the efficient closure of the wound
in the bowel. The liver had undergone changes sim-
ilar to those described in the foregoing cases, and
there was no obstruction of the bowels.
In the spring of 1895, I operated for the purpose of
suspending a retroverted and retrofiexed uterus in a
patient about thirty years of age. She had been under
my care for about ten years, and persistent efforts bv
the use of pessaries had failed to restore and support
the womb. She was in perfect physiral health, and,
measured by our present views of abdominal sur-
gery, the risk was as near to zero as could be ex-
pected. Tlie operation was simple and brief — a short
incision gave ready access to the parts, and the'
uterus was brought into a forward position and fas-
tened there. No severe shock was manifest, and the
622
MEDICAL RECORD.
[October 31, 1896
patient for twelve hours gave no evidence of any
trouble. On the morning following the operation she
was comfortable, but had regurgitated a small amount
of watery material. This fact made me anxious, par-
ticularly as she showed some fever not accounted for
by evidence of trouble in the operative field. On
seeing her again in the evening, the regurgitation had
increased and, though no brown color was yet present
in the vomited material, her evident tendency, as shown
by quickened pulse, rising temperature, and muddy
complexion, was to enter upon the course of the other
cases I have related. On the following day the vomit
became dark, nearly black, and she died a little over
fifty hours after the operation.
Not long after this case I operated for the removal
of a large uterine myoma in a woman about fifty years
of age. The patient was in fair general health, prob-
ably better than the majority of such patients, and the
removal of the uterus was unattended by unusual diffi-
culties or any accident. The magnitude of the opera-
tion, however, resulted in considerable shock, but the
reaction was satisfactory. For the first eighteen hours
all went well, when regurgitation began, and the now
somewhat familiar picture was reproduced, she dying
about forty-six hours after the operation.
Again, in February of this year, I operated on a
woman about thirty-five years of age and in good
physical condition, removing both ovaries, which were
cystic and presented papillomatous growths. The
cysts were each about the size of my two fists and
were firmly bound in the pelvis. The operation was
difficult but no accident occurred, and the shock,
which was moderate, soon passed off. For the first
twenty-four hours all went as satisfactorily as could
be wished. She was comfortable and cheerful and
the bowels responded satisfactorily and thoroughly to
the saline cathartic given on the morning following
the operation. During that afternoon, however, the
regurgitation began, but without notable abdominal
pain and no distention. The bowels continued to
move until death, the discharge becoming dark col-
ored toward the end. The vomit finally became
black, and she died about sixty hours after the opera-
tion.
Here are eight cases presenting a sufficient number
of signs and symptoms in common to indicate a simi-
lar origin and to justify placing them in a class by
themselves. The conditions common to all the cases
were: a sudden onset and rapid course of the trouble;
the reference of subjective symptoms to the abdomen,
such as pain and nausea; the presence of fever in
each instance, the fever usually becoming very high
just before dcatli; the occurrence of coffee-ground, or
black, vomit as the cases progressed; the absence
of the usual signs of peritonitis; the absence of evi-
dence of intestinal obstruction; the dusky or mudd\-
hue of the countenance some hours before death, witli
possibly moderate yellowness of the sclerotic; and
finally, the evidence furnished by the three autopsies
made in the series of eiglit cases as related. Only
one explanation has seemed to me tenable, and that
was the presence and activity in the intestinal canal
of some organism capable of producing a toxin which
could not only give rise to pain in the bowels, but
was capable of profoundly disturbing the function of
the liver so as to induce a parenchymatous hepatitis
with rapid softening and absorption, resulting in an
acute atrophy. Of course this process may have been
located in the liver more particularly than in the
bowels, but that point did not allow of determination
by any means at my hands.
• There w-ere four medical and four surgical cases in
the series, and the clinical history removed them from
the category of any ordinary infective process. Nei-
ther could we invoke the idea of some special micro-
organism of a contagious nature, for the cases were
isolated and not associated with similar cases either
by time or locality, nor were they subject to unusual
conditions or causes of disease, either in food, domi-
cile, or other element of environment. The fact now
recognized that the products of bacterial life are va-
ried by certain conditions, in some instances a patho-
logical micro-organism failing to give virulent pro-
ducts, while a cliange of conditions will result in a
full establishment of its malign properties, seems to
me pregnant with significance in many ways. It must
be accepted that bacteria exist in the intestinal canal
in all persons, and under certain yet unknown con-
ditions some of them may become capable of inducing
disease, though usually the tenancy is harmless. The
bacillus coli communis is a familiar example. The
only logical explanation of this fact lies in the as-
sumption that usually the functions are so discharged
that the enemy is either inhibited from pernicious
activity, or the special material upon which it depends
for action is not at hand. In a general way, this may
be represented by the terms immunity, resistance to
disease, and the like; nor are these idle terms. Thc\'
represent ideas that should command our attention
with a view to practical deductions. It is not prob-
able in the light of our present knowledge of pathol-
ogy that these eight patients at remote intervals and
places received into their bodies any micro-organism
or toxin from which all other persons in the vicinity
were exempt. It is more logical to suppose that they
had become specially susceptible to the influence or
activity of something present in the persons of others
as well as of themselves, where, however, it either was
not functionally active, or its products were neutral-
ized. In the surgical cases it requires but little strain
on the medical imagination to conceive that the shock
attendant on opening the abdomen could have a no-
table inlluence on the chemistry of the intestinal canal.
The subject has lately received considerable attention
from other standpoints, and we are quite familiar with
such terms as ".stercoral empoisonment," '' intestinal
ptomains," etc. We can conceive of no other ex-
planation, particularly of the fever, for all now accept
that fever is usually the result of the presence of some
toxin, whether the toxin residts from the bacillus
of diphtheria or typhoid fever on the one hand, or from
the staphylococcus present in a furuncle. Just what
constitutes the essential condition of vulnerability
and reaction in each case, why some are made ill and
others escape, is the problem that offers itself. Myri-
ads of typhoid bacilli are swallowed without patholog-
ical results. Most of us have received the diphtheria
germs in our bodies. Staphylococci are constantly
gaining access to the crypts of the skin in each one of
us without producing suppuration.
In many instances we can gather a clew to some of
the conditions favoring infection. No extraordinary
care is required to prevent local infection at pressure
points in patients confined to bed with a fever, but
when paraplegia exists all our best-directed efforts
will probably fail to prevent a bedsore. In this in-
stance a profound interference with innervation has
evidently contributed to the creation of a local sus-
ceptibility to certain pathogenic germs. A review of
the question of immunity has impressed me with the
varied conditions under which it may exist, and the
important fact that it may be lost.
In our surgical experience it is notorious that what-
ever diminishes the condition known as vital force —
a term we can hardly dispense with as yet — increases
the susceptibility to pathogenic organisms. Diabetics,
drunkards, in fact all those who are below par by their
own fault, or through diseases, do not present the same
chance for successful surgical work as do those in
good condition. A few pus-producing germs will
October 31, 1896]
MEDICAL RECORD.
62'
usually fail to incite suppuration if in contact with
healthy tissue, but even if in a healthy person they be
present on or in tissue locally disturbed, as in tissue
tightly ligatured, we can safely count on infection.
We know, too, that a contagious disease will fail to
infect some members of a family while others are
attacked, and yet those who escape may contract the
disease at a later exposure, and this without any phys-
ical change or deterioration in general health that we
can note. The immunity of the negro to yellow fever
is a fact for which we have no adequate explanation,
any more than for our inability to engraft syphilis on
the lower animals; but all these facts have a lesson
which we should note and utilize so far as we can. In
interpreting the phenomena connected with the cases I
have related, it seemed fair to conclude that the result
in the surgical cases was not due to the introduction
of infection at the time of operation. This conclusion
was justified by the absence of pathological changes
in the operative field, together with the fact that the
clinical history corresponded witli those cases in
which no operation was performed. If this conclu-
sion is justifiable it adds another reason to show us
that at present, much as has been done to diminish
the hazard of severe surgical procedures, there remain
some conditions involving risk to life which are as
yet beyond our control, and which should prevent us
from assuming that even an exploratory opening of
the abdomen is free from risk. Previous to the case
of suspension of the uterus, I had surgically entered
the abdomen in a series of over twenty-five successive
instances without a fatal result, and this simpler and
apparently safer case than any in that list succumbed.
In explanation of the process, as before indicated,
it seems reasonable to me to invoke the aid of shock
under the influence of which germs within the intes-
tinal canal were able to produce toxins, which under
ordinary conditions would not have been the case.
So far as the preparation of the patients was con-
cerned by examination in reference to the bodily func-
tions, including the kidneys, etc., by tlie use of salines
to " clean" the intestines, and by a proper diet in each
instance, all that reasonable requirements could de-
mand was done. It is not to be forgotten also that
the usual history in these cases was previous good
health, in some instances specially so. The speedi-
ness with which the condition developed and pro-
gressed to a fatal issue is also one of the important
facts.
In discussing these cases with some of my medical
friends, I learn that similar cases have occurred under
their observation, but, while I find that most surgeons
are inclined to credit them to acute " stercoral poison-
ing," they usually have ascribed the origin of the
trouble to obstruction of the bowels, either by ad-
hesions or the paralysis connected with peritonitis.
In my cases, the evidence so far as it is available is
opposed to such a conclusion ; nor does the clinicial
history correspond with that of intestinal obstruction.
In some of my cases the bowels were moved, and, in
the last one, the passages continued free to the end.
That there should be a paretic condition of the bowels
in a portion of the cases is not remarkable.
In a series of cases presented by Dr. H. O. Marcy
at the recent meeting of the American Medical Asso-
ciation, and printed in the Journal of the American
Mciiiia/ Assoiiafion {or August &, i8g6, I find that he
has assigned intestinal obstruction as the cause of the
trouble in all his cases. In some of them it is clear
that such was the explanation, but in others it is not
so clear. The following is one of the cases:
" Mrs. D , aged forty-two years. Very nervous
organization, but in fair general vigor, although for
some years a sufferer from a retroverted, adherent,
enlarged uterus, cystic ovaries, and diseased tubes.
The bowel had been freely evacuated; only fluid food
in small quantities, often repeated, given for some
days before the operation, with as large quantities of
water as could be easily taken. Operation, March 18,
1896. It was difticult, owing to the embedding of the
diseased adnexa in the pelvic cavity. After the re-
moval of the diseased structures, the enlarged retro-
verted uterus was brought forward and sutured upon
each side to the abdominal wall. The pelvic perito-
neum was reformed by lines of buried tendon sutures,
leaving only a small portion of the fundus of the
uterus uncovered, which was partially denuded of its
peritoneum owing to old adhesions. The small intes-
tines were covered by the omentum with great care, the
fundus of the uterus was dusted with sterilized aristol,
and a vaginal drain of iodoform gauze carried through
tiie posterior cul-de-sac into the vagina. Patient ral-
lied well from the ether. The night following the
operation was comfortable. Nausea and vomiting
ensued on the morning of the 19th, with a singular
weakening of the heart's action, followed by a rapid
elevation of temperature, reaching before death 107"
F. The skin was mottled with dusky patches some
hours prior to death. These conditions were believed
to be due to intestinal obstruction. The gauze drain
was withdrawn and an effort made to examine the pel-
vis through the opening, but without a^•ail. Regard-
less of every elTort, the patient died about forty hours
after the operation. The autopsy showed a loop of
the lower part of the small intestine attached to the
fundus of the uterus, which was separated with the
greatest ease. Th6 intestine above was filled with
several pints of a very fetid dark-colored fluid, be-
lieved to have undergone decomposition prior to
death."
It is manifest that this case does not correspond to
the usual histoiy of intestinal obstruction, nor does
the recent adhesion "which was separated with the
greatest ease" amount to an obstruction, for it is cer-
tainly common to have temporary adhesion of the
bowels after abdominal section and in cases of perito-
nitis, without serious trouble. The course and termi-
nation of the case, and the presence in the bowel of
•'several pints of a very fetid dark-colored fluid,"
speak strongly for the existence of some condition
which \vas more important than even the possible ob-
struction, which we may probably assume was not
occlusion. In our classification of cases it is impor-
tant to seize upon some essential element for the
assistance to be derived therefrom in our considera-
tion of the clinical histories, and this is accomplished
in placing to the front the idea of intestinal pto-
mains. I do not deny that intestinal obstruction
may be present in addition. What I do wish to call
attention to is that obstruction of the bowels without
concomitant changes in the intestinal contents is usu-
ally a quite chronic condition, a fatal issue occurring
at times only after many weeks. No doubt the ob-
struction is occasionally so prominent and important
a factor as properly to entitle it to become the desig-
nating feature, but in many of the cases it is a minor
element, and in still others does not exist.
It would give me pleasure to present a full expose
of the life history of the micro-organism to which the
process is due, but no light has been thrown on that
part of our subject.
In conclusion I must place my title in error by re-
lating a case that recovered, and I do so with some
iiesitation, for tlie account is so remarkable that it still
seems to me like a "traveller's tale." Nearly two
years ago I was requested by telephone to go to a
neighboring town prepared to operate for obstruction
of the bowels. I learned over the telephone that the
patient had given birth to a child about two days
before, that she had failed to have movements of the
624
MEDICAL RECORD.
[October 31,
1S96
bowels, was somewhat tympanitic, was vomiting a dark
fluid, liad fever and abdominal pain, and was very
much prostrated.
As it would be some time before I could reach the
place, and as cathartics had been tried in vain, it was
agreed that awaiting my arrival copious enemas of
water should be given. The treatment was diligently
pursued. A large bag of water was emptied into the
colon, and as it did not return, was followed by an-
other— in fact by several others. In the mean time,
the vomiting had increased in quantity and in fre-
quency, and finally became facal in odor, which was
at first regarded as confirmatory of the diagnosis of
obstruction.
On my arrival I found faces in fairly good-sized
pieces in the recently vomited material, while some of
that vomited at an earlier date was odorless, but con-
tained sediment nearly as dark as charcoal dust. The
patient was in a very weak condition, but she had be-
gun to perspire moderately and her pulse was slightly
less frequent, and the fever had fallen. Though I
believed she would die, the idea occurred that pos-
sibly the poison could be removed in this unusual
manner, and the washing was continued until the
vomited material was quite clear. In order to main-
tain the action of the heart, strychnine was given
hypodermatically in heroic doses, being guided by the
pulse. She hovered between life and death for sev-
eral days, then rallied somewhat, but developed a
broncho-pneumonia and its attendant pleuritis, which
placed her in great peril again. She finally recovered,
and I believe has remained well. It is manifest that
this treatment cannot be applied as a rule, but the
lesson it carries is patent.
The arguments that have been made to explain the
condition by the presence of a special microbe seem
to me to lack sufificient fulness to entitle them to stand
as final. Various organisms have been found in the
intestinal canal — in cases of "stercoral empoison-
ment," even the pus-producing staphylococci — particu-
larly in puerperal cases in which the pelvic organs
were free from pathological changes. The problems are
too recent and too complex to allow of definite conclu-
sions on that phase of the question. In view of what
is known of the behavior of micro-organisms under
varying conditions, it is not improbable that we may
finally arrive at two conclusions. First, the condition
may be due to a special ferment, either a bacterium or
an enzyme, and tliis may be present in the body with-
out pernicious influence until a favorable combination
of circumstances arises. This is
favored by what is known of such
organisms as the bacillus tuber-
culosis, the pneumococcus, etc.
Second, it seems quite probable
that the process may not depend
upon one special organism, but
circumstances may render one of
several the offending agent.
This last supposition would in-
volve the idea that the trouble is
not dependent upon a constant
cause, and, as a coroUar)', it would follow that the inter-
mediate steps may not be the same, or in other words,
that we now class together several distinct processes
on account of certain striking features in common.
Such a conclusion seems to me probable, for the vari-
ation in the signs and symptoms of the cases noted,
as well as in others I have not reported, seems to me
to justify the assumption that similar but not identi-
cal processes were to be expected in the final explana-
tion. However, the personal element of the equation
may prove more important than is suspected.
There is still another hypothesis that is not entirely
untenable. It is manifest that the chemistry of the
digestive process is to a positive degree under the in-
fluence of the nervous apparatus, not only as to the
rate of the process, but quite probably as to various
details of it. Hence it is entirely possible that, given
the usual elements of material and mechanism, if the
nervous influence is sufficiently disturbed, products
may result that could prove highly deleterious. The
disturbance in digestion that occasionally comes to
most people w'hen under depressing emotions is a
matter of common observation, and the limit of that
disturbance has not been defined.
Concerning the measures which we may rationally
take to protect our surgical cases from this danger, it
is manifest that whatever will place the intestinal
canal in a state of relative freedom from vitiated food
products and micro-organisms would be reasonable
measures to adopt. This can probably be best accom-
plished by a diet of plain articles of food, as milk,
fish, etc., for three or four days before the operation,
with the use of one or more doses of calomel, to be
followed by Epsom salts on the day before the opera-
tion. It is quite possible that calomel has a special
usefulness for this purpose. The free use of water
also, to aid in the elimination, particularly through
the kidneys, is important.
Still, do what we may, it is to be feared that for
some lime to come we will occasionally encounter one
of these sad cases, and, as we advance in a series of
successful operations, we should not flatter ourselves
that we have mastered all the jjerils attendant upon
surgery, or that the day of " capital operations" has
passed.
THE PHONENDOSCOPE.
liv HERMAN B. BARUCH, B.S., M.D.,
MT. SINAI HOSPITAL, NEW YORK.
This instrument was devised by Bianchi, of Florence,
Italy, with the aid of the celebrated ]5hysicist liazzi.
It has been extensively used in Europe for several
years, and Schwalbi, of lierlin, from whom I quote
below, commends it highly.
Following is a description of the instrument, which
will be made clear by referring to Diagram i. It
consists of two principal parts:
1. The resonator.
2. The conducting tubes of soft rubber.
The resonator is composed of three parts
A. Tlie resonator proper.
Fig. I. — The Phonendoscope.
B. A removable membrane.
C. A start of metal tipped with a hard-rulil)er but-
ton. This staff screws into a thread in Ji and can
be removed with it.
The resonator consists of a capsule having its sides
and top of metal. The bottom is made of anebonized
plate wiiich is pushed forward from within by a small
spiral spring. The plate is held in place by a metal
rim. The top of the metal capsule is perforated by
two converging apertures. Between these the spiral
spring is situated, inside the capsule. The second
membrane, also ebonized, may be attached to A by
two slits in the metal rim surrounding it, which re-
October 31,
1896]
MEDICAL RECORD.
625
ceive two projecting metal points on ^. Into Jf the
small staff above described is screwed.
The soft-rubber tubes are tipped with metal points
which are received in the converging canals in the top
of A. The other end of the tube is armed with a
small ear-piece which is self-retaining.
I have modified the instrument by attacliing the
distal end of the rubber tubes to the ear-piece of an
ordinary stethoscope. This is found to be more satis-
factory for prolonged and repeated use of the instru-
ment, as the tips originally provided have to be
introduced too far into the meatus auditorius for com-
fort, and often fall out of the ear. These rubber
tubes may be multiplied to any extent for the purpose
of affording to a number of students the means for
simultaneous use. The whole instrument weighs about
eight ounces.
To use the instrument the rubber tubes are con-
nected to the resonator, the ear pieces are inserted,
and the capsule is laid on the surface of the body.
The instrument is most sensitive when used without
the outer membrane and when both tubes are used.
It is least sensitive w hen the staff and outer membrane
are both attaclied and only one tube used.
I have thus carefully described the instrument, be-
cause only by accurately understanding its construction
can one realize its capabilities without actually testing
it. The inventor claims, and his claims have been
borne out by practical experience, that the phonendo-
scope is of great practical utility in the following
directions: i. The instrument enables us to appreci-
ate the normal and pathological sounds emitted by the
organs of the body. Many acoustic pnenomena which
are not audible by ordinary means of auscultation are
rendered clear and appreciable. The instrument en-
ables one to hear the respiratory murmur, the pitch
and quality of the sounds of the circulatory apparatus,
of the organs of digestion, of the ear, both in health
and disease; also of muscles, joints, and bones (frac-
tures, dislocations, etc.), of the pregnant uterus and
foetal heart, and even of the capillary circulation.
He also emphasizes the ease with which " comparative
auscultation" can be made, using two instruments
upon corresponding areas and using a tube from either
resonator. By squeezing the tube from one instru-
ment and then the other, an exact comparative study
of acoustic phenomena may be made. This is of es-
pecial importance in tracing the direction and extent
of the transmission of cardiac and aneurismal mur-
murs, and in deciding fine points in pulmonary diag-
nosis.
2d. It may be used to great advantage to determine
the form, position, thickness, and relations of separate
viscera, thus replacing percussion. For this purpose
we use the resonator with staff and second membrane
attached. The button of the staff is firmly pressed
upon the skin over the organ to be examined and gen-
erally only one tube is used. As the index finger of
the right hand gently strokes the skin near the button,
a distinct vibratory sound is elicited. This varies
according to the thickness and extent of the organ
examined. The ear soon becomes so trained that it
recognizes the slightest grades of change in intensity
and quality of this vibration. The stroking should
be done with a regular oscillating motion of the fin-
ger, care being taken not to vary the amount of pressure
used. Proceeding from the button to the periphery,
the stroking is continued until a decided change in
the quality of the sound is heard. This is very read-
ily appreciated and indicates a change in the conduct-
ing medium beneath. Marking the point at which
this change is heard, we go on with the stroking in
t another direction, marking as before. Thus we out-
line by dots upon the skin, with great exactness, the
underlying organs. The trained ear may not only
recognize the boundaries of underlying organs, but
also distinguish gross changes in structure and texture.
The following is a translation of the directions of the
inventor for outlining the various organs; by refer-
ring to diagrams 2 and 3, the points of election will
be readily seen :
Anterior Portion of the Body. — Lungs: Place the
phonendoscope above, upon, and below the clavicle
for the upper lobes (1-2) ; in the third intercostal
space for the (4) middle lobe; in the fourth for the
lower (5). Do not stroke too hard. In this way you
can readily distinguish the beginning of the lung, its
divisions into lobes, and the overlapping of the same.
When a pleuritic effusion is present, put the instru-
ment in the same positions and, after examining in the
upright and reclining positions, place the patient first
Fig. 2. — r, Upper lobe of lung; 2, upper lobe of lung; 3, middle lobe of right
lung; 4, lower lobe of right lung; 5, Heart — (.r) right ventricle, (r) right
auricle, (-) left ventricle, (:-) large vessels (aorta, etc.); 6 and 7, liver; 8 and
9, stomach; 10, ascending colon and csecum; 11 and 12, transverse colon;
13, descending colon; 14, bladder (uterus); 15, kidneys.
on the right and then on the left side, to ascertain the
variation in the level of the fluid. Stroke vigorously.
The heart: To determine the position of the heart,
place the instrument in the left parasternal line, fourth
intercostal space; for the right ventricle a little lower
to the left, for the right auricle a little lower to the
right; for the left ventricle, a little higher to the left;
for the large vessels, a little higher to the right (arch
of aorta, etc.) ; vigorous strokes. In this way we can
determine the exact size and boundaries of the heart,
its division into ventricles and auricles, and the posi-
tion of the large vessels.
The liver: Place the instrument in the following
positions successively : Beneath the xyphoid appendi.x
in the right mamillary line, in the seventh intercostal
space; in the ninth intercostal space over the mid-
axillary line. Vigorous strokes.
The stomach : Place the phonendoscope in the sev-
enth intercostal space, left midclavicular line, and
then on the linea alba near the left free edge of the
ribs. When the stomach is full, place the instrument
just below the greater curvature. We can thus dis-
tinguish the pylorus, cardia, the coils of the intestine,
and the nature of their contents, whether fluid or gase-
ous, and also the change in place and form of the
organs when the position of the patient is shifted.
Stroke vigorously for fluid, and lightly for gaseous
contents.
The colon : For tlie cajcuni and ascending colon
place the instrument in the right iliac fossa, beneath
626
MEDICAL RECORD.
[October 31, 1896
the free border and in the anterior axillary and mid-
axillary lines. For the transverse colon, on two or
three points, according to the breadth, above a line
which passes from right to left over the umbilicus
and strikes the left free border between the midaxil-
lary and posterior axillary lines. For the descending
colon, beneath the left free border in the midaxillary
line and also near the anterior superior spine of the
ileum. Stroking varies with the nature of the con-
tents.
Bladder: Place the instrument in the linea alba
above the symphysis pubis. Stroke gently when the
bladder is empty, vigorously when it is full of fluid.
Ascitic fluid: Place the phonendoscope on either
side in the anterior axillary line and in the linea alba
on a level with the umbilicus, ha\ing the patient
change from the upright to the reclining position, and
even stand on his feet. Stroke vigorously.
New growths, also deeply situated organs, as the
kidneys and spleen, can be outlined by placing the
instrument over the centre of the organ and stroking
the overlying region. Enlarged glands can be studied
in the same way.
Posterior Surface of Body. — Lungs: Place the
phonendoscope oa either side in the scapular line at a
Fig. 3. — I, Upper lobes of lungs; 2, lower lobes; 3, spleen; 4, kidney; 5, liver;
6, kidney.
level between the first and fourtli dorsal vertebras for
the upper lobes, and between the seventh and tenth
for the lower lobes.
Liver: Place the instrument in the right scapular
region at the level of the twelfth dorsal vertebra-.
Spleen: Place the phonendoscope on the left side
in the posterior axillary and midaxillary lines and in
the interspaces between the last ribs.
Kidneys: Place the instrument just within the
semi-scapular line, immediately below the regions of
the liver and the spleen.
My experience with the instrument extends to about
one hundred carefully examined cases. I have exam-
ined patients with the naked ear, then with the stetho-
scope, and with the phonendoscope. Heart sounds
have been especially studied. In cases of myocardi-
tis, when the heart sounds could not be distinguished
with the stethoscope, they have been distinctly heard
with the phonendoscope, and this through several
thicknesses of clothing. Murmurs which are inau-
dible to the unaided ear are so magnified and distinctly
reproduced as to be recognized with great ease. This
will be a ver)' substantial recommendation to phy-
sicians whose hearing is unfortunately defective. It is
remarkable that there is so little disturbance and dis-
tortion of sounds when we listen through several
thicknesses of material. Even fine crepitant rales
may be heard with distinctness through the ordinary
clothing. The heart can be examined with accuracy
without disrobing the patient. I have several times
detected even faint murmurs in this way and my diag-
nosis has been confirmed by my colleagues by obser-
vation with the stethoscope.
Another great advantage will be found in its use in
the clinical lecture room. The tubes can be multi-
plied to any number and many students can listen to a
heart or other organ at the same time, while the in-
structor demonstrates.
I am convinced that the phonendoscope is as great
an improvement over the stethoscope as the latter was
over immediate auscultation, and that we have in it a
most perfect aid to accurate diagnosis.
New York, September 17, 1806.
THE VISUAL DISTURBANCES DUE TO
NERVOUS DISEASES.'
Hv WARD A. HOLDF.N", A.M.. M.I).,
NEW VOKK.
Ix beginning these remarks it may not be inadvisable
to devote a few words to the theory of the tests of the
visual field, inasmuch as it is chiefly these tests that
give us information as to the location of the nerve
affections causing disturbances of vision.
The light sense, as respects the power of distin-
guishing between two different light intensities, is
most acute in the centre of the field of vision and
gradually diminishes in the periphery, although even
at the limits of the field slight differences in light in-
tensity can be recognized. The color sense, as re-
spects the ability to recognize a particular color,
diminishes in the periphery of the field much more
rapidly than the light sense, and at the limits of the
field for white, colors of ordinary intensity in areas of
moderate size are not recognized at all. If from any
cause the conducting power of the optic nerve is inter-
fered with uniformly, we find, first, that the acuteness
of central vision is diminished, so that an eye with
vision ID has now perhaps only |{j ; we find, second,
that the light sense is diminished in the entire field,
so that a patch of pale gray which the normal eye
could distinguish from a white ground at 60^ in the
periphery can now perhaiis only be seen up to 30" in
the {jeriphery ; and we find, third, that color perception
is diminished, so tliat the field for blue is small, for
red is smaller, and green is recognized only near tiie
point of fixation. The condition then is one of rela-
tive loss of all functions in the entire field.
If we suppose the conducting power of the optic
nerve to be still further interfered with, the acuteness
of central vision will be further diminished, the color
fields will be further contracted, the perception of
green being perhaps lost altogether, and the power of
distinguishing differences in light intensity will be
much diminished in the entire field and altogether
wanting in the periphery, where objects will not be
seen. We have now not only the former relative loss
of funtion in the entire field, but also an absolute loss
of function in the extreme periphery of the field. The
usual perimetric tests with a large white object will
reveal only absolute defects in the field, but by using
as a test object a pale gray patch or a small black
point that can just be distinguished from a white
' Read before the .\cadeniy of Medicine, October 15. 1896.
October 31, 1S96]
MEDICAL RECORD.
627
ground by the normal eye at the limits of the field, the
test becomes much finer and relative defects in the
periphery can be made out. By using a paler gray
patch and a smaller black point, or by using colors,
relative defects in the intermediate and central zones
will be revealed. In congenital color blindness with
normal acuteness of vision the light sense is unaffected
and functional tests may be made with the gray patches
or black points, but in every case of acquired color
blindness the color defect is accompanied with a light-
sense disturbance, so that the functional tests may be
done indifferently with colors or w ith grays and blacks.
The nature of a defect in the visual field is readily
made out by standing eighteen inches from the patient
and having him fix the finger held half-way between
his eye and the observer's, while a card with a similar
test object on each surface is brought in from the pe-
riphery in various directions, the point where the test
object is first recognized by the patient being com-
pared with the point where it is first seen by the
observer, the patient's abnormal field thus being com-
pared with the observer's normal field. For determin-
ing the exact extent of the defects and for recording
them a perimeter is required. Since the field varies
somewhat with fatigue, and since the errors of observa-
tion may be considerable when the fields for the differ-
ent colors are mapped out successively, the relative
extent of the color fields is best determined by holding
a blue patch side by side with a red or a green patch
and noting which color is first recognized as the two
are brought in from the periphery at the same time.
The normal eye will recognize blue first, red next, and
green last, and this will also be the case in the con-
traction from optic-nerve atrophy and in other relative
defects. But if there is a sharply limited absolute
defect, as in hemiopia, the colors will all be recognized
simultaneously at the margin of the defect; and it
will sometimes happen that the red is recognized ear-
lier than the blue, indicating a reversal of the sequence
•of the color fields. This reversal is due to imperfect
adaptation of the retina, which is the physiological
cause of the night blindness that accompanies retinitis
pigmentosa and other diseases affecting the pigment
■epithelium. This reversal is also a symptom of
Jiysteria.
When a colored test object is placed upon a while
ground the colored patch will be seen beyond the lim-
its of the color field as a dark spot on the white, and
when it is placed upon a black ground as a light spot
on the black. This renders it very difficult for the
patient to say exactly where the color is first recog-
nized. The difficulty, however, is largely done away
with by putting each colored patch upon a gray ground
having the same light intensity as the color. The
patch will then not be seen as it is brought in from
the periphery until the color is recognized, and in a
scotoma for that color the card will appear uniformly
gray.
In these ways we can most delicately determine the
degree and the extent of defects in the visual field,
and, since so many nervous diseases have visual dis-
turbances among their first symptoms, the early deter-
mination of defects in the visual field may be of great
value in diagnosis.
• In discussing the various types of \isual disturbance
in their connection with the lesion causing each, the
subject naturally resolves itself into three parts, for
some types of visual defect are characteristic of affec-
tions of the optic nerve, others of affections of the
chiasm, and others still of affections in the visual path
behind the chiasm. Disease of one nerve causes a
visual defect in one eye only, but a single lesion in
the chiasm or farther back in the visual path must
•cause symmetrical defects in the two eyes.
I. Diseases of the Optic Nerve.— With a diffuse
degeneration of the optic nerve, the ordinary atrophy,
there is gradual failure of central acuteness of vision
and peripheric contraction of the visual field, more or
less concentric, the color fields being also contracted
but preserving their normal sequence. The optic disc
grows pale in its temporal half and later in its nasal,
and finally the entire disc is white and excavated and
the retinal vessels are narrow. This simple atrophy
is most frequently due to a diffuse degenerative ner-
vous disease, such as tabes, paralytic dementia, or dis-
seminate sclerosis, and is often one of the earliest
symptoms, and in tabes it is thought by some that the
early occurrence of optic -nerve atrophy is an indica-
tion that the spinal lesions will be less severe and
longer delayed in their development. Simple atrophy
may be unilateral, but in most cases atrophy in the
second eye follows later. This same peripheric con-
traction of the visual field occurs in post-neuritic
atrophy of the optic ner\e. An optic neuritis may,
however, pass off without atrophy, and it is not un-
usual for a low degree of neuritis, probably dependent
upon a meningitis, to persist for months or years with-
out seriously affecting vision, and even the intense
optic neuritis or choked disc which is a remote symp-
tom of brain tumor may exist in a high degree without
visual disturbance, but when vision is once affected it
fails rapidly. This neuritis generally passes oft" after
trephining, even though the tumor is not removed. In
post-neuritic atrophy for a considerable time the out-
lines of the disc remain blurred and the retinal veins
large. The disc is grayish-white in color and it is
swollen instead of being excavated as it is in simple
atrophy. The final appearance of the disc after neu-
ritis does not always indicate the degree of visual
disturbance, and occasionally after meningitis in child-
hood the same picture of post-neuritic atrophy is found
in both eves when one has good sight and the other is
blind.
Entirely distinct in its pathology from peripheric
contraction of the field is central scotoma. In the
pure form there is diminished perception for red and
green in the centre of the field, while blue is recog-
nized here and the peripheric limits of all the color
fields are normal. The cause of this symptom is an
interstitial infiammation of the papillo-macular bundle
of the optic ner\e, that bundle which occupies the
infero-temporal third of the disc and is then distrib-
uted to the macular region of the retina. As the in-
flammation advances, after a transient reddening of the
disc its infero-temporal third becomes white and later
excavated, while the remainder of the disc is of nor-
mal color. The pale sector remains sharply defined,
.so that it cannot be confounded with the difi'use tem-
poral pallor of incipient general atrophy. The pure
chronic form of this retro-bulbar neuritis of the papillo-
macular bundle is usually due to tobacco and alcohol
poisoning. There is never peripheric contraction
of the field and until very late the central scotoma is
only relative.
Central scotoma is found occasionally with dissem-
inate sclerosis, with hereditary optic-ner\'e atrophy and
with the acute retro-bulbar neuritis following grippe,
etc. In these cases there is often an absolute central
scotoma and frequently also some contraction in the
periphery of the field. In simple atrophy vision once
lost is usually never recovered, but in neuritis, partic-
ularly when limited to the papillo-macular bundle, lost
vision may be entirely restored. In simple atrophy
vision is best in a bright light, in neuritis in a sub-
dued light.
The visual disturbances in hysteria, neurasthenia,
and simulation are similar and cannot be sharply dif-
ferentiated. All resemble the types of disturlaance
due to affections of the optic nerve. In extreme cases
there will be total blindness in both eves, of sudden
628
MEDICAL RECORD.
[October 31,
1896
onset, although more frequently total blindness is lim-
ited to one eye. In the usual cases there is slight
disturbance of vision for distant objects, more marked
disturbance of vision for near objects, and concentric
contraction of the field, or rarely a central scotoma.
There is also fatigue of the visual field, the limits of
the field varying with successive tests and gradually
becoming narrower, and accompanying this there may
be a reversal of the order of the color fields, that for
blue being narrower than that for red. When the loss
of vision is merely relative, the central acuteness may
often be brought up to the normal by patiently urging
the individual to read the letters lower down on the
test card and by putting indifferent glasses before the
eye. When there is apparently total blindness in one
eye the tests for simulation will show that there is
vision in each eye.
Before passing to the symmetrical disturbances in
the two eyes, the unsettled question as to the e,\istence
of crossed amblyopia should be at least alluded to.
.Some British neurologists believe that a single lesion,
presumably in the angular gyrus, can cause amblyopia
in the eye of the opposite side with marked concentric
contraction of the field and slight contraction of the
field on the same side. Nothnagel has denied the
existence of crossed amblyopia and many others have
doubted it. Gowers, who is one of its chief advocates,
reaffirms his belief in crossed amblyopia in his Bow-
man lecture of last year. He explains the amblyopia
by supposing a lesion to exist in a hypothetical corti-
cal visual centre higher than the half-vision centre in
the cuneus. " Impressions seem to pass," he says,
"to this higher centre in each hemisphere from both
half-vision centres in the occipital lobes in such a
way that in each higher centre both fields of vision are
represented, but that of the opposite side in greater de-
gree." In support of the existence of such a centre
he adduces, first, hysterical amblyopia (which is now
thought to be due to cortical disturbances), with which
hemiansesthesia is frequent, but with which hemiopia is
never found, the contraction of the fields being concen-
tric, as would be expected if the amblyopia were due to
involvement of the hypothetical higher visual centre.
He adduces, secondly, the subjective visual spectra in
the aura of epilepsy and in the scintillating scotoma
of migraine. These visual disturbances are symmet-
rical in the two eyes but not necessarily hemiopic,
sometimes more than half the field being involved,
sometimes less, so that it is diflicult to believe that
they are due to involvement of one half -vision centre.
The whole matter, however, is still vague, nor is it
likely to be soon definitely settled.
II. Diseases of the Chiasm. — Pressure on the
chiasm in front or behind, as well as pressure above
or below, if near the median line, affects only the
crossing fibres which are distributed to the nasal half
of each retina and receive impressions from the tem-
poral lialf of each field. The characteristic visual
disturbance in chiasm disease is therefore bitemporal
hemiopia. If the chiasm is cut through, all the cross-
ing fibres being divided, the result is the absolute loss
of the entire temporal half of each field, which is
called complete absolute bitemporal hemiopia. If the
chiasm is cut part way through so that only a portion
of the fibres is divided, the result is the absolute loss
of a portion of the temporal half of each field symmet-
rical for the two eyes, which is known as partial bi-
temporal hemiopia. If the chiasm is subjected to
pressure that is sufficient to diminish but not abolish
the conducting power of the crossing fibres, the result
is loss of color perception in the entire temporal half
of each field, while for large white objects the field is
normal, which is called relative bitemporal hemiopia
or hemiachromatopsia. Careful tests in this condition
will reveal not only a color defect in the temporal half
of the fields but also a light-sense disturbance, pale
gray patches and small black points not being per-
ceived. Chiasm affections may thus give rise to a
variety of visual affections, all corresponding to the
type of bitemporal hemiopia. The simplest case is
when the chiasm is slightly compressed by hemor-
rhage or exudation, or by the enlarged pituitary body,
as we have it in acromegaly. There will then be pro-
duced a complete but relative bitemporal hemiopia.
Central vision will be normal or nearly so; the field
for large test objects will be normal, but colors and
small test objects will not be seen in the temporal
fields. If the pressure increases, the bitemporal hemi-
opia will become absolute, central vision will be
diminished, and the optic discs will grow pale from
atrophy of the optic nerves. If a malignant tumor of
the pituitary body involves a portion of the chiasm,
there will be at first a small absolute defect in the
temporal half of each field, which will increase in ex-
tent until the bitemporal hemiopia becomes com-
plete. The extension of the tumor involving the
lateral bundles, the infero-nasal quadrant of one field
is lost and later the supero-nasal quadrant, so that the
eye is totally blind. Later the nasal half of the other
field will be gradually lost and both optic discs will
present the picture of complete atrophy.
III. Diseases of the Visual Path Behind the
Chiasm. — Homonymous lateral hemiopia, the loss of
each riglit or each left half of the visual fields, may
be relative or absolute, partial or complete. It is
rarely recovered from, although the defect may become
smaller in the first few days. Central vision is usu-
ally normal. Homonymous hemiopia may be due to
an aft'ection of the optic tract, when the crus is likely
to be involved, causing hemiplegia. It may be due to
an affection of the internal capsule, when it is fre-
quently associated with hemianaesthesia. And it may
be due to an affection of the optic radiation of Gratio-
let or of tiie cortex in the region of the calcarine fis-
sure, when it is usually unaccompanied by other focal
symptoms. If the lesion is peripheral to the primary
optic ganglia, the tract atrophies and the discs grow
pale. If the lesion is central to the primary optic
ganglia the optic discs do not atrophy. It is also
commonly stated that in lesions central to the primary
ganglia the pupillary reaction to light will be normal,
wliile in lesions of the tract there will be hemiopic
pupillary inaction. But it must be said that Wer-
nicke's symptom has not the great importance it is
supposed to have, because in cases in which theoreti-
cally there should be hemiopic pupillary inaction it is
often impossible to make it out with certainty. Oph-
thalmologists indeed have for the most part denied its
existence altogether, and almost all of the cases re-
ported have been seen by neurologists. Cases of
homonymous hemiopia from tract affections are rarely
seen, but bitemporal hemiopia from chiasm lesion is
not rare, and most of the reported cases of hemiopic
pupillary inaction, among them Seguin's often-
quoted ones, were cases of bitemporal hemiopia.
Here the determination of the presence of the symp-
tom is interesting but of no diagnostic value, since
the bitemporal hemiopia locates the lesion in the
chiasm. In three cases of this sort I was not once
able to elicit hemiopic pupillary inaction, though po's-
sibly the light was not thrown into the eye from a
point sufficiently peripheric. In reading the report of
Seguin's cases later, I find he states that when light
refiected from a mirror was thrown into the eye at an
angle of 90^ to the temporal side of the line of vision
no reaction occurred, but when the mirror was brought
forward until the beam of light fell into the eye from
an angle of 70° or 60' reaction occurred. Nor in this
extreme peripheric field of 20° or 30° was reaction
always completely wanting, but sometimes only less
October 31, 1896]
MEDICAL RECORD.
629
marked than when light was thrown into the eye from
a corresponding portion of the nasal field. Henschen,
among others who have occasionally elicited the
symptom, also describes it as being often only a less
marked reaction and not complete inaction. When
light is thrown into the normal eye from the extreme
periphery of the field, pupillary reaction is never very
marked, and often may be entirely wanting. Again
it may vary greatly in the same individual, in the
same conditions, and at one time be more pronounced
from the nasal side and at another more pronounced
from the temporal, the size of the pupil changing w^ith
the patient's constantly changing accommodation and
the accuracy of the results obtained by the ordinary
tests being exceedingly questionable. In order to
eliminate errors due to changing accommodation and
to Haab's cortical pupillary reflex, Heddaeus has
recently proposed that the patient shall fix a test
letter at two metres' distance, accommodating con-
stantly for this, while two shaded lights, one to the
patient's left and one to his right, are exposed alter-
nately, and any difference in the degree of pupillary
reaction noted. And it may be that, when performed
with such refinements, the test for hemiopic pupillary
inaction may give results sufficiently accurate to be of
value in diagnosis.
There have been reported a few cases of relative
homonymous hemiopia or hemiachroniatopsia in which
colors are not recognized in homonymous halves of the
visual fields, while for large white test objects the
fields are complete. Since in these cases coarse tests
have not always revealed light-sense defects, it was
supposed that, the cortical perceptive centres for form,
light, and color being distinct, the color centre was
here alone involved, or the color centre and the form
centre only. Hence until recently it has been posi-
tively stated that homonymous hemiachromatopsia
always indicated a cortical lesion. However, the
careful examination of such cases has revealed light-
sense disturbances also. In the only case that I have
personally had an opportunity of examining, a patient
referred from the ner\'ous department of the Vander-
bilt Clinic, there was a partial absolute homonymous
hemiopia, and besides the absolute defect there were
larger relative defects of different sizes for different
colors, the defect for green being a complete hemiopia.
But in each color defect there was a light-sense dis-
turbance equivalent to those which accompany defects
for the different colors due to lesions of the optic
nerve. And there is little doubt but that light-sense
defects will be found in every case of homonymous
hemiachromatopsia, as they are found in every case of
bitemporal hemiachromatopsia. It is difficult to sup-
pose that a cortical lesion of two different centres
could so exactly correlate the defects in color and in
light sense, and it seems much more likely that further
observations will lead us to the extreme opposite con-
clusion, viz., that hemiachromatopsia accompanied by
a hemiopic light-sense disturbance must be due to an
affection of the fibres of the visual path and not of the
ganglion cells of the cortex. Nor does the only au-
topsy yet made in a case of this sort disprove this
supposition.
45 West Thiktv-Ninth Street.
Eating — Children should be trained to eat slowly,
no matter how hungry or what important business is
pressing. Much safer a little food well ground than a
hearty meal swallowed in haste. Cold food is even
more difficult to digest than hot, if taken too rapidly.
The normal temperature of the stomach is about 98 "
F. ; food has to be raised to this temperature before
■digestion can take place. — Medical Council.
^fOflrcss of tJXcdical J^ciencc.
Retropharyngeal Abscess. — Dr. Ambler says (Cleve-
land Mcdiidl Gazette) this affection is more com-
monly met with in children than in adults, and when
occurring in the former is generally associated with
a strumous diathesis.
Symphyseotomy. — Dr. Mayariet (Z' Obstetrique,
January, 1896) says that the most recent statistics are
as yet somewhat discouraging. Neugebauer gives a
maternal mortality of ii.i per cent., and that of the
child 19 per cent. The operations of M. Pinard
and his followers in the last four years have given a
mortality of 10.14 per cent, for the mothers and of
11.59 percent, for the children. Perhaps this mor-
tality would diminish considerably if all operators
were careful and abstained from interfering whenever
any unfavorable condition exists in mother or child
which would compromise the success of the operation.
Bacteriology of the Hair.— Dr. L. Brocq {Journal
of Cutaneous and Gcnito- Urinary Diseases, September,
1896) says that when the bacteriology of the hair is
taken up various microbes are found in it. Six are,
however, discovered quite constantly. These are: (i)
a white fungus; (2) a yellow fungus; (3) a bacillus
subtiliformis; (4) a bacillus in the form of a boat,
staining with difficult)-; (5) a special micrococcus,
which Sabouraud designates provisionally under the
name of micrococcus cutis communis; (6) the spore
of Malassez, the flask bacillus of Unna, which he calls
the bacillus asciformis. These two microbes, which
appear to be the most important, are found in sebor-
rhoics who are not attacked with alopecia areata. No
one of these microbes would have the importance of a
causal agent in the disease.
Thoughts on the Origin and Spread of Contagious
Diseases.— Dr. Faulds (New York Medical Aews)
summarizes as follows : i. That non-virulent microbes
exist in all parts of the habitable globe. 2. That they
were made disease producing in the case of cholera,
small-pox, syphilis, diphtheria, and tuberculosis, in
the thickly populated centres of the old world,
through overcrowding and bad hygienic conditions,
such as have never been known to us. 3. That the
virus is always derived from a previous case, and is
spread, either directly or indirectly, through human
intercourse. 4. That increased vital resistance renders
persons immune only in tuberculosis and other excep-
tional instances. 5. That if virulent bacteria could
be prevented from finding a lodgment in human tissue,
they would, for want of nutritive pabulum, soon return
to their primitive dormant state. 6. That isolation,
quarantine, and disinfection, under the direction of
bacteriologists, are the only means by which we may
hope successfully to prevent the spread of contagious
and infectious diseases.
Suture in Veins and Arteries. — Dr. Sabanyeff, of
Odessa, reports two cases of this kind. In the first
the suture was applied to the femoral vein w^ounded
during incision of the inguinal glands; in the second
to the femoral artery. In the latter case the patient
died from the original disease, and Dr. Padalka found
by microscopical examination that the healing of the
wounded artery took place from without inward. Dr.
Heidenhans {Centralblatt fiir C/iirurgie) cites two pre-
viously recorded cases, one involving the common fe-
moral and the other the common iliac. He reports an
instance in his own experience, in which in removing
cancerous glands from the armpit an incision was made
in the main artery. The bleeding was arrested by digi-
tal compression, and the edges of the arterial wound
630
MEDICAL RECORD.
[October 31,
1S96
v.ere brought .together by a continuous suture of catgut.
Bleeding was thus completely arrested. The lumen of
the vessel was not apparently diminished. The su-
tures held in spite of strong arterial pulsation. The
patient made a good recovery. The a.xillary artery
could be felt pulsating along the whole extent of the
armpit.
Infection by Pets. — Cats have been suspected of
conveying the infection of diphtheria, and scarlet fe-
ver has been traced to them. To this may be added
the unwelcome news that a health officer has reported
a case of small-po.x which has been brought about in
the same way; that is to saj-, by a cat from an infected
house entering a neighbor's. — Popular Science.
Cerebral Concussion. — Kramer's study of cerebral
concussion is summarized as follows in the Lancet-
Clinic : A blow on the head produces a momentary in-
crease of intracranial tension and consequent com-
pression of the brain as a whole. The effect of this
compression is to cause an interference with the
blood supply to the entire brain, and this is suffi-
cient to account for the primary symptoms of cerebral
concussion. The so-called syncopic death, after se-
vere concussion, is produced by a paralysis of the re-
spiratory centres, the cardiac centres remaining intact.
This fatal result may, in many cases, be prevented by
the prompt institution of artificial respiration.
Seminal Vesiculitis. — Dr. Eugene Fuller {Journal
of Cutaneous and Genito- Urinary Diseases, September,
1896) describes several operations, and draws the fol-
lowing conclusions: I. Chronic non-tuberculous cases
of seminal vesiculitis can be successfully and satisfac-
torily treated by extirpation of the sac. 2. .Such an
extreme measure, however, should be reserved for ex-
treme cases, associated with serious or severe subjec-
tive symptoms. 3. Before resorting to extirpation the
patient should have the benefit of the stripping treat-
ment, if his circumstances allow it, and extirpation
should be advised only in case the stripping treatment
proves unsatisfactory. 4. In performing the operation
the Kraske incision is the method advisable.
Cystitis in the Female — Dr. Hersler's plan of
treatment is thus outlined and recommended as giving
tlie best results: (i) To remove any discoverable
source or sources of irritation which act through the
medium of the urine. This may be effected by a milk
diet and a discontinuance of the use of acids, pepper,
etc. Any mechanical source of vesical irritation
should receive appropriate treatment. (2) The urine
should be rendered bland by the use of a milk diet,
the ingestion of considerable quantities of water, the
administration of potassium citrate if the urine be too
acid, or of boric acid and salol if it be alkaline. (3)
I'elvic congestion should be relieved by hot vaginal
douches, placing the patient in the knee-chest position,
and the correction of constipation. (4) The inflamed
cystic mucous memlsrane may be relieved by the admin-
istration of boric acid, sandalwood oil, copaiba, or creo-
sote by mouth; or the use of injections of boric acid,
carbolic acid, or nitrate of silver in suitable strengths.
(5) The patient's general health should be improved
by tonics, etc. (6) Rest in bed, especially in all acute
cases, is absolutely imperative. While advocating di-
rect local treatment for cases of cystitis which do not
readily respond to ordinary therapeutic measures, I
must advise that it should be employed with judgment
and caution. — American Journal of Surgery and Gyne-
cology.
Treatment of Ileus. — Xaunyn {Separat-Ahdruck
d. Mittheil. aus d. GrcnzgcHet d. Aled. u. Cliir., I. Bd.,
i8g6) gives the following set of rules for the treatment
of ileus; i. The prognosis of the operative treatment
of ileus is most favorable on the first and second day
of its existence; it is markedly worse on the third day.
2. Seventy-two per cent, of the recoveries are obtained
in those cases in which obstruction is due to a rupture,
not including cases of strangulated hernia. 3. In pri-
mary peritonitis, this condition and not the resulting
ileus must determine the operation. 4. (<7) In chronic
intestinal stenosis the necessity for an immediate ope-
ration does not often arise ; (/' ) the seat of obstruction
can usually be made out e-xactly, if it is located in the
duodenum, descending colon, sigmoid flexure, or rec-
tum; otherwise it can only be guessed at; (c) strangu-
lation can often be diagnosed, and demands immediate
operation. 5. An e.xact diagnosis of ileus is possible
when it is caused by foreign bodies, e.g., gall stones,
volvulus of the sigmoid flexure, and intussusception.
Of treatment other than surgical. Dr. Naunyn says :
I. Avoid cathartics. 2. Large enemata of water or
injections of oil, five to sixteen ounces, are better.
Injections of air are less serviceable. 3. Opiates
should not be given in large doses. 4. Washing out
the stomach is recommended whenever there is faecal
vomiting or the stomach is overdistended. 5. I-"ood
and drink should be reduced to the minimum. 6.
Puncture of distended intestinal coils is of doubtful
value.
Anaesthesia. — The Medical and Surgical Reporter
gives the following instances in which chloroform is
the preferable anaesthetic: i. Chronic endarteritis oc-
curring in those advanced in years. 2. Chronic in-
flammatory affections of the respiratory tract and ad-
vanced pulmonary disease. Of course, acute catarrhal
aflfections of the respiratory tract are equally forbid-
ding to the use of ether; but a patient suffering from
such an acute inflammation should, unless delay were
hazardous, be cured of his catarrhal condition before
being subjected to any operative interference requiring
a general anasihetic. 3. Renal disease, acute or
chronic. 4. \\hen there is a history of ether having
been taken badly at some former operation. 5.
Chronic alcoholism. 6. Tho.se cases in which the
galvanic cautery is to be used in the neighborhood of
the mouth or ear passages. 7. Cerebral tumors or
abscess. 8. In old age. 9. In puerperal eclampsia
where an immediate effect is required. 10. Night
operations with artificial light. 11. During labor.
12. In military and naval practice, on the field of bat-
tle, its use seems to be at times justified, although
strongly contra indicated.
The following conditions are looked upon as pecu-
liarly unsuited for its administration, if not, indeed,
prohibitive: i. Surgical shock. 2. Epilepsy. 3.
Spina bifida and hydrocephalus (Morton). 4. When
there is a tendency to syncope. 5. Fatty heart and
chronic valvular disease. 6. Acute alcoholism: De-
lirium tremens (Sansom). 7. Fatty liver. 8. It is
unsafe to give chloroform to a patient already under
the influence of chloral, whether in obstetrical prac-
tice or otherwise.
Curettage as a Method of Inducing Abortion. —
Dr. Fuech presents the following conclusions in the
Annali de Gynicologia ct Obstetrica : i . Curettage
should have a place among the approved methods of
artificial abortion. 2. Before the fourth month it is
efficacious and free from danger. 3. It should be
adopted, particularly whenever rapid evacuation of the
uterus is indicated. 4. It should be adopted when-
ever economy of blood is especially indicated — in
anaemia and feebleness from any cause. 5. In intract-
able vomiting; particularly is it indicated for two
reasons advanced — rapidity in performance and econ-
omy in blood.
October 31, 1896]
MEDICAL RECORD.
6^1
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, & 47 East Tenth Street.
New York, October 31, 1896,
MENTAL THERAPEUTICS.
The wonderful influences of the mind on the complex
nutritive processes and on the various diseased condi-
tions of the body are readily acknowledged by every
observing physician. The old saw, faith in the medi-
cine and confidence in the doctor, has not only a
foundation in fact, but an e.xplanation in science.
The more we think on the possibilities of mental
therapeutics, the more we become convinced of its
wide range of practical appplication. So much ad-
vantage, however, is taken by quacks and other pre-
tenders of the well-known credulity of their victims,
that the truly scientific observer has been loath to
investigate the subject in the calmness of a judicial
e-xamination or with the unprejudiced aim of a seeker
after fundamental truths. That the general subject
deserves more earnest attention at our hands must be
apparent to every thoughtful man who endeavors to
explain certain nervous phenomena of almost daily oc-
currence, but which on casual examination appear be-
yond reasonable comprehension. Such, at least, is the
conviction of Dr. A. T. Schofield, who, in an address
on " Mental Therapeutics," published in a recent issue
of The Lancet, strives to aid investigators in this new
and attractive field of study. It will not be necessary
for our present purpose to do more than offer in outline
some of the main points upon which he bases his ar-
gument in proof of the intimate correlative agencies
affecting mind and body and their direct bearing on
both the natural and the perverted nervous tendencies.
He starts with the assumption that the conscious mind,
or ego, is but a very small part of the vast subcon-
scious mind upon which it rests. The former has its
seat in the cortex only, governing reason, feeling, and
volition, while the latter " is connected with — or may
we not say is the active principle of? — all life that lies
below, including reflex action." While it is not pos-
sible to be conscious of any vibrations that do not
reach the surface of the brain, the vast majority of
impressions are directly and uninterruptedly trans-
mitted through it to the subconscious mind, which
thus becomes the storehouse and registry of all those
intricate and complex energies which make up the re-
sponsive vital reflex of our varied and impressive en-
vironment. .\lthough full consciousness is the result
of the combination and interaction of the two condi-
tions named, the conscious mind so-called becomes
a party to the impression only when the latter is fo-
cussed on the cortex by the direct attention of the in-
dividual affected. To go a step farther, the author
assumes that the cortex not only receives impressions
from without in a primary and direct way, but is also
subjected to like impressions secondarily and indirectly
from the subconscious mind. In the one case, there
is an immediate and easily understood recognition of
the impression, while in the other the phenomenon is
not only without explanation to the individual, but is
entirely beyond his control. In the latter category art-
mentioned unconscious habits, unconscious cerebra-
tion, and the like. The conscious mind, when it wills,
dominates the unconscious, and thus in its own im-
perious way interprets sensations to suit its purposes,
diverts normal processes into abnormal directions,
changes the rhythm of vital processes, disarranges the
nutritive machinery of the body, and even tampers
with the pain signals in its mad misrule. Dr. Scho-
field says truthfully:
" The cortex, or surface of the brain — the seat of
conscious mind — is a special factor for good or evil
in every disease. Every organ and function is repre-
sented there, and there brought into vital unity. Pro-
fessor Laycock says : ' The hemispheres, as the organ
of thought and mental action proper, are in unity with
all the processes of life whatever, whether they be
termed vegetative or animal.' Indeed, the unity of the
body and to a great extent of the ' ego ' is formed in
the cortex. Bain shows that all tissue nutrition is
influenced from this great centre, and most physiolog-
ical acts can be arrested mentally by its action. It
controls unconsciously anabolic and katabolic cell ac-
tion ; and there is no doubt that a sound, cheerful
mind, acting through it, is a great protector against
disease of all sorts, and if disease has a hold a cheer-
ful mind can often cure it. Mental therapeutics can
be applied to the body in one of three w^ays: (i) By
the unconscious mind directly — in spiritual or physical
influences and surroundings; (2) by the unconscious
mind acted on by the conscious indirectly — in rousing
faith in persons, remedies, or places, etc.; and (3) by
the unconscious mind acted on by the conscious by
direct effort — in determination to get well, to shake off
illness, ignore pain, etc. With regard to the ailments
for which mental therapeutics is useful, it is a power-
ful means of cure in all organic and inorganic diseases,
while in hysteria and allied neuroses it is the only re-
liable means of permanent efficacy."
He then gives several interesting instances of the
influence of mind, conscious and subconscious, in or-
dinary disease and on the natural habits of thought
and action in the human organism.
"A patient suffering agonies with toothache was
told by her medical man to apply to the tooth a silver
coin wrapped in silver paper. Believing it to be in-
fallible, she did so several times and was relieved.
One day, however, she was told the remedy was wholly
mental, and at once it was powerless. Here is an in-
stance of the pernicious effects of the conscious mind
inhibiting after first aiding the subconscious. Unzer,
in i77i,says: 'The expectation of the action of a
remedy often causes us to experience its operation be-
632
MEDICAL RECORD.
[October 31, 1896
forehand.' I have just received a remarkable illustra-
tion of this, that, however, goes beyond this statement.
A colleague of mine gave a patient the other day some
opium pills to produce sleep, but forgot to mention
their object. Last week he found the pills had acted
well each morning, but the patient had had no better
sleep. Another patient thought she had taken a large
dose of rhubarb as a remedy for constipation, and the
'thought was effectual. Hunter says: 'By my will I
can fi-K my attention on any part until I have a sensa-
tion in that part;' while Miiller affirms that it may be
stated as a general fact that any state of the body
which is expected with certain confidence will be very
prone to occur as the mere result of that idea. It is
easy to produce symptoms by suggestions. If, for in-
stance, you press some particular part of the spine of
a neurasthenic and say, ' Do you feel any pain here ? '
he may say, ' No.' But if you persist in your sugges-
tion for half a dozen times, and the nervous centres
are at all susceptible, he will say, ' Yes,' and the pain
suggested by you will be felt. Now this is true with
regard to producing cures as well as in producing dis-
eases. The action of the subconscious mind in pre-
senting a fact to the conscious mind is remarkably
illustrated in a recent story of Sir R. Quain's. He
•was sent for by a man, aged forty years, who had a de-
lusion that his body had a most offensive smell, and
he even covered up his pictures lest they should be
tainted. No smell could be perceived, but a most
fetid iliac abscess was found and opened. His idea,
therefore, was not a delusion, but a recognition
through his subconscious mind of his condition."
Byway of illustrating the power of suggestion in the
treatment of so-called imaginary troubles, he mentions
the value of the time element in connection with the
watching of the mantel clock for indications of dosage:
"The real value of the clock in this, as in other
cases, is truly scientific, and depends for its potent
effects on rapidly formed accurate psycho-physical
habits, or artificial reflexes, in the brain. A woman
about seventy years of age came to me in deep distress
about her obstinate constipation, which was so severe
that every enema and pill had failed and mechanical
evacuation was the last resource. This condition had
continued for some years. The patient was of e.\cep-
tionally powerful mind and will and remarkable intel-
lect. Seeing this, I relied upon the clock as an effica-
cious aperient. I explained the power of an exact
habit over the bowels, and told her she would be cured
if at 9 :30 A.M. exactly by the clock on the mantelpiece
she sought relief each morning. .She was at first aided
artificially at the exact hour, but after a few mornings
when 9 :3o a.m. arrived, and she was taken out of bed,
the bowels began to act, only she sometimes wanted
to relieve them before the hour. This was never al-
lowed; she was told that to be too soon would pre-
vent the result as much as being too late. At the end
of six weeks the bowels were duly relieved without
medicine at half-past nine exactly, by the power of
subconscious habit, and at the end of six months she
had never missed a day. She has now no further
trouble."
It is probably within the experience of many of our
readers that similar cases are to be found, in which
the method of dosage was more than the dose itself,
the placebo more powerful than the real drug, and,
best of all and at the bottom of all, the belief that the
doctor understood the case and knew exactly the best
remedy to give. It is fair to assume, if the range of
psycho-physical ailments is great, there should be an
equal power of mental therapeutics to cure them.
The highest recommendation for mental therapeutics
is that it is not dangerous, that it is susceptible of
further profitable cultivation, and that it may serve in
many obscure and apparently desperate cases in effect-
ing a cure when all the usual means have failed.
THE DIAGNOSIS OF. TYPHOID FEVER.
An interesting experiment in the blood-serum method
of diagnosis of typhoid fever has just been instituted
by the board of health of the Province of Quebec. In
the circular issued by the board it is explained that
Pfeiffer and Widal have discovered that the addition
to a pure bouillon culture of typhoid bacilli of blood-
serum from a person suffering with typhoid fever
causes an abolition of the active movements of these
bacilli and an agglutination of the individual organ-
isms into large clusters. This effect is not observed
when blood serum from a healthy person, or from one
suffering with a febrile disease other than typhoid
fever, is added to such a culture. In the method
originally employed by Pfeiffer a rather complicated
technique was necessary to secure pure serum, but
this was greatly simplified by Widal, who found that
the test could be made equally well by means of a few
drops of blood collected in a sterilized glass tube.
Even with this advance the method was still not suffi-
ciently simple to permit of its general employment as
a reliable diagnostic measure. Dr. Wyatt Johnston,
of Montreal, bacteriologist of the board of health, has
recently shown, however, that a drop of typhoid blood
whicli has been dried for several days will give this
reaction promptly when moistened with water.
Tiiis discovery makes the method applicable to a
system of public laboratory diagnosis similar to that
now practised in many cities in the case of diphtheria,
and the board of health has therefore determined to
make a test of the method on a large scale. For this
purpose it has distributed a number of envelopes con-
taining a folded sheet of sterilized paper. A phy-
sician who has a case of suspected typhoid fever is
instructed to cleanse thoroughly the tip of the patient's
finger or the lobe of his ear, and, after carefully dry-
ing, to prick it with a needle sterilized in the flame.
The blood so obtained is dropped on the paper and
when it is dry the latter is folded and enclosed in an
envelope directed to the laboratory of the board. There
it is examined and a report is returned to the physician
the following day.
The board desires, through this public proving of
the test, to obtain data upon a number of points, and
it asks those taking advantage of the offer made to
them by the board to do all in their power to aid this
inquiry. The following are the questions upon which
October 31, 1896]
MEDICAL RECORD.
633
it is hoped to obtain some light: i. The proportion of
cases in which a correct diagnosis can be made by the
serum test, and the relative efficiency of the method of
employing dried samples. 2. The earliest period in
t)-phoid fever at which it can be expected to give in-
dications. 3. The length of time for which it persists
after convalescence. 4. The existence of any relation
between the intensity of reaction with the test and the
course of the disease. 5. The study of the nature of
the obscure febrile conditions, clinically termed gas-
tric fever, continued fever, abortive typhoid bilious
fever, typho-malarial fever, etc., about which our pres-
ent knowledge is very meagre and unsatisfactory.
The results of this experiment will be looked for
with interest, for the advantage of a reliable means of
diagnosis of typhoid fever in its early stages can
readily be appreciated.
HOT ROOMS AND CATCHING COLD.
We are so accustomed to the formula that American
houses are always overheated, and it has become so
much the fashion among medical men to attribute
catarrhal troubles to this cause, that it is interesting
to learn of an English writer who thinks it is better to
be warm than cold in winter. Dr. William H. Pearse,
writing in the Scalpel for September, says that he ven-
tures to differ from the popular belief, that there is
special danger in going from a hot room into the open
air, holding, on the contrary, that the heat of the room
or house is a great preser\-ative from chill or "catch-
ing cold" on going out into the open air. In Russia,
in Central Europe, Canada, and the Northern United
States, houses are made ver}* warm with a dry heat in
the W'inter, yet men, women, and children go out into
a temperature below zero. The stimulation and
heightened condition of the circulation and nenes,
and ultimate molecules of protoplasm, give a great
power of resistance to the outer intense cold, prevent-
ing "chill" in the first exposure until exercise with its
infinite motions, as it were, takes up and maintains
the conditions of resistance. Dr. Pearse says that he
has w-alked at midnight from a highly heated mansion
across Boston Common, in his dress coat only, on a
calm starry night, the temperature about zero. He
suffered no inconvenience and felt sure that the stim-
ulus of the heat of the house gave him power of resist-
ance to the cold.
Dr. Pearse is undoubtedly correct in his observation
that one can come from a hot room into the cold outer
air and run but little chance of catching cold. The
danger is rather in entering a hot room from without,
and especially in entering an overheated and unventi-
lated apartment filled with excrementitious products
from the lungs and skin of its inmates. A change
from a hot to a cold atmosphere can be made sud-
denly, but that from extreme cold to indoor heat
should be made gradually if one would avoid the
catarrhal consequences of "catching heat."
REVISION OF CODES.
Our good brethren across the water are at present
very much interested in the revision of their codes of
ethics, in the hope of adapting them more nearly to
the present requirements of medical men. It must be
confessed that these documents read exceedingly well,
the principles they contain are lofty and pure, the
lines of action straight and distinct, and their general
purposes laudable and just. The great difficulties,
however, are in their practical application. The evil
doer is apt to interpret the law to suit his own re-
quirements, and hence the differences of opinion as to
where the real boundary between right and wrong
should be drawn. This, however, does not apply to
the man who acts his best under all circumstances.
The gentleman does not need a law of conduct, and
the one who is not a gentleman can never be raised to
the common ground of honesty, high morality, culture,
or fair play. It is the golden rule, after all, w^hen it
can be properly applied. Any doubtful question can
easily be answered on such a basis. How would you
like it yourself? is a very direct question to the man
with an elastic conscience and an easy adaptability to
tricky situations. Even the ten commandments are
nicely balanced on the " Do-unto-other" principle.
We know' of lots of good men and true who need no
other code — men whom we are always glad to meet in
council, whom we can always trust alone with our pa-
tient, and in whose mouths our professional character
is always safe. It is not What code do you follow?
but What kind of man are you?
A Woman's Bicycle Class in first aid to the in-
jured is an indication of the progression of the wheel.
THE WINTER HEALTH RESORTS.
In the present issue we publish an account of the
principal winter health resorts of this country, as a
companion article to " Summer Health Resorts," which
appeared in these columns several months ago. It has
been truthfully said that on this continent there can be
found every variety of climate during the year, suitable
not only for the most exacting requirements of every
class of invalids, but for such as require merely those
changes of environment necessary for simple rest and
needful recreation. So much is being done to adver-
tise the special advantages of particular localities by
parties interested in their development, that it is of-
tentimes difficult to select such on the basis of simple
and well-established merit. The writer of the article
in question has endeavored, very successfully, to be
absolutely impartial in his statements, and with no
other end in view than that of obtaining reliable data
has merely presented them for what they may be worth,
leaving each reader to choose for himself and adapt
them to the individual cases seeking his advice. Cli-
mate cure, like every other means to the end, demands
careful study and judicious application. The physician
should be able to select his climates with as much cer-
tainty as his other remedies. To such an end the data
have been collected, and it is to be hoped they will serve
their purpose, not only for present study but for future
reference. The American people are notoriously a
nation of travellers during all seasons of the year, and
634
MEDICAL RECORD.
[October 31, 1896
it behooves the physician to be acquainted with the
more frequented regions, their mean temperature, alti-
tude, scenery, and conveniences, in order to advise
those who go for pleasure as well as for health.
Aside from this, we trust that the accounts given of the
varied attractions of the different resorts will afford in-
teresting and profitably suggestive reading to such as
may believe in voyages of discovery and may yearn
for the new experiences which are their legitimate re-
wards. The tired doctor, above all, may need, in the
midst of his winter's work, just the little trip which
may be thus suggested to him, the taking of which
may, perchance, still longer delay the inevitable obit-
uary.
I^cms of the WXcch.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
October 24, 1896: Assistant Surgeon M. S. Elliott,
ordered to the naval laboratory and department of in-
struction. New York.
Dr. Milton E. Artman, of Buffalo Creek, Col., died
from pulmonary hemorrhage on September 29th. He
was a graduate of the College of Physicians and Sur-
geons in this city, and served as interne in Bellevue
Hospital. He practised for three years in Rochester,
but, his health failing, he went to Colorado about two
years ago.
Medical Practice in Victoria. — The Melbourne
correspondent of the Medical Press draws a very long
face over the state of the medical profession in that
colony. He says the doctors are too thick on the
ground, and consequently the normal competition has
grown into a struggle for existence. The population
of the colony hardly reaches a million and a quarter,
and the number of qualified practitioners is one thou-
sand and seventeen. The number increases by about
sixty yearly, which is out of proportion to the growth
of the general population. It appears also that the
physicians of the younger generation, or some of them
at least, have been encroaching upon the correspon-
dent's clientele, for he says that the city is flooded
with young men who neglect no opportunity of bring-
ing themselves into conspicuous notice; and, more
than all that, "the younger members of the profession
have not only no reverence for their elders, but, on tiie
contrary, look down upon them as unprogressive fos-
sils, and comport themselves accordingly."
The Body of George Du Maurier, the artist and
author, who died recently in London, was cremated,
in accordance with his often expressed wish.
Prophets Not without Honor. — When Crown
Prince Frederick of Germany was suffering from can-
cer of the throat, he sent to England for a laryngolo-
gist; when the Tsar of Russia was ill, he had his own
physician, but sent to Berlin for a consultant; and
now Queen Victoria is suffering from failing vision,
and has sent to Germany for an oculist. Dr. Pagen-
stecher, of Wiesbaden, to examine her eyes. The
Medical Times says that there is a pamphlet in circula-
tion in which many of the leading oculists of Eng-
land are spoken of in disparaging tones, and it is inti-
mated that the Queen was influenced by that to send
abroad for advice.
An Epidemic in Merv.— A telegram from Merv,
dated October 1st, states that during the past two
months a malignant fever has raged among the Tur-
comans, nearly ten thousand persons having been car-
ried off. Mo.st of those attacked are children. A
similar violent outbreak of fever occurred in 1893.
International Congress of Hydrology, Climatol-
ogy, and Geology. — At the session of this congress,
lield during the last week of September, at Clermont-
Ferrand, France, the following officers were elected:
Hydrology: J'residnf, Dr. Cazan (Eaux Bonnes);
Foreign Honorary President, Dr. Jules Felix (Belgium) ;
Vice-Presidents, Dr. Ferres Luchon (France), and Dr.
Pinella (Spain).
Climatolog)-: President, "^l. Hurion, director of the
Puy de Dome observatory; Foreign President, M.
Lancaster (Belgium) ; Vice-Presidents (France), MM.
Plumandon and Piche; Vice-Presidents (foreign), MM.
Angel Angiuano (Mexico) and Faralli (Italy).
Geology : President, Dr. Labat ; Honorary President
(foreign), Dr. M. E. Tietze (Austria-Hungary).
President oj the Congress (national), Dr. de Ranse;
Honorary President (foreign). Dr. Berthenson (Russia) ;
Vice-Presidents (national), M. Linder (inspector-gen-
eral of mines), M. Angot, and Dr. Garrigan; Vice-
Presidents (foreign). Professor Ludwig (Austria-Hun-
gary), Professor Kuborn (Belgium), and Laurence
Rotch, director of the observatory of Blue Hill (United
States).
The London School of Medicine for Women has
recently received a gift of $5,000 from a lady of
wealth who had been attending some of the lectures.
Diphtheria is prevailing to an unusual degree in
London, the mortality from the disease during the first
week in October having been greater than that of any
week this year.
The Women's Medical Institute in St. Peters-
burg, recently established, is forbidden by its regula-
tions to receive any students who are not of the Chris-
tian faith. A petition signed by the Jews resident in
Odessa, praying for the admission of certain women of
their belief, has been rejected.
The Water Supply of Denver, according to the
Colorado Medical Journal, is as bad as that of Chicago.
For years, says our contemporary, the citizens of Den-
ver "have been led to believe that they were drinking
pure mountain water, piped directly from the snow-
capped peaks in the mountains. Such a monstrous
lie was never before circulated. Instead of pipes, are
open irrigating ditches; instead of mountain water,
pond and contaminated river water is the source of
supply."
St. Joseph's Hospital, New York. — Dr. Alfons
Muller has been appointed visiting physician to St.
Joseph's Hospital.
October 31, 1896]
MEDICAL RECORD.
635
Dr. Carl von Kupffer, professor of anatomy in the
I'niversity of Munich, has been elected rector of the
university for the coming year.
The Jubilee of the Pathological Society of Lon-
don was celebrated on the evening of October 24th.
There was a reception and an address was delivered
by the president, Mr. H. T. Butlin.
To Investigate a Consumption Cure. — Drs. Bou-
chard, Chauveau, and d'Arsonval have been appointed
a special committee by the Academy of Science in
Paris to report on the alleged cure for consumption
practised by Dr. Crotte. His method comprises the
use of electricity and antiseptics, the electricity being
employed to open the way for the parasiticide.
Typhoid Fever in Madeira. — A correspondent of
the Medical Times writes that the water in the Island
of Madeira is very bad, and that typhoid fever prevails
there to a very great extent. Last spring there were
four deaths in four weeks among the English visitors,
and that the danger still exists is shown by the fact
that one of the English resident physicians is just
convalescent from an attack. One fatal case, it is
stated, was directly traceable to drinking a glass of
water.
The Jubilee of Anesthesia. — The following con-
gratulatory cablegrams were read at the exercises in
Boston, on October i6th, in celebration of the semi-
centennial of the first operation performed under
ether:
" Christiaxia, October 16, 1896.
" Trustees and Staff, Massachusetts General
Hospital, Boston: Best congratulations on fiftieth
anniversary.
"Cesar Boeck."
"Moscow, October 16, 1896.
"Boston, Massachusetts General HosprrAL.
Collins Warren : The Moscow Surgical Society, at
a special meeting held in honor of the fiftieth anniver-
sary of the introduction of anesthetics, celebrates the
memory of Morton and Simpson, the great benefactors
of mankind. It greets the committee and wishes it
every success in its labors on behalf of science, which
knows no geographical boundary.
" DiAKOX, President.
" U'arneck, Secretary."
Mr. Thomas Bryant has been appointed surgeon -
extraordinary to the Queen, and is thereupon made
the subject of the following puff -extraordinary in the
London Star: " It has been said of the new surgeon-
extraordinary that his services are in such request that
he wears out six pairs of carriage wheels in a year.
He is not one of the showy surgeons, but a business-
like, sturdy man of large experience, whose long pro-
fessional life and freedom from fads have endowed
him with much professional skill, and who has filled
most places of honor to which surgical distinction
leads in his time. Mr. Bryant is above the middle
height, broad-shouldered, and erect, with hair shaded
with gray, and firm, full lips. He lives in Grosvenor
Street, and has a kindly and sympathetic manner."
Dr. A. Jacobi, in an address at the dedication of
the Bender laboratory connected with the Albany
Medical College, October 27th, referred to matters of
hygiene, and dwelt upon the part taken by laboratory
workers in bringing hygiene, and the etiology and pre-
vention of disease up to their present high standard.
He pointed out the shortsightedness of laws which
would restrict vivisection in laboratories devoted to
the advancement of science, the prolongation of hu-
man life, and the abolition of suffering.
An Anesthesia Number — The October issue of
T/ie Practitioner is devoted to the jubilee of ansesthe-
sia, and contains the following articles: '"The Past,
Present, and Future of Anaesthesia," by Frederic W.
Hewitt; '"The Work of Simpson, Snow, Lister, and
the Hyderabad Chloroform Commission," by George
Rowell; "The Administration of Father," by F. Wood-
house Braine; " The Principles of Ether Administra-
tion," by George H. Bailey: "The Story of the Dis-
covery of Anaesthesia," by Dudley Wilmot Buxton;
" Anaesthetics in Operative Surgery," by Frederick
Treves; " Ancesthetics from the General Practitioner's
Point of View," by Alfred Hartley; "The Need for
Better Instruction in the Administration of Anaesthet-
ics," by !Marmaduke Sheild; " Hypnotic Anaesthesia,"
by J. Milne Bramwell; and "The Present State of the
Law as to the Administration of Anfesthetics," by R.
W. Turner. There are also bibliographical sketches
of the "pioneers of anaesthesia," William Thomas
Green Morton, Horace Wells, Sir James Young Simp-
son, John Snow, and Joseph Thomas Clover. The
first administration of ether in England to induce an-
festhesia, the editor writes, took place on December
19, 1846, at 24 Gower Street, London, the house of
Dr. Boot, to whom the news of Morton's discovery
was communicated by the late Dr. Bigelow, of Boston.
The agent was administered to a Miss Lonsdale by
Mr. Robinson, a dentist, who extracted a molar tooth
from her lower jaw while she was under its influence.
On December 2 2d Robert Liston amputated a limb
under ether in I'niversity College Hospital, and so in-
tense was the emotion of the great surgeon on the oc-
casion that when he turned to address the spectators
after the operation he could hardly speak. The ad-
ministrator was Dr. William Squire, who is still
living.
Southern Surgical and Gynecological Association.
— The ninth annual meeting of this association will
be held in Nashville, Tenn., Tuesday, Wednesday,
and Thursday, November 10, 11, and 12, 1896. The
Nicholson House has been selected as headquarters
for the association. Those who contemplate attending
the Pan-American Medical Congre.ss, to be held in the
City of Mexico, November i6th-i9th, will have time
to do so after the meeting of the Southern Surgical
and Gynecological Association. A rate of one fare
the round trip has been made on account of the con-
gress, stop-over privileges being allowed the holders
of tickets. The president is Dr. F.. S. Lewis, of New
Orleans, La. ; and the secretary, Dr. W. E. B. Davis,
of Birmingham, .\la.
636
MEDICAL RECORD.
[October 31, 1896
NEW YORK ACADP:MY OF MEDICINE.
Stated Meeting, October /j, i8g6.
Joseph D. Bryant, M.D., President, in the Chair.
The Relations of Diseases of the Eye to General
Diseases. — In connection with this subject three
papers were read, the first one being on
The Effects of Extrinsic Poisons on the Eye
Dr. J. H. Clairorne was the author. The list of
agents which when taken into the system produced dis-
turbance of vision was a long one. He would speak
of the more frequent ones, and in doing so would ac-
knowledge indebtedness for much of the information
to the works of De Schweinitz and Wood. The im-
portance of the subject appeared from the brief sum-
mary with which the author concluded his paper: i.
There were certain poisons which, when introduced
into the human system, produced characteristic to.xic
symptoms in the eye. 2. These poisons were divided
into two grand divisions: {a) Those which produced
organic changes in the optic nerve and retina. (/')
Those which produced no organic changes but whose
effects on the eyes was only functional. 3. The ma-
jority of these poisons were found in the list of medi-
cinal remedies.
-A-mong the agents in the first division which the
author dwelt upon were alcohol and tobacco, which
occupied respectively first and second place. The
h ibit of taking many small doSes of alcohol a day,
particularly before meals, was most likely to produce
retrobulbar optic neuritis. This was illustrated in
bartenders. Idiosyncrasy had something to do with
it, for some parsons drank all their lives and were not
thus affected, while others suffered after limited indul-
gence. Most cases occurred between forty and fifty
years of age, and men were naturally afi'ected oftener
than women, because the latter were less addicted to
alcohol. This was equally true of tobacco amblyopia.
Those who smoked short pipes and strong cigars were
more likely to have ambloypia than those who did not.
Some claimed to be able to distinguish between alco-
hol and tobacco amblyopia. The first symptom com-
plained of was indistinctness of vision, and the
patients were apt to come for glasses, especially if
presbyopic, as they usually were. Perhaps the most
distinctive symptom was inability to recognize red
and green— central scotoma for these colors. The
ophthalmoscope would show optic neuritis, but it was
a question whether this form of optic neuritis alone
would ever lead to complete blindness. It was well
to look to syphilis as a combination, for tobacco, alco-
hol, and syphilis frequently went together. For his
own part he had no faith in the word of chronic
smokers and drinkers when questioned as to their
venereal history.
Quite a number of cases of amblyopia from carbon
bisulphide, used chiefly in the manufacture of vulca-
nized rubber goods, had been reported. Perhaps chlo-
ride of sulphur, associated with it, had something to
do with the ocular symptoms. Some other agents
named in this class, but less certain in their action,
were hashish, cannabis indica, iodoform, arsenic.
Lead was apt to affect sight as well as to produce
muscular paralysis. Quinine occasionally caused
amaurosis, the dose necessary to do this varying with
the idiosyncrasy of the patient. The author's case
was the only one on record in which the blindness
continued two years. Further, among tne agents of
the second division. Dr. Holden mentioned the venom
of serpents, ergot, absorption of mercury rarely, male-
fern, pomegranate, belladonna, hyoscyamin, duboisine,
cocaine, ptomains from eating spoiled fish, etc.
Among agents which produced contraction of the
pupils were opium, chloral and its hydrate, eserin,
pilocarpine, strychnine, and nicotine.
The poisons which produced variable eye symptoms
constituted a long list. Among them were santonin,
anilin, naphthalin, bromide of potassium, picric acid,
amvl nitrite.
Eye Diseases Seen in Some of the General In-
fectious Diseases. — Dr. Charles J. Kipp, of New-
ark, read the second paper, or as much of it as the
time would permit. He said it contained nothing
new. Beginning with the eruptive fe\ers, in measles
a catarrhal inflammation of the conjunctiva was regu-
larly present before the appearance of the eruption,
and usually went away in the course of a few weeks.
In e.xceptional cases it persisted for months. If ulcers
of the cornea should form they might lead to its de-
struction if maltreated, as in one case which he had
seen. Meningeal or cerebral complications might
lead to atrophy of the optic nerve and blindness.
Rapid and destructive suppuration of the cornea, also
gangrene of the lids, acute inflammation of the lacry-
mal glands, and albuminuric retinitis had been seen
in measles.
In scarlet fever inflammation of the conjunctiva was
present in many cases during the eruptive stage, but
by no means so often as in measles or small-pox.
Blindness had often been observed when the scarlet
fever was accompanied by renal disease, and optic
retinitis with more or less impairment of sight had
been observed during convalescence when no signs of
renal disease were present. Albuminuric retinitis was
more likely to be seen later. Dr. Kipp had seen one
case of embolism of the central retinal artery in the
left eye on the thirteenth day of the fever, without
signs of renal or cardiac disease. One similar case
was on record. Pustular inflammation had occasion-
ally occurred in the lacrymal gland, on the cornea,
etc.
The aft'ections of the cornea might be said to be the
most dangerous of all the lesions seen in small-pox.
Circumscribed ulceration and infiltration of the cornea
was most commonly seen about the fourteenth day.
Dr. Kipp had seen a number of cases, and they were
characterized by the slowness of repair, four to six
months, or even more, elapsing before the cornea
healed. In two there was total destruction of the
cornea. Disease of the uveal tract was occasionally
met with. The course of iritis was, on the whole,
favorable. Pustules on the lids should be opened and
treated with some simple ointment. Hyperemia of
the conjunctiva was nearly always present.
With the exception of a mild form of conjunctivitis,
affections of the eye were rarely observed in typhoid
fever. During and after convalescence weakness of
accommodation, transient amaurosis, optic neuiitis,
ulcers of the cornea, and iritis had occasionally been
observed. Optic neuritis might be due to meningitis,
which was not infrequently mistaken for typhoid fever.
Dr. Kipp also read on diseases of the eye in septi-
casmia.
The Visual Disturbances Due to Nervous Dis-
eases.— Dr. Ward .\. IIoi.dkx treated of this subject
in a technical way (see jjage 626).
A Warning to' the Youthful Smoker.— Dr. Her-
man Knapp opened the general discussion. With
regard to blindness being permanent in simple optic
atrophy, he had seen one case in which the sight in
one eye returned in two-thirds degree, the other re-
maining totally blind, the original cause being, it was
said, meningitis during childhood. But he had never
seen tlie optic atrophy of locomotor ataxia improve.
If Dr. Kipp meant to say that septic irido-choroiditis
October 31, 1896]
MEDICAL RECORD.
(^ii
was mostly fatal to sight he could agree with him, but
if he stated that it was always fatal to sight he must
disagree, for in one instance he had known the sight
again to become and remain good. He had never
seen total blindness from tobacco or alcohol. Scarcely
a case of tobacco amblyopia in his experience had oc-
curred in a person who did not begin the habit before
the twentieth year, most of them before the age of
thirteen or fourteen. In tobacco and alcohol cases it
was the central field which was aiiCected, in quinine
amblyopia it was the peripheral field. Those who
drank and smoked much could not see so well during
the day, but could see better comparatively at dusk.
Another symptom was premature presbyopia. They
had to use glasses five to ten years earlier than their
state of refraction would warrant. Dr. Claiborne had
mentioned some poisons with which Dr. Knapp had
had no experience, but one he had not mentioned,
namely, coal gas. He had seen one case of ambly-
opia due to inhaling coal gas in a sleeping-room.
Dr. Joseph Collins mentioned a case of tumor of
the aqueduct of Sylvius and immense internal hydro-
cephalus, with pressure on the optic chiasm, which
did not cause visual disturbance until a few days
before death. He could corroborate Dr. Claiborne's
statement that there might be optic neuritis without
much disturbance of vision; also as to the effects of
tobacco and alcohol. He was unable to comprehend
how sight could be recovered in the case of blindness
attributed to early meningitis in Dr. Knapp's ase, in
view of the fact that the neuraxon when once destroyed
could never be regenerated. The necessity for a thor-
ough examination of the eyes was shown by the case
of a girl who went to an ophthalmologist for failing
vision and he treated her for hypermetropic astigma-
tism. Six months later she was seen by Dr. Collins,
who discovered signs of cerebellar disease, and the
diagnosis was further confirmed by an examination of
the eyes made by Dr. Holden. To-day there was
complete blindness from optic atrophy. Dr. Collins
invoked a higher centre than the visual centre in the
cuneus in explanation of crossed amblyopia. Regard-
ing hemiopic pupillary reflex, he said great care was
required to elicit it.
Dr. T. M. Poolky thought that in tobacco and
alcohol amblyopia, which was due to a form of chronic
inflammation of the optic nerve, there was more
marked interference with the clear outlines of the
optic disc than in other forms of retro-bulbar neuritis.
The important factor in tobacco poisoning was the
nicotine. Persons who began using the weed in adult
life had comparative immunity from complications of
the eye. Pipe smokers and those who used strong
tobacco were oftenest affected. He had seen a number
of cases of quinine amaurosis, and must disagree
with the statement that it was usually complete. In
the cases which he had seen the central vision had
remained good. The contraction of the field of vi-
sion never, so far as he knew, became free. He was
sceptical as to arsenic. He had seen complete paral-
ysis of accommodation from wearing belladonna plas-
ter and also from ordinary doses of hyoscyamus too
often repeated. He had seen the morphine habit
produce marked diminution of the amplitude of ac-
commodation after it h^d been left off, and in two
cases it had caused nystagmus, which afterward dis-
appeared. In fact, affection of the extrinsic muscles
of the eyes was present in a number of cases of toxic
amblyopia. All cases of septic irido-choroiditis seen
by him followed the course stated by Dr. Kipp and
ended with total blindness. Dr. Pooley had seen a
case of complete restoration of the field of vision
which had been disturbed by syphilitic gumma.
Dr. William Leszvxskv said he was present when
Dr. Seguin demonstrated his case of Wernicke pupil-
lary reflex to the satisfaction of the ophthalmologists
of the hospital. He was sorry Dr. Holden did not
refer to the fact that examination of the visual field
was not of a great deal of value without a complete
examination of the eye. In Dr. Knapp's case of coal-
gas poisoning, it might be explained by small hemor-
rhages about the nerve nuclei, which were absorbed
before they did much damage. Dr. Leszynsky had
seen a case of peripheral neuritis from arsenical
poisoning, in which there was also optic neuritis.
Dr. Cl.aiborne said he must have been misunder-
stood on one or two points. He had not said there
was total atrophy of the optic ner\-e from quinine.
Regarding Wernicke's symptom, he thought it was of
value when it could be elicited, but its absence was
not significant.
SECTION ON SURGERY.
Stated Meeting, October 12, iSg6.
B. F. Curtis, M.D., Chairman.
The evening was devoted to the presentation of cases.
Extirpation of Tongue for Epithelioma. — Dr. A.
L. FiSK presented a man thiity-three years of age,
who had come to the hospital with epithelioma of the
posterior portion of the tongue on the right side,
which had started in February of this year. He ex-
tirpated the entire tongue and the enlarged glands of
the right side in the neck. The interesting point was
the unusual rapidity of healing, the man being able to
sit up on the third day: and at present, two weeks
after the operation, was able to speak so as to make
himself understood.
The Radical Operation for Carcinoma of the
Breast. — Dr. R. A. Sands presented a woman on
whom he had performed the radical amputation of the
breast for carcinoma. Some of the arm portion of the
pectoralis was left. Dr. Sands called attention to the
fact that he purposely modified the incision; instead
of carrying it into the middle of the axilla, carrving
it upon the arm. This gave a better functional' re-
sult than in Halsted's cases, the patient being able to
carry the arm up to the back of the head in dressing
the hair; there were less trouble from the scar, and
less likelihood of cedema of the arm.
Metastatic Abscess from a Latent Appendicitis.
— The chairman. Dr. Curtis, presented an Italian
boy, who, he said, gave a rather curious history. He
had come to his clinic, suffering with a swelling of the
heel. Under wet dressing the swelling subsided some-
what, but after four or five days he returned, with a
painful swelling in the arm, evidently an inflamma-
tory swelling in the region of the biceps. The ab-
scess, for such it proved to be, was incised and con-
siderable pus was evacuated. It had no connection
with bone, was entirely in the muscle, and he remarked
to the staff that it must be metastatic, although the ori-
gin was not apparent. The second night after the
operation the boy complained of some pain in the ab-
domen, but had not done so before. Placing his hand
over the appendix. Dr. Curtis found a considerable
tumor, and on operating evacuated an abscess between
the ccecum and omentum. Of course, the peritoneal
cavity had to be entered, which necessitated large
packing of the wound. The boy also had a rather
severe bronchitis, also of metastatic origin, and was
generally septic, but made a good recovery.
Resection of Knee for Tuberculous Disease Dr.
Curtis presented a boy who for some years, or since
the sixth year, had had tuberculous disease of the knee,
which had resulted in ankylosis at 90^. He was
brought to Dr. Curtis for amputation, but it was de-
cided to try resection, removing as little bone as pos-
sible. Everything was cut, except vessels and nerves.
638
MEDICAL RECORD.
[October 31, 1896
down to bone,' a few foci of disease were gouged out,
the leg was straightened, and it looked at present as
though there would be complete healing. The short-
ening was about an inch, and a sufficient amount of
the epiphyseal cartilage was left, he thought, to permit
of further growth of the limb.
Amputation of Hip for Sarcoma. — I)r Curtis pre-
sented a girl, aged six years, who had had swelling
of the left thigh since infancy. Finally a distinct tu-
mor developed on the thigh just below the pelvis, be-
coming as large as the child's head, and presenting
an ulcerated papillomatous surface anteriorly. A
fragment was excised and was pronounced myxosar-
coma by the pathologist. It had evidently been a
myxoma which had undergone sarcomatous degenera-
tion. The limb was amputated. On account of the
tumor on the anterior part of the thigh it was impos-
sible to get an anterior flap; consequently a long pos-
terior flap was made, and it was in tiiis fact that the
interest of the case lay. In another instance he had
been compelled to resort to a long posterior flap for
the same reason, the tumor lying so far to the front of
the thigh. The wound of amputation being distant
from the anus and genitals, there was less danger of
infection than when an anterior flap was obtained.
There was little tendency to hemorrhage, but what
there was he controlled by the Macewen method, an
assistant pressing upon the abdominal aorta through a
folded towel.
General Fecal Peritonitis Following Perforative
Appendicitis. — Dr. Howard Lilienthai, presented a
young woman, whom he had first seen on March 26th,
after two days' illness. The first day she had had
pains in the abdomen, and the second day violent
chills and high fever. Evidently there was appendi-
citis; slight thickening existed on the right side. An
incision was made in the right iliac region; pus was
encountered on opening the peritoneum; the perfo-
rated appendix was in a mass of adhesions. It was re-
moved, and a small incision was made in the median
line, to learn whether the entire cavity was infected.
There was peritonitis of a most intense type, and a
large amount of fa;ces present in the peritoneal cavity.
He washed out the cavity as thoroughly as he could,
through a catheter inserted into the small median in-
cision, and injected some of Dr. Gibier's streptococcus
antitoxin, feeling that it could do no harm, since the
patient would die any wav. Greatly to his surprise,
-she was better next day, and continued to improve.
About the tenth day slie had a chill and fe\er, and
a few days later he felt a resistance in the left side,
which he cut down upon and evacuated an abscess,
which communicated along the posterior ^vall of the
pelvis and behind the uterus with the opening orig-
inally made on the right side. From that time on
recovery was uneventful but slow. The sinus closed
and the patient went home; hut at her first menstrua-
tion after the operation the sinus reopened, and liad
shown a disposition to close and reopen since. Fluid
injected into one opening passed out of the other. He
thought of injecting a fifty-per-cent. zinc-chloride so-
lution, with the liope tliat it would cause it to heal
permanently.
Rebellious Tuberculous Disease of the Skin Treated
with Nosophen. — Dr. ],ilienthnl presented a young
man, who had first appeared at the Mt. Sinai Hospital
nine years ago, when he had a sinus of the forearm and
a cicatrix of the upper arm. The surgeon at the hos-
pital opened tiie sinus in the foreann, and found a
small focus of disease in the ulna. From that time
until the present, nine years, the boy had sinuses in
the arm, apparently always limited to the soft parts,
except on one occasion, when the surgeon found a
small focus of disease in the olecranon. The opera-
tions were numerous; the arm was covered with scars.
the elbow was stiff, and the arm was wasted and prac-
tically useless. The condition was looked upon as
tuberculous. Finally, all of the wounds healed ex-
cept one, which was very rebellious. In his experi-
ments he put on nosophen in powder, and at once the
aspect of the wound changed entirely, and after the
second dressing was quite healed. He did not wish
to suggest that nosophen would have healed the orig-
inal disease nor a sinus which was not drained.
Discussion on the cases being called for, Dr. Cur-
tis remarked that in his opinion the operation per-
formed by Dr. Fisk in his case of cancer of the tongue,
a combination of \\"hitehead's and Kocher's, was the
only proper one.
Dr. F. Torek thought Dr. Sands had not performed
Halsted's operation on the breast, for, as he under-
stood it, Halsted left no part of the pectoral muscles.
Dr. Torek had performed the operation, after the man-
ner described by Willy Meyer, five times, and pre-
ferred it to all others.
Dr. Fisk had operated several times by carrying
the incision up somewhat on the arm instead of into
the axilla, but had obtained the idea from Dr. Mixter
and another surgeon in Boston. It had the advan-
tages referred to by Dr. Sands — no cedema, good skin
approximation, useful arm. Of four patients operated
upon by him, there had been no local recurrence in,
any, but in two death took place from cancer of in-
ternal organs within about a year.
Dr. Gallant had employed the curved incision on
the arm in about six cases, and said it was a safer one
than the other, because of less danger to vein and nerve.
Dr. Curtls thought the extent of the operation for
carcinoma of the breast should depend upon the case.
Halsted's operation was not necessary for small mov-
able tumors not adherent to the pectorals. Not
enough time had elapsed to pass final judgment upon
the curative value of Halsted's operation. His (Fial-
sted's) first statistics were not large, and were pub-
lished too soon after the operation to exclude possible
recurrence.
Dr. Sands remarked that he had just read Halsted's
description of his operation, and could positively as-
sert that sometimes a part of the pectoral muscles at
their insertion was left.
Dr. Gallant inquired whether it was safe to allow
pregnancy to go on in a woman who not long before
conception had had the breast remo\ed for cancer.
Dr. Samiel Llovi) had had no experience with
carcinoma bearing on this (|uestion, but in a case of
removal of tlie breast for mastitis the woman subse-
quently had one or two abscesses about the axilla
during lactation following pregnancy and childbirth.
Dr. R. T. Morris said, with regard to gauze pack-
ing in appendicitis cases, that it was employed through
fear of infection of the general peritoneal cavity. It
having seemed to him that surgeons were thus getting
a good many weak abdominal walls, he had resorted
to rather a smaller drainage tract and walled off the
area with aristol or something similar, which would
produce a lymph coagulum about the drainage tract.
The result was satisfactory. Another method which
could be employed as a safeguard against hernia con-
sisted in attaching the ca;cum, or that portion of it
from which the appendix had been removed, to the
margin of the abdominal wound. The caL-cum acted
as a plug, preventing hernia. He had used this method
in six cases.
Dr. Kammerer would leave a free opening and use
plenty of gauze in appendicitis with abscess and threat-
ening general peritonitis.
Dr. F. Tii.dex Brow.v thought there might be
some danger of hernia of the cacum or inversion
thereof, when stitched to the abdominal wound, as de-
scribed by Dr. Morris.
October 31, 1896]
MEDICAL RECORD.
639
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, May 27, i8g6.
John Slade Ely, M D., President.
Dilated Stomach Simulating Ascites. — Dr. C. N.
DowD presented a greatly enlarged stomach, taken
from a patient who had the usual signs of ascites, with
ilatness on percussion in the dependent portion of the
abdomen, no matter what position the patient was in,
and tympanitic resonance above. There was also a
small nodule in the right hypochondrium. The pa-
tient was doing badly, and an exploratory incision
was made to determine whether she would be benefited
by any operative procedure. This enormous stomach
was found to occupy practically the entire abdominal
cavity, extending into the pelvis below and pushing
out the abdominal walls on each side. There were
several quarts of fluid swashing about in it, and this,
with the gas which was also there, gave the signs of
ascites. It was impossible to pass a stomach tube.
The patient made a good recover)- from the ether, but
died at a later time of inanition. The pyloric thick-
ening was cancerous.
Scope of the Work of the New York City Board
of Health Dr. Hermann M. Biggs said that he had
been connected with the health department since 1887,
at the time of the first of the recent cholera outbreaks
in this city. Dr. W. M. Smith, the health officer of
the port, had requested him to make a bacteriological
examination to establish the diagnosis of cholera. Dr.
Prudden was associated with him in this work. This
was the second time that such an examination had
ever been made for the purpose of diagnosticating
cholera. Shortly afterward, at the request of Health
Commissioner Bryant, they had been made bacteriolo-
gists to the health board. The disinfecting-station
was then established. In the fall, at his suggestion,
a memorial was presented to the health board, regard-
ing the restriction of pulmonary tuberculosis; but so
much opposition was made by the medical profession
that nothing was done, except in an educational way.
At that time, only one prominent medical practitioner
supported the view that pulmonary- tuberculosis was a
communicable disease, and that the health board
should take steps looking toward its restriction. In
1892, when a number of cases of cholera actually
gained entrance to this harbor, it became possible to
get money for the establishment of a bacteriological
department. A resolution was introduced by Dr.
Bryant, and passed December 18, 1892, establishing
the division of patholog)-, bacteriology, and disinfec-
tion. In 1893 a system of house disinfection and dis-
infection at Sixteenth Street were put in force, and
means for the transportation of articles was secured.
An outbreak of typhus fever soon put the new system to
a severe test. In January, 1893, the speaker said, he
presented a communication suggesting the appointment
of a bacteriological diagnostician for diphtheria and
naming Dr. W. H. Park as a suitable person for the
position. He was appointed in April, 1893, and the
work in the bacteriological diagnosis of diphtheria was
begun. In 1893 and 1894 the temporary- corps was
kept on duty. In the spring of 1894 his investiga-
tions in Berlin into the question of the value of diph-
theria antitoxin had so impressed him with the value
of the new treatment that on his return he urged the
board to enter upon this w-ork.
\ special appropriation of $3,500 was made in Jan-
uary, 1895, and the permanent force of the laboratory
was then considerably increased, it reaching in the
year a total of thirty-one. In another communica-
tion he had recommended that some steps be taken
toward the control of pulmonary tuberculosis. -Ar-
rangements were early made for the free distribution
of diphtheria antitoxin. Experiments had also been
carried on regarding the tetanus antitoxin, the testing
of the virulence of bacilli found in throats which were
affected ap'parently by simple angina, etc. Dr. Hud-
dleston had recently carried on experiments to deter-
mine the best methods of producing vaccine virus.
Last summer Dr. Alexander Lambert studied this sub-
ject in the large cities of Europe, and as a result of
all this it was decided to adopt the fluid virus. More
than thirty thousand diphtheria cultures had been ex-
amined during the past year: about two thousand ex-
aminations of sputa for tubercle bacilli had been made
by Dr. Fitzpatrick; about five hundred vials of anti-
toxin had been produced weekly. The discovery of
diphtheria antitoxin fortunately furnished a plea for
securing money from the board of estimate and ap-
portionment which could be used for the establish-
ment of a research laboratory. None of the largest
cities in this country, he said, was at the present time
without a bacteriological laboratory for use in connec-
tion with the work of health boards. The money col-
lected from the sales of antitoxin here had been suffi-
cient to assist very materially in the scope of the work.
Mixed Infection and Virulence of Diphtheria Ba-
cilli.— Dr. W. H. Park said that he had been deeply
interested in the question of mixed infection, because
of the important bearing of this subject on the anti-
toxin treatment of diphtheria. He presented tempera-
ture charts of three children affected with laryngeal
diphtheria. In the first case, between Februarv nth
and 19th, the temperature had ranged between 105^
and 105.5^ F. The glands had become swollen four
days before death, and the pneumonia which had been
present had become more marked. The autopsy
showed broncho-pneumonia, and lesions of the kid-
neys and other organs. The cultures from the lungs
showed numerous streptococci, as well as Loeffler ba-
cilli. The cultures from the neck were nearly pure
growths of streptococci. Cultures from the blood of
the various organs showed pure growths of streptococci.
\\'hen these streptococci were injected into a rabbit,
they were found to be of moderate virulence. His
experience had been that after the streptococci were
passed through a few rabbits they increased somewhat
in virulence, but then the virulence remained sta-
tionary.
The second case was that of a child of one year,
with laryngeal diphtheria and high temperature. It
was given antitoxin. Twenty-four hours later it was
intubated, but after three and one- half hours the tube
was removed. Thirty-six hours after admission the
temperature was io5" F., and remained high until
death. The child remained a large part of the time
in a position of opisthotonos. The lung showed a
late stage of broncho-pneumonia. Cultures from the
lungs and other organs gave streptococci.
The third child had been sick only two davs, but
the chest was full of rales. There was no membrane
in the throat; some diphtheria bacilli were found in
the throat. The temperature at the end of forty-eight
hours reached 107^ F., and the child died. The au-
topsy showed both lungs consolidated. Cultures from
the lungs and from the blood showed the pneumococ-
cus, and a few colonies of diphtheria bacilli were
found in the cultures from the lungs.
Cultures from the blood of those dying early in
diphtheria, without high temperature, were usually
sterile; when there was a high temperature, septicje-
mia was generally found. When the lungs showed
lesions, diphtheria bacilli were always present in the
consolidated areas. Streptococci were also found.
The diphtheria bacilli were found in the blood only
twice in fourteen cases. It had been suggested by Dr.
H. M. Biggs that the work done some time ago regard-
ing the virulence of the diphtheria bacilli be again
640
MEDICAL RECORD.
[October 31, 1896
and of these 22
In 24 doubtful
tested. In cases in which the clinical diagnosis was
follicular tonsillitis or pseudo-diphtheria, the viru-
lence of the cultures was tested and notes were made re-
garding the number of diphtheria bacilli, a^d whether
or not they were characteristic. In four months 71
such cases had been tested, and from 50 of these ba-
cilli were obtained in pure culture and inoculated into
guinea-pigs. In 38 of the 50, the bacilli were charac-
teristic and abundant; in 37 they were virulent; in i,
non-virulent. In 2 the bacilli were atypical. Out of
48 characteristic cultures, the bacilli were virulent in
46 and nan-virulent in 2. In 2 cultures of the
pseudo-type they were virulent. Of those tested, in
26 the diagnosis was not diphtheria;
were virulent and 4 non-virulent,
cases the bacilli were virulent in 22, and in 2 not
virulent — in other words, in twelve per cent, of the 50
cases they were non-virulent. In 2 of these the ba-
cilli would be called atypical.
Dr. L. Waldstein asked Dr. Park if he had noted
any relation between the size of the individual links
and the lengths of the chains and the virulence of the
bacilli; also whether in making cultures of the strep-
tococci the virulence was affected by the alkalinity or
acidity of the medium.
Dr. Park replied that he had examined swabs from
slight pus cases, and in these the chains had been very
long. In some of the cultures from the severer cases
the chains had been rather short. He had made no
e.vact observations as to the effect of the alkalinity of
the medium on the virulence of the bacilli.
Tetanus Antitoxin. — Dr. Alexander Lambert
said that he had been trying for three years to get a
culture of tetanus bacilli which would retain suffi-
cient virulence to allow him to investigate the tetanus
antito-xin. Finally he had obtained a culture one
cubic centimetre of which would kill a guinea-pig in
five or six days. It then occurred to him that, as clin-
ically tetanus was usually a mixed infection, it might
be well to try mixed cultures. He had, therefore,
mixed the tetanus bacillus with the bacillus rosaceum
metalloides. The result was that a guinea-pig
inoculated with this mixture promptly died in te-
tanic spasms. Following out this line of investi-
gation, he was soon able to get a toxin 0.00 1 c.c. of
which would kill a guinea-pig in two and one-half
days. He was now able to obtain from the horse
the tetanus antitoxin, one cubic centimetre of which
would kill three million three hundred and fifty
thousand grams of guinea-pig. Apparently, two and
one-half to three times the equivalent of antitoxin was
necessary to protect the animal from a fatal dose of
toxin. Antitoxin already obtained was of therapeutic
strength, and he believed it would soon be placed by
the health board upon the same commercial basis as
diphtheria antitoxin.
Dr. George P. Biggs said that he had found that
the antitoxin animals were capable after a time of tak-
ing enormous quantities of the antitoxin. The doses
taken now by some of the animals under treatment the
longest were five hundred cubic centimetres at a time.
It had been found that new horses could within four
to six weeks be made to yield an antitoxin of high
strength, whereas formerly it was thought that three
months were required. The expense of production
was thereby much lessened and a higher grade of
antitoxin obtained. Ver)' few of the horses this year
had died under the treatment with toxins. He had
made autopsies on many of the patients dying at the
Willard Parker Hospital, but no new lesions had been
found in the cases treated by antitoxin.
The President asked if any lesion had been found
in the horses which had died, which would explain the
death or their susceptibility to the toxins.
Dr. Biggs said that autopsies had been made, but
nothing had been found to e.vplain the varxing sensi-
tiveness of different animals.
Vaccine. — Dr. J. H. Huddleston said that the vi-
rus was collected from heifers two to four years old.
Clinical tests could alone furnish a guide as to the
quality of the virus. Experiments were made to deter-
mine in what part of the vesicle the living germ was
present, using for this purpose four young children
and vaccinating them in from three to fi\e places.
The vaccinations were successful in all of these chil-
dren, and it was found that the base gave the best re-
sults and the serum the poorest, although it was the
latter that had been usually employed on quills and
ivor}' slips. Other comparati\e tests showed that the
younger the animal the better the results, and the more
nearly typical the eruption. In practice, heifers two
to three months old were found to be best, all things
considered. It had been found that a small area cov-
ered with well-developed vesicles yielded as much as a
larger area, because on the latter the vesicles were not
usually so numerous. The area selected was usually
the posterior portion of the abdomen, and a small ex-
tent on the inner surface of each thigh. The maxi-
mum quantity of lymph was obtained just before the
vesicle became a pustule — in other words, usually four
or five days after vaccination; but there was a consid-
erable individual variation in the animals. If several
vaccinations were made on the calf at interAals of a
day, the later vaccinations, as in the case of a child,
would be found to mature much more rapidly than the
first ones. Continued experiments had shown that the
liquid virus gave a higher percentage of successful
vaccinations in the proportion of seventy-one success-
ful vesicles by the dried virus to one hundred by the
latter. The best method of preservation had not yet
been determined. Experiments had been made of
mixing it with lanolin, with glycerin, and with chlo-
roform water, and glycerin and water. The lanolin
seemed to be the best preservative of the vaccine, but
the glycerin had more power to limit the number of
bacteria in the vaccine. The receptacles for the virus
consisted of small stoppered glass vials. The virus was
so thick that it was with great difficulty that it could be
drawn up into capillary tubes. The heifers were exam-
ined by a veterinarian, and, if found healthy, were kept
for two or three days before vaccination. There was
no advantage in previously disinfecting the skin with
sublimate solution, for it must become infected again
before the time for removing the virus. When the
vesicles had pro|5erly developed, the parts were thor-
oughly cleansed and the pulp was taken and passed
through a rolling maciiine, and at the same time mixed
with glycerin. The average porduct from each of fifty
recent calves was 16.5 c.c. By using a small spear-
shaped lancet and moistening the point with the tiuid
vaccine, one quick puncture was sufficient to complete
the vaccination. The vaccination made in such a way
yielded a small, typical vesicle, \\ ith a small areola, and
caused the patient scarcely any discomfort. There
seemed to be considerable evidence to show that a
single inoculation was not as complete a protection
against small-pox as it had been supposed to be. An
inspection of a number of these scars showed them to
be so minute that they might be after a time easily
overlooked.
The Examination of Tuberculous Sputum Dr.
Charles B. Fitzpatrick. said that the method of stain-
ing that he had employed was that described by Gun-
ther. In this, Ehrlich's anilin-water-fuchsin solution
was used for the coloring agent, and a three-per-cent.
solution of h)'drochloric acid in alcohol as the decol-
orizing agent. The bacilli by this method were stained
a very distinct red. Examinations made in eight cases
of influenza during the past winter failed to show the
presence of any specific bacillus. In many instances
October 31, 1896]
MEDICAL RECORD.
641
the examinations of the sputum showed a mixed infec-
tion— a few tubercle bacilli with, perhaps, a strepto-
coccus infection. On the disappearance of the mixed
infection, it was often reported by the attending phy-
sician that the patient showed marked general im-
provement. The addition of twenty-four parts of
English salt to a one-half-per-cent. solution of carbolic
acid acted with the same efficiency as a preservative
as did a five-per-cent. solution of carbolic acid, and it
did not coagulate the sputum into balls.
The President said that for several years he had
entirely abandoned the use of strong acid solution.
He would take about eight ounces of alcohol, and drop
into it a few drops of sulphuric acid. This formed an
excellent decolorizing agent, although perhaps some-
what slower in its action than the stronger solutions.
Nuttall had found that many of the tubercle bacilli
were decolorized by strong acid, and proposed the use
of this weak-acid decolorizing solution.
Dr. F1TZP.4TRICK said that with a simple mixture of
alcohol and water one could remove enough of the
primary stain to admit of the application of the secon-
dary stain to the bacilli.
Dr. Waldstein said that in the decolorization of
smears it was not important to have the acid dissolved
in water; but in staining sections the solution should
be an aqueous one, in order to avoid the shrivelling of
the sections.
Isolation of Diphtheria Antitoxin. — Dr. Miller
said that so far he had been unable to fully corroborate
the interesting experiments of Brieger on the isolation
of the antitoxin. The essential point was the separa-
tion of the antitoxin as a zinc compound. It seemed
to be especially difficult to completely separate it from
the albumin.
The society then went into e.xecutive session.
freely she expired about fifteen minutes later. No
autopsy was performed. The midwife denied having
given ergot.
I
(Clinical gcpavtnicut.
A CASE OF RUPTURE OF THE UTERUS.
By JOSEF S.A.XL, M.D.,
NEW YORK.
One night last week I was summoned in haste to at-
tend a woman in labor. Her husband told me on the
way to the house that she was thirty-two years of age,
of Bohemian nationality, and that this was her sixth
confinement. She has always been in perfect health.
For all previous confinements as well as in this one
she was attended by a midwife.
She was in labor for five hours, and then suddenly
the pains ceased and she fainted away"with a piercing
cry.
On arrival I found the woman semi-conscious, pale,
and covered with clammy sweat. There was complete
absence of radial pulse, the heart was very weak and
rapid, the respiration was shallow and rapid, and the
woman vomited twice. The abdomen was distended
and doughy to the feel. The fcttal head was presenting
upon the perineum. I injected strychnine, gr. -yL, and
digitalin gr. ^ /,yf, hypodermically, raised the foot of the
bed, and proceeded to deliver with forceps. The child
was dead. I removed the placenta and examined the
uterus, and found a tear through the cervix on the left
side, extending up to the body of the uterus. After
that I administered ergot and compressed the womb
from above, and directed the midwife to give her an
enema of salt water and whiskey. The patient revived
somewhat and regained consciousness, but complained
of terrific pain in the abdomen. I gave her a dose of
morphine and atropine hypodermically, and she seemed
to do well for about half an hour, after which she
fainted again, and although stimulants were given
A RELAPSING FEVER.
By H. G. MURRAY, M.D.,
BALTIMORE, WD.
The following case seems to me worth reporting. I
was called on August 14th to see the patient, a strong,
robust farmer, who was suffering, as he said, from in-
tense fever. The temperature was 104° F. ; pulse, 90.
He complained of great pain in the back and limbs.
The spleen was slightly enlarged. The ne.xt day
jaundice developed, but was not severe. There were
no other symptoms of any account. On August 21st
the patient was well, and on the 22d he was riding a
bicycle. On August 28th he was again attacked, the
fever reaching 105° F. on the first day. The muscular
pains were not severe. Jaundice was not present. In
a week the temperature began to decline, and soon
reached normal. He is at present very weak and
much depressed. A blood examination was not made,
and, of course, the case is not complete ; but no doubt
will exist as to a case with such a history being one of
relapsing fever.
The treatment recommended was useless. Quinine
in powerful doses had no effect. Diet, sponging, and
stimulants were used.
TWO CASES OF TAPEWORM.
By frank OVERTON, A.M.. JI.D.,
PATCHOGL'E, N. V.
In the spring and summer of 1894, Mr. W , a
nurse in a city hospital, passed links of tapeworm at
intervals. For his relief the mixture of malefern,
pomegranate root, pumpkin seed, and croton oil, pop-
ularly known as the " early-bird mixture," was pre-
scribed, without special attention being given to
previous dieting. About an hour and a half after
he had taken it his bowels began to move; there were
cramps, and he felt extremely nauseated. Some of
the worm was passed through the anus, when an attack
of vomiting came on, in which the patient felt a large
lump coming up, which gave him a severe sensation
of choking so that he felt faint. By violent retching
he finally expelled the lump, which proved to be a
mass of tapeworm. He examined it for a moment and
saw that it tapered to a small thread and then he went
away, intending to examine it carefully later, but an
attendant emptied it down the closet. But little of
the worm was passed by the anus. For six weeks,
until he left the hospital, there was no recurrence of
the trouble.
Vomiting of the ascaris lumbricoides is compara-
tively frequent; but persistent search and inquiry has
failed to reveal another case in which a tapeworm was
vomited.
In September, 1895, a young woman presented her-
self in great distress of mind, bringing a few joints
of tapeworm which she had just passed. The "early-
bird mi.xture" was prescribed after brisk catharsis had
been established with Rochelle salt. In about two
hours a large mass of tapeworm was passed. Exami-
nation showed that there were two tapering strings of
tapeworm, each becoming as fine as a thread; but only
one head was found.
About six weeks afterward the patient again began
to pass links of tapeworm, and the same treatment
brought away a single tapeworm, about ten feet in
length, which tapered to a fine thread; but no head
could be found.
642
MEDICAL RECORD.
[October 31, 1896
In six or seven weeks she again passed links, and
treatment again brought a long tapering string of tape-
worm, but without a head. As before, links began to
be passed inside of two months. She then consulted
an eclectic physician, who administered three drachms
of malefern in two ounces of castor oil. Although he
failed to find the head, there has been no recurrence
of the trouble.
This case is interesting because it demonstrates the
extremely rapid growth of the worm. For three suc-
cessive times its head produced enough links in six
weeks so they were passed from the bowel. So if the
head is not found, and no links are passed for two
months, the trouble is almost certainly cured.
OCCUPATION NEUROSIS OR IRONER'S
CRAMP.
By L. pierce CLARK, M.D..
ASSISTANT PHYSICIAN AT CRAIG COLONY, SONYEA, N. Y.
I DESIRE to place on record a case of ironer's cramp,
as I am not aware of its having been reported before
by writers on neurology. There seems to be no reason
why it should not be a common affection, but I have
never seen or heard of a similar case. It appears
that ironer's cramp partakes also of the nature of a
pressure paralysis, as described by Cowers. Occupa-
tion and professional neuroses, as Gowers,' Dana,"
and StriimpelP term them, are very common affections
in this work-a-day world, and there is no reason why
the same should not be common among ironers.
Probably the firm grasp of but two or three fingers
upon the flatiron has greater etiological significance
than the pressure resulting from the weight of the
shoulder and arm. Therefore, all things being equal,
the stronger and the more vigorous the worker, the
greater the liability to the disease. This affection of
ironer's cramp and its kindred aff'ections ought to be
classed under the more comprehensive and preferable
heading of occupation neuroses or spasm, and many
cases of pressure neuritis would properly come under
this head also. We generally find the neuralgic and
spasmodic symptoms closely associated in the same
case, as the one here reported shows. There is some
inflammation with almost all occupation neuroses,
eitlier in the early part of the disease or later on, es-
pecially after long-continued application of the cause.
The following case, which has but recently come
under my observation, is reported :
VV. S , thirty-one years of age, laundress. For
three months she was employed at laundry work, and
during this time she was engaged in the sole occupa-
tion of ironing. After tvvo weeks of this kind of work,
the two middle fingers of the right hand became
"numb," and at night the pain was quite severe, run-
ning from the wrist to the elbow. The sharpest pain
was noticed just at the elbow, on the anterior surface
of the forearm. She also noticed that within the next
four or five days the muscles of the right arm became
quite weak, and that the numb and painful sensation
made itself felt almost nightly. Occasionally this was
present when she was unemployed for a few hours.
After ironing for some time, these two fingers cramped
and became " stiff," and she was unable to bend them
easily. Upon examination, parajsthesia was found to
be present in the forearm, wrist, and palmar surface
of the hand. About half the time two points appeared
as one, when applied simultaneously. Dynamographic
examination showed the right hand pressure to be sixty-
eight pounds; left hand, seventy-eight pounds. Dur-
' Gowers' "Text-Book of Nervous Diseases," vol. ii., page 710.
' Dana's " Text-Book of XerAous Diseases," page 469.
'" Text-Book of Medicine," page 545.
ing the next three days the affection grew steadily
worse, and in consequence she made several trials in
using her left hand instead of the right in doing her
work. As this practice did not prove satisfactory, her
occupation was changed. The pain in a great measure
ceased, numbness and prickling sensations were no
longer troublesome, but the loss of muscular power
still persisted.
The treatment of an occupation neurosis is unsatis-
factory : First, because of the tendency of the affection
to recur after having been once firmly established;
secondly, because the physician is usually obliged to
make concessions to the causation. It is necessary
to exercise twice as much ingenuity in the treatment
of an occupation neurosis in the very poor, because the
patient cannot cease from daily labor. This case was
no exception to the rule. Deep massage was first tried.
It was applied from the centre of the palm to the el-
bow. The greater freedom from pain and the
" cramped feeling" was obtained when massage was
applied two hours after the daily work. If the mus-
cles were painful before going to work in the morning,
they were massaged again before work was begun, and
at all spare moments during the day systematic mus-
cular exercise of the affected hand was maintained.
Finally, this treatment failed of its desired effect,
and douches and tonics were supplemented. These
gave freedom from '' pain and cramp" for a few days,
when they, too, failed, and laundry work was ordered
discontinued. A month's treatment has improved the
use of her hand, although full muscular power has not
yet returned.
HERPETIC NERVE DISTURBANCE.
Bv W. M. WELLER. M.D..
ITHACA, MICH.
In the Medical Record of September 26, 1896, 1 no-
tice an article entitled " Counter-irritation in the
Treatment of Herpes." I do not question the value of
blisters in treating the nerve disturbance accompany-
ing herpes, but give them an important, if not, indeed,
first place as a remedy; yet they sometimes fail to give
relief.
I have a case of herpes zoster under treatment now,
in which I have not only failed in getting the happy
results which Dr. Wilkins describes, but have failed
to give any permanent relief whatever, although the
area affected has been pretty well covered by repeated
blisters, beginning early in the attack and continuing
to the present time.
My patient is an old lady, sixty-seven years of age,
and in rather feeble health. Severe pains commenced
four weeks ago in the right side, and were followed in
a few days by an eruption of isolated patches of vesi-
cles, extending from the spine across the subscapular
and mammary regions to the median line in front.
The pain has continued with unremitting severity up
to the present time, September 29, 1896, aggravated
by movements and relieved only by hypodermic injec-
tions of morphine.
.\nother case, which was a great source of perplexity
and discouragement to me, happened in my early pro-
fessional struggles. This patient, too, was an old
lady, and the case lasted for many weeks.
On the other hand, I have seen cases like those de-
scribed, in which a blister seemed to cut short the
pain as if by magic.
The point I wish to make is this: that while the
majority of cases of herpetic nerve disturbance are
amenable to treatment in a time ranging from a few-
days to t\vo or three weeks, cases occurring in the
aged, and in which there is a well-marked neuritis,
may possibly continue so long as to be a source of dis-
couragement to both patient and physician.
October 31, 1896]
MEDICAL RECORD.
643
CONGENITAL TRANSPOSITION OF THE
VISCERA.
P,Y F. C. STUDLEV, M.D.,
MILWAL-KEE, WIS.
'1'he following case of congenital complete transposi-
tion of the thoracic and abdominal viscera may, per-
jiaps, be interesting to the readers of the Medical
Record. In this patient the apex beat of the heart is
in the right thora.x;, between the fifth and sixth ribs,
directly in the nipple line. Left of the sternum I
could not detect any dulness whatever on percussion.
The liver, which is somewhat enlarged, is entirely in
the left hypochondriac and epigastric regions; while
the stomach, from cardia to pylorus, and the spleen as
well, are placed to the right of the median line. The
patient, a German, thirty-seven years of age, aside
from occasional attacks of indigestion with cardiac pal-
pitation, does not complain of any indisposition what-
ever; nor, so far as one can understand, is his condi-
tion at all inconsistent with long life and perfect health.
DOUBLE OVARIOTOMY, FOLLOWED BY
PREGNANCY; AND DOUBLE OVARIOT-
OMY DURING PREGNANCY, FOLLOWED
BY THE BIRTH OF TWINS AT TERM."
By R. STANSBURY SUTTON, ^t.D., I.I..D.,
PITTSBURG, TA.
(Jn October 18, 1892, Mrs. J. R. P , aged twenty-
eight years, was admitted to my private sanatorium.
She was greatly emaciated and feeble. Pulse, 40.
Her abdomen was very large. Diagnosis, ovarian
cystomata.
She was married in 1S85, at twenty-one years of age.
One year later, in 1886, her only child was born at
term. Prior to the birth of this child, her attending
physician diagnosed an ovarian tumor lying to the
right of the uterus. Si-x years and seven months in-
tervened between the date of this discovery and her
admittance to the hospital.
On October 20, 1892, two days after her admission,
I opened her abdomen and removed from the right side
a twenty-five-pound multilocular ovarian cyst, the ped-
icle of which I severed with a Paquelin cautery, the
ligature on the .stump lying close to the horn of the
uterus. From the left side I removed a multilocular
cyst weighing six pounds. The cautery failing to get
hot, I severed the pedicle with a pair of scissors; the
ligature on this pedicle lay close to the horn of the
uterus. The cavity was sponged dry, and the patient
elevated to the Trendelenburg posture. The wound
was long, the abdominal wall exceedingly thin, and
the pelvic contents were fully exposed. The uterus
was somewhat larger than normal, the pedicle stumps
were short, and the ligatures lay close to the uterine
comua. The uterus was retroverted ; the fundus was
brought forward to the lower angle of the wound ; a
patch of its peritoneal covering was abraded with the
edge of a knife; it was then fixed at the lower angle
of the abdominal wound with two buried silkworm-gut
sutures. The wound was closed. The operation oc-
cupied twenty-five minutes. The tumor from the right
side contained a large amount of colloid material, and
this was characteristic of the one on the left side.
To repeat: This operation was done on October 20,
1892. On June 10, 1894, the subject gave birth to a
male child weighing ten and one-half pounds. Again,
on February 25, 1896, she was delivered of a male
child weighing eight pounds.
Some ovarian tissue must have been left in one of
the pedicles, and the tube must have remained patu-
' Read by title at the International Gynecological Congress,
Oeneva, Switzerland, August 31 to September &, 1896.
lous, through which the o\um found its way into the
uterus.
Prior to the operation the patient had remained
sterile for about six years after the birth of her first
child. In this instance we have the remarkable para-
dox that double ovariotomy terminated the sterility.
My opinion is, that in this case an aberrant patch of
ovarian tissue existed at a point close to the uterus
and adjacent to the tube, that the section of both with
the scissors brought the cut surfaces of the patch of
ovarian tissue and tube into juxtaposition, that the
lumen of the tube was not destroyed, and that ova
passed from the patch of ovarian tissue into the uterus.
This case has a remarkable bearing on the question
of surgical conservatism in dealing with the ovaries.
If, in this instance, no ovarian tissue had been left,
two fine children would not have been born. This
case and the numerous conservative operations by
operators in all lands urge the necessity and prove
the wisdom of saving even a small particle of ovarian
tissue wherever it is possible, and when there exists
no contraindication for such action.
The case has also suggested to my mind the possi-
bility of ovarian grafting, and the wisdom of doing
our cases in pairs — that is, two cases at the same time,
in order that we may find in two cases sufficient
healthy ovarian tissue to supply both patients, by
leaving some healthy ovarian tissue in one and trans-
ferring some by grafting to the other patient, if neces-
sary.
The second case referred to in the title of this report
now follows: On February 13, 1893, Mrs. D ,
aged thirty-four, widow for ten years, mother of one
child, thirteen years old, was sent to me for operation.
At her menstrual periods she had cataleptic seizures
and frequent attacks of severe pain in the ovarian re-
gions. She was incapacitated for work, and all reme-
dies had failed to relieve her. She stated that she
had menstruated two weeks prior to this date. Digital
examination revealed a linear stricture at the juncture
of the upper and middle third of the vagina, which
arrested the finger. The finger was no\v transferred
to the rectum, and by the aid of the superimposed
hand I made the following diagnosis: Stricture at the
upper third of the vagina, lacerated cervix, subinvolu-
tion of the uterus, chronic salpingitis and ovaritis.
On the 1 8th, five days later, I made a very short in-
cision in the median line, and through it removed the
ovaries and tubes. I noted the supposed subinvolu-
tion of the uterus, and closed the wound. The patient
recovered promptly, and left the hospital.
About ten months after her discharge from the hos-
pital her attending physician informed me that in
nine months less forty-one days after the operation,
he had attended her in confinement. She gave birth
to twins, healthy children.
This case and others in our literature prove the
tolerance of the pregnant uterus to surgical operations
on its appendages. It has also proven that we are not
safe in placing too much dependence on statements
made to us by female patients.
The suggested merits of these cases, I trust, may
prove a sufficient apology for presenting them to this
learned body of representative gynecologists.
Instruments A heaping tablespoonful of washing-
soda to a quart of water is the proper proportion for
the solution in which instruments should be boiled for
sterilization. Do not boil non-metallic sutures in this
liquid, for it will very greatly w'eaken them. Do not
boil an aluminium instrument in this liquid, for it will
be corroded and completely ruined. — ItitcrnatioiiaJ
Journal of Surgery.
644
MEDICAL RECORD.
[October 31,1 896
©ortrcsponcTcnce.
OUR LONDON LETTER.
(From our Special Correspondent. J
THE FIKST HUXLEY LECTURE PROVINCIAL MEDICAL
SCHOOLS SIR J. LITTLEJOHN AT LEEDS — MR.
HUTCHINSON AT MANCHESTER MR. VICTOR HORSLEV
AT LIVERPOOL — THE CARTER-HORSLEV CONTROVERSY
THE COMMITTEE ON WATER SUPPLY— DEATHS OF
MR. MORRANT BAKER AND DR. LANGDON DOWN
MEDICAL COUNCIL CANDIDATES.
London, October 9, 1S96.
The first " Huxley lecture" was delivered on Monday
by Prof. Michael Foster, at Charing Cross Hospital.
This lecture has been founded to commemorate the
late Professor Hu.xley, whose medical education was
obtained at Charing Cross. Dr. Foster proposed that
this first lecture should be a sort of preface to those of
the future, as his successors would probably single out
some new advance in science and expound its bearings
on medicine and surgery. He therefore took account
of the state of science when Huxley took his seat as
a student in the school, compared with its present con-
dition. But he could not give an account of the pro-
gress made in those fifty years, and would, therefore,
only dwell on two or three points. These were the
observations of the brothers Weber on the inhibitory
action of the vagus, Bernard's discoveries as to tiie
effects of section of the sympathetic leading to our
knowledge of vasomotor action, the formation of gly-
cogen, and Waller's observations on ner\e nutrition.
The lecturer concluded with a notice of Huxley's in-
fluence on physiology, and asserted that tlie hopeful
position of English physiology to-day is in large meas-
ure due to that influence.
The provincial schools of medicine have of late
shown a vigor that does them credit. They have
always celebrated (October ist with the time-honored
introductory, and often invited lecturers from a dis-
tance to occupy the chief place on the occasion. The
value of these schools has now and then been called in
question, and their defence was taken up at the open-
ing of the session at Sheffield by Sir H. Littlejohn,
who had been invited to come from Edinburgh to de-
liver the lecture. Taking up the subject of provincial
schools, he maintained that they had certain advan-
tages over such great teaching centres as London,
Edinburgh, and Dublin. He pointed out that in
smaller schools there could be more personal superin-
tendence on the part of teachers, so that Uie deficien-
cies of students were ascertained and a healthy stimu-
lus given. This, which is a revival of pupilage in a
better form, could not be the same in large schools,
and the close companionship of teacher and taught
could not fail to strengthen good resolutions and beget
that esprit de corps \\\\\c\\ is the essence of professional
life. Besides this, the great provincial hospitals
afforded ample scope for clinical work, and in this re-
spect contrasted favorably with the wards of metropol-
itan hospitals, crowded with the students of tiie great
schools. In the provincial schools students could now-
complete their education with practical bedside tuition
in all departments, including attendance in lunatic
asylums, in hospitals for children, for infectious dis-
eases, and for diseases of the eye, all of which has now
become compulsory and which can scarcely be practi-
cable in the largest schools.
Mr. Victor Horsley went to Leeds to deliver the in-
troductory lecture at the Yorkshire College. He called
attention to the sui^erlative value of chemistry in the
study of physiology and pathology, and expatiated on
the advantages and disadvantages of guilds, mediaeval
and modern. This led up to the subject of combina-
tion for medical defence, which was treated with con-
siderable vigor. In fact, Mr. Horsley gave a parting
shot anent tlie controversy with Mr. Brudenell Carter,
respecting the Medical Council, on which I have
already written and which is now over. Mr. Carter,
in his last letter, again twits his an ..agon ist with loose-
ness in the use of English words; says he cannot
" understand the force either of the adverb or the ad-
jective" in the phrase "practically commits literary
forgery," and asks whether non-literary forgery would
be one " not yet written down'" .' There is a para-
graph, too, about the phrase "misrepresenting acts of
Parliament," which Mr. Carter says is an offence he
had no idea could be connnitted, though he can imag-
ine "the possibility of misrepresenting the language
of the acts, or their intention, or their effect." After
this, he rather superciliously suggests that this maybe
what Mr. Horsley means, and "his obscurity may only
be due to his not knowing how to express himself."
This trifling is amusing enough, but convinces no
one. It is no more an argument than telling Mr.
Horsley he is so much the younger. Mr. Carter closes
by saying: "The farrago of rubbish and falsehood,
the meanness and malignancy of which I have, 1 think,
sufficiently exposed, is connected together by coarse
personalities and vulgar abuse, such as are no longer
tolerated in any decent society. I do not think it
would be consistent either with my own dignity or with
my professional position to continue a controversy
which my opponent conducts in such a manner." The
editor has said the correspondence must cease, and re-
grets the "bitterly personal nature" of many of the
letters, and wisely adds that "neither the cause of
medical reform nor the elucidation of the medical arts
is furthered by accusations of mendacity and other
crimes."
Mr. Hutchinson went to Manchester and discouised
on " Medical Education" to the students of Owens
College. He set before them a high ideal, advising a
training in a wide knowledge of all that concerns our
terrestrial environments. Not to discourage students
too much, he mentioned some things they might, after
learning them properly, forget, as not likely to be
called upon to practise. None, he thought, should
neglect to spend a few months in Paris and "Vienna
before settling down, and should learn the languages
in those months, as he would afterward want to read
them. As to recreation, he assured them that whoever
enters with proper zest into the study of climate, to-
pography, botany, geology, and zoology would never
be at a loss for motives to go into the fresh air and get
exercise, and such might very well leave cricket, foot-
ball, and golf to men of less resource and less re-
sponsible pursuits. He would also relieve them from
such things as games of cards,- and possibly also from
the gratification of music. Altogether an arduous
curriculum, as he acknowledged, but then he said it
was onlv temporary, and its reward lasting through
life.
The report of the select committee on the bills of
the London water companies shows that the question
of supply ought not to be delayed. The committee
pronounces the existing state of things to be a most
unsatisfactory compromise between public control and
commercial enterprise. It results in waste of large
sums in promoting and opposing various bills, thus add-
ing to the burden of consumers. It is difficult and al-
most impossible to decide the extent of monopoly that
should be granted to enable the companies to procure
ample supplies without adding unfairly to the capital,
and therefore to the compensation whenever they are
bought up. It is a fact, I believe, that, though the
companies have made and are making enormous sums
out of their monopolies, the consumers pay more for
October 31, 1896]
MEDICAL RECORD.
645
their water than it costs in a fourth-rate continental
city.
During the dry summer I had to report that a con-
siderable district was suffering from want of water, to
the great danger of the public health; and this be-
cause the company, running short, did not choose un-
til very late to buy the overflow of another company.
Yet that company has collected its dues just as if it
had fulfilled its contract. In that case, I tliink it
would be only just to forfeit the monopoly. In every
case in which such a company fails to carry out its
contract, the least compensation to the public should
be the forfeiture of die current quarter's dues.
Mr. Morrant Baker died on October 3d, after a
long illness. He resigned the surgeoncy of St. Bar-
tholomew's Hospital several years ago, on account of
ill health. He had filled other offices, and had been
on the council of the College of Surgeons, and also
examiner in surgery at the London University. He
contributed valuable papers to St. Bartholomew's Hos-
pital Reports, to the societies, and to the medical jour-
nals.
Dr. Langdon Down died on Wednesday, aged sixty-
seven. His career was associated with the London
Hospital, of which he had become consulting physi-
cian after passing through the various positions open
to him. Soon after graduating at the London Uni-
versity, he was appointed resident physician to the
Earlswood Asylum, and this appointment he was al-
iowed to retain several years after he became assis-
tant physician to the London. This asylum (for
idiots) directed his attention to the education and
training of the feeble in mind, on which he pub-
lished a monograph in 1876, and this was followed in
1887 with his " Mental Affections of Childhood and
Youth." Meantime, he contributed numerous papers
on allied subjects to the societies and journals. At
the same time he carried on his work at the London
Hospital until, on the expiration of his term, he was
elected to the consulting staff. His residence at
Hampton Wick was also an establishment for the fee-
ble in mind and the scene of many hospitalities to
his professional brethren.
The Society of Members have endorsed the nomina-
tion of Mr. Rivington by the Association of Fellows
of the College of Surgeons. He has accordingly
issued an address, accepting the joint invitation to
contest the election, and, having been a leading re-
former for many years, will doubtless recei\e much
support.
OUR PARIS LETTER.
(From our Special Correspondent.)
PARISIAN MEDICAL AND SURGICAL MEASURES DURING
THE czar's RECENT VISIT THE BABY GRAND-
DUCHESS OUT FOR AN AIRING — PUERICULTURE AND
PROTECTION OYSTERS PROPAGATE CHOLERA AND
TYPHOID FEVER PROFESSIONAL SECRECY — DOCTORS'
LETTERS CANNOT BE PRODUCED IN COURT.
Paris, October 15, 1S96
So important an event as the visit of the Czar and
Czarina of all the Russias to Paris could not but make
its influence felt upon the medical department, as well
as upon the profession at large. Many physicians
preferred, in fact, to prolong their vacations rather
than be subjected to the crowds and many difficulties
of attending to their practice. When we add that it is
estimated five millions of people were in Paris during
the stay of their imperial majesties in the capital, some
idea of the serious impediment to free circulation and
traffic may be formed. In other words, the entire
population of Paris was doubled, or very nearly so in-
deed, during the fetes which are just over.
The danger to life and limb was correspondingly
great; there were numerous medical and surgical
accidents, such as asphyxiations, syncopes, falls, lun-
overs, etc.; also several deaths therefrom, notwith-
standing the e.xcellent police and sanitary organiia-
tions. The latter took the form of ambulances,
stationed in different parts of the city along and near
the routes that the emperor and empress would take
when going to any function or visiting any public
building. These ambulances were changed every day
during the three days' visit of Nicholas II., and the
prefect of police, AI. Lepine, had posters put up in
the eighty different quarters of Paris before the arri-
val of the nation's guests, telling explicitly where these
ambulances were to be found each day. Cards, or
" (W//yf/t'y," were also issued to physicians, enabling
them to pass the lines of police and soldiers.
It was not uninteresting to see the baby Grand
Duchess Olga, the only child of the emperor and em-
press, being taken out for an airing in the arms of her
nurse, clashing down the Avenue I'Alma, the carriage
surrounded by cavalry. This brings us to the subject
of puericulture and protection, upon which Dr. Ledd
has just written a very valuable essay. The conclu-
sions he reaches are these: In order to assure equal
protection to child and nurse, the age of the milk of a
woman that is to act in the capacity of wetnurse
should be limited to five months. The nurses should
be strictly supervised, and situations given them only
after they have received medical certificates. Chil-
dren should receive only natural milk (mother's or
wetnurse's milk) until they have cut at least four in-
cisors. After the appearance of these teeth, the addi-
tion of a small quantity of animal milk, cow's milk
sterilized, may be tolerated, to which a pap of flour
may be added during the period of second dentition.
Only after the appearance of the canines ought we to
attempt to wean children, or begin feeding them with
eggs and soups until completely weaned; and they
should always be closely watched by the physician and
weighed frequently.
Speaking of food hygienically, the oyster is likely
to fall into disfavor with the general public, which is
beginning to realize the serious risk it runs of con-
tracting not only typhoid fever but sometimes cholera,
as was demonstrated by the epidemic of Grimsby, in
1893. In 1889 Giaxa made a series of bacteriological
experiments, with reference to the action of sea water
and oysters on pathogenic microbes. He found that
the multiplication of the cholera bacillus in sea water
depended upon the number of other microbes present.
The opinions regarding the presence of the bacillus
of Eberth and its harmful power were not thoroughly
established until Professor Chantemesse took up the
question and cited facts proving the reality of the
propagation of typhoid fever by oysters. A merchant
in a small town in the province of He'rault, not long
since, received a consignment of oysters coming from
Cette. Fourteen persons of the town (where there had
not been a single case of typhoid fever for a year)
contracted the disease after eating of these fresh raw
oysters; two of them died of malignant typhoid fe\er.
It was impossible to deny the relation of cause to efi'ect
in this instance, so well studied and authenticated.
The point to elucidate was whether other oysters, com-
ing from no matter where, were capable of producing
the same deleterious results. In order to determine
this absolutely. Professor Chantemesse bought at the
Paris markets Marennes oysters, English and Ostende
oysters, oysters from Portugal, and other countries.
A bacteriological examination disclosed to him the
presence of numerous germs, and especially that of
the coli bacillus. -Some of the best and most healthy
oysters were placed in sea water purposely contami-
nated with the dejections of typhoid cases and the ba-
cillus of Eberth; after remaining twenty-four hours in
646
MEDICAL RECORD.
[October 31, 1896
the water, they were taken out and preserved closed
twenty-four hours longer. At the expiration of that
time they were still fresh and contained numerous
coli bacilli and typhoid bacilli living. There is,
therefore, a manifest danger as regards the contamina-
tion of oyster beds or parks for fattening and preserv-
ing oysters, by rivers, brooks, and streams carrying in
their currents morbid germs of different sorts, as they
empty into the ponds, coves, inlets, or bays where oys-
ter cultivation is usually carried on. Unfortunately,
it is ne.xt to impossible to guard against this danger
effectively. But there is a ray of hope for the epicure
— a good cook can produce a preparation of the lus-
cious bivalve quite as palatable as the raw material,
while he destroys in the fiery furnace the death-deal-
ing microbes.
The case of Dr. Playfair, of London, who was re-
cently condemned for revealing professional secrets,
has been a good lesson to all who do not hold suffi-
ciently sacred the confidences obtained in the e.xercise
of their profession. Let us now hear the French on
this point. The court of appeals of Douai decided
quite recently that in no case can a tribunal authorize
the production in court of letters written by a physi-
cian and having reference to the treatment and care
given a patient, even though the production of said
letters be authorized by the physician himself.
It would seem from the foregoing that the permis-
sion of the recipient of such missives is not even to be
considered. Neither is anything said with reference
to their production in court when both writer and re-
ceiver agree to it. But as this is strictly a medico-
legal question, we prefer to leave it in abeyance. It
is enough to know that in France the violation of
professional secrecy is a criminal offence, punishable
by fine and imprisonment, and that the English law is
in the same tenor.
THK TREATMENT OF ACUTE ABSCESSES.
To THE Editok of the Medical Record.
.Sir : A wrong statement is made in the article appear-
ing under the above title in this week's Medical
Record, which must not, in my opinion, be left un-
corrected. Dr. Peet says in his paper on the treat-
ment of acute abscesses :
"The acetate of aluminium is made up as follows:
^ Pulv. alum 3 V.
Pulv. pliimbi acft Z -xxv.
Aquae destil q.s. ad O iv.
M.
"There is a precipitate when this solutfon is made
up and the bottle should be shaken before its contents
are used."
This would give one the idea that the precipitate is
the acetate of aluminium, or at least some ingredi-
ent with medicinal properties. As a matter of fact,
the precipitate is the inert sulphate of lead, and
should never be used when acetate of aluminium is
wanted, but should always be filtered away; or, still
better, the perfectly clear solution of aluminium ace-
tate is decanted after allowing the heavy sulphate of
lead to settle down to the bottom of the \essel. The
chemical reaction occurring in making this prepara-
tion is as follows :
K,Al,(SO,). + 4 Pb (CHjOOj = A1,(C,H,0,). + 2 KCHoO,
.Alum. Lead acetate. Alumin. acetate. Potass, acetate,
-f 4 Pb SO,.
Lead sulphate.
As the solution of aluminium acetate is, on account
of its harmlessness, generally used profusely in open
wounds, granulating surfaces, extensive bums, etc.,
the presence of the sulphate of lead may prove a posi-
tive source of danger, namely: the absorption of lead
may cause lead poisoning. That this possible source
of danger is taken into consideration by others be-
sides myself is shown by the fact that in all pharma-
ceutical books in which a formula for the preparation of
soluble aluminium acetate or solution is given, the di-
rections are added that it be not made in warm weather
or that it be allowed to stand a few hours on ice before
being filtered, so as to allow the lead sulphate to precip-
itate out as completely as possible (the latter being to
a very slight extent soluble in warm water). In con-
clusion I will say that the solution of aluminium acetate
has been used for decades as an antiseptic dressing
and is the well-known " solutio Burrowi," of the Euro-
pean physicians. The formula, though, dift'ers mate-
rially from that given by Dr. Peet, the latter containing
an unnecessarily large proportion of lead acetate and
too small a proportion of alum.
William J. Robinson, Ph.G., M.D.
New York, October lo, 1896.
Indications for Removal of Surgical Dressings.
— I. The removal of stitches. 2. The removal of
drainage tubes. 3. Saturation of dressings by an
abundant discharge. 4. Soiling of dressings by fa-ces,
urine, or vomited matter. 5. The disturbance of the
dressing by a restless patient. 0. Pain if it is due to
pressure, and especially if of a pulsating character.
7. The occurrence of secondary hemorrhage. 8. Fever
if it points to some trouble in the wound. — Roth.
Malignant Diseases of Larynx. — Dr. Delavan
{jVc-iii J'c/vt Ah-iiical Journal, September 5, 1896) ad-
vances the following propositions: i. Every malig-
nant growth of the larynx of intrinsic origin which can
be dealt with should be treated by an operation, in the
absence of a decided indication to the contrary, and
the operation should be performed with the least pos-
sible delay. 2. Every tumor of the larynx suspected
to be malignant, of intrinsic origin, of limited extent,
and apparently freely removable, justifies an explora-
tory thyreotomy in a suitable patient, in the absence
of infiltration of the surrounding structures and of af-
fection of the lymphatic glands.
Treatment of Crural Hernia by an Inguinal
Operation. — This operation is performed in six stages,
\iz. : I. Ojjening of the inguinal canal. 2. Exposure
of the superior orifice of the crural canal and isolation
of the neck of the crural sac. 3. Extension of the
crural hernia into the inguinal wound. 4. Opening
of the crural sac and removal of the same, together
with any omentum it may contain. 5. Closure of the
crural ring by sticking Poupart's ligament to the pec-
tineal fascia. 6. Closure of the inguinal wound by
sutures. — Rc-ruc de C/iirurgk, March, 1896.
Pus Tubes. — Dr. Thomas A. Ashby {Ameruan
Journal of Surgery and Gynecology, August, 1896) says:
" I have become more and more convinced from a large
experience with pus tubes that the best results will fol-
low in those cases in which the uterus is removed with
the pus sacs. The rule I adopt is this: When the pus
tube or tubes can be enucleated and removed without
rupture or without leaving an infected area behind, to
confine the operation to a simple removal of the pus
sac. When the tube is closely attached to the uterus
and cannot be easily separated from it, or when the
uterus has been infected, either by the constant dis-
charge of pus through the uterine cavity, or by soften-
ing or localized deposits of pus in its walls, it is far
safer to remove the entire organ or to amputate at the
junction of the body with the neck.
October 31,
1896]
MEDICAL RECORD.
647
Spastic Paralysis Dr. Bullard (Boston Mcdkal
and Surgual Journal, September 3, 1896) summarizes
as follows: Operative procedures — tenotomy and teno-
myotomy— are of much value in cerebral spastic paral-
ysis when their aim and scope are fully understood.
They correct the deformity permanently, and they place
the limb in a favorable condition for treatment by
other means; they are not themselves curative. Mus-
cular tissue alone should not be divided. When pos-
sible the tendons should be cut. When this is not
possible either muscle and tendon, or muscle and
aponeurosis.
Operative Gynecology and Insanity. — Dr. A. H.
McKarland, in the Cincinnati Lancet-Clinic, says that:
I. Gynecological operations are more likely than any
other surgical procedure to distract the mind. 2.
Hereditary antecedents of the patierft should always
be determined. 3. In insane patients operations
should be performed only when the physical condition
endangers life or renders it insupportable. 4. Patients,
precedent to the operation, should be in a calm frame
of mind; hence, moral treatment of the patient pre-
vious to operating is the best prophylaxis. 5. Inher-
ited and acquired insane constitution is the fundamen-
tal factor in most cases of insanity. This conclusion
does not, however, justify us in ignoring physical dis-
eases immediately preceding or associated with in-
sanity. 6. Healthy genital organs do not give rise to
refie.x symptoms; consequently caution should be ex-
ercised in operating for the relief of insanity. 7.
Operations may be satisfactory in properly selected
cases.
Fistula in Ano. — Dr. S. G. Gant gives the follow-
ing twelve cautions that should be observed in operat-
ing for fistula in ano: i. Ahvays operate under rigid
aseptic conditions. 2. Be certain that all sinuses
and diverticula have been divided. 3. See that the
director is not forced out of the main tract into the
neighboring tissues. 4. Divide the sphincter at a
right angle, and not obliquely. 5. Ligature or twist
all spurting vessels. 6. Guard against injuring the
peritoneum when the sinus is high up. 7. Guard
against cutting the vagina, prostate, or urethra when
the sinus is in the anterior wall of the rectum. S.
Do not operate on patients suffering from acute phthisis
or Bright's disease, g. Give patients the benefit of
the sun as much as possible. 10. Do not pack the
dressings tightly after the first twenty-four hours, but
lay the gauze loosely in the bottom of the tract. 11.
Warn your patient of the possibility of incontinence
following the operation. 12. Be guarded in your
prognosi s. — Langsdale Lancet.
Tuberculous Abscesses Dr. Gage, in the Boston
Medical and Surgical Journal, September 10, 1896,
draws the following conclusions: (i) An abscess oc-
curring in connection with tuberculous disease of the
bones or joints is always secondary in importance, as
well as in development, to the primary disease. Its
treatment must not, therefore, in any way interfere
with the treatment of the original lesion. (2) When
the abscess is accompanied by any evidences of con-
stitutional impairment, or interferes in any way by its
location with the use of proper mechanical treatment,
it should be immediately opened. When there is no
interference with general health or with mechanical
treatment, the abscess, if it presents a pure tuberculous
infection, may be left until it is nearly ready to open
spontaneously. If it presents a mixed infection, it is
to be opened at once. (3) In all cases abscesses are
to be opened as soon as they approach the surface, to
avoid unnecessarily extensive burrowing. (4) Of the
methods commonly used in opening these abscesses,
aspiration with irrigation, free incision with curetting,
all seem to give inferior results to those obtained by
simple incision in the most dependent portion, with the
least possible interference with the walls of the ab-
scess.
Hip-Joint Disease — In young children the very
beginnings of hip-joint disease are announced by mus-
cular twitchings during sleep; added to this, the sub-
ject is irritable, the secretions are disturbed, the ap-
petite is fictitious, the muscles are fiabby and shrunken
away on the aft'ected side, the countenance is pale,
and the signs of illness are very apparent. Soon fol-
lows a little limp in the gait, attended with pains in
the knee or ankle-joint — not often in the hip. These
pains are at first very slight, and may escape attention
unless the medical attendant is very alert. A rise of
temperature will be sometimes noticed in the evening,
and it may be continuous; tow^ard the last of this stage
more or less spasm of the muscles will have super-
vened.— Medical Arena.
Absolute Alcohol as a Disinfectant for Instru-
ments.— Dr. Robert L. Randolph publishes, in the
Johns LLopkins Hospital Bulletin. September-October,
1896, a bacteriological study of Squibb's absolute al-
cohol (98!,- to 99 ("ij per cent.) as a disinfectant for cut-
ting instruments used in eye operations. The fact
that cataract operations require a keener knife than
other operations in surgery, and that heat is therefore
objectionable, because it dulls the edge, led the writer
to test the value of alcohol, which Reinicke says is the
quickest disinfectant that can be relied upon for disin-
fecting the hands. Scrubbing them in alcohol of ninety
per cent, strength for fi\e minutes, he thinks, in taking
up the fat takes up the bacteria from the hands, so that
they can be washed away. The writer has found no ex-
periments recorded as bearing upon the efficacy of alco-
hol as a disinfectant for instruments, and in so far his
tests represent the only work of the kind that has been
done. Inoculation of fifty tubes with fifty eye instru-
ments, taken at random from the experimenter's < ase
and from those in hospital use after being cleansed in
the usual way, resulted in sixteen tubes remaining
sterile. We will not enter into the experimenter's test
methods, but in his own words : '' It is evident that the
alcohol in the first and second series was adequate for
disinfecting purposes, but it is equally true that alco-
hol is totally inadequate for disinfecting instruments
which have been infected with the staphylococcus albus
in pure culture, and this might contraindicate our re-
lying upon absolute alcohol for disinfecting instru-
ments which had been used in an operation when the
pyogenic organisms are present in great numbers — as.
for instance, in panophthalmitis." The conclusions
he draws are: ist. That of a given number of eye in-
struments, by far the majority are infected by exposure
to the air. 2d. That absolute alcohol would seem a
valuable disinfectant for instruments infected under
the conditions which ordinarily surround us in every-
day life. This conclusion seems warranted by the re-
sults obtained in the first and second series of experi-
ments. Attention may be called to the fact, too, that
in the second series the nails were all without a doubt
infected, and it might be said that they had been ex-
posed to conditions which, to say the least, were ex-
traordinarily favorable for infection; so that this
series, I think, is strongly suggestive that alcohol pos-
sesses disinfectant properties of no little value. 3d.
That the septic character of instruments infected with
a pure culture of staphylococcus albus is not altered
by exposure for twenty minutes to the action of abso-
lute alcohol.
648
MEDICAL RECORD.
[October 31, 1896
^ewieius nml +3lotices.
An'atomy. Descriptive and Surgical. By Henry
Gr.w, F.R.S., F.R.C.S., Lecturer on Anatomy at St.
George's Hospital Medical School. A New Edition,
thoroughly Revised by American Authorities from the
Thirteenth English Edition, Edited by T. Pickering
Pick, F. R.C.S. With 772 illustrations, many of which
are new. Philadelphia: Lea Brothers & Co. 1896.
This new edition of Gray's Anatomy is thoroughly revised
and brought up to date. There are many new illustrations,
though the old ones which we have cause to regard, through
long association, with some affection are in great part
retained. With these constant and careful revisions, Gray's
will long remain pre-eminent among the text-books of
■ anatomy.
A Tkxt-Book for Training-.Schooi.s for Nurses.
Including Physiolog\' and Hygiene and the Principles and
Practice of Nursmg. By P'. M. Wise, M.D., Medical
Superintendent, St. Lawrence State Hospital; Editor of
the State Hospitals Bulletin ; Professor of Psychiatrj',
University of Vermont. With an Introduction by Dr.
Edward Cowles, Physician-in-Chief ami Superintendent
of the McLean Hospital, Boston, Mass. In two vol-
times. New York: G. P. Putnam's Sons. i8g6.
The first volume of this useful work is devoted to a brief
study of anatomy and physiology and to the elements of
nursing, such as bedmaking, observation of symptoms, and
clinical records. In the second the principles and practice of
nursing are taught in a thoroughly practical and interesting
manner, considerable space being devoted to the nursing of
the insane in hospital and in the household. The two vol-
umes together constitute an excellent book of instruction for
nurses, and one which they may profitably study as a sup-
plement to the lectures and bedside teaching in the training-
school.
A Pictorial Atlas ok Skin Diseases and Syphilitic
Affections. From Models in the Museum of the Saint
Louis Hospital, Paris. With explanatory woodcuts and
text by Besnier, Fournier, Tenneson, Hallopeau,
DeCastel, Feulard, and Jacquet. Part IV. Edited
and Annotated by J. J. Princle, M.D., F.R.C.P. Lon-
don: The Rebman Publishing Company, Limited. Phila-
delphia: W. B. Saunders. 1896.
Plates XIIL to XVI. in regular series represent in this
part myco.sis fungoides (two plates), psoriasis, and tubercular
leprosy of the face. The first of the illustrations of Alibert's
■disease was made in 1889 from one of Besnier's cases. It
is a typical case of what .'Mibert called in 1812 Piau fungoide.
The second photolithochrome shows a single ulcerating
tumor in the axillary region— illustrative of the form in
which tumors appear from the first. Accompanying this
instructive article are six woodcuts showing various stages
of this affection. The text is furnished by the careful pen of
Henri Feulard, while Ernest Besnier has written the in-
teresting description which goes with the first plate.
Feulard also contributes the article on psoriasis, for which
the illustration is taken from a model of one of Fournier's
cases. It is of the ordinary type.
The lesions upon a separate figure of the penis would
need the etiquette to make one sure of the disease.
Tuberculated leprosy is well represented and the disease
is well treated of by Besnier. A woodcut shows the same
patient nine years later, when the face has been freed from
active lesions by internal and external treatment. A high
order of lithographi" work and of literary accompaniment are
combined to make this production valuable.
Rheum ATis.M, Its Nature, Its Pathology, and Its
Successful Treatment. By T. J. Maclac.an, M.D.,
Physician-in-Ordinary to their Royal Highnesses Prince
and Princess Christian of Schlcswig-Holstein. Second
Edition. London: Adam and Charies Black. 1896.
New York : The Macmillan Company.
It is twenty years, the author tells us, since he wrote the
opening sentences of the preface to his first edition. We do
not remember having reviewed the first edition, so cannot
dismiss the present attempt with the usual few lines poindng
■out the changes and improvements made in the rewriting.
To us and to most readers it is a new work. Those who
read the first are, many of them, dead, but others will remem-
ber the author's introduction of salicin as a remedy for
rheumatism, in 1876. Prior to this rheumatic fever was, as
the author says, the despair of physicians, who were practi-
cally helpless in cutting short the attack. In the opening
chapter the forms of rheumatism are described and com-
pared with each other, and with conditions which occasion
similar symptoms. Then follows a review of the lactic-acid
theory, the neurotic theory, the action of malaria, etc.
The writer considers the lactic-acid theory ingenious and
beautiful, and by no means devoid of foundation, but one
which cannot be accepted without careful consideration.
It is impossible, he says, that the curative effect of salicylic
acid can be due to any neutralizing action on lactic acid.
The many and varied forms of treatment which have pre-
vailed at different times are discussed, perhaps at greater
length than the fallacious theories upon which they are based
would seem at times to warrant. A good-sized chapter is
devoted to the made of action of the salicyl compounds.
Chapters on rheumatic hyperpyrexia, the relation of rheu-
matism to chorea, and anomalous forms of rheumatism,
which close the work, furnish interesting reading. The pa-
per and printing are excellent.
The Hu.mane Society ok the Commonwealth of
Massachusetts. Report 1895 and 1896. Boston.
1896.
This volume contains an interesting report by Drs. J.
Collins Warren and George B. Shattuck of an
investigation into the methods of resuscitating the apparently
drowned. It contains also much valuable information con-
cerning the society and its work.
Jackson's Ready-Reference Handbook of Skin
Diseases. The Ready-Reference Handbook of Diseases
of the Skin. By George Tho.mas Jackson, M.D., Pro-
fessor of Dermatology, Woman's Nledical College of the
New York Inhrman' and in the University of Vermont,
Chief of Clinic and Instructor in Dermatology, College of
Physicians and Surgeons, New York. New (second) edi-
tion. In one i2mo volume of 589 pages, with 69 illus-
trations and a colored plate. Cloth, $2. 75. Philadelphia:
Lea Brothers & Co. 1896.
In bringing out a second edition of this work considerable
improvement has been made both by the author and by the
publisher. The volume presents a better appearance, and
the text and illustrations have been added to, both in quantity
and quality.
The same yellow-jacket-like frontispiece confronts one as
heretofore. While the pathological portion of the picture
may be true to nature, the outline drawing of the individual's
anatomy can scarcely be so considered. One is always pre-
pared to admire in art, though never having seen it in nature,
a blue Italian sky or a lilac atmosphere of the Pacific Coast,
although believing the painting overdrawn. It is difficult to
admire this picture from the artistic side, or to believe that
the coloring is not exaggerated. However, the case is an
interesting one.
While the alphabetic arrangement of skin diseases is not
to be compared to a scientific classification, were one possi-
ble, it does away with the possibility of controversy and
criticism, and makes reference to particular subjects easy.
To the list of the first edition have been added some
seventeen additional diseases, beginning with acromegaly
and ending with porokeratosis, and the number of extra
illustrations exceeds the new chapters.
The text in many parts has been rewritten and added to,
enhancing the value of an already useful work conscientiously
prepared.
Intercostal Neuralgia, double-sided and very vio-
lent, persisting for months, was completely and defi-
nitely cured by Dr. (Goldberg after three injections of
ichthyol. The solution employed contained thirty
centigrams in one hundred grams of water. A syringe-
ful each day was injected. The pain lasted two or
three hours after each injection, but was not too severe
to keep the patient away from the theatre. — Gaz. hebd.
Med. de la Russie Mcr., No. 2, 1896.
October 31, 1896]
MEDICAL
Pseudo-Jusquiamine, one of the three alkaloids dis-
co\ered by Merck in the Duboisia myoporoides, acts
as a mydriatic, decreases salivary secretion, and when
injected subcutaneously, even in large doses, dimin-
ishes the number of pulsations without paralysis of the
vagus. It has no value in hystero-epilepsy, and is not
toxic even in large doses. — Buonarotti.
Headaches. — Dr. M. Galliard directs attention to a
form of headache which is differentiated from migraine
and syphilitic cephalalgia by its continuity, the absence
of nausea and vertigo, and its cessation at night. It
is nearly always limited to the forehead, occasionally
to the verte.v, to the occiput, or to the temples. It
generally survives any coincident disorder of the
primas via;, and is distinct from the persistent head-
ache of neurastiienia, which it resembles in its resis-
tance to ordinary remedies. Dr. Galliard recommends
a grain and a half of calomel in the morning before
breakfast for six consecutive days. On the third or
fourth day diarrhoea with colicky pains may set in.
The gums should be carefully watched. If the head-
ache should persist, a similar six days' course should
be given after a few weeks.
Alcohol as a Disinfectant in Obstetric Practice.
— Drs. Ahlfeld and Vahle ' {Dciitsihe nudninisc/ie
Wocheiiscliriff, 1896, No. 6) describe some experiments
made to ascertain the value of alcohol as a practical
disinfectant in obstetric practice. The results ob-
tained by disinfecting the hands with alcohol have
been ascribed to the solvent properties of alcohol upon
fatty tissues, thus allow-ing bichloride of mercury and
other antiseptics to come into immediate contact with
the bacteria. Some assert that alcohol does not de-
stroy bacteria, but coagulates theepithelia of the skin,
and in this way hardens them without preventing the
passage of germs. It has been found that alcohol does
destroy germs, but acts more efficiently upon micro-
organisms containing water or those found in tissues
containing water. Dr. Ahlfeld finds that alcohol does
not act simply by dissolving fatty si:bstances, because
ether, which is a better solvent of fat, is not very effi-
cient as an antiseptic. Experiments prove that alco-
hol exerts a direct inHuence in destroying virulent
streptococci. Alcohol exerts but feeble influence upon
dried tissues containing bacteria and upon bacteria
from which the water has been removed. An experi-
ment was made with amniotic membrane when wet
and when dry, which illustrated in a striking manner
the action of alcohol on a moist membrane. Experi-
ments upon the hands of attendants and nurses de-
monstrated the value of alcohol as a disinfectant.
Disinfectants in Obstetrics Dr. Jewett {Ameri-
can Gynecological and Obstetric Journal) submits the fol-
lowing interesting conclusions to an article on this sub-
ject : There is no clinical proof that puerperal infection
can occur from normal vaginal secretions. All childbed
infection in women previously healthy is by contact.
Prophylactic vaginal disinfection as a routine measure
is unnecessary, and even in skilled hands is probably
injurious. Its general adoption in private practice
could scarcely fail to be mischievous. In healthy
puerper*, delivered aseptically, post-partum douching
is also contraindicated. These rules must hold good
in the simpler cases of manual or instrumental inter-
ference in which tiie uterus is not invaded. A purulent
vaginal secretion exposes the woman to puerperal in-
fection. In the presence of such discharges at the
beginning of labor, the vagina should be rendered as
nearly sterile as possible. Concentrated antiseptic
solutions should not be used, and the process should
RECORD. 649
be conducted with the least possible mechanical in-
jury to the mucous surfaces. In case of highly infec-
tious secretions, the preliminary disinfection should
be followed by douching at intervals of two or three
hours during the labor. Sterilized glycerin, or other
suitable material, may be used to restore the proper
lubrication of the birth canal. The safest and most
efficient means for correcting vicious secretions is a
mild antiseptic douche, repeated once or oftener daily
for several days during the last weeks of pregnancy. It
is the duty of the obstetrician to know before labor
the amount and character of the vaginal discharge.
Clinically, the amount of the discharge, its gross ap-
pearance, and that of the mucous and adjacent cuta-
neous surfaces usually furnishes a sufficient guide to
the treatment. Probable unclean contact within
twenty-four or forty-eight hours is an indication for
prophylactic disinfection.
Measles. — Chronic bronchitis, broncho-pneumonia
long in resolution, and, though less often, empyema,
are familiar sequela;, as well as chronic tuberculosis,
especially of the lungs and bronchial glands. Mea-
sles indeed seem to prepare the ground for the tuber-
culous process in a large proportion of children who
die from tuberculosis in its various forms, whether
acute or chronic; and there are ver)- frequent instances
of previously healthy children in whom wasting and
chronic disorder, both in the pulmonary and alimen-
tary tracts, and not necessarily tuberculous, seem to
arise directly out of severe attacks of measles. — H.
Bryan Donrin, The Diseases of Cfiildhood, p. 186.
Eczema of the Breast and Nipple. — The treatment
of eczema of the breast and nipple is with soothing
lotions, dusting powders, and cooling salves. When
fissures occur, every effort should be made to avoid
weaning a child dependent upon its mother's milk;
and in such event pencillings of the crack with weak
solutions of the nitrate of silver or with compound
tincture of benzoin may be used. The Lassar paste,
made stiff enough with talc to resist simple contacts
sufficient to remove a softer unguent, is an admir-
able application to these surfaces. All lotions and
salves require removal with a weak alkaline and gly-
cerin wash before tiie child is put to the breast. The
use of the rubber nipples and shields sold in the shops
is not wholly satisfactory. In treating eczema of this
region it is of value to spread strips of soft muslin
with the unguent or pomade ordered, and to retain the
dressing in contact with the inflamed surface by the
aid of cheese-cloth bandages. — James Nevins Hvde^
M.D., Tic'C/itieth Century Practice, \o\. w, p. 226.
Neurasthenic Headache
K Ammonii carlionatis 3 iij.
Tinct. moschi 3 vi.
Spts. lavandiiUt § i.
Eli.x. ammonii valerianatis | viij.
M. S. Two teaspoonfuls in water at a dose.
^Hamilton.
Paralysis Agitans. —
IJ Strychnince sulphat gr. i-
Acid, arseniosi gr. i.
E.\t. belladonna? gr. v.
QuininLi; sulphat 3ij.
Pil. ferri carbonat 3ij.
Ext. tara.xaci 3i.
M. et ft. pil. No. 90. S. One pill three times a day.
— S. W. Gross.
Obstinate Vomiting of Pregnancy was cured by
the application of electricity, but it was discovered
that the battery was not in working order at the time
the electrodes were applied, so that it was purely by
suggestion that the result was accomplished. — Dol£-
RIS, Lyon Medicate, May 17, 1896.
650 MEDICAL
Lobelia may be-given in nauseating doses to facili-
tate reduction of strangulated hernia. — Adulphus, The
Medical Brief, October, 1896.
Dyspeptic patients with constipation and enlarged
liver often do better on bicarbonate of sodium, ten
grains to a pint of hot water, slowly sipped three times
daily, than on any other form of treatment.
Loeffler's Solution. —
I^ .Mcohol 60 parts.
Toluol 37 "
l,iq. f erri perchloridi 4 "
Swab the affected parts with this everj- two or four hours.
Malarial Chills.—
W, Liijuor potassii arsenitis.
Tinct. iodi aa /. <r.
S. Ten drops in water or milk three times a day.
— A^ew York Polyclinic.
Antiseptic Wash for the Mouth —
1{ Thymol gr. iv.
Henzoic acid gr. xlv.
Tincture of eucalyptus | ss.
Essence of peppermint 3 i.
Chloroform "I xv.
Alcohol 1 iij.
M. Twenty drops of this solution, in a glass of water, may
be used at a time.
— Presse Midicale.
Ulcerated Sore Throat.—
\\ Chloral hydrate gr. x.x.
Water 5 iij.
Syrup 5 i.
S. Teaspoonful every hour or two for pain and to induce
sleep.
— Brodnax, Medical Council.
Preventive Treatment of Gout — We may almost
always prevent the painful attacks in chronic gout and
dissolve the deposits of biurates in the joints by com-
bining the use of lycetol with proper regime. This
drug has the uric-acid solvent properties of piperazin
joined to the diuretic action of tartaric acid. — Hkn-
LEY, Denver Medical Times, January, 189G.
Hot Baths in broncho-pneumonia of children are
advocated by Dr. Lemoine (Gaz. Med. de Lie^^e, May
7, 1896). Fifty-si.K cases have been thus treated.
They were all severe and all recovered. If there are
no extensive pulmonary lesions in the beginning, a
tepid bath is given and repeated every three hours
until defervescence. If lesions are extensive and the
fever is high, twice daily for two or three days a mus-
tard bath is given, and in the intervals a simple bath
every three hours. In five adult cases of very severe
congestion in the grippe, the bath succeeded completely
after all other medication had failed.
Asthma. — There have been numerous classifica-
tions of the disease, but it appears to me that they
can all be included under three heads, according to
the apparent provoking cause, viz. : (i) Irritation of
the terminal filaments of the vagus nerve, either in the
respiratory passages, particularly the nasal, or in the
digestive tract, the stomach probably chiefly ; (2) irri-
tation of the main trunk of the nerve itself; (3) irri-
tation of its origin in the brain. Of these three
causes, the first two are decidedly the most common,
and are frequently combined, as is illustrated by some
of the cases I have recorded. The last, or purely
ner\'ous forin, in which the paro.xysm occurs indej^en-
dently of any local irritation, is probably rare, and, I
am inclined to believe, will be found to be more un
common the more thoroughly we are able to investigate
the conditions in each of our patients under which an
attack occurs. — Dr. Saunders, Canadian Practi/ioner,
March, 1896.
RECORD.
[October 31, 1896
Oil of Cloves is added to small doses of ipecac to
correct the nauseating properties.
Threatened Abortion. — Inject by the rectum twenty-
five or thirty drops of tincture of asafcetida in two or
three soupspoonfuls of water. — \\'ar.mann.
Antineuralgic Powder.—
H Powdered ^'uarana 0.75 cgm.
Sulphate of quinine 0.20 "
Bicarbonate of sodium 0.75
Salicylate of sodium 0.75
For one dose to be taken in several cachets.
— Le Scalpel.
Intestinal Hemorrhage in Typhoid. —
M, Henzonaphthol 5 gm.
Salicylate of bismuth 10 gm.
Extract of opium ; o. 10 cgm.
Syr. of rhatany 30 gm.
Syr. of orange flower 30 gm.
JIucilage 120 gm.
Soupspoonful every hal'-hour.
• — /(• Scalpel.
Aqueous Extract of Cannabis Indica is said by
Lees {British Medical Journal, I., 300, 1895) not to
possess the almost to.xic infiuence of the alcoholic
preparation. It does not infiuence the secretion of the
bronchial glands, and hence is at times preferable to
opium. In phthisis it is said to calm the attacks of
cough, and is a valuable soporific in diseases of in-
fancy. The adult dose is from two to four grams,
while children may be given one or two centigratus for
each month of their age. The following formula is
given :
1^ E.x. cannabis indicv aq 10 gm.
.•\q. aurantii llor ;o gm.
Saccharin (soluble) 0.2 dgni.
Dessertspoonful once or twice daily.
Extract of Myrtle. — This jireparation, made from
the dried fruit of the vaccinium myrtillus, has been
employed by W'inturnitz in certain cutaneous affections
(Blatter fiir klin. Hydroth., No. 4, 1895), such as se-
borrhctal, mycosic, and squamous eczemas, with prompt
and favorable results. Other observers have extended
its beneficial infiuence to the treatment of burns. A
thick layer is i)ainted upon the skin and covered with
a thin layer of absorbent cotton, and the whole is re-
tained by a gauze bandage. Upon the face after the
extract is applied rice ])owder is sprinkled. When
the cotton adheres it should be removed once a day or
less freciuently, after moistening with a one-per-cent.
chloride-of -sodium solution.
Constipation in Women. — .\ very frequent cause
of disease in women is constipation. It is remarkable
how careless many women are in this respect. It de-
volves upon the mother to educate the daughter that it
is necessary to health that the bowels shoidd move at
least once in twenty-fotn^ hours. Not only do they
have from constipation a ])oisoning of the .system from
absorption of the licpiid and gaseotis contents of the
bowels, the ptoinains or poisons developed in them
from fermentation i^roducing depressing effects on the
nervous system, with derangement of the stomach and
assimilative organs, as shown in pale faces, debility,
neuralgia, headache, etc.; but we get, in addition,
from impaction of the fa;ces in the rectum, uterine dis-
placement, with its consequent disturbances in the
pelvic circulation and with its general refiex neuroses.
Gynecologists know well that the left o\ary is more
often diseased than the right one. The left ovarian
vein has no valve, and a slight pressure upon it pre-
vents it emptying. Doubtless the pressure of a loaded
rectum in this event is a prolific cause of ovarian dis-
ease, especially on the left side. — Dr. Holms, South-
ern Medical Journal.
October
1896]
MEDICAL RECORD.
6si
l%tw Justrunicnts.
TtVcdical Items.
TWO NEW NEEDLE HOLDERS.
By GEORGE HASLAM. M.D.,
FREMONT, NEB.
Some time ago Messrs. Tiemann & Co. made for me a
needle holder which has proved very satisfactor)' for
suturing or catching on a needle and thread a bleed-
ing point in any deep cavity.
The blades of the instrument are five inches long,
making the whole instrument nine and one-half inches
in length; at the same time the blades are only one-
fourth of an iiich in cross-section.
As seen in Fig. i, the chief advantages offered in
Contagious Diseases — Weekly Statement Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending October 24, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Smallpox
Fig. I. Fit.. 2.
this instrument are an almost unobstructed view of the
site of operation; an instrument which will with equal
facility hold a Hagedorn or an ordinary needle;
lastly, the ease with which a needle is caught, for
there is no necessity of passing one jaw under the
needle, as with most instruments.
Fig. 2 represents a smaller instrument, fitted with
the well-known automatic catch, and designed for
more superficial work. I5oth instruments have proved
very useful in my hands, and they are readily cleaned.
An Imaginary Invalid, who lived in a large
square of London, was ordered by his doctor to take a
turn round the square every morning before breakfast.
One day the doctor found him very nervous and de-
jected. "Ah, doctor," he said, '" I am certainly much
worse. I have been able to walk round the square
until to-day, but this morning I was so tired that when
I had walked half-way I had to return home again." —
TAe Sca/pc/.
The Russian Government has issued instructions
to all its consuls to give the necessary zise to the pass-
ports of all physicians, whether Jew or Christian, who
may wish to attend the Moscow congress.
Insomnia is a common complaint of Arctic e.xplor-
ers who winter in the polar regions, but with the re-
turn of the sun the ability to sleep the usual number
of hours is regained.
Medical Women in the Elizabethan Period
During the sixteenth centurv luo women were licensed
to practise, one surgery and the other medicine, in
Norwich.
The Cost of a Medical Education in Germany is
estimated to be about S700 a year for four years.
This includes only the neces.sary e.xpenses for tuition
fees, books, and board, and allows nothing for beer
and tobacco.
An Inspector of Medical Schools. — It has been
proposed that an ofiicial be appointed to inspect all
the medical schools of the country, in order to make
certain that they do what they promise in their cata-
logues to do in the way of imparting an education.
^00 ks ^lecciuctl.
IVhil:! the Medical Record is fieaseJ to receive all new publi-
cations which may he sent to it, and an ackno'vUdgment ivill be
promptly made of their receipt under this heading, it must be with
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it 7ohich in the judgment of its editor %i'ill not be
of interest to its readers.
A Text-Book ui Diseases ok the Nose and Throat, f.y
Francke Huntington Bosworth, M.D. Svo, S14 pages. Illus-
trated. William Wood and Company, New York. Price: mus-
lin, S5.50; leather, S6.50.
A Practical Treatise on Medical Diagnosis for Sti--
DEN'TS and Physicians. Svo, 938 pages. Illustrated. Lea
Brothers & Co. . Philadelphia, P.a.
Transactions OK niE Miciiii;an Siaik MKiiit:AL Societv
fur the year 1S96. Svo, S34 pages.
I'kansactions ok the Medical Society ok Wisconsin
for the year 1896. Svo. 593 pages.
Diseases ok ihe Eye. By G. E. de Schweinitz, M.D. Sec-
ond Edition. Svo, 679 pages. Illustrated. W. B. Saunders.
Philadelphia, }'a. I'rice: cloth, S4.O0; sheep or half morocco.
$5.<x).
.\ Text-Hook ok Si'Ecial Pathological Anatomy. By
Ernst Ziegler. Translated and edited from the eighth German
editition. By Donald Mac.Mister, .\I.D., and Henry W. Cattell,
.\I.I). Svo, 575 -!--''■'''<'•• pages. Illustrated. The Macmillan
Company, New York.
Modern Creek Mastery: A Short
Greek. By Thomas I,. Stedman, M.D.
Harper & Brothers, New \'ork.
KOAD T') .\ncient
i2mo. 380 pages.
6S2
MEDICAL RECORD.
[October 31, 1896
c<(lltntcf Jlcaltlx ^%csovt5.
liv A. F. McKAV. .M.l)..
CHICAGO, ILL,
From meteorological tables, geographical and other
data, a general opinion can be derived as to the na-
ture of the climate of a section, and whether it is fa-
vorable or unfavorable to health. It will generally
be found, however, that there are strictly local condi-
tions which may seriously affect the salubrity of a par-
ticular resort or hotel, as too much shade, bad drain-
age, poor water, malaria, etc., which should enter
into consideration in determining whether a given
locality is or is not the best place to send a special
case, which can be ascertained only by a personal ex-
amination by disinterested parties. We would, there-
fore, call attention to the responsibility assumed by a
physician in sending a patient a long distance from
home, merely with a vague idea of the benefit to be
derived from a change, without a precise knowledge
of the place or conditions which the patient will find
at his destination.
Climate is so dependent upon purely local condi-
tions, pertaining often to only a limited area of terri-
tory, that it is impossible for any work based solely
upon "official" data, taken at fixed points, to convey
anything more than a generalization. These condi-
tions can only be ascertained by a careful study of
the localities claiming the patronage of the health
seeker, and the physician who prescribes climatic
change for his patient on generalizations will benefit
just about as large a proportion of them as he would
if he filled his prescription for all patients from one
bottle. The ideal health resort must have a natural
basis upon which to build, conditions of soil which
render it easily drained, ample supply of water free
from contamination and not too strongly impregnated
with minerals to be suitable for drinking-purposes.
Owing to the attempt so often made to combine the
functions of health and pleasure resorts, places which
have the elements of the former in large degree are
often rendered useless as such from the preponderance
of the latter. In studying winter resorts we will save
space and avoid repetition by making a classification
of climates into four classes, based upon variations of
altitude, temperature, rainfall, and humidity.
Class I. — A low, damp, warm climate will include
all below fifteen hundred feet in altitude, with a mean
annual temperature of 55' F. or above, an annual rain-
fall of thirty-five inches or more, and a relative humid-
ity of seventy-five per cent, or more.
Class 2. — A medium, damp, warm climate will in-
clude all having an altitude between fifteen hundred
and three thousand feet, a mean annual temperature
of 50' F. or higher, an annual rainfall of twenty-five
inches or more, and a relative humidity of seventy per
cent, or more.
Class 3. — A medium high, dry climate is one be-
tween three thousand and forty-five hundred feet in
altitude, with an annual mean temperature of 45^ F.
or higher — governed by latitude — a rainfall of twenty
or more inches, and a relative humidity of sixty-five
per cent, or more.
Class 4. — A high, dry climate is one above forty-
five hundred feet in altitude, with mean temperature
from 40' to 50^ F., an annual rainfall of less than
twenty inches, and a relative humidity of below sixty
per cent.
While in a low, damp, warm climate pulmonary
affections are less prevalent as indigenous disease than
in a low, damp, cold climate, yet it is not so favor-
able for recovery as the higher and drier climates.
Kidney disease, in general, is most favorably affected
in the medium high, dry climate, where evaporation
from the skin is active if not subject to too sudden
changes. Digestive diseases are less frequent and
less severe in the low, damp, warm climate than in
almost any other, although aft'ections of the liver are
more frequent, this type of disease being more preva-
lent in all warm, damp climates. The warm, damp
climate is the most favorable for nervous diseases,
especially if complicated by disturbances of the circu-
lation. Acute inflammatorj' diseases are more preva-
lent and more severe in the high, dry climates than
in the low levels and where there is more moisture.
Rheumatism is generally improved by the high, dry
climates more than the low, damp ones, except when
complicated by cardiac affections, when a low altitude
and dry climate should be selected. While this clas-
sification is but crude and fragmentary', yet it may aid
the physician somewhat in the selection of a resort for
various classes of invalids.
In the consideration of winter resorts the aim will
be not so much to cover all the possibly available re-
sorts of the South as it will be to mention a few re-
sorts available for all classes of invalids, not only
classes with regard to the diseases for which it may be
desirable to find a resort, but with regard to the cir-
cumstances and conditions of the health seeker.
Beginning with Washington, on the border line be-
tsveen summer and winter resorts, we will consider a
limited number in Virginia, North Carolina, South
Carolina, Georgia, Florida, Alabama, Tennessee,
Mississippi, Louisiana, Arkansas, Kansas. Colorado,
New Mexico, Texas, Arizona, and California.
WASHINf.TOX, D. C.
In an article of this kind no detailed description of
Washington as a city need be attempted, further than
to state that it furnishes more attractive entertainments
as a winter resort than perhaps any other city in the
union. The winter climate is an uncertain one, as
experienced by the writer during nine years' residence.
Some winters, in fact most of them, average delightful
weather: yet there are many disagreeable days and
occasionally a winter of severity, when cold weather
and a frozen river remind the Northern visitor very
forcibly of the weather he left behind him. Washing-
ton is practically at sea level, the Potomac being a
tidal river to a point some miles above the city. The
mean annual temperature is 55' F. : mean precipita-
tion, forty-three inches: per cent, of cloudiness for
winter, fifty-eight: and relative humidity, seventy-two
per cent., bringing the city under Class i. Washing-
ton is not a desirable winter resort for pulmonary
invalids.
Virginia
Can hardly be considered a winter resort, except, per-
haps, along the coast region, on the ocean and great
bays which indent its shores, where fine fishing and
hunting afford ample sport for the pleasure seeker,
while the invalid will find almost too many winter
days, and is likely to move on farther south. Rich-
mond, Norfolk, Virginia Beach, Newport News, Old
Point Comfort, Char'ottesville, Lynchburg, and Dan-
ville, all are places where breaks in the journey to
the Southern resort may be made and many enter-
taining features be enjoyed: but none except those on
the coast offer any special attraction as resorts.
North Carolina
Furnishes quite a variety of resorts, varying in alti-
tude from sea level to a number of thousands of
feet above The State is divided into three distinct
October 31, 1S96]
MEDICAL RECORD.
65:
divisions, known as the "eastern section," the "mid-
dle and Piedmont section,'' and the "• mountain sec-
tion." These divisions are a consequence of tlie
general topography of the State, which may be de-
scribed as a vast declivity, sloping from the summit
of Smoky Mountain, at an altitude of seven thousand
feet, to the level of the Atlantic Ocean, which forms
the eastern boundary of the State. The length of this
slope is about five hundred miles, and it is made up of
three immense terraces. The first is the "eastern sec-
tion,'' constituting a vast plain extending from tlie
coast inland for a distance of about one hundred and
twenty-five miles. The surface of this plain rises by
easy gradations at the rate of a little more than a foot
to the mile. The second or "middle section," com-
prising nearly half the area of the State, varies from
three hundred to one thousand feet above the sea
level. The third terrace, or " mountain section," is
the highest elevation in the United States east of the
Rocky Mountains, averaging about three thousand feet
above the sea. With a situation nearly midway of
the nation, north and south, and with the varieties of
altitudes, North Carolina furnishes all the gradations
of climate found at sea level between the Gulf of Mex-
ico and the Gulf of St. Lawrence, and a variety of
products, from the palmetto and Magnolia grandifiora
to the white pine and hemlock, and from the sugar
cane and rice to Canadian oats and buckwheat. One
of the first of its resorts reached by rail from the
north is
Raleigh, situated midway of this general slope and
on the second terrace, enjoying the average of the
general temperature of the State. The city is situated
upon a granite foundation, which crops out on its
southern limit, furnishing abundant material for the
finest buildings. The site slopes gently in every di-
rection, affording perfect natural drainage. The clear
water streams rising from the granite mountain ren-
ders the problem of an abundant and pure water sup-
ply one of easy solution. Raleigh is called the " City
of Oaks," some of the most magnificent specimens of
this monarch of the forest gracing the streets and parks.
The elevation of Raleigh above sea level is three hun-
dred and fifty feet. The mean annual temperature is
60.1° F. The mean temperature for January for a pe-
riod of twenty-one years is 41.2 ' F. The mean of the
lowest temperatures for January is 32.1^ F., and, as
January is the coldest month, these figures give an idea
of the coldest weather likely to be e.xperienced. The
average yearly rainfall in 47.67 inches. The average
for January is 3.38 inches, and for February 3.67
inches, this being a light average for the two months
most likely to be needed as a resort for Northern inva-
lids. Raleigh, being the capital of the State, naturally
abounds in social and educational advantages for the
home-seeking invalid to whom its medium climate
may be adapted. There are good hotel accommoda-
tions, and quite a resort business has been attracted.
Raleigh comes under Class i.
Salisbury. — Passing westward and upward from
Raleigh, we come to Salisbury, at an altitude of seven
hundred and sixty feet. It is one of the best of the
small cities of the State, and in climatic features is
very similar to Raleigh, the slight rise of a little over
four hundred feet not being sufficient to make any
marked difference in temjierature.
Hickory. — At an altitude of eleven hundred and
seventy-fi\-e feet and among the foothills of the
■"mountain section" is Hickory, which, with a fine
hotel and beautiful country surroundings, offers many
attractions for the invalid.
Hendersonville.— Next to Asheville in size and
advantages of hotel and modern city improvements,
Hendersonville is the best resort in the mountain sec-
tion of North Carolina. Its altitude is twentv-two
hundred feet, only two hundred and forty feet below
that of Asheville, and, as far as climate is concerned,
essentially in the same class.
Charlotte is historically interesting, from the fact
that it was here that the Mecklenburg declaration of
independence was adopted. It is also the centre of
the North Carolina gold fields, has well-paved streets,
and is, perhaps, as typical a city of the " new South"
as can be found. Tourists 01 route to or from Florida
will find Charlotte an excellent place to break the
journey, as most excellent hotel accommodations are
obtainable. The altitude of Charlotte is eight hun-
dred and eight feet; mean annual temperature, 60^ F. ;
mean annual rainfall, fifty-three inches; mean relative
humidity, sixty-seven per cent., bringing the city un-
der Class I.
Asheville. — Cntil quite recently Asheville has been
known principally as a summer resort, but since the
erection of several large and very fine hotels especially
adapted to the winter business the place has steadily
grown in favor as a winter resort and is one of the
most popular in the South. Asheville is situated in
the "mountain section" or high terrace of the State,
at an altitude of twenty-three hundred and forty feet,
protected on all sides by spurs of the Appalachian
chain of mountains, which constitute the "feature" of
this section. Asheville has attracted some of the
wealthiest men of America, who are spending millions
of dollars in beautiiying and embellishing a country
for which nature has done much. The city has spent
other millions in furnishing every convenience known
to modern city building. Six mountain streams, drain-
ing as many valleys, afford perfect drainage for Ashe-
ville, while springs of the purest water gush forth in
endless number from the hillsides in every direction,
thus furnishing an abundance of that very essential
element of the ideal health resort. The mean annual
temperature at Ashexille is 59^" F. : mean for winter,
45° F. Total annual rainfall, 42.6 inches, of which
9.5 inches fall during the winter: relative humidity,
70.1 per cent. Asheville is within Class 2 in every
particular, and may be considered an eligible resort
for consumptives as well as many other invalids.
Tyrone is a little hamlet of about three hundred in-
habitants, nestled among the hills at the foot of the
Tyrone range of mountains, forty-three miles south-
west of Asheville. Its population is almost exclusively
of Northern and Western people, and it aftords a desir-
able resort for the home-seeking invalid of moderate
means. The altitude of Tyrone is fifteen hundred feet
above sea level. Mean temperature for Januar)-,
41.29° F. ; February, 41.3° F. ; March, 52.8° F. —
bringing Tyrone on the dividing line between Classes
1 and 2.
South Carolina.
In topography South Carolina very much resembles
the eastern and middle sections of North Carolina,
but it lacks the mountain section, the highest ele\a-
tion in the State not exceeding one thousand feet and
falling gradually from the northwest to the southeast.
The eastern or coast section has but one place of an)'
importance as a resort, viz.,
Charleston. — The climate of Charleston differs but
little from tliat of many favored localities of southern
Europe. The mean annual temperature is 67" P\, and
the mean annual rainfall sixty inches. The relative
humidity is seventy-eight per cent. Charleston comes
under Class i, and is hardly to be considered a desir-
able climate for consumptives, but more favorable for
nervous diseases, especially those with cardiac compli-
cations. Charleston offers many attractions for the
tourist, as the city has many interesting features along
commercial and historical lines.
Columbia. — The men who laid out the citv of Co-
654
MEDICAL RECORD.
[October 31, 1896
lumbia over one hundred years ago were far-sighted,
liberal-minded men, for the streets are one hundred
feet wide, with avenues of one hundred and lifty feet in
width, and the site, elevated on a picturesque hilltop
overlooking valleys for scores of miles, is one rarely ex-
celled. It affords excellent natural drainage, and there
are no stagnant pools or marshes in the vicinity. C'o-
lumbia has one of the finest water powers in the South.
Many of the streets have magnificent rows of elms that
shade the walks, and also rows through the middle of
wide avenues, reiving the city the appearance of a large
park. The mean annual temperature at Columbia is
63° F. ; and of winter, 47.5 ' F. The total rainfall is
forty-seven inches, the average for the winter months
being a little less tlian four inches. The altitude is
four hundred feet.
Aiken has for many years been a jjroininent resort
for consumptives. It is situated in the i)ine woods,
which fact gives it some advantages over places with
similar climate but without the woods. The mean an-
nual temperature is about 64" F., with a mean for
winter of about 50'' F. The mean relative humidity
is about sixty-three per cent., tiie rainfall forty-nine
inches, and the altitude two hundred and fifty feet, the
town being situated on a ridge overlooking the low
country around.
Georlii.a.
In general topography Georgia differs but little
from South Carolina, except that in the extreme north-
western portion the country is given the characteristics
of western North Carolina by the southern extremity
of the .\ppalachian mountains. The highest altitudes
in the State are less than two tliousand feet, sloping
gradually down to the ocean on the cast and toward
the Gulf on the south. IJeginning with the higher
resorts, the most prominent from its importance as a
metropolis is
Atlanta, the name of which has been so indelibly
written on the historical and commercial pages of this
nation's history. It is not within the scope of this
article to enter into detail with regard to the great
industrial and commercial interests of .Atlanta, except
so far as it may be a matter of interest to the invalid
or tourist to know that there will be found every mod-
ern convenience and comfort of the most metropolitan
cities of the North, together with a climate which ad-
mits of the enjoyment of these advantages almo.st
uninterruptedly a great portion of the winter. Atlanta
is at an altitude of eleven hundred and thirty-one
feet, has a mean annual temperature of 62' F., annual
rainfall of fifty-se\en inches, and relative humidity
of sixty-nine per cent., coming within Class ,1, except
as to humidity, in which respect it is below that
class.
Lithia Springs. — Within forty minutes' ride of
Atlanta are the Bowden Lithia Springs, where the
temperature rarely goes above 85° or 90° F. in sum-
mer, or below 40^ F. in winter. '1 he altitude is twelve
hundred feet. The place has a semi-sanatorium witli
artesian water, besides the springs, which contain over
fcjur grains of lithium bicarbonate to the gallon.
Mount Airy is one of the highest resorts in north-
ern Georgia, seventeen hundred feet above sea level,
and has quite a reputation as a winter resort for con-
sumptives and asthmatics, is free from malarial influ-
ences, and is worthy of consideration.
Marietta, but a few miles distant from .\tlanta, is
quite a popular winter resort, and has some reputation
as a resort for consumptives, though why more favora-
ble than other points similarly situated is not apparent.
Rome is a Hourishing city of over fifteen hundred
inhabitants, situated in the northwestern corner of the
State sixty-five miles north of .Atlanta. Rome is situ-
ated among the fooJiills of the southern .\ppa!achian
mountains, at an elevation of nine hundred feet, and
has a picturesque as well as healthful location.
Augusta is situated on the Savannah River, two
hundred and fifty miles from its mouth and two hun-
dred feet above the sea. The city extends along the
river bank for a distance of about four miles, giving
it a pleasing picturesqueness. The streets are very
broad, are bordered with fine trees, and are exception-
ally well kept, many being paved with asphalt. Just
outside the city, about two miles, is Summerville, built
upon the sand hills, a natural sanatorium. Summer-
ville is on the same chain of hills as Aiken, S. C, six-
teen miles distant. The mean annual temperature at
.Vugusta is 65"' F. ; rainfall, fifty inches; and relative
humidity, sixty five per cent.
Savannah is pre-eminently a beautiful city, and it
is to the fortunate early arrangement of the town that
it owes much of its beauty. No oiher American city
has such wealth of foliage, united with all the conven-
iences of a great commercial city. Its parks and
squares are adorned with statues, fountains, and gi-
gantic oaks and magnolias, and among these are roses
which bloom luxuriantly in open air all winter. Sa-
\annah is eighty-seven feet above sea le\el, has an
annual mean temperature of 67'' F., annual precipita-
tion of fifty-three inches, and relative humidity of sev-
enty per cent. Points of interest near Savannah are
Honaventure, a cemetery noted for its unique foliage;
and Thunderbolt, where oyster roasts and fish dinners
are great attractions. The Isle of Hope is another
popular resort, where the best of fishing is found. All
of these are reached by electric cars.
Brunswick has grown in ten years from a straggling
\illage to a thriving city of ten thousand .souls. Situ-
ated upon a peninsula almost completely surrounded
by salt water, and with a complete system of sewerage,
the town is exceptionally healthful. One of tlie pleas-
ant features of Brunswick is its chain of a dozen sea
islands, with long stretches of magnificent beach,
which are rapidly gaining prominence as a winter le-
sort. These islands abound in game, such as wild
boar, deer, and c|uail. From the standpoint of either
business, pleasure, or health, Brunswick should not
be overlooked by the tourist or home seeker. Bruns-
wick is supplied with artesian water from wells four
hundred feet deep. The mean temperature for six
months, from October to March, is 59" F. The mean
for January is 47° F., while that of August is 82° F.
Thomasville. — .Among the pines of southern Geor-
gia is Thomasville, which for some years has been
gaining in popularity as a winter resort for invalids,
especially those of a tuberculous type. Thomasville
is three hundred and fifty feet above sea level, and
with a rolling topograph}' has good natural drainage
and freedom from malarial influences. Realizing the
value of invalid patronage, Thomasville lias provided
liberally in the way of hotel and boarding-house ac-
commodations. The mean annual temperature is 68"
F. ; the mean for December being 52.70' F. ; Januar}-,
52.15 F. ; and Februar)% 56.60 F.
Fi.<)Rin.\.
The genera', reputation of Florida as a winter re-
sort is so well established that little need be said in
the way of an introduction. That many invalids who
have been sent to Florida might have done much
better somewhere else is not so much an evidence
of the defects of Florida as a health resort as of the
ignorance of its true sphere on the part of those who
sent them there. For consumptives for whom there
is a chance of recovery in Florida there are better
localities, while for those for whom palliation only
remains there is perhaps no place more favorable;
while for the nervous, wornout invalid, with func-
October 31, 1896]
MEDICAL RECORD.
655
tional or organic heart complications, tlierc are few
if any more favorable places than Florida.
Fernandina, situated just within the border, in the
•extreme northeastern corner of the State, otters many
attractions to the tourist. A seaport on the Atlantic,
with a fine harbor and all the "modern improve-
ments," there is no lack of attractions. The climate
is practically the same as that of Jacksonville, thirty-
six miles distant.
Jacksonville. — The largest city of the State is Jack-
sonville, which, with its thirty thousand of population,
stretches back from the banks of the St. Johns Ri\er.
lieing the gateway through which the throngs of win-
ter visitors pass to the many resorts of the State, the
city has a metropolitan air. The accommodations for
the tourist and invalid are extensive and of every
■class, from the very highest to those which can meet
the requirements of a limited purse. The mean an-
nual temperature is 6g" V. ; mean precipitation, fifty-
ihree inches; and relative humidity, seventy-four per
<:ent. Average cloudiness for winter is forty-seven
per cent, of possible svmshine.
St. Augustine. — As one proceeds southward along
the coast, St. Augustine is the next resort of note. St.
.\ugustine has many attractions of antiquity as well as
modern improvements, and is one of the most inter-
esting places in Florida. Being situated on the At-
lantic, its climate is more essentially an ocean climate
than is that of the resorts situated inland or on the
Gulf coast. Other resorts along the coast line, with
climatic conditions varying but little except to escape
all frost, as one goes farther south, are Ormond, Titus-
ville, Rockledge, and Lakeworth, the latter being the
most southerly point accessible by rail on the Florida
peninsula. Almo.st directly across the peninsula on
the (}ulf coast is
Punta Gorda, which means full point or fat point.
Though the town is not yet full-grown, it is taking
shape and beauty, and affords excellent hotel facili-
ties for the winter tourist, who finds sport and recrea-
tion in the waters of the bay. Punta Gorda was be-
low the frost line in the disastrous winter of 1894-95,
which so materially altered the meteorological records
of the State of Florida.
Fort Myers was an army post for many years, but
now is assuming all the airs and ambitions of a health
resort. The streets are shelled, and shaded by tropi-
cal trees. The Punta Raesa River afl'ords the finest
sport in tarpon fishing to be had in Florida waters,
over a hundred a day of these gamy monsters having,
been landed by the fishermen.
Tampa is to the west coast of Florida wliat Jack-
sonxille is to the east, /.c, the gateway from the Gulf
of Mexico. Tampa has rapidly grown to an important
connnercial centre, and is becoming a rival of Jack-
sonville for the patronage of the winter tourists, hav-
ing hotels equal to those of any of the resorts of the
Atlantic side of the State. \\ hile it is not the pur-
pose of this article to mention hotels in particular,
it is perhaps excusable for us to say that the Tampa
Fiay Hotel has no superior anywhere from the stand-
point of sanitary perfection. The mean winter tem-
perature of Tampa is 72" F.
St. Petersburg. — From Tampa can be seen St. Pe-
tersburg, a growing village six miles away, located on
the southern extremity of the peninsula which lies
between Tampa Hay and the <Julf. 'I'his is a delight-
ful resort for the invalid in winter, and is especially
ap|)ropriate for those who do not care for the more
expensixe attractions of the larger hotels.
Bartow. — Thus far we have considered only the
coast resorts of the State. Almost directly east of
Tampa, near the centre of the State, east and west, is
Bartow, a town of twenty-five hundred people, with
manv interesting features.
Lakeland, as suggested by its name, is in the centre
of the lake region. The lakes of Florida all have a
common le\el and are on the highest land of the
State. Lakeland has pure air, pure water, and an ex-
cellent hotel.
Orlando. — The largest interior town in the State,
situated among the lakes and with excellent hotel fa-
cilities, Orlando offers good features to those who
prefer an inland resort. For many classes of invalids
the inland resorts are more favorable during January,
February, and March ; but by April the weather gets
warm and the ocean resorts are more comfortable for
those who do not care to return North so early.
Gainesville is the centre of an "all-around" region,
and is the meeting-point of the up-country and low-
country products. Corn, oats, and Jersey cows flour-
ish, and, although tropical fruits catch a frost occa-
sionally, it is a good region for the home-seeking
invalid.
Pensacola. — Western Florida has been less promi-
nent as a health-resort region than the peninsular
section, but Pensacola is entitled to a place among
the eligible resorts, and is by all odds the leading re-
sort of western Florida. Its principal attraction is its
bay and the entertainment that can be derived from
fishing and sailing thereon. Many winter tourists
already appreciate the attractions of Pensacola, and its
old forts, its navy yard, and its facilities for driving,
boating, fishing, and hunting will attract increasing
numbers. The mean annual temperature is 64° F. ;
rainfall, sixty-nine inches; relative humidity, seventy-
six per cent.
Alabama.
There are no marked features of special interest to
the tourist or invalid in Alabama. The topography
is without much variation, except in the extreme
northern portion of the State, where the terminal
spurs of the Appalachian Mountains render the coun-
try rough and rugged, the highest points lying about
two thousand feet above the sea, and gradually sloping
from that to its level or nearly so at the southern line.
Huntsville. — Situated in the northwestern portion
of the State, at an altitude of seven hundred feet, with
the mountain spurs surrounding it to a height of sev-
eral hundred feet, Huntsville ofi'ers many attractions
as an early winter and early spring resort. In fact,
the entire winter is mild and pleasant, though not en-
tirely devoid of winter features, such as an occasional
snow and frost. Huntsville has good hotel accommo-
dations and as good water as can be found anywhere.
The mean annual temperature is 62*^ F. ; annual rain-
fall, fifty-eight inches; relative humidity, seventy per
cent. There are a number of fine mineral springs in
the vicinity of Huntsville.
Citronella, in southern Alabama, in the pine belt,
has more than a local reputation as a consumpti\e re-
sort. It is not much of a place, but has a good sana-
torium and enjoys a large patronage.
Mobile. — Mobile Bay and its attractions offer in-
ducements for the tourist, though the city has not made
any effort to attract invalids. While Mobile is a sea-
port city, it is quite elevated, afifording good drainage,
and, with the breeze from the Gulf to temper the heat
of summer and the cold of winter, it has a mild and
equable climate. The annual mean temperature is
67° F.; rainfall, sixty-six inches; and relative humid-
ity, seventy-four per cent.
Tennessee.
While Tennessee is not far enough removed from
the snow and ice of the Northern States to be con-
sidered a typical winter resort, the region has a good
winter climate and is especially well adapted to the
656
MEDICAL RECORD.
[October 31,
1896
purposes of a "half-way" stopping-oft' place for early
winter and late spring for invalids who must leave
the North early and return late. It is a high, dr)',
and healthful State, free from malaria, as a rule, and
offering many advantages for the home-seeking in-
valid.
Nashville is five hundred feet above sea level, in
the beautiful and fertile Cumberland valley. The city
is one of the best built and best paved in the country,
and offers many advantages for either the invalid,
tourist, or home seeker. The mean temperature is
60"" F. ; rainfall, fiftj'-two inches; and relative humid-
ity, seventy per cent.
Chattanooga. — In the southwest corner of the State
and in the heart of the mountain region of Tennessee
lies Chattanooga, which, with its Lookout Mountain,
comprises one of the most attractive resorts of the
South. It is far enough south to have the advantages
of a mild climate without the debilitating effects of
malaria, which are to be guarded against in the lower
Southern resorts. The traveller expects to find such
combinations of mountain and plain in the edge of the
Rockies and other great mountain chains, but it is
doubtful if any other such combination is to be found
so accessible to all the great centres of the country.
Lookout Mountain has one of the finest resort hotels of
the Soutii. Chattanooga is seven hundred and eighty-
three feet above sea level, while Lookout Mountain is
twenty-three hundred feet. The mean annual temper-
ature of Chattanooga is 61° F. ; annual rainfall, si.xty
inches: and relative humidity, seventy per cent.
Knoxville is nearly in the centre of the east Ten-
nessee valley, in full view of the highest peaks of the
Appalachian Mountains, and surrounded by hard-wood
forests and valuable mineral deposits. Knoxville has
forty-five thousand population and excellent hotel ac-
commodations, is nine hundred and eighty feet above
the sea, has a mean annual temperature of 57" F.,
rainfall of fifty-three inches, and relative humidity of
seventy-two per cent.
Memphis. — In the extreme southwestern corner of
the State, on a bluft" rising one hundred feet above the
Mississippi, is Memphis, not noted as a health resort,
yet having many features which will commend it to
the winter tourist and certain classes of invalids, viz.,
those of a nen-ous type. The city is built on a series
of low hills, affording excellent drainage, which has
been supplemented with an excellent sewer system.
It has an ample supply of pure artesian water, and
has in ten years reduced one of the highest mor-
tality' rates to the rank of one of the lowest. With
good hotels and a number of excellent sanatoriums,
Memphis offers much to the invalid other than pul-
monary. The mean annual temperature is 61'^ F. ;
rainfall, fifty-five inches; and relative humidity, sev-
enty per cent.
Mississippi.
With the exception of a few resorts upon the Gulf
coast, Missssippi has but two or three places worthy
of mention.
Holly Springs, in the northern portion of the State,
is a pretty and well-drained town of moderate size,
but with better than the average hotel accommodations.
Jackson is the State capital, and as such has many
advantages not enjoyed by other cities of the State.
The topography is rolling, aft'ording good drainage,
besides which the city has many other attractive fea-
tures.
Vicksburg. — Since the great siege of Vicksburg by
Grant, its name has been a familiar one to everv intel-
ligent American. Probably few of this generation are
aware that the city is situated upon a high bluff', rising
very abruptly from the river to a height of several
hundred feet, which fact gives it a unique place among
the cities.of the Mississippi Valley. There are excel-
lent hotel accommodations, and aside from its histor-
ical interest the city has a place among winter resorts.
Bay St. Louis is located on the Bay St. Louis, an
arm of the Gulf of Mexico, and for some years has
been growing in popularity both as a winter and as a
summer resort. Being only fifty miles from New Or-
leans, it is a popular resort for the people of that city in
summer, and for the invalid or tourist from the North
in winter. VN'hile the hotel accommodations are fair,
there is room for a very much better resort hotel.
There are numerous boarding-houses.
Pass Christian — Like Bay St. Louis, this town is
situated upon a long peninsula. Along the entire
water front is a shell-paved avenue, hing under the
shade of magnificent live oaks and magnolias, which,
with its surrounding forests of pine, cover the place
with a perennial verdure. Roses and violets bloom
all winter, and it is always a land of flowers. The
mean annual temperature is 60" F. Pass Christian
has one of the best hotels on the Gulf coast.
Biloxi possesses all the advantages of climate and
attractions characteristic of the Mississippi Gulf coast,
and is a popular resort for Southern people, with a
growing popularity for the Northern tourist as a winter
resort. The town has several hotels, which were built
for summer-resort purposes, but have been recon-
structed to meet the demands of the Northern visitors
in winter. None of the Mississippi resorts are pro-
vided with as fine hotels as are the prominent Florida
resorts, but from all other standpoints they are fully
the equals of Florida.
LOUISI.'VNA.
Louisiana has a few points where with better hotel
accommodations a large class of invalids would find
congenial climatic conditions, but in this respect not
much is to be said.
New Orleans, with its unique cosmopolitan charac-
teristics, with its cemeteries, old markets, old ci\ili-
zation, and good hotels, will afford a desirable and in-
teresting point for a time, and should by all means be
included in the itinerary of the tourist who proposes
to "do" the Southern resorts. The mean annual tem-
perature is 69° F. ; rainfall, sixty-five inches; relative
humidity, seventy-one per cent.
Hammond. — Fifty miles north of New Orleans, at
an elevation of fifty feet above sea level, is Ham-
mond, situated in the long-leaf pine region which
stretches across the southern portion of the State. The
soil at H.uiiniond is sandy, well drained, and \ery pro-
ductive. Hanmiond has a good hotel, pure and abun-
dant artesian water, and in all respects is a most fa-
vorable place for the classes of invalids who must
keep to a low altitude. Bright's disease is almost un-
known among the inhabitants, and the locality has
proven very beneficial in many cases, the pure water
and mild climate with the " piney" air seeming to be
a good combination.
La Fayette. — Westward from New Orleans about
one hundred and fiftv miles is La Favelte, a town of
some five thousand population, and the only place be-
tween New Orleans and the Texas line that has any
appreciable elevation above the sea level. La Fayette
is situated upon a sandy soil, fifu-two feet above the
sea, and for a few miles the topography is rolling and
broken, offering excellent drainage. There is com-
parative freedom from the malarial influences which
are more or less prevalent in the towns of the low-
lands. La Fayette has very good hotel accommoda-
tions, but it must be remembered that very few places
in the territory southwest of the Mississippi have first-
class hotels, according to the Northern standard.
Lake Charles is located in southern Louisiana, at
October 31, i8g6]
MEDICAL RECORD.
657
the eastern end of the long-leaf pine region of western
Louisiana and eastern Texas. It lies beside a small
lake, is a well-built town, made up principally of
Northern people, and affords excellent opportunities
for the home-seeking invalid or for the tourist not too
fastidious as to accommodations, although they are not
below the average.
Kansas.
Many consumptives have passed through one of the
most favorable regions in the country for the climatic
treatment of their disease to regions better known but
no more favorable than southern and southwestern
Kansas. The latter, especially, is a region which
comes so near the point of aridity as to be uncertain
for agricultural purposes except under irrigation, but
one which combines with a medium altitude a very
large percentage of sunshine, absence of severe weather,
and entire freedom from malarial influences — condi-
tions which have proven curative to hundreds of pul-
monarv invalids.
Wichita. — The city of Wichita is in central south-
ern Kansas, not far from the southern line of the State.
It is a city which outgrew itself, but has many metro-
politan features which render it available as a health
resort. Good hotels, abundant supply of good water,
good drainage, and freedom from malaria are there.
Mean annual temperature is 54° F. ; rainfall, twenty-
nine inches: relative humidity, 68.4 per cent., with
two hundred and eight\-eight fair days in the
vear. The altitude is thirteen hundred and sixty-
six feet.
Hutchinson is a substantial city of ten thousand
people, the centre of the Kansas salt industry. It is
on the Arkansas River, and has much to commend it
as a winter resort for the pulmonary invalid, especially
those with nervous or cardiac complications. The
altitude is fifteen hundred and fort}' feet above the sea
level. The general meteorological data are about the
same as those of Wichita.
Garden City is a small place at present, but its
boom left it good buildings, water works, and sewer-
age not often acquired by the small town away out on
the plains. Its climate is especially adapted to the
needs of the pulmonary invalid. It lies at an altitude
of three thousand feet, the mean annual temperature
is 53' F. ; rainfall, 20.8 inches; and it averages sixty-
three per cent, of sunshine.
Arkansas.
The eastern half of Arkansas is composed largely
of swamp land, and has perhaps as unsavory a reputa-
tion as regards healthfulness as any portion of the
United States. But the western or Ozark Mountain
region is as exceptionally healthful as is the swamp
region unhealthful, and the time is coming when this
mountain region will become a favorite sanatorium,
both on account of its healthfulness and of its acces-
sibility.
Hot Springs. — The .-Vrkansas Hot Springs are too
well known to need more than a mention. Everything
that money can add in the way of embellishment is
being furnished to make the more available the many
natural attractions. Situated among the southern foot-
hills of the Ozark Mountains, the place is surrounded
with the spurs of the mountains, giving it a topography
both pleasing and healthful. The place is well sup-
plied with hotels and bathhouses, which will sustain
any standard of comparison. The altitude is six hun-
dred and ten feet; mean annual temperature, 61' F. ;
mean for winter, 51.77' F. ; annual precipitation,
72.26 inches.
Eureka Springs — The altitude of Eureka Springs,
which is twenty-one hundred feet, together with its
general meteorological and sanitary conditions, enti-
tles it to consideration as a medium-altitude resort for
pulmonary cases. While the precipitation is rather
high, the exceptional facilities for drainage render the
soil very dry, as shown by a relative humidity of 59.4
per cent. This is considerably below that of most of
the popular low- or medium altitude resorts. An-
nual mean temperature is 58.93° F. : mean for
winter, 42.08' F. ; rainfall, 32.79 inches; clear and
fair days, two hundred and ninety-nine. Eureka
Springs has e.xcellent hotel and boarding accommo-
dations.
Little Rock. — While not posing as a health resort,
Little Rock offers good hotel facilities, good society,
and a winter climate permitting much life out of doors.
The city stands upon rolling ground, affording excel-
lent natural drainage, and has all modern city im-
provements. Little Rock is three hundred and sev-
enty-one feet above sea level, has a mean temperature
of 63° F., annual rainfall of fifty-six inches, and a
relative humidity of seventy-two per cent.
Texas.
To attempt to describe Texas, with all its alti-
tudes, climates, and conditions, would require more
space than is allotted to this article, for it includes
almost every variety to be experienced in the entire
country, from sea level with sixty inches of rainfall
and roses in winter in the southwestern portion, to
seven thousand feet elevation, fifteen inches of rainfall,
and the winter of the temperate zone in the northwes-
tern portion. Between these extremes are all grada-
tions. The high altitudes of the northwest are cold
and rigorous in winter, while the high altitudes of the
south are mild and free from snow or ice.
Fort Worth Entering the State by the principal
northern roiite, Fort Worth is the first city likely to
be considered as an eligible health resort. The city
is somewhat rolling in topography, has excellent hotel
accommodations, and though in some seasons it expe-
riences considerable winter, yet the average for that
season is mild and pleasant.
Waco. — Following the central valley of the State
southward, Waco, with its hot artesian wells rivalling
those of Arkansas in valuable therapeutic effect, lies
in the direct pathway of the tourist. Waco has one
of the finest natatoriums with sanatorium combined to
be found anywhere in the South. Waco has fair ho-
tels, but they are the least of her resort attractions.
Austin. — The capital city has many natural advan-
tages as a winter resort, though no especial effort has
been made to attract tourists. Lake McDonald, formed
by the great dam across the Colorado River, constitutes
an attractive feature not to be found elsewhere in the
State. Austin has one excellent hotel and a number
of good ones. The mean annual temperature is 68^
F. ; that of Januar)% 50' F. ; Februarj-, 54^ F. ; March,
58° F. The annual precipitation is thirty-three
inches, and the relative humidity si.xty-eight per
cent.
San Antonio. — There is probably no city in Texas
or elsewhere in the Southwest so well known as a win-
ter resort as San Antonio. Situated just on the edge
of the arid region of southwest Texas, it partakes
somewhat of the characteristics of the country north
and east, which has ample rainfall for agricultural pur-
poses, and of that of the south and west, where irriga-
tion must be depended upon. The result of this loca-
tion is a considerable rainfall in average years, yet a
dr)' climate from the rapid absorption of the moisture
by the atmosphere of the arid region just beyond.
While San .\ntonio has not a tourist hotel proper, yet
it has e.xcellent hotel facilities and very numerous and
good boarding-houses. The city is of varied topog-
6^8
MEDICAL RECORD.
[October 3 i.
1896
raphy, well drained naturally, and has now a complete
sewer system and an excellent water supply. Mala-
rial influences are scarcely ever experienced. The
altitude of San Antonio is six hundred feet; mean
annual temperature, 68' F. ; annual rainfall, 31.88
inches; relative humidity, sixty-eight per cent. With
proper precaution in dress against an occasional
"norther," San Antonio is a very desirable resort for
the pulmonary invalid who has still a chance of re-
covery.
Kerrville is seventy miles north of San Antonio, at
an altitude of seventeen hundred feet, and offers about
the same general climatic conditions as that city, ex-
cept as to altitude.
Boerne is forty miles from San Antonio and fourteen
hundred feet above sea level. It has quite a reputa-
tion as a resort for consumptives, many of the San
Antonio physicians sending their patients there for a
change of scene and air.
Llano. — One hundred miles northwest of .\ustin,
at an altitude of eleven hundred feet, is Llano, situated
upon a granite formation, which insures the best of
sanitary conditions. This place is worthy of consid-
eration in looking up the Texas resorts.
Corpus Christi. — One hundred and sixty miles
southeast of San Antonio, on the Gulf of Mexico, is
Corpus Christi, a town of about six thousand inhabi-
tants, with good society and considerable reputation
as a winter resort. The region about Corpus Christi
affords the best of winter fishing and hunting, and
offers unlimited entertainment for the tourist or in-
valid. The climate of Corpus Christi and the Live
Oak Peninsula adjacent is the driest coast region
on the Gulf, and for mildness and dryness in winter
can be compared only to the climate of San Diego,
Cal. The hotel accommodations are not better than
those of the ordinary type, and would not suit fastidi-
ous invalids.
Galveston has many attractions, the principal one
being the magnificent beach, where bathing is fre-
quently indulged in all winter. Roses, orange blos-
soms, and strawberries are abundant all through the
ordinary winter. Galveston has a fine tourist hotel,
and is a progressive modern city. The mean temper-
ature is 70^ F. ; rainfall, fifty-three inches; and rela-
tive humidity, seventy-seven per cent. Galveston is
not a favorable resort for pulmonary invalids, but is
best adapted to those suffering from neurasthenia and
the general run of nervous diseases.
Houston is one of the best cities of Texas, though
as a health resort perhaps not so desirable as some
others. Yet there are good hotels, and many would
find it a pleasant and in every way desirable place to
spend a season.
Sour Lake is a small place about forty miles out
of Houston, toward the east, noted locally for its
medicinal qualities in the treatment of rheumatism.
While somewhat crude in its accommodations, many
well-to-do patrons go there for treatment.
El Paso.— Next to San Antonio, El I'aso is the best-
patronized winter resort in Texas, 'i'he climate of
Kl Paso is essentially that of New Mexico, as it is but
a few miles from the southern border of that Territory.
The city is substantially built upon a gently sloping
site, and is naturally well drained. The city water
supply is pure .so far as regards contamination, but is
not of the best quality for drinking, the best water for
that purpose being procured from springs adjacent to
the city. While the hotel accommodations are ordi-
nary, there are many good private boarding-houses and
a most excellent sanatorium. Hotel Dieu. where inva-
lids can obtain the very best of care. The altitude at
El Paso is thirty-seven hundred and sixty feet; mean
annual temperature, 64^ F. ; rainfall, eleven inches;
and relative humidity, forty-seven per cent.
New Mexico.'
New Mexico has for some years been gaining in
favor with the medical profession as a winter resort
for the pulmonary invalid. The portions of the Ter-
ritory best adapted as winter resorts have thus far
received the least attention, owing, very likely, to the
less desirable accommodations than are obtainable at
the northern resorts. W'hh the development of irriga-
tion so that available tracts of land can be brought
under cultivation, more attention will be given to
points in the southern part.
Las Vegas. — Entering the Territory from the north,
the first place of any note is Las ^'egas, near \\here is
located the most pretentious resort hotel in the Terri-
tory. Las \'egas Hot Springs, six miles distant, have
also gained quite a reputation for their medicinal
qualities. These are two distinct towns, though rap-
idly growing together, and the distinction of race is
also becoming less pronounced as the towns approach
each other. Las Vegas is at an elevation of sixty-five
hundred feet, has an annual temperature of 49' F.,
rainfall of fifteen inches, and relative humidity of forty-
five per cent. Las Vegas has a winter, but the snow
which occasionally falls lasts but a little while, the
dry soil rapidly drinking it up.
Santa F6. — Rising to an altitude of seven thousand
and sixty-four feet at Santa Fe, the invalid will find
the atmosphere a little light if he has come rapidly
from the low altitudes of the north and east. But at
this high altitude and in the very heart of the conti-
nent, he also finds the oldest civilization in the land.
Santa Fe abounds in interesting features and offers
many attractions to the tourist. The hotels are uniqui
and interesting. Many invalids find the winters a
little cooler than is agreeable, but there is no doubt
that if persistent the invalid will do as well here as at
the more southerly resorts. The mean temperature
1348° F. ; rainfall, fourteen inches; and relative hu-
midity, forty-five per cent.
Albuquerque is lower down the valley of the Rio
Grande, at an altitude of five thousand feet. The win-
ter is less severe here than in Santa Fe, but some snow
and frosty weather will be encountered. Albuquerque
has more of the characteristics of the modern city than
any other place in the Territory; very fair hotels and
boarding-houses afford accommodations.
Las Cruces. — ISetween Albuquerque and Las Cruces
there are a number of tovns of some importance, but
they have but meagre accommodations. As they de-
velop, Socoro and Rincon will become good towns.
Las Cruces is in the centre of the Mesilla Valley,
about forty miles north of !• 1 Paso. Las Cruces is
one of the oldest settlements in the Territory. As a
winter resort for the tuberculous invalid, its climate is
unsurpassed. It is a land of almost constant sunshine,
with very little rain, where the invalid can be out of
doors from autumn until spring. The altitude of Las
Cruces is thirty-eight hundred feet; annual mean tem-
perature, 59" J'.; annual rainfall, seven inches.
Deming. — .About one hundred miles west of El Paso
is Deming, at an altitude of forty-six hundred feet, and
with general conditions very favorable to the tubercu-
lous invalid, es|x;cially in the matter of pure water.
Silver City. — North of Deming some sixty miles,
among the fooihill.s, at an altitude of six thousand feet,
is Silver City, one of the best of New Mexico's health
resorts, as far as climate is concerned. \\'ith an alti-
tude the same as that of Colorado Springs and Las
Vegas, it is much milder in winter than either, ^'ery
fair hotel accommodations are obtainable.
Southern Arizona.
Southern Arizona comprises but little except moun-
tains and desert, but for the pulmonary invalid offers
October 31,
1S96]
MEDICAL RECORD.
659
superb climatic conditions, and where water can be
obtained for irrigation tlie pursuits of horticulture and
agriculture are profitable.
Tucson iias the characteristics of a medium altitude,
twenty-four hundred feet, and, with fairly good hotels
and good social advantages, is the best point for those
who require more altitude than Phcenix affords.
PhcEnix has, perhaps, the better climate for those
cases a little farther advanced or for those compli-
cated with nervous or cardiac symptoms. The altitude
is eleven hundred and fifty feet: rainfall, eleven
inches; mean temperature, 67.2^^ F. ; reU^tive humid-
ity, forty per cent. This city has less wind — an
average of less than three miles per hour — than
any other resort known to the writer, and the winter
climate is superb. Phcenix has exceptionally good
hotels and other accommodations desired by the in-
valid.
Yuma. — At an altitude of one hundred and forty
feet, situated on the t'olorado River about one hun-
dred miles from the Gulf of California, Yuma offers
a mild and genial climate in winter; but, with the
exception of the railroad hotel, which is very good, the
accommodations are limited.
California.
The first place to be noticed as a winter resort after
crossing the Colorado River into. California, is
Indio. — The place is situated on the northern bor-
der of the old bed of the Gulf of California, in what
is known as the Colorado desert. This is the only
place where the invalid can get the benefits of com-
pressed air permanently, as it is forty feet below the
level of the sea. Some most remarkable recoveries
have been accredited to the very peculiar climate
of Indio. Patients have been carried there on
stretchers, pronounced to be in the last stage of
consumption, and after a few months have gone
back to business. It is an almost rainless region,
but with a very productive soil where under irriga-
tion. The place consists of a hotel and a few cot-
tages for invalids.
Beaumont is situated on the edge of the desert also,
but at an altitude of twenty-five hundred feet, being
almost on the summit of the ridge between the Colo-
rado desert and the Pacific slope. Beaumont has good
hotels and excellent climatic conditions for the tuber-
culous invalid.
Riverside has an altitude of one thousand feet, is
a town of several thousand population, and affords a
desirable winter home, though not especially as a
health resort.
Los Angeles is the typical climatic centre of south-
ern California. It is the distributing point for inva-
lids as well as merchandise. For all-the-year-round
purposes, Los Angeles, with its immediate ^•icinity,
which includes Pasadina, Mt. Lowe, Santa Monica,
Long Beach, San Pedro, and Santa Catalina Island,
comprises the finest combination of high and low alti-
tudes, coast and inland resorts, to be found in this or
any other country. At no other place can the invalid
go from blooming roses and sea-bathing in January to
snow-clad mountains and a moderate winter climate
at five thousand feet elevation, in three and one-half
hours by electric car. Los Angeles is well provided
with everything to be found or desired in a first-class
resort except a really first-class hotel. She has many
good hotels, but not what tourists call a real first-
class one. The altitude of Los Angeles is two
hundred and seventy feet, topography very favorable
for good drainage, and water supply good. The
mean annual temperature is 62° F. ; rainfall, seven-
teen inches; and relative humidity, sixty-nine per
cent.
Two Me.xican Health Resorts.
From an unpublished article entitled " From La-
redo to the City of Mexico, thence West to Morelia
and Patzcuaro, over the Mexican National Railroad
and Its Branches," by Dr. R. H. L. Bibb, chief sur-
geon of the road, who resided and practised for many
years in Saltillo, and who is thoroughly familiar with
health resorts in Mexico, the Mepicai. Recorp is per-
mitted to copy the following description of Monterey
and Saltillo.
" Stepping out of the sleeper," says Dr. Bibb, " one
is confronted with one of the gentlest, balmiest
breezes, one of the brightest, bluest skies, and one of
the grandest, most picturesque outlooks that ever de-
lighted the soul of man. In front and all around
stands Monterey, sometimes written Monterrey, the
' Mountain King,' the capital of Nuevo Leon, at the
foot of the Sierra Madre Mountains, one hundred and
seventy miles away from the Texas frontier, and at an
elevation of seventeen hundred feet, like a mighty
sentinel guarding ingress into Mexico from the north-
east. Northward from the gently sloping declivitv
on which the city is built the verdure of the plain
beneath seems to mingle with the azure of the sky
above. To the east the aerial head of the Saddle
Mountain juts high aloft, the Garcia and the Mitre
Mountains on the southwest, while the grand old
' Mother of Saws ' to the south, w ith her jaggy sum-
mits looking upward into the vaulted canopy, majesti-
cally presides over the lovely panorama below.
" Monterey is a rich progressive city of sixty thou-
sand inhabitants, who are rapidly absorbing American
ideas and customs from hundreds of permanent Amer-
ican residents of the city, and from thousands of
American tourists and invalids seeking health and a
(lolcc-far-nii'iite life in the Aztec republic, who an-
nually find rest, repose, and restoration in the genial
suns and balmy breezes of this great health resort.
"There are four American physicians in Monterey,
an excellent German drug store, an Episcopal, a Bap-
tist, a Methodist, a Presbyterian, and numerous Cath-
olic churches and schools; five good American hotels;
beautiful alamedas, plazas, drives, and promenades;
delightful fruits and vegetables; excellent, tender
juicy meats, game, and fish, and a supply of water
from crystal spring and rippling mountain streams
which is abundant, wholesome, pure, and sweet.
" From meteorological observations taken at the
Civil College at Monterey for a series of years, the
following figures are taken, viz.:
Winter Temper.^ture.
Ma.ximum TS-Z" F.
Minimum 46.2° F.
Average 57.1'!''.
Summer Te.mperature.
Ma.ximuni 102.3° F.
Minimum 46.2' 1'.
Average 86.0° F.
Barometer.
Ma.ximum 29.24 in.
Minimum 27.96 in.
Average 28. 10 in.
.•\verage relative humidity 66.3
-Average yearly rainfall 3S.22 in.
.\very yearly amount of clouds 4. 5
Average yearly rainy days 50
Prevailing winds, northeast.
" Four miles north of Monterey, to be reached by a
tramway, are the renowned Topo Chico Hot Springs,
the Baden-Baden of America, the virtues of whose
waters, if Indian legends be worthy of belief, was
known to the ancient Montezumas years before the
-Spanish conquest.
"Topo (Jhico waters — very similar to those of the
Arkansas Hot Springs — with a temperature of 106^^ F.
at the spring, 102" F. in the bathtub, and an output
66o
MEDICAL RECORD.
[Octyber 31, 1896
of sixty-eight tiiousand gallons per hour, contain, ac-
cording to the' Mexican Pharmacopceia :
Hydro-sulphurous acid. . . i o.oio per gallon.
Sodium chloride 0.296
Calcium chloride 0.040
Magnesium chloride 0.076
Calcium bicarbonate o.ioo "
Calcium sulphate 0.416
Aluminium silicate o.ioS
Calcium silicate 0.350
" One maj' drink to repletion, for da\s and weeks, of
these waters, and aside from the very copious perspira-
tion which always follows, feel neither nausea nor
other inconvenience; but when a mixture of the same
ingredients in the same proportions is made and heated
to a temperature of 106' !•'., a disgustingly nauseating
compound results, thus proving that elements put to-
gether in nature's own laboratory, heated in her cru-
cibles, and distilled in an alembic of her own choosing
possess properties not imparted to them when com-
pounded by the chemist, however expert or learned he
may be.
"The waters of Topo Chico, when properly used, as
the writer can attest after many years of experience
with them, are of signal efificacy in the treatment of
gout, rheumatism, syphilis, Bright's disease, hepatic
and gastric troubles, uterine, nasal, and vesical ca-
tarrh, chronic malaria, and many forms of skin dis-
eases.
"An excellent hotel — close to the capacious bath-
house— constructed of black marble which is found in
large quantities and of the best building qualities in
the mountains north of 'I'opo Chico Springs, furnishes
a comfortable home for the many invalids and visitors
to this northern Kethesda.
•• Saltillo — a little jump — 'Highlands of Many
Waters,' ' the City of Roses,' the place where Hidalgo,
the author of Mexican independence, on his way to
the United States in quest of aid for the struggle for
liberty he had inaugurated, was betrayed and cap-
tured; now the capital of the rich and prosperous
state of Coahuila, on the Mexican National Railroad,
two hundred and thirty-seven miles from the Rio
Grande, with a population of twenty thousand people,
is located fifty-five hundred feet above the sea, at the
foot of the Ruena Vista tablelands, five miles north
of the memorable battlefield of Buena Vista, on a
chalky, limestone plateau that gradually dips north-
ward with a grade of six to eight feet per hundred, in
a basin in the Sierra Madre Mountains, in latitude
55° -5' '5 " ^- ^"'' '" longitude 100° 29' ^;^" west from
Greenwich.
"The city, especially noted for the evenness of its
temperature and its excellent water supply, has two
good American hotels, .\merican physicians and drug
stores, a Baptist, a Methodist, a Presbyterian, and six
Catholic churches, with their schools and other insti-
tutions of learning. Its water supply, slightly im-
pregnated with lime, furnished by a bold and limpid
stream which bursts forth from the mountain side high
above the city, and far away from all contamination,
is cool, refreshing, and inexhaustible. Its fruits and
its flowers, its meats and its vegetables, its fish and its
game, equal in savor, in wholesomeness, in variety,
and in profusion those of any other town of equal size
in .Vmerica. Here it is that the fragrance of the rose
mingles with the violet's sweet incense from January
to December, and it is here where one's table may be
supplied with the luscious strawberry from one's own
garden the year round.
" Meteorological observations, carefully taken at
Saltillo for the past ten years, show for that period:
-Average temperattire 62.6" F.
Ma.ximum 96.3' F.
Minimum 32.8° F.
Average barometrical reading 24.86 in.
Ma.'iimura 25.34 in.
Minimum 24.43 in-
Average relative humidity 59
Maximum gg
Minimum 11
Prevailing winds North.
.\verage velocity of wind 3.93 miles.
Ma.ximum velocity of wind 41.50 miles.
Clouds, average amount 4.3
Rainy days, average 66. 10
.\verage rainfall 22.67 in.
Total rainfall 226.75 in.
•■ These observations also show that the average tern-
perature at Saltillo in Januar)', the coldest month of
the year, for the past ten years has been 52' ¥., and
that the average July temperature, the warmest, has
been ■j2° V.
"Near Saltillo are several warm springs of high re-
pute among the natives for the cure of skin diseases,
gout, rheumatism, scrofula, malaria, and syphilis.
The waters are strongly impregnated with sulphur,
iodine, bromine, and arsenic.
"Taking these geographical, topographical, .socio-
logical, and meteorological facts into consideration,
it will be easily seen that Saltillo, hidden away in its
mountain fastnesses, with towering peaks and enchant-
ing scenery on every side, high above the yellow-fever
line and away from other epidemic influences, offers
not only a safe and a pleasant refuge for the many
overworked and worn, and the niunberless victims to
lung, throat, and bronchial troubles, fleeing from
summer's heat and winter's cold, but also ideal facili-
ties for a modern sanatorium — facilities not surpassed,
hardly, if at all, equalled, on the American continent.''
Diphtheria. — Dr. Ustlersays: "Where a bacterio-
logical examination cannot be made, the practitioner
must regard as suspicious all forms of throat aflection
in children, and carry out measures of isolation and
disinfection."
Bloody Stools. — Dr. I'Uman (Buffalo Medical Jour-
na!, September, 1S96) names the following disease
processes which we should bear in mind: (i) Toxic
inflammations and strong drastic cathartics. (2)
Traumatisms. (3) New growths, as carcmomata and
polypi. (4) Circulatory diseases: (</) embolism of
the superior mesenteric artery, a condition coming on
in disease of the heart and general atheroma. It
occurs in the feeble and the aged and is accompanied
by all the symptoms of peritonitis, great ))ain, tense,
rapid pulse, meteorism, and the passage of blood: (/')
general venous hyperamia ; (c) congestion of the por-
tal systein; (d) small aneurisms of intestinal vessels;
(f) venous varicosities, especially in the small intes-
tine; (/) amyloid degeneration of the vessel walls.
(5) Diseases of the blood: (a) pernicious anfemia
and leuka-mia; (/') grave intermittent fever; (c) ha-mo-
globinuria. (6) Diseases of the stomach: (a) carci-
noma; (/') ulcus ventriculi ; (<•) acute gastritis. (7)
Diseases of the intestine: {a) acute enteritis; (/')
amcebic dysentery ; {c) ulcerations from typhoid fever;
(li) carcinoma; (f) duodenal ulceration; (/) incar-
cerated hernia; (g) ankylostomum duodenale; (//)
fissure and hemorrhoids. (8) Constitutional dis-
eases: {a) scorbutus; (/') purpura ha;morrhagica ; (<•)
phthisis; (fi) diabetes mellitus. (9) Infectious dis-
eases: ((/) typhoid fever; (/') yellow fever.
Police Surgeons in Liverpool are paid $350 a year
and furnish their own medicines. The average num-
ber of men under the care of each surgeon is two hun-
dred and eight)', and, deducting the cost of the drugs
supplied, the surgeon receives about one dollar per
annum per man.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 50, No. 19.
Whole No. 1357.
New York, November 7, 1S96.
$5.00 Per Annum.
Single Copies, loc.
(Oviainal Articles.
ON THE TREATMENT OF SOME FORMS OF
ALBUMINURIA BY RENIPUNCTURE.'
By REGINALD HARRISON, F.R.C.S..
I PURPOSE offering you a few remarks bearing on the
treatment of some forms of albuminuria by renipunc-
ture as a contribution to the inaugural proceedings of
our session that opens this evening.
Earlv this year, in connection with some observa-
tions I published' on kidney tension relative to albu-
minuria, I narrated the particulars of three cases in
which albuminuria of some standing completely and, I
believe, permanently disappeared after the digital ex-
ploration and puncture or division of the kidney cap-
sule was practised. I will briefly refer again to these
cases, together with some others to which my attention
has since been called, as bearing upon the point to
which I desire to direct your attention on this occasion.
It is, however, only right to state that my cases were
all instances in which the kidney was explored and
punctured, or incised, not with the intention of treating
an albuminuria, but with the object of discovering
some other coexisting morbid condition, which, though
previouslv suspected, was not on exploration foimd to
exist. I regret that only scanty notes were kept at the
time of these and some other cases to which I might
have referred, arising from the fact that, in the absence
of what was more directly sought for, the existing con-
di.ions were insufficiently appreciated, while the good
results accruing appeared at the time either unexplain-
able, or were referred to local states, such as the acci-
dental fixation of a movable kidney, the division of a
disordered nerve, or the moral effects of an operation.
It was not until several instances had come under my
notice in this way that I began to suspect that a differ-
ent explanation, for the total disappearance of one
symptom of disease at least, might with some degree
of reason be offered. My cases are briefly as follows ;
Case I. — In 1S7S I cut down on the kidney from
the loin in a youth aged eighteen years, expecting to
find a suppuration either within or around the organ.
The patient was suspected to have had scarlet fever
three weeks before this was done and had since suf-
fered from intense lumbar pain. He had had a slight
rash, some desquamation, a sore throat, and albumi-
nous urine with casts. I undertook the operation with
some hesitation and limited my incision so as just to
enable me to put my finger on the kidney. It felt so
tense that I e.xtended my incision and ojDened it with
confidence, expecting to find matter. This was not
the case, and I closed the proceeding with the feeling
that I had made an error in diagnosis. There was a
full discharge of blood and urine from the wound for
some days. The latter was lightly plugged with lint
and in the course of ten days or so healed soundly.
.\fter the incision was made, the excretion of urine
' Being the presidential address delivered before the Medical
Society of London, October 12, lSg6.
* Lancet, January- 4, i8g6.
became far more abundant, and the albumin gradually
and completely disappeared.
Case II. — In 1887 I operated upon a man, aged
fifty vears, who by nature of his occupation spent a
large part of his time underground. Occasionally he
suffered from hematuria in conjunction with colicky
pains about the groins, and I came to the conclusion
that he was suffering from renal calculus. As, how-
ever, the symptoms were neither urgent nor confined
to one kidney, the consideration of operation was
postponed. In the course of a few months after I first
saw him, and while he was continuing his work under-
ground, the urine became largely and constantlv albu-
minous and there was some pain, referred to the right
loin. I took him into the Royal Infirmary at Liver-
pool, where I was then residing, and explored the
right kidney. The organ was found to be enlarged
and tense. An incision of an inch in length was
made through the cortex, and the pelvis was explored
with the finger, but after careful examination no stone
could be found. There was a considerable discharge
of blood and urine, which continued for a fortnight or
so, a drainage tube being retained in the wound: on
the withdrawal of the latter healing followed, and the
urine became quite normal. I heard some time after-
ward that the patient remained in excellent health
and was able to resume his ordinary occupation.
Case III. — The third case is one that came under
my observation in 1893. It was that of a woman,
aged forty- four years, who had suffered from slight
hiematuria at times for a year previously ; occasionally
the urine was albuminous. Shortly after I saw her
she had a severe attack of influenza, which was fol-
lowed by an aggravation of her renal symptoms. She
complained of pain on pressure over the left kidney,
and the albumin not only increased in quantity but
was constantly present in the urine. As she believed
she had passed a small calculus some months previ-
ously, I thought it a proper case for exploration, and
this was accordingly made. The late Mr. Durham
saw the patient in consultation with me. The left
kidney was found to be swollen and very tense. It
was opened and explored with the finger, but no cal-
culus could be discovered. There was a free drain of
urine with some blood, which continued for about a
fortnight, when the wound closed. The patient is now
quite well and the urine normal.
Looking at the three cases I have briefly related, I
believe that the first was scarlatinal nephritis, the
second nephritis from exposure to cold and damp, and
the last subacute nephritis following most probably
upon influenza. Among other features each case was
characterized by the presence of albumin in the urine,
which I am inclined to attribute to previous inflam-
mation or its immediate effects.
Since these cases were published, Newman, of Glas-
gow, has recorded two others in which albuminuria
ceased after the performance of an operation for fixa-
tion of the kidney. The cases are thus epitomized : '
Case A. — Right movable kidney, causing torsion of
the ureter and leading to hydronephrosis, albuminuria,
and tube casts in the urine. With the onset of the
paroxysms of pain, hydronephrosis was sometimes
' Clinical Societ)* of London, Lancet. January iS, 1S96.
662
MEDICAL RECORD.
[November 7, 1896
present; sometimes it was absent or not observable,
but was attended by high specific gravity' of the urine
and albuminuria, and tube casts always appeared in
the urine at the same time as the pain. Since the
operation no albumin or tube casts had been found.
Case B. — Left movable kidney causing torsion of
renal blood-vessels, albuminuria, tube casts, severe
pain, and suppression of urine. There was no hydro-
nephrosis, and operation was succeeded by recover)-.
The kidney was only freely movable, but no increase
in size could at any time be made out.
Commenting on these cases Dr. Newman observes:
" In the cases of occasional hydronephrosis the pres-
ence of albumin and tube casts was more difficult to
explain. Why did the transient passive hypera-mia
lead to the presence of tube casts, the occurrence of
which physicians were in the habit of regarding as
of grave import and an indication of inflammatory
trouble?"
Both of these cases appear to me to have an impor-
tant bearing both upon the pathology and treatment of
albuminuria.
I am indebted to Dr. Hoeber, of Homburg, for the
following particulars. He writes: •" I have seen a
case very similar to those you describe, about two
months ago. A man of about thirty-si.x years of age,
very strong and otherwise perfectly healthy, got, after
an attack of influenza which did not appear very se-
vere, most intense pain in the right lumbar region
associated with slight albuminuria. As the pain
lasted over a fortnight and yielded to no kind of treat-
ment, I sent thi patient to a surgeon, with the diagno-
sis of probable renal suppuration, particularly as there
was slight feverishness. The incision brought a con-
siderable discharge of blood but no pus. The patient
became rather anaemic, but lost the feverishness and
albuminuria at once, and has had no return since."
From a careful consideration of these cases I do not
think it is possible to avoid arriving at the conclusion
that the disappearance of albumin from the urine was
directly connected with the surgical treatment to which
in each instance one of the kidneys was submitted.
That the organs were in a state of tension, in one class
of cases as the result of inflammatory hypera-niia,
while in the other from mechanical vascular obstruc-
tion, seems also to be a conclusion which is equally
irresistible. Referring to the hyperaemia which exists
in the initial stages of nephritis, Sir T. Grainger Stew-
art' observes: "Albuminuria is very often due to
changes of an inflammatory character in the tubules
and in the stroma of the organ, and in a very large
proportion of the cases in which it occurs in practice
it is dependent on this cause." That the changes
which subsequently ensue as a consequence of nephri-
tis, however commencing, by the substitution of a
lower for a higher excretory tissue, as we see in the
cirrhosed forms of Bright's disease, is due to the
damage the organs received in the early and active
stage of inflammation or congestion, seems by no
means improbable. Sir Thomas Watson observed in
his lectures: "The stress or congestion which befalls
the kidney in cases of febrile anasarca may set on
foot a morbid process that long works silently and
unobserved, but at last declares its- operation by symp-
toms."
Nor is there wanting demonstrable evidence as to
the high state of tension which is sometimes present
in the kidney. I have frequently called attention to
this at the time of operation for exploration of one of
these organs. In one instance the degree would re-
semble that of a ripe or almost bursting plum, while
in another the kidney w-as comparatively flaccid and
unresisting on pressure with the finger. Yet these
differences were not always at the time explainable.
' " Lectures on Albuminuria," iSS8.
That the relief of renal tension by direct surgical
interference has been proved to be practical and is
under certain conditions indicated, is also supported
by the cases I have cited. Surgeons have long since
learned to recognize the disastrous and far-reaching ef-
fects of tension as it occurs in the human body, whether
arising from inflammation or otherwise, and do not
hesitate to negative any evil effects it may give rise to
by means which render this very unlikely to happen.
Possibly my surgical experience has led me to ex-
aggerate the disastrous effects of tension on the tis-
sues of the body, though for the most part it has been
gained in regions which may be said to be less highly
organized and delicate than the excreting apparatus
of the kidney. It certainly seems somewhat remark-
able at the present day that so many different views
exist, or have been put forward, explanatory of the
process by which albumin exudes so as to form a vari-
able part of the urinary excretion. These various
theories I shall not attempt to discuss in detail or to
reconcile.
I may briefly remind you of two illustrations which
seem to be analogous with the subject I am now dis-
cussing, both relative to the disastrous effects tension
is capable of effecting in a part, and the relief that
can be afforded on the pressure being removed by arti-
ficial means.
In the eye we have an example of a very highly de-
veloped and sensitive organ. Here one of the most
disastrous effects of intra-ocular tension is seen in
that condition to which the term '"glaucoma" is ap-
plied. The recognition of the true pathology of this
affection and the adoption of mechanical treatment by
iridectomy or an allied operation, for the removal of
tension and the prevention of the degenerative changes
thus initiated, as first practised by Von Graefe, at
once resulted in the saving of a large number of eyes
which previous to this discovery would undoubtedly
have been lost.
In the testicle when it becomes inflamed we have,
not unfrequenlly, transient as well as permanent evi-
dence of the damage that inflammation and tension
are capable of bringing about in an organ which, rela-
tive to its secreting and investing structures, bears a
resemblance to the kidney. It will be in the recollec-
tion of many that the late Mr. Henrj- Smith was the
first to draw attention to certain advantages that fol-
lowed puncture or limited incision through the cap-
sule of the testicle in acute forms of orcliitis. It was
alleged, and I believe with a considerable amount of
truth, that not only was the pain or tension in this
way immediately relieved but that permanent damage
to the secretory structure of the testis was averted.
In fact sterility, so far as the organ involved was con-
cerned, was by this means rendered unlikely to occur.
It may not be out of place here to remind you of the
structural arrangements of the kidney relative to the
influence that tension is likely to exercise upon it. It
may be said to be a highly organized gland surrounded
by a thin fibrous capsule and divided up into com-
partments or sections by barriers of a similar nature.
It is capable of distention to almost any degree by a
gradual force acting from within, as, for instance, the
retrograde pressure proceeding from strictures which
oppose the escape of its excretion, but from the nature
of its structural constituents is incapable of adapting
itself to sudden emergencies of this kind, as those usu-
ally arising in connection with the early stages of
acute nephritis.
.\ssuming, however, that the means I have thus sug-
gested for dealing with intrarenal tension, under cir-
cumstances to which I will presently refer, are
applicable, it may be urged that as the kidney, as
normally disposed, is a double organ, both glands
must be directly submitted to the proceeding proposed,
November 7, 1896]
MEDICAL RECORD.
66'
inasmuch as in tlie ordinary forms of nephritis both
kidneys are usually similarly involved. This, how-
ever, does not necessarily follow, as the sympathies
existing between the two organs are such as to cause
impressions e.xercised upon one to be reflected on the
other. Relief aiTorded to one kidney, as my cases
illustrate, usually assists the other, while, when the
excretory power on one side is suspended or arrested,
the opposite organ speedily takes up the whole of this
work.
I might further illustrate this point in a variety of
■ways. The following case, however, seems to me to
directly bear upon it. It was that of a man, aged
thirty, whom I saw early in 1889, ten days after he had
received an injury to his loins by falling down the
hold of a ship and alighting on a case of goods. The
right loin was ecchymosed and from the presence of a
little blood in the urine, which continued for some
days after the injury, it was concluded that either one
or both kidneys had been severely contused. The
daily amount of secretion was considerably diminished,
and the day I saw him it had amounted to only sixteen
ounces in the twenty-four hours. There was pain on
pressure over the right loin, which remained swollen,
discolored, and tender to the touch, and the temperature
had risen and was variable. I thought it probable
that perirenal suppuration had occurred. I therefore
exposed the right kidney from the loin, and removed
some extravasated blood in the course of the incision.
The kidney was found very- tense and congested. I
believed that suppuration had taken place within it,
and therefore a small exploring trocar was inserted in
two or three places but without discovering pus. Fur-
ther, at one point where it was very tense I made an
incision into the cortex, but only blood and serum es-
caped. Considering that we had thus got rid of some
of the products of the injury which were on the verge
of suppuration, the wound was lightly packed with
antiseptic lint and left open; there was a free dis-
charge of blood and some urine for some days after,
and all the symptoms which rendered the incision
desirable were at once relieved and the patient made
a good and complete recovery. It was interesting to
notice that the excretion of urine was more than dou-
bled in the twenty-four hours following the operation,
and the daily amount now remained normal through-
out. Here the tendency toward suppression of urine
was evidently connected with the intense congestion
resulting from the injury in which probably both
organs were involved, a condition of the circulation
which was at once removed by the treatment described.
We do not, I think, sufficiently recognize the high
degree of vascular and tubular infarction that attends
some grades of nephritis. Some years ago I saw- a
girl, aged seven years, who was suffering from scarlet
fever of a malignant type. Almost complete suppres-
sion of urine was the leading feature in the case, and
death took place in four days from the commencement
of the illness. At the necropsy the kidneys were found
to be so highly congested that I was not surprised at
their being unable to excrete. I remember the pass-
ing impression arising in my mind that an incision
into them appeared to be the only means that might
have been effectual in restoring their function. In
a recent paper on "Scarlatinal Nephritis and its Vari-
eties," Dr. Meadows Turner' remarks: '"Out of the
five thousand one hundred and nine cases, fifty-five
died with nephritis, either alone or complicated with
other lesions. This number includes those who pre-
sented some symptoms during life, as well as some
others in whom post mortem extensive disorganization
of the kidney was found, though during life there were
no sufficient symptoms for diagnosing such a compli-
cation."
'Guy's Hospital Reports, 1894.
I will now endeavor to indicate the kind of cases of
nephritis in which it may seem desirable to adopt the
practice I have illustrated. In resorting to such
measures we cannot entirely, as I have already stated,
lose sight of the fact in connection with the subject of
albuminuria that its treatment, as it at present stands,
cannot be regarded as entirely satisfactory or progres-
sive. Commenting upon this point. Sir Grainger
Stewart, one of our most modern writers on the sub-
ject, and with whom I had the advantage of conversing
a short time ago in reference to the point that is now
before us, observes : "Sir William Roberts and Pro-
fessor Rosenstein have come to the same general con-
clusion as Dr. Saundby as regards the inetficacy of
drugs in diminishing albuminuria, and I have satisfied
myself by a long series of careful obser\-ations that we
have no right to credit any drug with the power of
directly diminishing the discharge of albumin."
The grounds upon which it may be desirable to give
relief by surgical means directly applied to the kidney
may be illustrated by some of those cases of nephritis
which are seen as consequent on scarlet fever, though
it seems to me that its application is not neces-
sarily limited to these. In the larger proportion of
cases of scarlatinal nephritis the kidney complication
is only of a temporary character and the disappearance
of albumin from the urine is both gradual and com-
plete. Under such circumstances surgical interfer-
ence could not be regarded as warrantable. On the
other hand, there is a considerable number of cases
met with in which this is not so. These may be ranged
into two groups. The first includes those instances
in which the kidney complication is, from the onset, of
the gravest nature and death is imminent with more
or less suppression of urine, as in the case I have pre-
viously referred to in which after death the kidneys
were found in a condition of most intense vascular en- '
gorgement. In these cases a fatal issue usually ensues
most rapidly, the duration of life being largely deter-
mined by the degree of suppression that is arrived at.
The second group of cases includes those in which
after a limited time the tendency, so far as the renal
symptoms are principally concerned, is not in the
direction of recovery. The amount of albumin does
not decrease, tube casts as well as other evidences of
disorganization are found in the urine, and the latter
in quantity is below that which may be regarded as
an average. Though a physical examination of these
organs, either from the loin or by abdominal manipu-
lation, may fail to give any indication as to their con-
dition, tenderness on pressure is often complained of.
It is from among the cases represented in these two
groups that instances will be found in which I believe
the measures advocated may sometimes be advan-
tageously practised. It is in these instances that
death either rapidly occurs, or is brought about no
less surely in the course of time by the more chronic
forms of nephritis in conjunction with the cardiac
complications which so frequently arise in connection
with them.
That many cases of nephritis with high tension and
subsequent structural deterioration must necessarily
be attended by cardiac hypertrophy or enlarged pow-
ers of circulation, is at once obvious. Diminished
capacity to excrete can only be compensated for by
increase in the force of the blood current. In the
restoration of function we have the only safeguard
against the development of this complication.
In conclusion I will offer a few remarks on the pre-
cise nature of the surgical treatment of renal tension
associated with albuminuria. It is hardly necessary
to remind you that by anesthetics, and the antiseptic
treatment as developed by Sir Joseph Lister, we are
now in the position not only to explore various or-
gans of the body with perfect safety, but, further, we are
664
TVIEDICAL RECORD.
[November 7. 1S96
enabled by these means to study what I would speak
of as living pathology. It would not be possible for
me to illustrate the truth of this observation more
vividly than in the case of renal disease. Here, by
anaisthetics in combination with antiseptics, a vast
number of di.seases have been brought not only within
reach of surger)-, but with a degree of success which
previously would have been unattainable. The opera-
tion of exploring a kidney by an incision from the loin,
so as to enable the operator to examine this organ
carefully and deliberately with the finger, and, if found
necessar)', to proceed further, has now been so safe-
guarded as to remove from the mind of any careful
surgeon undertaking it the feeling that he is exposing
his patient to any undue risk, relative to the cause
that is judged to demand it. I cannot say that I ever
saw any ill result follow the exposure of the kidney
by an incision from the loin for the purpose of its
digital exploration. On the other hand we have seen
in numerous directions the necessity for such a pro-
ceeding in many cases in which, though recovery fol-
lowed, a correct diagnosis had not previously been
arrived at. Such instances include the presence of
pus or fluid within the kidney, morbid growths requir-
ing the removal of the organ, stones, undue mobility,
and other abnormal conditions.
In the class of cases 1 am now referring to. the kid-
ney should be exposed by a moderate incision from
the loin, so as to enable the operator to feel the organ
distinctly both in front and behind, aided of course
by pressure exercised on the kidney by the hand of an
assistant from the front of the abdomen. If, in con-
junction with the presence of albumin in the urine, the
kidney is found in a state of tension, such as I have
illustrated, three or four punctures may be made
through the capsule in various directions, or should
the organ be found in a state of higher tension, then a
limited incision into the cortex may be practised.
After one or other of these measures has been adopted,
the wound should be lightly packed with gauze, or a
drainage tube substituted. In either case the incision
should be dressed in such a manner as to provide for
the free escape of eitlier blood or urine or whatever
products mav be exuded. For this practice I ventured
to think some reason will be found in the illustrations
which have formed the text for mv observations this
RECENT .ADVANCES IN OUR KNOWLEDGE
CONCERNING THE M.M.ARIAI, ORGAN-
LSM.
I!y CHARLES 1". CKAIC, M.D., -
DANBCKV, CONN.
MEMBER OK THE AMERICAM MICROSCOPICAL SOCIETY ; CONNECTICUT STATE
MEDICAL SOCIKTV ; FAIRFIELD Col NTV MEDICAL ASSOCIATION; PATH-
OLOGIST TO THE DANDl'RV MEDICAL SOCIETY.
It is now an almost undisputed fact among those who
have investigated the subject that in the blood of
patients suffering from the various forms of malarial
fever there occurs the organism known as Laveran's
Plasmodium malaria-. Si.xteen years have elapsed
since Laveran ' discovered this organism, and during
that time the subject has been continually worked
upon, and a vast mass of literature has accumulated
devoted entirely to it. .-Vs to the truth of this we have
only to glance over the very complete bibliography of
malaria compiled by Thayer and Hewetson," of Balti-
more, which comprises over three hundred and fifty-
nine separate articles. .Among the distinguished
scientists who have added to our knowledge of this
subject may be named Laveran and Carter, of India;
Marchiafava. Celli. Golgi, Hignami, and Thommasi-
Crudelli, of Italy; Mannaberg, of .Austria; Manson,
Prout, and Thin, of England; and Osier, Sternberg,
and Doch in our own countr)-.
It is the purpose of this paper to bring together in
a convenient form the advances in our knowledge con-
cerning the malarial organism, especially those which
have been made more recently. In the opinion of the
author, such a resume is of great use to the general
practitioner, who, though anxious to keep abreast of
the times in matter scientific, is greatly hampered by
the lack of time to peruse and the inabilitv to procure
the scattered literature upon such subjects. It is for
this reason that I have ventured to compile this paper
presenting the recent observations concerning the
malaria plasmodium, and containing necessarily but
little original work.
I. Methods of Examining the Blood. — ^^■e have
long since passed the lime when any obscure fever,
particularly if it prove fatal, can be called malarial,
for, as Osier has stated,^ " the diagnosis of the malarial
fevers can be made with certainty by the blood exami-
nation." .All that is needed by any one to make such
an examination is a good microscope, knowledge of
the technique involved, and proper preliminary train-
ing.
Much has been written tending to make the searcher
for the parasite believe that it is difficult to find, but
if it be searciied for in the right way nothing is easier
to demonstrate. -As to the frequency of its occurrence,
it may be said to be always present in active malarial
disease. Manson ' has never failed to find it in such
cases, and Mannaberg ' states that he failed to find it
only in three out of one hundred and thirty cases. In
their recent monograph upon malaria, Thayer and
Hewetson " say: "Excepting two or three instances
where the patients entered the hospital during con\a-
lescence, the specific micro-organism was found in
every case (6i6) of malarial fever treated in the
wards." From his own limited experience the author
would state that in all the cases which he has exam-
ined (24) he has never failed to find the organism.
.As to the best time for examining the blood almost
all authorities agree that the organisms are best seen
about the end of apyrexia and the beginning of the
fever, when they are pigmented and large. They are,
however, most numerous during the fever, but are so
small that they are apt to be overlooked by the be-
ginner.
The blood can be examined fresh or staining meth-
ods may be used. I think that the examination of
fresh blood is most satisfactory in diagnosis, although
if permanent specimens are desired, staining is re-
quired.
Daniels' claims for staining the following advan-
tages; Ease with which the organisms can be seen,
using one-fourth or one-eighth objective; one's own
convenience can be followed by staining, whereas fresh
blood has to be examined immediately; no danger of
confusing the parasites with other appearances in the
blood, as vacuoles, etc. On the other hand, many
authorities believe that the organism should prefer-
ably be studied in its living condition* in the fresh
blood.
Method of Examining Fresh Blood. — Cover glasses
and slides should be carefully washed in alcohol, just
before using. The blood is generally taken from the
finger, as follows; Wash the skin thoroughly with soap
and water over the place to be punctured, and then w ith
alcohol; then with a prefectly clean steel needle punc-
ture the skin and allow- a drop or two of blood to fall.
Then take the glass slide and allow it gently to touch
the tip of the drop of blood upon the finger, and im-
mediately drop the cover glass upon it. If the slide
be clean, the cover glass will instantly flatten the
blood out. and the corpuscles may be seen lying side
by side entirely unaltered. Be careful and get but a
No
vemoer
/•
fS96]
MEDICAL RECORD.
66 s
very small drop of blood upon the slide. Such speci-
mens remain in good condition for about an hour.
Although, if desirable, a one-twelfth oil immersion
may be used to examine with, I have always used in
preference a one-eighth dry objective on account of
the greater ease of manipulation. For diagnostic
purposes the one-eighth objective is entirely sufficient.
Stained Preparation. — .\ staining method which is
as good as any in results, and better than some in the
ease of its application, is that devised by Chenzinsky.'
A watery concentrated methylene-blue solution, diluted
one-half with water, is mi.xed with an equal volume of
a one-half per cent, solution of eosin in sixty per
cent, alcohol. The blood is collected, as described,
upon cover glasses, and fixed by gently heating it over
the alcohol lamp, after the blood has dried upon the
slide. Place the slide in the staining solution and
allow it to remain five minutes; then wash in water,
and mount in balsam. The red corpuscles are seen
to be stained with eosin. while the parasites are col-
ored by the methylene blue.
There are many otlier staining methods, but the
above secures as good result as any of them. Good
stained specimens are not always secured with any of
the methods, and disappointment is often the rule
rather than the exception, in stain-
ing the Plasmodium malaria;'.
In closing this section of our
subject, I will give in full a method
of preparing malarial-blood films
recently devised by Manson," and
which recommends itself to any who
will take the slight labor of learn-
ing it. " Cleanse with ether as
many microscope slides as are likely
to be required, and place them on a
table near the patient. Three or
four oblong slips of very fine clean
tissue paper one and a half inches
by five-eighths of an inch are also
prepared. The patient's finger is
cleansed and pricked in the usual
way. A droplet of blood is then
expressed from the puncture and
taken up by touching it with one of
the papers, the blood being applied
about one-half inch from the end of
the paper. The charged surface of the end of the paj^er
is then placed upon a glass slip toward one end. In
a second or two the blood will have run out in a
thin film between paper and slip. When this has
taken place — not before — the paper is drawn along
the surface of the glass. The same paper, without
recharging, is placed in a similar way upon a second
slip, and so on. When exhausted, the paper is re-
charged from the finger as many times as may be
found necessary. In this way fifty or one hundred
exquisitely fine films may be obtained in five or six
minutes. Labels are then attached and the slides
stowed away to await convenience. Before staining,
a little absolute alcohol is dropped upon the films to
fix them. In staining he uses borax (five per cent.)
methylene blue (one-half per cent.) solution, for about
half a minute: then washes in water, dries, and mounts
in balsam.
II. Structure of the Organism. — If the blood from
a case of tertian malaria be examined at various pe-
riods, the following apjsearances mav be noted, which
are slightly modified in the quartan and testivo-
autumnal forms.
Taking the blood during the chill, or just before
the chill, a number of bodies, pale in color and spher-
ical in shape, may be seen grouped around a central
mass of pigment dark red or brown in color. The
entire organism lies within the red blood corpuscle.
Fig. 4.
which may be distinguished as a pale yellow ring en-
circling it (Fig. i). Besides this corpuscle-encircled
body may be seen similar bodies unenclosed by the
blood corpuscle, and we notice that the little spheri-
cal bodies do not constitute one body as before, but
are separated (Fig. 2), and in some places may be seen
single spherules scattered among the red corpuscles
(tig- 3)- Besides the forms just noted may be seen
small colorless bodies inside the blood corpuscles,
possessing anuKboid movements (Fig. 4). In blood
examined during and after the fever stage, the only
bodies to be seen are colorless amoeboid bodies, in-
side the red blood corpuscle. These bodies are con-
stantly changing their form, presenting sometimes
very singular appearances (Fig. 5). In the course of
two or three hours these bodies will be found to have
enlarged, and scattered granules of dark pigment are
now present (Fig. 6). These pigment granules have
an exceedingly rapid trembling motion. If the blood
be examined from this time on, at inter\-als, it will be
found that the intra-corpuscular body enlarges so as
to almost fill the corpuscle, the pigment congregates
toward the centre, the hyaline body begins to show
lines of cleavage, and at last, just before another rigor,
we find the segmented masses described heretofore.
Fig. 3.
Q)Q00
Gip
o0r
W
Fig.
Fig. 6.
Now in order to find out the structure of these bod-
ies, staining has to be resorted to, and various observ-
ers have added very interesting material to our
knowledge on this subject.
The tertian parasite has been studied by Ronia-
nowsky.' He has distinguished a nucleus containing
a more deeply stained portion, which he believes to be
the chromatic portion of the nucleus, lying within the
nuclear Huid, and states that while the organism is
segmenting, karyokinetic changes may be observed
within this portion. Sacharow ' also distinguishes a
nucleus and nucleolus in the a-stivo-autumnal organ-
ism.
Mannaberg" recognizes a nucleus and nucleolus,
and states that, while the nucleus grows in common
with the organism, it disappears before the organism
undergoes segmentation, merging into the substance
of the parasite. As the organism segments, each new
spore or segment develops a nucleus of its own. The
analogy here between the organism and ordinary cell
division cannot but be noticed.
Thayer and Hewetson ' thus admirably sum up the
exi.sting knowledge upon this subject as follows:
'" In summarj-, then, the substance of the parasite
has by careful study been shown to consist of a more
deeply staining outer part, which contains the pigment
granules, and an inner part which is pale and non-
staining, excepting for a small, more deeply colorable
666
MEDICAL RECORD.
[November 7, 1896
body, which is usually situated close at one side on
the border line between this area and the more deeply
staining outer layer. This colorless area is generally
interpreted as a bladder-like nucleus, the dot on one
side representing the chromatin substance or the
nucleolus."
Romanowsky is the only observer who has described
karyokinetic changes taking place within the nucle-
olus.
III. The Relation of the Organism to the Vari-
ous Types of Malarial Fever. — It was not until
1885 that the subject of the relation of the malarial
organism to the several forms of malaria was first
approached, with the publication of the first work of
Golgi " upon the organism of quartan fever.
From that time until now there have existed two
main parties, difl^ering in their views of the nature of
the malarial organism.
Of these, Laveran and those who believe with him
constitute one, their belief being that the malarial
parasite is a single organism, and that there is no
relation between the forms in which it appears and
the fevers.
Laveran '■' thus states his belief: " This parasite is
to be seen in a considerable variety of forms, which
one can, however, resolve into the four following
types: (i) spherical bodies; (2) flagella; (3) cres-
centic bodies; (4) segmenting bodies or rosette
forms." Again he says: "I do not believe that there
exists a constant relation between the forms under
which the ha;niatozoa appear in the blood and the
clinical manifestations of paludism; one can only
say that certain forms of the parasite are more often
seen in certain cases. . . . The differences which one
makes out in the evolution of the haimatozoa of palu-
dism are not sufficient to authorize one in admitting
the existence of several distinct varieties of parasites. "
In his latest contribution upon the subject " he says
that he does not believe that the malignant fevers of
tropical latitudes are caused by an organism distinct
in each, but that the fever germ becomes more virulent
owing to its surroundings. He never yet has met with
the varieties described by some authors as peculiar
to tertian, quartan, and irregular fevers, and he ad-
heres to the belief that the malarial germ is a mor-
phological unit in all countries.
The belief of the second party, which includes the
Fig. 7. Fig. 8. Vu:. g. Fic. :
Crescent or Semilunar Shaped Organisms Occurring in /Rstivo-Atitumnal Fever. Fig. 7.— Crescent in-
side a red blood corpuscle. Fig. 8.— Crescent with the remains of a red corpuscle attached to it, pigment
scattered. Fig. 9. — Crescent showing the pigment collected in the centre, attached to a red blood
corpuscle. Fig. 10.— Crescent showingthe remains of a red corpuscle attachetl to it, asa faintly marked
ridge. Fig. ri. — Crescent lying free within the bUxid plasma.
majority of w-orkers in this line, is that there may be
distinguished different types of the malarial parasite,
corresponding to and occurring witli tiie chief varieties
of malarial fever.
Golgi was the first to assert this theory and Marchi-
afava," Celli," Grassi, Feletti," Mannaberg," Ro-
manowsky," Councilman,'" Doch," and Thayer and
Hewetson '■" are among those who uphold it and have
contributed valuable material regarding it.
They believe that there occur in the tertian, quar-
tan, and irregular or a'.stivo-autumnal fevers distinct
varieties of the malarial organism, associated with
each form of fever, and that the variety of organism
occurring in one never occurs in anv other form of fever.
As a resume of this part of the subject, I will quote
the results obtained by Thayer and Hewetson in an
analysis of six hundred and sixteen cases of malaria
in Baltimore. This is one of the latest and best con-
tributions to our knowledge upon this matter, and
states briefly the general views held by the majority
of observers.
They say:"" " We have distinguished three varieties
of the malarial parasite:
'■ I. The tertian parasite.
"2. The quartan parasite.
"3. The £Estivo-autumnal parasite.
" (i) The tertian parasite requires about forty-eight
hours to accomplish its complete development, and is
associated with relatively regular tertian paroxysms,
lasting on an average between ten and twelve hours,
associated almost always with the three classical
stages — chill, fever, and sweating. Frequently, infec-
tion with two groups of tertian organisms gives rise to
quotidian paroxysms; rarely, infection by multiple
groups of organisms gives rise to more irregular sub-
continuous fevers.
" (2) The quartan parasite is an organism requiring
about seventy-two hours for its complete development.
It is associated with a fever showing regular quartan
paroxysms, similar in nature to those associated with
the tertian organism. Infection by two groups of the
parasite causes a double quartan fever, paroxysms on
two days, intermission on the third. Infection with
three groups is associated with daily paroxysms.
" (3) The cestivo-autumnal parasite passes through
a cycle of development the exact length of which has
not, as yet, been determined. It probably varies
greatly from twenty-four hours or under to forty-eight
hours or more. But few stages of development of the
parasite are found ordinarily in the peripheral circu-
lation, the main seat of infection being apparently in
the spleen, bone marrow, and other internal organs.
Infection with this organism is associated with fevers,
varying greatly in their manifestations.
"Nothing in our experience has led us to believe
that these varieties of the parasite are interchange-
able. They are, we believe, distinct varieties, though
closely allied to one another biologically."
IV. The Crescentic Bodies — In the irregular or
ffistivo-autumnal fevers there occur in the blood, after
a longer or shorter period, peculiar bodies known as
the crescents or crescentic bodies.
These bodies lie sometimes within
the red blood corpuscle, sometimes
partly without, and sometimes free
in the blood plasma. Their struc-
ture and significance have always
been matters of controversy between
plasmodists, and it will be of inter-
est to dwell briefly upon the more
recent theories in regard to them.
Grassi and Feletti " think that
the crescents are a totally different
variety from other forms occurring
with them, and believe that sporu-
lation takes place within them. They have given the
name of laverania to them. They describe a surround-
ing membrane and crescents containing two nuclei.
Bignami," in 1889, states that this furm of the par-
asite is possibly not a living organism but a degene-
rate body which does not proceed to reproduction, and
neither does he think that they comprise a separate
group of organisms.
Marchiafava and Celli " agree with his conclusions.
Mannaberg'" thinks that the crescents are formed
by two of the small hyaline bodies joining together to
form one, and that the process is one of conjunction
or copulation. He bases his opinion upon the fact
that several hyaline bodies are often seen within
Fig.
November ;, 1896]
MEDICAL RECORD.
667
Fig.
one corpuscle, and upon the formation of a mem-
brane, peculiar arrangement of pigment, and segmen-
tation.
Manson '■' believes that the crescent form of the
parasite is a step in preparing the organism for its life
outside the human body.
Laveran," in one of his latest works upon this sub-
ject, states his belief that the crescents are but or-
dinary parasites, which, developing under altered
conditions in the blood of cachectic patients, become
encysted.
Thayer and Hewetson say : '' " From practical ob-
servations, then, we can say that the crescents represent
a very resistant form of the organism; that their pres-
ence in the blood alone is often unassociated with
fever; that in many instances where they have previ-
ously been seen without fever relapses have occurred,
but always in association with small hyaline and
amoeboid forms ; that in connection with these attacks
of fever we have never seen reproductive forms; that
it is clearly demonstrated that the crescents may
change into the round bodies from which flagellation
is frequently observed. We feel that our observations
do not justify a definite conclusion with regard to the
significance of these bodies."
In a recent contribution, Danilewsky" describes in
protracted infections very large crescents, which he
thinks might give rise to serious nervous troubles by
plugging the vessels of the medulla. They were from
two and a half to three times the length of a red blood
corpuscle.
V. The Flagellate Bodies. — If a specimen of
malarial blood be taken just before the paroxysm and
placed under the mi-
croscope, in the course
of from fifteen to twenty
minutes certain bodies
will make their appear-
ance which are known
as the flagellate bodies.
These consist of a ma-
larial organism, pos-
sessed of two or more
actively moving prolon-
gations or flagellae,
which are generally
knobbed at their extrem-
ity. If these organisms
be watched, the flagells
will sometimes be seen
to separate themselves
from the parent body
and, by means of their
power of locomotion, shoot rapidly around among the
blood corpuscles. As with the crescents, the nature and
significance of these bodies is still an open question.
Golgi *' thinks that they form a phase in the devel-
opment of the crescents, and that they are degenerative
forms of the parasite.
Grassi and Feletti "" believe that they are involutive
forms of the parasite, while Sacharoff^" thinks that
they develop only outside the body and are produced
by the action of a low temperature upon the blood.
He thus implies that they are degenerate parasites.
Bastianelli and Bignami " also believe the flagellate
bodies to be degenerative forms of the parasite. On
the other hand, many observers tend to the opinion
that the flagellate bodies are really the most highly
developed organisms, and that instead of dying these
are in fact reproducing new organisms.
Laveran^' believe^ that they represent the most per-
fect stage of development of the parasite, and denies
that they have anything in common with the sarcodic
prolongations of the normal red corpuscle produced
by heat.
Doch'" and Mannaberg'" also believe that the flagel-
late bodies are not degenerate forms of the parasite,
and Mannaberg says: "I suspect that the flagellate
bodies enter upon the first steps of a cycle of existence
outside the human body." He remarks that they do
not develop until the blood has been some time with-
drawn from the body.
Thayer and Hewetson" conclude as follows:
"While our observations concerning the time at
which these bodies appear, their association with
undoubted degenerative forms, their persistence after
disappearance of the fever and after the administra-
tion of quinine, the manner in which they are engulfed
by the phagocytes, are all, it seems to us, suggestive
evidence that these bodies are degenerative in nature;
on the other hand, the extreme regularity in the shape
of the flagella, their extraordinary activity, their power
of individual motion, cause us to hesitate seriously in
accepting this view."
Great interest attaches to the views of Manson '*
upon this subject, and in a recent paper he announces
his firm belief in the theory that the flagellate body is
a form of the parasite calculated to maintain the life
of the organism outside the human body.
He thus forcibly describes these bodies: "It is a
strange, weird-looking, octopus-like creature, with
long whirling, curling, lashing, tentacle-like arms at-
tached to a central, somewhat spherical mass, in
which are black melanin particles tumbling about in
a state of continual agitation. If we keep on watch-
ing this body we sometimes see one or more of the ten-
tacle-like arms break away and swim about in the liquor
sanguinis with a spirillum-like movement."
Fig. 13.
Fig. 15,
Various Forms of Flagellate Bodies. Fig. 12.— Flagellate parasite from tertian fever. Fig. 13.— Flagellate parasite from
quartan fever. F'ig. 14. — Flagellate parasite from Kstivo-autumnal fever. Fig. 15. — Flagellate parasite from a;stivo-
autumnal fever.
He then describes the development of the flagellate
from the crescent bodies, and states his belief that it is
not a " degenerative change in a dying or dead para-
site'' but a '• vital evolutionary change — a normal step
in the life of the parasite." His reasons for so think-
ing are the following:
1. The movements of the flagella when attached,
and their individual power of locomotion when sepa-
rated from the body of the parasite.
2. The fact that flagellation occurs in the majority
of the organisms, if under natural conditions.
3. The similarity in the flagellated organisms as
regards their form and movements.
Manson then concludes his paper by claiming that
the flagellated plasmodia are the extracorporeal germs
of malaria, as follows:
'• I conclude then that the crescent body and the
tertian and quartan spherical bodies which proceed to
flagellation are the extracorporeal sporulating homo-
logues of the intracorporeal sporulating bodies; that
the flagellum is the extracorporeal homologue of the
intracorporeal spore. Both types of sporulating plas-
668
MEDICAL RECORD.
[November 7, 1896
modium have corresponding functions, both arise from
the same source ; one is the germ of the plasmodium
inside the human body, the other is the germ of tiie
Plasmodium outside the Iiuman body; both function
in the propagation of the parasite."
VI. Reproduction, Life Outside the Human
Body, and the Mosquito Theory — Reproduction
takes place, according to the majority of observers,
by sporulation, which was first satisfactorily described
by Marchiafava and Celli, "' and the flagellate bodies
are believed to be another form of reproduction by
Laveran,'" Mannaberg,'" and Manson.'"
Our knowledge concerning the life of the malarial
organism outside the human body is very limited;
indeed, it may be said that until the very recent ap-
pearance of Manson's " papers upon the subject, our
knowledge was ////. In these papers, which comprise
a series of lectures given before the Royal College of
Physicians of London, Manson states his theory of the
extracorporeal life of the organism and the relation
in which mosquitoes stand to malaria. As has been
heretofore noted, Manson believes that the flagellate
bodies are in reality the first stage in the extracor-
poreal cycle of the organism. Not developing until
the blood is withdrawn from the body, he thinks that
suctorial insects, such as the mosquito, taking blood
from malarial subjects, the flagellate bodies develop
in such blood within the stomach of the insect. He
says : " Casting about for an agent that would meet
the requirements of the case, it occurred to me as it
had already occurred to Laveran, that, as the Plasmo-
dium is a passive blood parasite, its escape from the
human body might be eft'ected on the same principle as
that by which the escape of the passive blood parasite
is effected. As the latter obtain their opportunity by
being swallowed by some flesh eater — some carnivor-
ous animal — I thought the former might get its chance
of development by being swallowed by some blood
eater — some suctorial animal, such as the flea, the bug,
the louse, the leech, the sandfly, or the mosquito."
He believes that the blood corpuscle in which the
Plasmodium is encased acts as a protective sheath
from the phagocytes, while in the iiuman body, but
when the organism reaches the stomach of the mos-
quito the flagellate body is developed and bursts
through the enveloping corpuscle into the stomach:
and then, as Manson believes, by means of their active
movements the flagella pierce tlie wall of the stomach
and thus reach a suitable soil for the organism to
develop. Just where this evolutionary process takes
place \<ithin the mosquito is not known, probably in
the blood cells. The malarial organism may then by
means of the exuvia; of the insect be scattered over
the country, in stagnant pools especially, and, as these
infected pools are the breeding-places of mosquitoes,
it can be easily seen how the larva; can in turn be-
come infected. ^L^n may become infected by swal-
lowing such polluted water containing the mosquito-
bred Plasmodium or by inhaling the plasmodia in
dust from dried-up pools. He tiiinks that the Plas-
modium upon entering man may develop into a flagel-
lated spore and so penetrate the mucous surfaces and
reach the human blood cell.
That the plasmodia upon reaching the stomach of
the mosquito do develop into flagellated bodies, has
been proven by Surgeon-Major Ross, who undertook
experiments in this line for Manson.
Ross placed a native suffering from malarial ca-
chexia, and whose blood contained numerous crescents,
under a mosquito net, introduced mosquitoes which he
had reared from the egg,* and collected the insects
after they had filled themselves with the patient's
blood. He then examined carefully the blood in
these mosquitoes' stomachs with the following results:
"((7) Practically all crescents become spheres a few-
minutes after being taken into tiie mosquito's stom-
ach. (/') From thirty to forty per cent, of the spheres
die after one to two hours, the rest having given out
flagella, been eaten by phagocytes, or having simply
broken up.'"
I have given here only a brief outline of Manson's
ingenious and, it must be acknowledged, probable
theory regarding the life history of the malarial Plas-
modium outside the body, and the reader is referred
to his most interesting paper for further particulars,
VII. Phagocytosis, and the Action of Quinine
upon the Organisms. — The colorless blood corpus-
cles act in malaria, as in various other diseases, as
safeguards to the health of the body by destroying the
Plasmodium. This process is called phagocytosis and
takes place in the blood-vessels of the spleen and liver
chiefly, but also in the general circulation. If mala-
rial blood be examined it will often be noticed that
the colorless corpuscles contain within their substance
malarial germs in various stages of e\olution, and also
isolated clumps and granules of melanin or pigment.
These phagocytes are most numerous in cases of per-
nicious malaria, in the vessels of the spleen and liver,
but may also be often observed in the tertian and
quartan varieties in blood drawn from the circulation.
It is not my purpose here to enter into a detailed de-
scription of the process known as phagocytosis, but
simply to define it as the engulfing and destruction of
hurtful organisms by the colorless corpuscles or leuco-
cytes.
The process, as it occurs in malaria, has been care-
fully studied by many observers recently.
Bignami " describes the process in pernicious mala-
ria, and states that he has seen the leucocytes engulf
not only free plasmodia but also red corpuscles con-
taining them. He thinks that it is largely due to the
protecting action of the phagocytes that all cases of
malaria do not become pernicious.
Pastianelli ''" found that in tertian, quartan, and
testivo-autumnal fevers phagocytosis occurred period-
ically, beginning at the time of the paroxysm, and
states that tiie bodies occurring within the phagocytes
are the following, in order of frequency: ((/) pigment;
(l>) sporulating forms and spores; (<•) red corpuscles
containing sporulating forms or pigmented bodies;
((/) red corpuscles containing parasites; (f) free
bodies with central pigment clumps; {/) red corpus-
cles containing free aniiL-boid bodies; (j^) crescentic
bodies. He does not belie\e that the phagocytosis is
the chief factor in hindering the development of
simple into pernicious malaria, but thinks that the
important element in spontaneous recovery is the os-
cillation in the virulence of the plasmodium itself.
Mannaberg'" makes the following statement upon
this subject: '"The spontaneous cure of malaria de-
pends upon three factors, namely: the activity of the
macropiiages of the spleen and bone marrow: on the
circumstance that many parasites remain sterile;
finally, on the destructive action of the febrile parox-
ysm which is manifested by the fragmentation of nu-
merous half-grown and full-grown parasites.''
Man.son " notes the fact of the very^ rare occurrence
(which he himself has never witnessed) of intracor-
puscular parasites within the leucocytes. He says:
" I have see a phagocyte move up to one of these cres-
cent bodies (enclosed by the red corpuscle), touch it
with its pseudopodia, first at one point, then at another,
move round about it — feeling, as it were, if all were
right within, suspicious apparently that things were
not quite as they should be. Rut the corpuscular cap-
sule seemed to deceive the phagocyte: for, after a
time, the vigilant watchman would leave the masked
parasite and move away, satisfied apparently, to some
other part of the field. Should, however, the crescent
proceed to development in the direction of becoming
November 7, 1896]
MEDICAL RECORD.
669
a flagellated body, to attain which state it has to
burst and leave the sheltering blood corpuscle, it is
then, being no longer protected by its corpuscular
sheathing, exceedingly liable to be set on and de-
voured by the phagocytes." He uses this liability of
the flagellated organism to be devoured by phagocytes
as an argument that it does not pre-e.\ist in the blood
as such, and that it is a distinctly e.xtracorporeal
phase of the plasmodiuni, the ensheathing red corpus-
cle protecting the crescentic body, from which the
flagellate body develops, from the phagocytes while in
the circulation.
Regarding the action of quinine upon the malarial
organisms not much has been added recently to our
knowledge. All observers agree that in the tertian
and quartan fevers quinine markedly affects the para-
site, while its influence is not so marked in the ajstivo-
autumnal fevers.
Romanowsky" and Mannaberg,'" in stained prepa-
rations, note the loss of staining properties in the
chromatin substance in the nucleus and believe the
change to be due to necrosis when quinine is adminis-
tered, and also that the spores show no nucleoli.
Golgi'" found that in tertian and quartan fever qui-
nine destroyed the young free spores most easily.
Quinine is best given just before a paroxysm, when,
although it will not destroy or hinder segmentation, it
will almost entirely destroy the young spores.' Given
at any time during a paroxysrn in sufficient dosage
(gr. V. to X.), quinine will delay or even prevent the
next chill, but the parasites will not be wholly de-
stroj'ed. In either case continued doses should be
used for a week or so entirely to drive the disease
from the system. Quinine, to secure the best results,
should be in solution in the blood when segmentation
takes place and the young spores are liberated, and
accordingly should be given several hours before the
chill.
VIII. Modes of Infection and Experimental Infec-
tion.— Though we know much of the evolution of the
malarial parasite within the body, we know but very
little of the manner in which it enters into the human
organism. Various obser\'ers have differed in their
theories regarding the mode of infection, but the fol-
lowing, as given by Thayer and Hewetson " are the
most important: By the respiratory tract ; by the di-
gestive tract; by the skin (insect bites, etc.).
It is but reasonable to suppose that infection may
occur through inspiring air containing the malarial
germ. Anderson," in a recent discussion before the
Royal Medical and Chirurgical Society upon this sub-
ject, noted numerous examples in which malaria oc-
curred in houses which were exposed to wind pass-
ing over newly turned earth. We must, however,
admit that we have no positive proof of malaria caused
by infected air.
The question of the role of the digestive tract in
malarial infection has received much attention, and
many authorities believe that infection is often intro-
duced in this way. Anderson " (quoted above) be-
lieves that water, either inhaled as vapor or swallowed,
is the vehicle of infection, and Manson ''^ thinks that
the ingestion of water may be productive of infection.
On the other hand the negative evidence of infection
through the digestive tract is very strong, many inves-
tigators having proven that water from ponds and
marshes in malarial localities may be swallowed with-
out danger. Curnow," in support of the theory of
infection through water, states that sailors often con-
tract malaria after water has been taken in at ports
where they have not landed, and that at the Panama
canal ships which took in water became infected,
while vessels that condensed their drinking-water es-
caped. He also quoted an observation where one
hundred and twenty soldiers partook of water from a
malarious locality and one hundred and three of them
had malaria, while sailors under similar conditions,
but drinking water from another source, escaped with-
out a case.
I have already given in some detail Manson's theory
of infection through mosquitoes, and as inoculation of
malaria through the skin has been proven easily pos-
sible, his theory is not without many stanch adher-
ents.
No one as yet (save Coronado, who asserts that he
has cultivated organisms from water) claims success-
fully to have cultivated the malarial plasmodium, but
many have produced the disease artificially, and so
proven the relation of the organism to it.
Marchiafava and Celli " in 1884 inoculated five pa-
tients with malarial blood and secured results in three.
Antolisei and Angelini,'" having inoculated two
patients with blood from a case of tertian malaria,
found eleven days afterward that malaria was present
in both cases and tertian organisms were found in the
blood.
Sacharoff '' obtained blood from leeches used in a
case of pernicious malaria and inoculated himself in the
arm with one centimetre of it. In twelve days chills
and fever came on, there being two paroxysms on suc-
cessive days, and the organisms were found in the
blood.
Di Mattel " inoculated four patients with blood
from a case of quartan fever, and in two of them, after
incubation of seventeen and eleven days respectively,
typical quartan ague developed with organisms. He
also inoculated one case with organisms from aestivo-
autumnal fever, which was followed by irregular fever
after a period of fifteen days, and the characteristic
organisms were found in the blood.
An interesting experiment, cited by Manson " as
supporting his mosquito theory, was made by Surgeon-
Major Ross. He administered to a perfectly healthy
native a certain quantity of water in which a couple
of malariased mosquitoes had died after depositing
their eggs. The remains of the insects had been re-
moved, but the eggs and grubs were swallowed.
Eleven days afterward the man had fever, headache,
etc., but no chill. This fever lasted three days. In
the blood the ring form of the plasmodium was found.
Ross states that there could be no doubt of the mala-
rial nature of the disease.
The above are a very few of the more recent experi-
ments showing the relation of the plasmodium to the
disease and the fact that it can be inoculated.
IX. Identity of Malaria in Man and in the Lower
Animals. — Hitmatozoa, as is well known, occur both
in cold and warm blooded animals, and in many in-
stances closely resemble the malarial parasite. Es-
pecially in birds is this so, and they are subject to a
disease very much like malaria as it occurs in man.
Grassi and Feletti '° claim that the organisms found
in the blood of birds suffering from malaria are the
same as those found in man.
Dambewsky " has devoted much study to the mala-
rial blood of birds and distinguishes two varieties,
one producing acute malaria and going through the
same stages as the parasite in man, and the other
causing a chronic malaria. In his latest work "^ he
affirms his belief that the malaria of birds and man is
caused by identical organisms.
In closing this paper the author wishes to express
his indebtedness to the splendid work of Thayer and
Hewetson upon " The Malarial Fevers of Baltimore,"
and to acknowledge his free use of many data therein.
BIBLIOGRAPHY.
1. Note sur un nouveau parasite, etc
Med. de Paris, November 23, 1880.
2. Johns Hopkins Hospital Reports, vol. v., 1895
Bull, de I'Acad. de
670
MEDICAL RECORD.
[November 7, 1896
3. Medical News, November 23, 1895, p. 562.
4. Brit. Med. Jour., .-August 24, 1895, p. 489.
5. Ibid., April 27, 1895, p. 920.
6. Chenzinsky: Inaug. Diss., Odessa, 1889.
7. Krit. Med. Jour,, July 13, iSg6. p. 122.
8. Diss., St. Petersburg, June, iSgi.
9. Centrbl. fur Bakt., Februar)' 5, 1894, xv. , Nos. 5 and 6, 15S.
10. English Translation, New Sydenham Society, vol. cl.,
London, 1894.
11. Sulla infezione malarica. Arch, per le Scienze Med., x.,
1886, 109-135.
12. Du Paludisme, Svo, Paris, 1892 (Encyclopedia Scientitique
des Cercle-Memoires).
13. The Malarial Parasite. Sem. M6d., May 9, 1896.
14. Bull. d. R. Accad. Med. d. Roma, anno xvi.. May 4, 1890,
287.
15. Centralblatt fur Bakt., 1891, ix., 403, 429, 461.
16. The New Sydenham Society, vol. cl., London, 1S94.
English translation of Die Malaria-Parasiten, Wien, 1893.
17. St. Pet. med. Woch., 1S91, Nos. 34 and 35.
18. Med. News, Phila., 1887, i., 59-63.
ig. International Med. Magazine, February, 1892, i., 28.
20. Johns Hopkins Hospital Reports, vol. v., 1895, 5-215.
21. Arch. Ital. d. Clin. Med., Milano, 1S94, xxxiii., 207-265.
22. Bull. d. R. Accad. Med. d. Roma, 1893-94, xv., vol. xx.,
151.
23. Ibid., March 27, 1892, anno xviii., fasc. v., 297.
24. Lancet, December 15, 1893, i, 6-ig.
25. Rev. Scientitique, Paris, 1894, ii., 449-455.
26. Centralblatt fur Bakt. u. Parasit., September 19, 1895.
27. Arch. Ital. de Biolog. , 1889, xii., p. 49.
28. Centralblatt fur Bakt., 1891, x.. No. 14. 448.
29. .Ann. de I'lnst. Pasteur, 1891, 445-449.
30. Riforma Medica, iSgo, Nos. 144-146.
31. Du paludisme et de son hematozoaire, Paris, iSgi.
32. Medical News, July ig, iSgo.
33. Johns Hopkins Hospital Reports.
34. Brit. Med. Jour., March 14, lSg6, pp. 641-647.
35. Fortschritte der Med., 1S85, iii.. No. 24, 787.
36. Brit. Med. Jour., Decembers, 1894, vol. ii., 1,306.
37. Ibid., March 14, 21, 28, 1896.
38. .Atti della R. Accad. Med. di Roma, anno .xvi., v., 1890.
3g. Bull, della R. .\ccad. Med. di Roma, anno xviii., v., 1892.
40. Brit. Med. Jour., March 21, i8g6, p. 713.
41. .St Petersburg, med. Woch., 1891, Nos. 34 and 35.
42. Deutsch. med. Woch., 1892, 661, 707, 729.
43. Brit. Med. Jour., February 29, 1896, p. 530.
44. Ibid,, February 15, lSg6, p. 404.
45. Fortschritte der Med., 1885, iii.. Nos. 11-14.
46. Rif. Med., September 28 and 29, 1889.
47. Cent, ftir Bakt., February 5, 1894.
48. Archiv fiir Hygiene, 1S95, 191-300.
49. Brit. Med. Jour., March 28, 1896, p. 776.
50. Cent, fiir Bakt., iSgl, No. 14.
51. Ann. de ITnst. Pasteur, December, 1891, 75S.
52. Russ. Arch, of Path., Clin. Med., and Bact., vol. i., pp.
1-9, lSg6.
PRIMARY MUSCULAR DYSTROPHY IN TWO
BROTHERS.'
Bv THEODORE DII.LER, .M.D.,
I'lTTsnURG, PA.,
VISITING PHVSICIAN TO ST. FRANCES' HOSPITAL ; PROFESSOR OF PHVSIOLOGV
IN THE PITTSBURG DENTAL COLLEGE.
The term muscular dystrophy is now generally em-
ployed to designate those fomis of progressive muscu-
lar weakness, attended with atrophy or pseudo-hyper-
trophy, in which the seat of the disease is in the
muscles themselves and not in the cord or nerve
trunks. The dystrophies include pseudo-muscular hy-
pertrophy, characterized by enlargement of muscles, on
the one hand; and simple idiopathic muscular atrophy
(Gowers), characterized by muscular atrophy, on the
■other hand. This latter form of muscular dystrophy
is subdivided into two types, distinguished by the
muscles chiefly involved in the atrophy, viz. : the juve-
nile form or F.rb's type, characterized by atrophy of
shoulder girdle, upper arms, and thighs; and the in-
fantile or Landouzy-De'jerine type, characterized by
involvement of the face. This last-named type is, as
pointed out by Sachs," nothing more than the Erb type
' Paper read before the Pittsburg .Vcademy of Medicine, Oc-
tober 26, 1S96.
^ " Nervous Diseases of Children," p. 422.
///is involvement of the facial muscles, which atrophy
is usually first to appear.
It is now well established that pseudo-muscular hy-
pertrophy is, like the two types of simple idiopathic
muscular atrophy, due to disease in the muscle itself,
and is not dependent upon a spinal lesion at all.
There is in this disease, as in the atrophic forms of
muscular dystrophy, a progressive muscular weakness,
in spite of the hypertrophy which is due to fatty and
connective-tissue deposits. "There is practically no
other distinction between these various types of myo-
pathies than the mere distribution of atrophy or hy-
pertrophy." '
These primary muscular dystrophies are distin-
guished clinically from progressive muscular atrophy
of spinal origin by their onset in childhood or youth;
by the presence of the disease in more than one mem-
ber of a family (heredity) ; by the absence of qualita-
tive electrical changes and of fibrillary twitching;
and by the fact that the atrophy does not begin in the
small muscles of the hand.
While the three types of muscular dystrophy are
closely associated and many atypical forms have been
described, showing the gradation of one type into an-
other or- the presence of different types in several
members of a family, vet they are, by the points just
given, sharply distinguished from progressive spinal
muscular atrophy. This is certainly true for the most
part, but it is well to bear in mind that the neuron
with its axis-cylinder process (the nerve) and the
muscle constitute a trophic unit. Erb has, indeed,
concluded that these dystrophies are tropho-neuroses,
and may result from disturbances of trophic centres.
It is not surprising that this trophic unit should at
times be involved in more than one of its component
parts, and a symptom-complex result which shtjuld
represent a blending of muscular dystrophy and pro-
gressive spinal muscular atrophy. As a matter of fact,
Striimpell ' has reported just such a case, in which
atrophy began in the hand muscles. The autopsy dis-
closed muscular, nerve, and spinal-cord lesions. He
believed that the disease originated in the muscles
and ascended the nerve trunks to the neurons in the
cord.
The hereditary feature of the muscular dystrophies
strongly points to their being due to developmental
defects; and this heredity, as has been pointed out, is
one of the chief clinical characteristics of the muscu-
lar dystrophies. But Hoffman ' has reported two
brothers in two families (four children) affected with
spinal atrophy. Autopsies on one child in each of
these families revealed neuron, nerve, and muscle de-
generation, most advanced in the cord and diminishing
toward the periphery — thus forming the exact counter-
part of Striimpell's case.
Just why one part rather than another of this tro-
phic unit should be involved, we possess no means of
knowing; and wiiile the disease may, in the great ma-
jority of instances, confine itself to one part of the
trophic unit, cases like those of Striimpell and Hoff-
man show that parts other than the one first attacked
may be subsequently involved. So, while the clinical
and pathologic features of the spinal atrophies and
muscular dystrophies are, for the most part, quite
distinct, they do occasionally merge into each other,
as one might, from a priori reasoning, expect.
With these brief considerations, I wish to report the
cases of two brothers affected with progressive muscu-
lar dystrophy. The parents are healthy and besides
these two boys have one other child (a girl), who is
a twin of the elder boy and who seems to be quite
healthy.
' Sachs, op. cit.
' Deutsch. Zeit. f Ur Nervenheilkunde, vol. iii. , No. 6.
2 "Brain," Winter, 1893.
November 7, 1896]
MEDICAL RECORD.
671
-Erb's Type of Progressive Mus-
cular Dystrophy.
Case I. (Fig. i). — Referred to me by Dr. McGrew,
of Alleghany. L. S , boy, aged thirteen years.
There was no trouble at birth and he was quite healthy
up to the age of three years. He learned to walk as
soon as infants usually
do. At three years he
contracted measles and
was in impaired health
for several weeks after-
ward; but he ulti-
mately recovered his
usual health and
strength. When he
was about five years of
age some muscular
weakness began to be
noticed, but its begin-
ning was so insidious
that the exact time is
not certain. This
muscular weakness has
steadily progressed up
to the present time.
There was no pain or
other sensory symptom
at any time. At about
the age of eight, the
boy began to stumble,
and from this time up
to the age of twelve
his legs frequentlv
gave way in walking, so that he often fell; and during
this time, in rising from the floor, he would climb up
his own body, supporting hands on thighs, in the
manner described by Cowers.
By November, 1895, the weakness had increased so
much that he was unable to stand, and about this
time contractures of knees, thighs, and ankles were
noticed, which have progressively increased up to the
present.
Soon after the muscular weakness was noticed, the
parents observed that the upper arms and thighs were
disproportionately thin; they state there has been a
progressive wasting in these parts ever since it was
first noted. There has never been fibrillary twitching
at any time. Mentally the boy is quite bright. It
was not thought that the calves were enlarged at any
time.
Examination, May 20, 1896: The boy is of quite
large frame for his age. There are no mental symp-
toms. The lower jaw protrudes, and the front teeth do
not come in contact, because of the fact that the mo-
lars strike first. He is quite helpless, unable to
stand ; but he can make some progress about the room
by the use of his hands on the floor. There are marked
contractures of legs and thighs; marked wasting of
thighs and upper arms. The calves seem to be about
normal in size. There is some atrophy of the fore-
arms, but much less than of the upper arms. Prona-
tion is much stronger than supination. There is
marked atrophy of shoulder and hip girdles. The
deltoids stand out prominently, being either actually
or apparently much hypertrophied. Knee jerks ab-
sent. No fibrillary twitching.
MEASUREMENTS.
Right. Left.
Thigh 1 1 "4 in. ii"^ in.
Calf io;/2 " 10^ "
Upper arm 6 " 6% "
In calling upon me to examine his brother, the
mother at first stated that her other son (Case II.) was
healthy. Only upon examination and direct inquiry
was I enabled to obtain the following history and ex-
amination. Then the mother stated that her younger
son did not seem to be so strong as he ought to be,
and that he was pretty clumsy at times; that he always
held to the railing in going up-stairs. She said that
several of the neighbors, observing these points, had
predicted that he would be like his brother — helpless
in time. But she had not laid these fears to heart,
for she had noted large calf muscles in the boy.
Case II. (Fig. 2). — Boy, aged seven; bright, intel-
ligent looking. For about two years past it has been
noted that he does not seem to have as much strength
as other boys of his age; that he is somewhat clumsy
in his movements. Other boys of his age outstrip him
easily in running and in various games. He holds on
to various objects to assist himself, e.g., to the rail in
going up-stairs.
Examination reveals weakness in various move-
ments. For example, when told to run up-stairs as
rapidly as possible, he is able to go up only in a
slow, labored manner. In walking he has a slow,
waddling gait. There is considerable weakness in
arms and forearms; more in the latter than the former.
Supination is much weaker than pronation.
Inspection reveals atrophy of upper arms and shoul-
der girdle. The deltoids are, in contrast with other
arm and shoulder muscles, enlarged. (This is not
nearly so marked as in Case I., and is not well shown
in the photograph.) There is moderate atrophy of
the thighs and of the pelvic girdle, while the calves
are quite distinctly hypertrophied. There is marked
lordosis. The knee jerks are absent. There are no
fibrillary twitching and no sensory symptoms. The
forearms and arms on both sides each measure six
and one-half inches; each thigh, twelve and one-half
inches; each leg, ten and one-half inches. All meas-
urements were taken at
widest circumference
and at corresponding
points.
Remarks. — The di-
agnosis of progressive
muscular dystrophy in
both these cases can, I
think, scarcely be ques-
tioned. The slow on-
set in childhood and
the progressive feat-
ures; the atrophy af-
fecting chiefly the
shoulder girdle, upper
arms, and thighs ; the
presence of the disease
in two brothers with
non-involvement of the
face in both cases and
the absence of fibril-
lary twitchings taken
together make this
diagnosis certain.
The contractures in
Case I. e.xclude the
Landouzy-D e j e r i n e
type.
Case I., with atrophy
of upper arms, shoulder
girdle, and thighs, and
with deltoid hypertro-
phy, makes it conform
quite closely to Erb's
type.
Case II., with the very considerable hypertrophy of
the calves, suggests pseudo-muscular hypertrophy.
The lordosis and waddling gait present are also fea-
tures belonging to this form of dystrophy. But the
marked atrophy of upper arms and shoulder girdle,
with apparent moderate hypertrophy of deltoids and
Fig. 2 (Brother to Fig. i").— Progressive
Muscular Dystrophy, representing a
rai-xed type — one between muscular pseu-
do-hypertrophy and Erb's type.
672
MEDICAL RECORD.
[November 7, 1896
slight atrophy of thighs, are features distinguishing
Erb's type.
The enlargement of the infraspinati, according to
Gowers ' and Jacobi ' a distinguishing feature of pseu-
do-muscular hypertrophy, is absent.
On the whole, I am inclined to regard this second
may be seen in a single individual. They afford sup-
port, too, to the view that the different types of muscu-
lar dystrophy are only forms of the same disease.
There can be little doubt that the muscular dystro-
phies attack boys very much more frequently than
girls. The exemption of only one of the three chil-
dren of the family in which my cases occurred, and
that child a girl, a twin of the elder boy, affords a cu-
rious and interesting support (so far as it goes) to this
rule.
As a sort of appendix to this paper, I wish to call
attention to the photographs (Figs. 3 and 4) of a case
of progressive spinal muscular atrophy, an account of
which was recently published.' Although the case
was atypical (having begun suddenly), it will serve
well to bring into relief certain features distinguish-
ing this form of atrophy from the progressive muscular
dystrophies.
The patient, a man aged forty-eight years, sufifered
palsy of the right arm three years ago, soon followed
by atrophy affecting a group of radial muscles, those of
the thenar eminence and of the deltoid and biceps and
scapular muscles. Some months later, loss of power
and atrophy in corresponding muscles of the left arm
set in and progressed slowly. The muscles of the neck
have recently become involved. Although for a time
the progress of the disease seemed to have been
checked by treatment (strychnine), the loss of power
and atrophy in the hands, arms, shoulders, and neck
are now progressing. There is no involvement of the
lower limbs.
Westinghocse Building.
Fig. 3. — A Case of Progressive Spinal Muscular Atrophy, showing wasting of
hands, forearms, upper arms, and shoulders ; more marked in right arm.
case as one representing an atypical or mixed type of
muscular dystrophy — one possessing features belong-
ing to Erb's type and to muscular pseudo-hypertrophy.
These two cases together afford another illustration
of what has been insisted upon by Erb, Gowers, Sachs,
Jacobi, Dana, and other recent writers upon this sub-
FiG. 4. — Posterior View of Patient represented in Fig. 3, showing very marked
atrophy of scapular muscles and of deltoids.
ject, and what has been referred to before in this paper,
viz., that more than one form of dystrophy may be seen
in different members of the same family, and that fea-
tures belonging to more than one type of dystrophy
' " Pseudo-Hypertrophic Muscular Paralysis," London, 1879.
Also, " Diseases of the Xer\'ous System," vol. i., p. 519.
' " Nervous Diseases by American Authors," p. 865.
A BRIEF NOTE AND REMARKS UPON A
CASE OF EMPYEMA OF THE VERMI-
FORM APPENDIX.
By GEORGE R. FOWLER, M.D.,
BROOKLYN, N. Y.,
PROFESSOR OF SURGRRV IN THE NEW YORK POLYCLINIC, SfRGBON TO THE
METHODIST EPISCOPAL HOSPITAL AND TO THE BROOKLYN HOSPITAL.
There is scarcely room for doubt in the minds of
those who have been brought much in contact with the
disease appendicitis that surgical measures, and these
alone, are competent to deal effectually with the dis-
ease when the latter is progressive in character. In
mild cases of catarrhal appendix or endo-appendicitis,
with but slight interference with the blood supply, and
in the absence of virulent infection, the inflammatory
action may not extend beyond simple thickening of
the mucosa and submucosa, or at the most involve but
slightly destructive alterations in the organ; hence
these cases should quickly clear up under saline pur-
gation and rest in the recumbent position. One con-
dition is occasionally found, however, as a result of
these so-called " catarrhal" attacks (which, by the way,
are not catarrhal in the true sense, since they almost
invariably involve at least the submucosa), and that is
the occurrence of narrowing or even complete obliter-
ation of the lumen of the appendix at one or more
points. If the inflammatory action is of a sufficiently
high grade and extensive enough to involve the entire
length of the organ alike, the subsequent dangers to
the patient are not nearly so great, since under these
circumstances obliteration of the entire lumen may
take place, as when this is limited to one or more
points, particularly at its base or point of attachment
to the crecum, the site of the appendiculo-caecal orifice.
Occlusion at this point constitutes a source of danger
not heretofore sufficiently dwelt upon by writers upon
the subject, and which is illustrated by the following
case:
' New York Medical Journal, June 6, 1896.
November 7, 1896]
MEDICAL RECORD.
673
J. E. S , Jr., aged twenty- one years, was taken
suddenly ill at about i .^o a.m. while on a visit to
Shelter Island. His hostess administered a dose of
so-called cholera mixture which contained a liberal
quantity of opium. l)r. \V. K. liutler, of this city, saw
him a few hours later and found him quite comfortable,
with a practically normal pulse rate and temperature.
The entire abdominal wall was relaxed and absolutely
without tenderness upon pressure, save at a point which
could be covered with the end of the finger, somewhat
below the centre of the right iliac region.
I saw the patient at 7 p.m. of the same day, and
found him entirely free from pain; the local tender-
ness had also decreased, both of which conditions
were probably due to the opium taken. The temper-
ature by the rectum was 100.6" F. and pulse 80. He
expressed a general feeling of well-being, and was
cheerful and unconcerned about himself. The follow-
ing points were related to me by Dr. Butler as a part
of his previous history: Two years before he had
suffered from an attack commencing in the same man-
ner, and one year later from another, for both of which
he had been treated by a physician for "cold in the
bowels.'' The last attack necessitated a week in
bed.
In view of this portion of his history I decided to
have him removed to the city at once for operation, in
spite of the fact that the then present attack appeared
to be already upon the wane. Accordingly he was
carefully transferred to an easy mattress and cot and
transported by special train to Brooklyn and taken in
an invalid coach to the Methodist Episcopal Hospital.
Preparations were made for immediate operation, and
at 12:30, just twenty-three hours after the first acute
symptoms, the abdomen was opened and the appendix
removed. The latter lay in the S. E. position (down-
ward and inward), crossing the brim of the pelvis and
lying upon the peritoneal covering of the iliac vessels.
No adhesions were at first apparent. The organ w'as
uniformly enlarged to about one and a half times its
normal size, but in other respects presented a normal
appearance. The walls of the organ fluctuated upon
palpation, and the enlargement was evidently due to a
distention of the organ by fluid, and extended from
its base to the distal extremity.
With proper precautions to protect the peritoneal
cavity from infection, by thoroughly walling off with
gauze compresses, the ctecum with its attached appen-
di,ic was brought into the wound. The meso-appendix
was ligated en masse close to the base of the appendix,
the latter separated, a purse-string suture passed upon
the cffical wall about half an inch from the base of the
organ, and the latter amputated, after the precaution
of encircling it near its proximal extremity with a liga-
ture to prevent its contents from escaping had been
taken. As the section was made there welled out from
the short stump a purulent fluid. An attempt was now
made to pass a small probe into the cavity of the cae-
cum, when it was found that the orifice leading to the
latter was wanting; the communication was entirely
shut off by a stricture, the result of one of the previous
attacks, probably the last.
Subsequent examination of the organ revealed the
following: The appendix was unusually long. Upon
opening it lengthwise it was found to be filled with
purulent fluid, the result of hypersecretion from its liv-
ing mucous membrane ; this was undergoing suppura-
tive changes. Its mucous membrane was thickened
and at the extreme tip the latter was ulcerated for an
area slightly larger than a pin's head. At this point
the submucosa, as well as the wall of the organ, had
taken part in the ulcerative action, only the serosa
remaining intact. Upon the serous covering opposite
this point of ulceration the remains of an adhesion
were found, which had evidently given way with the
slight traction exercised in bringing the organ into
the wound.
The significance of the location in which the appen-
dix was found, as well as that of the infection of its
wall and serosa at the tip, became apparent later on.
The case pursued an uneventful after-course until the
eighth day, when a left femoral phlebitis made its ap-
pearance, which in all probability commenced as an
infectious iliac paraphlebitis and finally resulted in a
phlebitis, the infection having its origin in the tip of
the appendix at the point where the ulcerative action
was in progress. This infectious process extended to
the right iliac vein finally, as evinced by a subsequent
right femoral phlebitis. These complications delayed
the patient's convalescence to at least double the
length of time required for recovery from an average
uncomplicated operative case of appendicitis.
The case related is one in which all the symptoms
of a mild endo-appendicitis, with its promising favor-
able termination under nature's efforts, disclosed upon
operation an astonishingly dangerous condition of
affairs. The lumen was shut oft' from the cavity of the
cfficum by the presence of a stricture, the result of a
previous attack. The infectious agents thus impris-
oned had remained in an innocuous quietude for a
time, when finally an irritation emanating from these
micro-organisms, and with the predisposition fur-
nished by some casual interference with the blood
supply to the organ, such as probably results from
changes in position in the organ when freely movable
in the peritoneal cavity — an attack of so-called " catar-
rhal" inflammation, followed by increase of secretion-—
furnished the pabulum for the proliferation of the
micro-organisms present. This proliferation initiated
suppurative changes in the exudate, and pressure and
infection combined to set up the ulcerative changes in
the tip of the organ, where the vital resistance is re-
duced to the minimum by the absence of proper blood
supply in an organ whose vestigeal character and evi-
dent final fate through evolutionary changes stamp it
as the most dangerous of that class of which it and
the tonsils and the wisdom teeth are the types.
The fact that the appendix lay across the brim of
the pelvis and rested with its point, at which perfora-
tion threatened, lying upon the left iliac vein fur-
nishes the explanation of the subsequent occurrence
of the femoral phlebitis. The infection extended from
the serosa of the organ to the posterior layer of the
peritoneum and thence to the connective-tissue layer
surrounding the iliac vein. The infectious paraphle-
bitis and subsequent phlebitis thus set up extended
first in the direction of the left, and finally to the
right, femoral vein.
The case scarcely requires further comment. It is
published with the hope of attracting attention to a
class of cases not frequently alluded to, and to show
the fallacy of relying upon the train of fortuitous cir-
cumstances which are believed to hedge in these so-
called "catarrhal" cases and lead to a favorable
termination in apparently mild attacks of appendicitis,
particularly when the history of the case includes a
statement of previous attacks of the disease. The
links in the pathological chain are so unmistakably
and uninterruptedly connected that it would certainly
seem as if " he who runs may read."
Warts. — Dr. Laubenburg has discovered that if a
spot is touched with fuming nitric acid, and then im-
mediately afterward with pure liquid carbolic acid,
there is a strong chemical action, the effects of which
penetrate deep into the tissues, and completely and
permanently cure wartiji condyloma, angioma, etc. —
Centralblatt Jiir Chiruigie, August 8th.
674
MEDICAL RECORD.
[November 7, 1896
SOME THOUGHTS ON DISORDERED MEM-
ORY AND KINDRED CONDITIONS.
By C. a. drew, M.D.,
ASSISTANT PHYSICIAN, ASYLUM FOR INSANE, MEDFIELD, MASS.
It is held by some physiologists whom we honor that
all healthy ganglionic nerve cells have memory: /. c.,
are subject to permanent impressions by every tempo-
rarily acting stimulus. In this sense, memor)- is con-
ceived of as possible independent of consciousness;
the idea being that memory consists of the impres-
sions registered on the ganglionic cells of the cerebral
cortex, irrespective of whether those impressions are
recognized and correctly interpreted by the individual
consciousness or not. If we conceive of memory as
the recognition by consciousness of impressions made
on the ganglionic cells by e.xternal stimuli, our con-
ception will harmonize with the general idea of that
intellectual function commonly recognized as memory;
not complete nor entitled to tlie name, divorced from
consciousness.
Whether we conceive of memory as commonly rec-
ognized, or in a modified or broader sense, we natu-
rally associate a good memory with healthy well-nour-
ished nerve cell of the cerebral cortex. It is believed
that the assumption of such a relation, as a rule, \vill
be supported by the observation of every medico-psy-
chological student. As a rule, I say, because there
are some notable exceptions that add much to the in-
terest as well as to the difficulty of solving the prob-
lem and fixing the relationship between ganglionic in-
tegrity, memory, and consciousness.
It is interesting to note that certain specialized
memories are represented by different cerebral convo-
lutions. We know that a more or less complete loss
of memory for articulation, motor aphasia, almost
surely follows any considerable lesion of the posterior
part of the third frontal convolution; and that a con-
dition known as " word deafness," the subject of
which can understand written but not spoken words,
hile expressing himself freely by both written and
c I speech, commonly follows a circumscribed lesion
of 'le sujxirior left temporal convolution. Again, it
has ten demonstrated that a circumscribed lesion of
the si erior occipital and angular gyri is followed by
a cona lion known as "word blindness," in which the
individual cannot recall the name of a printed or
written word nor associate it with its object, although
he can express himself correctly and has no trouble in
understanding oral speech. " In right-handed people
all the memory centres are in the left cerebral hemi-
sphere; in left-handed people they are in the right
hemisphere." '
We know that these functional disturbances from
pathological conditions are compatible wiiii so much
mental integrity that the subject may not be consid-
ered insane; but we also consider complete loss of
any specialized memory as strongly indicating circum-
scribed organic brain disease.
A partial failure of any form of memory may be rea-
sonably considered physiological, and, perhaps, ex-
plained on the hypothesis that excessive action of the
ganglionic cells of one convolution would naturally
cause ana;mia and decreased functional activity of
other convolutions, representing different faculties of
mind. He who can turn quickly from intense exer-
cise of concentration of attention and the reasoning
faculty, supposed to depend on functional activity of
the anterior portions of the frontal convolutions of the
brain, to recall without hesitation the name of an in-
dividual not frequently met, or a technical term for-
eign to the subject on which the mind has been dwell-
ing, may congratulate himself that the vasomotor
' " Nervous Diseases," C. 1.. Dana, p. 320.
mechanism of his brain is nicely adjusted and quickly
responsive indeed.
It is highly probable that the energizing functions
of certain cortical areas are practically quiescent while
faculties represented by a distant brain area are espe-
cially active; and this serves at once as a rational
guide for mental therapeutics and indicates the danger
to mental health from the mind dwelling unremittingly
on one thought or closely related thoughts.
Besides the disorders of memory belonging to well-
recognized forms of mental derangement, those rare
anomalies of mind function known as " loss of per-
sonal identity," "double personality," and "double
consciousness" are especially interesting. Frequently
the news columns of our dailies have accounts of some
man, perhaps not manifestly insane nor delirious from
fever or toxic agents of any kind, who cannot, or claims
he cannot, give any clew to who he is or where he
came from. It is highly probable that some of these
persons are dissemblers, individuals hungry for noto-
riety; and yet it is a fact, well established, that
through some obscure pathology not well understood
an individual's mind may become as a blank from
which all the impressions have been erased. It is be-
lieved that the impressions which have been potent in
the e\olution of that man's mentality are still indeli-
bly impressed on that brain cortex, to last while that
brain retains its structural integrity; yet the connect-
ing link binding past to present has in some way been
broken. "The light of consciousness" is no longer
able to illuminate those myriad images hidden among
the tortuous cerebral sulci.
Among the cases of lost personal identity recorded
by members of our own profession, H. C. Wood ' tells
of a man wlio was brought to the hospital suffering
from sunstroke, from which he recovered promptly
and was entirely rational, but for several days could
not tell his name nor give the slightest clew to his own
identity or where he came from. " Double conscious-
ness" is a periodic failure of memory, sometimes asso-
ciated with a coincident change of disposition. A typi-
cal case is quoted by Dr. Wood from Dr. Mitchell, of
New York, from which I cannot do better than to
quote. A highly educated young woman fell, without
warning, into a dt-ep sleep lasting several hours. On
waking she had lost all former knowledge. " It was
necessary for her to relearn ever}'thing — the alphabet,
to read, write, and reckon. Some months later she
again fell into a deep sleep and woke in the normal
state. Then she remembered all that she had learned
in her original condition but remembered nothing that
had occurred in her abnormal state. For many years
after this she alternated between the first and second
condition, in each state knowing only \\hat she had
learned in previous periods of the same state. When
she made acquaintances she recognized them only
when she was in the state in which she had been
at the time of their first meeting. Her handwriting,
which was good in the first condition, was very bad in
the second state."
Each case of " double consciousness" will present
some atypical features and individual jjeculiarity. It
is common for a deep sleep and inten.se headache to
usher in the abnormal state; although the duration of
the sleep may not be more than a few minutes. It is
a rule for all the experience of the abnormal period to
be utterly forgotten when the subject passes again into
the natural state. There is great variation in the com-
parative memory and activity of the intellectual facul-
ties of different individuals while in the unnatural
state; some, like Dr. Mitchell's subject, are conscious
only of impressions made during former similar ab-
normal conditions, while others remember, with an ex-
alted acuteness, not only the experiences of former
' " Nervous Diseases," H. C. Wood, p. 372.
November 7, 1896]
MEDICAL RECORD.
675
like attacks, but all the events of the normal life as
well.
Along with a changed consciousness, comes a
changed personality in many cases. One naturally of
a melancholy temperament, passing into a mental
world of new memories, may take on a vivacious, light-
hearted, thoughtless disposition. The moral qualities
may also be equally changed for the worse, or possibly,
for the better.
When we say that " double consciousness" is a pe-
riodic failure of memory, we state only part of the
truth; because, while memory for the past is obliter-
ated, new impressions are '" registered and reproduced
in sufficient number and intensity to serve as a guide
to rational action," as is evidenced by the fact that
eminent members of our profession have not classed
individuals manifesting pure double consciousness as
insane.
While pure cases of well -authenticated double con-
sciousness are rare, every large hospital for the insane
will furnish incomplete mixed cases.
The conditions known as " double personality,'' in
which the subject believes himself to be two distinct
individuals, to have "a double," which may follow him
about constantly talking to him, is so identified with
delusional insanity that we may safely class these sub-
jects as having passed the border land of sanity into
the domain of mental aberration.
We know the border line between sanity and insan-
itv is very indefinite and shadowy, and that there are
many psychological phenomena which, so far, have
puzzled progressive experimental physiologists and
pathological microscopists.
When tottering reason and failing memory come to
us in a cracked and weakened vessel; and, after a
time the pathologist reports a shrunken, waterlogged
brain, gummatous tumors, or congested gray substance
with milky arachnoid; or obliterated lumina of impor-
tant cerebral arteries; or ganglionic cells with soft-
ened walls minus processes and nuclei, then we feel a
satisfied congratulatory thrill; our theories are so far
vindicated. The mental condition was consistent with
a demonstrated cause. The organ of mind was dis-
eased— corresponding dementia was natural and inevi-
table.
Mental confusion with emotional depressions, and
memory almost nil, may come to us in a body weak
from inanition. We naturally expect its brain cells
to be also starved. The mental attitude precludes a
fair quantity of nourishment being taken. A heavily
coated tongue, foul breath, and parched lips tell of
wanting normal secretion, with probable toxic prod-
ucts, in the place of needed peptones in the digestive
tract. A saline purge, perhaps an irrigation of that
mucus-coated stomach, a pint of beaten milk and eggs
twice or thrice daily through a stomach-tube, and in
a few weeks apparently almost a miracle is wrought.
Mind and memory come again when toxic products are
eliminated and nutriment is furnished those starving
cells of the central nervous system. We congratulate
ourselves again and mentally say, brain is the organ
of mind; see that metabolic debris does not obstruct
and poison the life current from which those brain
cells drink constantly, supply the needed pabulum,
and mind with memory will not desert the intellectual
throne. True, we acknowledge that every mechanism
has its limitations, and we realize how frail some
nervous mechanisms are. We also insist that for
long ser\'ice no one part of the mental machinery shall
be in constant use.
We can understand why all organic diseases of the
brain should cause dementia with loss of memory.
We explain the almost entire loss of memory for re-
cent events with good memory for the experiences of
early life, by saying that the softened ganglionic cells
have lost their power to register impressions, while the
power to reproduce impressions made when the brain
was at its best is still retained.
It is not uncommon for one with acute mania or
confusional insanity to wake from a sleep entirely
rational, to ask where he is, how long he has been in
the hospital, etc.; he may remember the events of his
delirious period as one remembers a bad dream, or all
the impressions of his abnormal period may be lost to
rational consciousness. After remaining rational a
few liours, he may pass again into a maniacal state, to
be dominated by the same irrational ideas, begotten of
his morbid fancy. Indeed, according to the writer's
observation, one passing suddenly from the utter inco-
herence of acute insanity to perfect rationality is very
apt to relapse; while it is a good omen for the mental
cloud to lift gradually.
These alternating rational and irrational periods of
the insane seem to be closely analogous to '" double
consciousness." It is another witness to the shadowy
line of demarcation between the sane man with a neu-
ropathic constitution and the man who is mildly but
legally insane.
Occasionally v.e are confronted by psychological
phenomena seeming to throw doubt on the entire de-
pendence of memory on healthy well -nourished cells
of the cerebral cortex. There is a popular belief that
before the mind of a drowning man, whose nerve cen-
tres must be suffering for want of oxygen, at least, the
minutest events of his life pass in rapid panorama.
However this maybe, there is authentic evidence that,
under certain conditions, memory is uncommonly ac-
tive when the body is weakened by disease, and there
are individual cases of insanity with memory exalted
above the normal.
When the higher faculties of judgment and volition
are paralyzed by the hypnotic state, the individual
frequently manifests a phenomenal memory, reciting
poems without an error, speaking in a language en-
tirely lost to memory in the subject's normal state,
etc.
These exceptional and apparently paradoxical cases
have been made the most of to support many kinds of
occult psychological theories. One of the recent and
most interesting attempts at solution of these extraor-
dinary manifestations of mind is by T. J. Hudson
under the title of "The Law of Psychic Phenomena."
It being, in the language of the sub-title, " a working
hypothesis for the systematic study of hypnotism,
spiritism, mental therapeutics, etc."
The basal proposition of this unique and well-writ-
ten book is that man's mind is dual, in function at
least, and may be considered, for purposes of study, as
consisting of two distinct entities, which for conven-
ience and in harmony with carefully observed phe-
nomena, he designates the subjective and objective
minds. The former is identical with the soul of man,
it is constantly amenable to control by suggestion, and
is incapable of inductive reasoning. But when domi-
nating the individual, as it does in the hypnotic state,
trance, and certain conditions of insanity, it accepts
as verity any suggestion from without or any disor-
dered sensation from witliin, and may reason deduc-
tively, from a false premise, with unerring accuracy.
In the language of the author : " The objective mind
takes cognizance of the objective world. Its media of
observation are the five physical senses. It is the
outgrowth of man's physical necessities. It is his
guide in the struggle with his material environments.
Its highest function is that of reasoning.
The subjective mind takes cognizance of its envi-
ronments by means independent of the physical senses.
It perceives by intuition. It is the seat of the emo-
tions and the storehouse of memory. It performs its
highest functions when the objective senses are in
676
MEDICAL RECORD.
[November 7, 1896
abeyance. In a word, it is that intelligence which
makes itself manifest in a hypnotic subject when in a
state of somnambulism."
Belonging to the subjective and objective minds
are subjective and objective memories, between which
there is a wide and distinctive difference. The objec-
tive memory, being a function of the brain, " has an
absolute localization in the cerebral cortex." And the
different varieties of memory, such as visual memory,
auditory memory, memory for speech, etc., can be de-
stroyed by localized disease or by surgical operation.
" Subjective memory, on the other hand, appears to
be an inherent power and free from anatomical rela-
tions. At least, it does not depend upon the healthy
condition of the brain for its manifestation."
It is foreign to my purpose to defend Mr. Hudson's
position, nor do I wish to attack it. One cannot help
feeling that there is much doubt of the reliability of
many of the alleged facts on which his clever hypothe-
sis is based. But I deem his theories sufficiently in-
teresting to be considered in relation to phenomena
which many will recognize, and few, if any, attempt to
explain.
The tendency of modern thought, particularly in our
profession, is toward a strictly materialistic explana-
tion of all the phenomena of mind.
In an excellent paper on "The Treatment of Insan-
ity," ' Dr. Homibrook voices the belief of a vast ma-
jority of the most progressive in our profession, when
he says: " I informed him that the immaterial mind
was ' beyond my ken,' and that, with my limited ca-
pacity, it was impossible to conceive of an insane
mind in a perfectly healthy and properly developed
physical organization."
It is certainly true that the history of mental dis-
ease is a history of brain disease or nervous derange-
ment. We note the coincident evolution of mind with
cerebral development. We observe that the mental
states of well-being, depression, joy, or misery are de-
pendent on or are modified by the condition of the
different organisms, and that many of the intense
pleasures of the highly gifted intellects come through
the agency of the material organs of special sense.
It is possible to err by giving attention only to one
class of evidence; and we are all the more likely to
throw- out competent evidence tending to prove an im-
material or spiritual element in the human intellect
because it is so mixed with the chaff of duplicity and
pretension offered by so-called spiritualistic mediums
and the like.
I'hat the brain is the organ of the mind or soul is
not questioned. That the mind cannot manifest any
of its higher capacities under normal conditions, ex-
cept through the material nervous organization, is not
doubted. It is observed, however, that the plausible
explanations of mentalization on the hypothesis of
ganglionic reaction to external and auto-stimulation
assumes consciousness as an endowment, " latent in
the new-born infant." And to assume the highest and
most distinctive attribute of mind, " without which," in
the language of Dr. Covvles," "there can be no mental
action," seems like begging the whole question. And
there are many thoughtful observers of intellectual
phenomena who will not assent to the proposition,
growing logically out of the position taken by some
psychologists, that the mind or soul of man is but a
convenient term for the product of physical and chem-
ical action; and that all the manifestations of mind —
hopes and fears, love and aspirations — are products of
the brain alone, as bile is the product of the liver.
"Attraction plus repulsion of molecules," says
Maudsley, " constitutes our conception of matter; and,
in observation of its mode of energy, attraction is rec-
' Iowa Med. Jour., October, 1S95.
' " The Mental Symptoms of Fatigue," p. 10.
ognized in gravitation, cohesion, magnetism, affinity,
love; while repulsion is found in centrifugal force,
heat, electricity, antipathy, and hate." '
This gifted writer sees no contrast between vital
action and the kind of action exhibited by inorganic
nature.
From a different standpoint Noah Porter writes:
"The excitement of a nervous organism does not and
never can be made to signify the same thing as to
know, to feel, or to will. Its excitement a second time
can never be the equivalent of to remember. The
partial excitement of many nerves or nerve products,
limiting or helping one another, can never signify to
reason." . . . These are psychic activities, and no
amount of research will ever elucidate anything further
than that certain corporal organs take a certain paral-
lel action when the soul externalizes its own activi-
ties." "
To the question. What is mind? science gives a
very imperfect answer; and this is true, whether the
explanation follows the teaching of the ancient Aristo-
telian philosophy — includes the more modern meta-
physical idea of immaterial '" primitive forces," modi-
fied and organized to form the faculties of mind,
coincident with the growth and evolution of the ner-
vous organism, or accepts the propositions of the
strictly materialistic psychologist, who holds that, by
the expenditure of a sufficient amount of energy, inor-
ganic may be raised to organic, and the lowest or-
ganic to the highest organic matter.'
It is natural for physicians to give most weight to
the conclusions of tliose who reason from a purely
physiological standpoint. Indeed, the very terms used
by those who begin the study of mind by an analytical
examination of their own consciousness seem to most
of us but the introduction to a "meaningless meta-
physical haze." This may, however, be due largely
to the fact that our education has been along entirely
different lines of thought, and it is to be regretted that
there are physicians, having a very limited knowledge
of the writings of Spencer, Bain, and Maudsley, who
use these names as a justification for siiallow and
offensive ridicule of those who believe in the theolog-
ical idea of an immortal soul and a future life beyond
death, etc.; and it would not lessen the prestige of our
profession if ridicule of a religious faith was dele-
gated to those alone who have weighed all the evidence
for and against such a faith.
Inasmuch as Maudsley is an authority often quoted
by those who believe all the phenomena of mind are
adequately explained on tiie hypothesis of nervous
ganglia reacting to external stimuli, and that the idea
of an immaterial soul is a ghost of superstition — laid
beyond peradventure — the following, from the pen of
Maudsley, is quoted:
" Without speculating at all concerning the nature
of mind — which, let me distinctly declare at the out-
set, is a question science cannot touch, and I do not
dream of attempting to touch — I do not siirink from
saying that we shall make no progress toward a mental
science if we begin by depreciatitig the body. . . .
The portion of the universe with which man is brought
into relation by his existing sentiency is but a frag-
ment; and to measure the possibilities of the infinite
unknown by what he knows is very much as if an oys-
ter, judging all nature by the experience gained within
his shell, should deny the existence on earth of a hu-
man being, because its intelligence cannot conceive
his nature or recognize his works. Encompassing us
and transcending our ken is a universe of energies.
How, then, can man, the feeble atom of an hour, pre-
' " Theoiy of Vitality," p. 226.
'"The Human Intellect," p. 55.
^ Ibid., p. 472.
■■ " Theory of Vitality," p. 243.
November 7, 1896'J
MEDICAL RECORD.
677
sume to affirm whose glory the heavens declare, whose
handiwork the firmament showeth ! C'ertainly true
science does not so dogmatize."
POSTURE IN LABOR.'
By THOMAS \V. HARVEY, M.D.,
ORANGE, N. J.
In every field of muscular effort we find that there
has been a careful and scientific study of the best and
most efficient methods for making the eff^ort tell for the
greatest results. We seek for a maximum of effect
from a minimum of effort. The oarsman, the soldier,
the cycler, the bo.xer, the athlete generally, the work-
man lifting or carrying burdens, have all been studied
and their muscular movements analyzed. They have
been taught how to stand, how to hold the body, when
to put forth the greatest e.xertion so as to apply the
muscles in the most eiificient way.
When we come to the most necessary muscular
effort of all, the one for which women were created,
without which all things human end — the labor of par-
turition— we do not find that any effort is made to
train the young woman how to use her natural forces ;
and while in savage and semi-civilized nations contin-
uation of the species is thought of such importance
that the young girls are taught in their childish dances
the proper feminine posturing and movements that
make sexual congress most successful, there has been
no training for the important function of motherhood
— the idea being that instinct should direct the method
of putting forth her strength most efficiently. But
many young women seek a posture that will relieve
them of their pain, and do not seek, but rather avoid,
a posture that will allow them to use their voluntary
muscles most efficiently. The whole subject of child-
birth is still obscured by the cloud of traditions and old
wives' tales, and the darkness of superstition of the
"wise woman," who has either forgotten her own ex-
perience or who dropped her babies like kittens, with-
out special effort. Under her advice, a woman is pre-
vented from assuming such postures as nature indicates,
but must have her baby in the traditional posture of
her particular ge7ts.
If we review the history of obstetrics, we find that
here, as in other matters, fashion reigns, and a woman
is put in one or another posture to suit the fad. To
any one who has attempted to introduce the forceps
with the woman lying on her side, it will ever be a
mystery why our English brethren continue that posi-
tion for operative work. In all other gynecological
work the English operator recognizes the value of tlie
dorsal position, but when tlie forceps are to be applied
over the patient goes on her side — and only the con-
servatism of fashion can account for it.
If we study the postures assumed by the women of
different lands, it is surprising to learn how many and
various, and often how artificial and complicated, are
the observances and postures that they assume. In
civilized nations, where medicine is more scientific,
tradition may not govern, but fashion does; among the
semicivilized, where the midwife reigns supreme, we
have the inflexible laws of her craft, founded only on
ignorance and superstition. If we go among the wild
women, we find still that the same influences are acti\e.
It seems that the most natural position for the
mother during the expulsion stage would be squatting
on the feet, with a firm hold on a post or tree in front
of her. This is the attitude assumed by the women of
many of our Indian tribes. Many of us have found
the rude peasant woman of continental Europe in the
same position.
' Paper read before the Orange Mountain Medical Society.
.\mong the Africans and also among American tribes
this is often modified to a kneeling position ; but if we
put a woman in a semi-recumbent position, with her
knees fle.xed, the feet firmly implanted on the bed
against a box or the foot of the bed, and something that
she can take hold of with her hands to steady the
body, we place her in a position to use her muscular
powers to the utmost degree, for the one purpose of
forcing out the child.
This position was prevalent in the days of the ob-
stetric chair, and is found modified in many ways
among different people. The Japanese woman is con-
fined reclining on a wicker framework covered with
matting. The French Canadian turns a chair back
down, and on this inclined plane lays a mattress, on
which she reclines. The .South American is confined
in her hammock. Many women of many lands work
the husband into their service, and use his lap for a
couch. Often another woman assumes this position ;
and again, with arms encircling her abdomen, the
hands pressing on the fundus, an auxiliary force of
much effect is brought to the assistance of the partu-
rient.'
The posture of general flexion is the most effective.
You will often see a woman straining in her labor —
her legs extended, her head thrown back, and the body
arched forward. If you make an examination during
a pain, you will find very little descent of the child.
This is a trick that the woman has learned during the
first stage of labor, to keep the child from pressing too
hard upon the undilated cervix, and during that stage
is of value and assistance to her ; but if the time has
arrived for the descent of the child, then such posture
is harmful and delays the labor. And if you will have
her change her position to one of general flexion,
chin on the chest, back bent, legs and thighs flexed,
an examination during a pain will show a descent of
the head.
This is to be borne in mind when the head reaches
the perineum in a primipara. If there is danger of
rupture of that part of the canal from the violence of
the labor, the woman may be turned over to her side
with benefit, with the effect of prolonging her labor
and giving the parts a chance to dilate.
This last suggestion brings us to a part of our sub-
ject which will bear careful study and which presents
many unsolved problems, viz., the effects of posture
upon the mechanism of labor.
The factors of our problem are the pelvic inclined
planes and the leverage that may be brought to bear
upon the fcetal head through the long axis of the foetal
ovoid.
If you have a certain inclination of the long axis of
the fatal ovoid to the plane of the brim, you certainly
can change the relation of the fcetal head to the pelvis
by changing such inclination, i.e., by rolling the wo-
man over. And you can effect such a change up to
the time when the head becomes tightly fitted to the
pelvic planes, and when, by the escape of the waters
and the moulding that takes place as labor progresses,
the influence of posture is diminished. Then it is
easier to bend the foetus on itself than it is to turn the
head. It is, therefore, in the early stages that we can
affect the mechanism of labor.
The knee-chest position, in the early treatment of
prolapse of the cord, is classical.
There is a class of cases in which labor is tedious,
without there being any very apparent reason why it
should be delayed. In these we shall find the follow-
ing condition of affairs: A multipara is having weak,
inefficient, and infrequent pains; the os is well di-
lated, but not retracted; the membranes may be intact
or not, but the head remains at the brim. Examina-
tion shows deflexion of the long axis of the foetal
' Engelmann : " Labor among I'rimitive Peoples."
678
MEDICAL RECORD.
[November 7, 1896
ovoid, very much exaggerated, either laterally or in
front. Now, if the woman be placed on her back in a
semi-recumbent position, the uterus straightened up,
and pressure with the hands made upon the fundus,
assisting the pain, the child will be found to descend
very rapidly.
In occiput-anterior labors, it will often be found
that a change of position of the mother, thus changing
the inclination of the foetal axis to the pelvic planes,
w'ill facilitate labor. This is a wrinkle that it is well
to remember in cases of labor with delayed first stage,
when we often find the cervix driven down before the
advancing foetal head, which condition is one of dan
ger, because of the thinning of the uterus wall just
above the internal os. The body retracts, the cervix
is held down by the head, and this point in the uterus
wall becomes thin and frail.
When we find the os in this condition, labor maybe
faciiit.ited by observing which lip is being pushed be-
fore the head and turning the mother accordingly.
If she is on her back and the anterior lip is the one
in trouble — a very common condition, by the way —
she should be turned on that side which frees the lip
most completely. If it is a lateral lip and she is on
her side, a turning on to the back or other side will
often free the lip.
When we try to apply the effects of change of pos-
ture in occiput-posterior cases, we are confronted with
a class of cases many of which I have always consid-
ered should be treated by manual interference as early
as possible — those cases in which the os is not well
dilated and the cervix is not retracted. Associated
with this there is very little descent of the child's
head. This condition may be recognized very early,
and in such cases the introduction of the hand, with
or without ether, will enable one often to change the
position of the head, either by rotation or by fiexion.
With a little care in changing the posture of the
mother, in such a way as to counteract the influence of
the position of the child, the ditificulty of retaining the
head in a proper position may be overcome.
In all positions of the head there is a deviation of
the long axis of the foetus from the vertical axis of the
brim of the pelvis, and consequently a deflexion of the
head — the finger touches the parietal bone instead of
the sagittal suture in the median line of the pelvis.
Now, if the mother's posture be shifted to the other
side, and the uterus and its contents shifted to the
other side, the relations of the fcttal and pelvic axes
must be changed al.so; and the relation of the head
to the pelvis must be appreciably affected.
In advanced cases, when the os is well dilated and
retracted over the head and the head is well down in
the pelvis, it is not so easy to affect the relations of
the head to the pelvis by changing the relations of the
fcEtal and pelvic axes, the body of the fatus bending
too easily.
Reynolds recommends the knee-chest posture in oc-
ciput-posterior cases, if seen early, even recommend-
ing the posture before labor begins, as a prophylactic
measure when occiput posture has been diagno.sed.
We have the influence of gravity, the head recedes,
and as the head recedes there is a tendency for the
heavier posterior half of the child to rotate forward.
After rotation has taken place, the patient should lie
in the latero-prone position, upon the side to which
the occiput is directed, and should remain in that po-
sition until the head is firmly engaged in the new po-
sition.
In breach or footling cases, changes of posture of
the mother will often facilitate labor when delay is
due to deviation of the long axis of the fatus.
In shoulder and arm cases, the proper posture is of
very great importance. You can facilitate the bring-
ing down of the head or of the feet very materially
by making the woman lie on the side toward which
you wish the other extremity to go. The knee-chest
position has been advised for version, and I can re-
call cases in which that position would have been of
assistance in introducing the hand; but ordinarily I
think that the dorsal posture is the best for the intro-
duction of the hand and for reaching the feet, to be
changed to the lateral with advantage when the feet
ha\e been seized.
Theories are useful, but their application at the
bedside is the crucial test. In abnormal labors there
are so many factors that may be causing the unusual
condition that we must study each case by itself; but
the recognition of the effects of maternal posture upon
the position of the foetus will often help us out of a
serious complication. I have two cases of midwifery
which illustrate the value of such a means of assisting
nature, which I will detail.
The first was a brow presentation, which is one of
the most serious forms of malposition of the head, and
which, if not remedied early, will certainly end in the
death of the child.
The second was a face presentation, w ith chin back-
ward, which has an equally serious prognosis for the
child.
Mrs. B , aged thirty-seven, American, a multi-
para, sent for me about i p.m. She felt that labor had
begun, but she was having little pain. The os was
about half-dilated. Mrs. B 's previous labors had
all been of a very easy character and of short dura-
tion. Examination, at three o'clock, showed the os
well dilated, and the membranes ruptured, but that
there was very little pain. The head was presenting,
but was at the brim. A further examination showed
that the presenting part was the brow, w ith the chin di-
rected backward and toward the right sacro-iliac syn-
chondrosis. The woman was lying on her left side.
The examination stimulated the pains, so that they
began to appear about once in fifteen minutes. The
right hand was introduced into the vagina, and the
chilli's head rotated so that its chin pointed toward the
right thyroid foramen of the mother's pelvis. When
the pain came on, the head was twisted back to its
previous position. This was repeated three times. I
then took the head of the child in my hand and ro-
tated the chin as before; and while I held the head in
that position I had the woman roll over on to her
right side, and held the head in position until the
next pain came on, when I had the satisfaction to feel
the chin slip down to the lower edge of the symphysis
pubis, where it remained. The labor made good
progress until the forehead reached the perineum, when,
the force of pains becoming inefficient (they had never
been very strong during the labor), I put on the for-
ceps and delivered her quickly. A healthy living
child was born about five o'clock. The manipulation
of the head was done without anasthesia, and did not
cause much distress; the forceps operation was done
under chloroform. The woman made a rajiid and an
afebrile recovery.
The second case was that of an Irish woman, of
thirty, with her third child. The first labor had been
very long, ending in instrumental delivery- ; the second
was tedious but normal. She had been in labor for
about tw o hours when I arrived : the membranes had
ruptured early; there was now good dilatation; the
head was at the brim, the face presenting with chin
directed toward the left sacro-iliac synchondrosis.
F.xamination was made while the woman was lying
on her right side. When she had a pain, the chin of
the child was pushed down into the hollow of the sac-
rum, fortunately returning to its first position between
pains. Birth is impossible in face presentations with
the chin backward. Accordingly, the woman was
placed upon her back and the uterus straightened up.
November 7, 1896]
MEDICAL RECORD.
679
The mere change in posture rotated the child, so that
the long axis of the face was transverse, the chin
pointing to the left. During the next pain the chin
slipped down toward the symphysis pubis, and with
a little encouragement of the hand was held there
until well engaged. The delivery after this was rapid,
and a healthy child was born, the mother making a
good recovery. The labor was over in less than an
hour. I think that in both of these cases the effect of
changing the posture of the mother was of the greatest
value in determining speedy delivery of the mothers
and the birth of living children.
^?roflrc6s jof |]tXaUail Science.
Physiology of the Cervix Uteri. — Dr. Keiffer
{Medical Week) discusses the question as to whether
the cervix uteri is similar in structure and functional
activity to other sphincters, and the results of his re-
searches are that: i. The cervix uteri is a genuine
sphincter with circular and radiating fibres; that is to
say, composed of a constricting and a dilating muscle.
2. The tonus of the cervix uteri is maintained by the
reflex activity of the lumbar spinal cord. 3. The tonic
centre of the uterine sphincter is situated at the level
of the fifth lumbar vertebra in dogs. 4. Experimen-
tally, contraction and dilatation of the cervix uteri
may be determined by excitation of the spinal cord and
of certain peripheral sensory ner\es, more particularly
the crural nene. 5. The pneumogastric is not a di-
rect motor nerve of the muscles of the cervix uteri, its
action being purely reflex. 6. Acute anjemia deter-
mines complete relaxation of the cervix, while trans-
fusion of blood results in its constriction and in that
of the entire body of the uterus. 7. Asphyxia exerts a
marked constrictive action on the body and neck of
the uterus, followed by an inhibitory effect on the en-
tire organ. 8. In co-ordination of the muscular ac-
tions on the body and of the neck, opposite effects may
be produced.
Congenital Narrowing of the Mitral Orifices as
a Cause of Dwarfed Lives and Irritable Heart. —
Dr. Curtin's reasons [Boston Aledical and Surgical
Journal, September 3, 1896) for considering the disease
due to constriction of the mitral orifice, are: i. The
chronic congestive lung trouble found associated with
this condition. 2. The chronic lung disease almost
always found on the left side. 3. The venous stasis
and weak arterial circulation. 4. The character of
the murmur. It is presystolic, mitral, or with the
early part of the first sound. 5. The location over the
left border of the heart. 6. The loudness of the mur-
mur would indicate that it required the force of the
blood current found only in the left side of the heart.
7. It is a short, sharp, whiffy murmur, which sounds
quite near to the chest wall. 8. It is never transmit-
ted e.xcept when the lung is consolidated. 9. The
symptoms generally tally with those of cases having
acquired mitral stenosis of a mild character. 10. The
hypertrophy of the left auricle, which almost always
accompanies mitral obstructive disease. 11. The ac-
centuation of the pulmonary second sound; for, if we
have constriction of the mitral orifice, the stopping of
the current of the blood, when hurried, dams the blood
backward, causing a sudden shutting down of the pul-
monary valve and causing the pulmonary second sound
♦o be accentuated.
Injections of Guaiacol and Iodoform in Sterilized
Olive Oil for Tuberculosis. — Dr. lireton (Journal da
J'raficiens, No. 9, 1896^ has used this method for four-
teen months, having under his observation thirteen pa-
tients, who received in all one hundred and fifty
injections. Five of these patients, being in the last
stage of the disease, died. The injections are made
into the abdomen or flank, with all antiseptic precau-
tions. The formula is: Guaiacol, five parts; iodo-
form, one part; sterilized olive oil, one hundred parts.
The amount is gradually increased from fifteen drops
to three or four times that amount. The injection is
repeated every eight or ten days. The inconvenience
is a persistent, burning pain. During congestive at-
tacks, when there is fever or ha;moptysis, or even when
there are small masses of blood in the expectoration,
then there is intolerance or momentary saturation ; or
when albuminuria supervenes, this treatment is con-
traindicated. The results are a diminution and, later,
disappearance of the thoracic pain; the dyspncea is
relieved, the cough becomes less frequent and less
painful; the expectoration is less abundant, less dis-
colored, but the bacilli are not diminished in number;
the appetite is reawakened, and the general condition
improves. The sweats are less abundant, and, finally,
auscultation shows that real progress is being made.
Clinical Significance of the Hand. — Dr. Wohlman
(Bristol A/edico-Cltiruigical Journal) remarks that the
diagnosis between gout, rheumatism, and rheumatoid
arthritis is often one of extreme difficulty, and that
the observation of the hands is of the greatest utility.
The hand aftected by chronic rheumatism may be dis-
torted into all sorts of curious shapes, partly due to
pressure of bony outgrowths, or to changes in liga-
ments and atrophy of supporting muscles. In rheu-
matoid arthritis the same lesions may be exhibited,
due to the same forces at work; but, above all, the
original deformity is generally to be seen — the char-
acteristic swellings, once soft and impressible, now-
hard, calcareous, and fixed. Tuberculous dactylitis
may at first sight closely simulate rheumatoid disease
in children; but the spindle swelling is caused by
bone expansion and is accompanied by suppuration,
in both of which points it differs essentially from the
latter disease.
Examination of Unmarried Women. — The P/iila-
dclphia Polyclinic remarks that in supposed pelvic dis-
ease in young unmarried women, a pelvic examination
is too often proposed and carried out. It should be
remembered in this connection that the large majority
of diseases peculiar to women are sequences of coition
and its results, either pregnancy or specific infection.
Neoplasms are, of course, excepted. Consequently it
can usually be predicted that a pelvic examination
will result negatively, and is consequently unneces-
sary. Dr. Baldy finds this to be true in the majority
of cases, and urges the advisability of paying more
attention to the patient's general health and antece-
dents. This is the more important, as an hysteric or
neurotic girl's attention being once pointedly directed
to her pelvis as the seat of her trouble, she often be-
comes a chronic pelvic sufferer. As is the case with
opium eaters and chronic alcoholics, the medical pro-
fession is also responsible for making a large class of
pelvic sufferers.
Neuritis Dr. Bondurant (Medual Neics, October
3, 1896) says the causes of neuritis are many and va-
ried, and, used as a basis of classification, give rise to
a number of more or less easily recognizable clinical
varieties of the disease, some of them being: i. The
neuritis occurring as a result of direct injury to the
nerve trunk — wounds, blows, pressure, as from sleep-
ing on the arm, from dislocation of bones, from tu-
mors. 2. That form resulting from exposure to cold.
When the trunk of the seventh cranial nerve is
involved, as is often the case, we have a familiar
form of facial paralysis. 3. The forms resulting from
direct extension to adjacent nerves of the infection of
68o
MEDICAL RECORD.
[November 7, 1896
bacterial diseases, as pneumonia, diphtheria, tubercu-
losis. 4. Those forms due to the presence in the
blood of the poisons of these infectious diseases,
especially syphilis, diphtheria, typhoid fever, malaria,
variola, and tuberculosis. 5. The varieties resulting
from introduction into the blood of toxic agents from
without, as alcohol, arsenic, lead, opium. 6. The en-
demic or epidemic forms frequent in Asia and the
islands of the Pacific, as the kakke of the Japanese
and the beriberi of the Malay peninsula. 7. Cer-
tain forms affecting especially the cutaneous ner\-es,
and accompanied by trophic disorders of the skin in
the areas supplied by the diseased nerves, of which
herpes zoster is a familiar example.
Marriage of Epileptics Connecticut has enacted
a law which provides that no man and woman, either
of whom is epileptic, imbecile, or feeble-minded, shall
intermarry or live together as man and wife, when the
woman is under forty-five years of age. The penalty
is not less than three years' imprisonment. — Sout/i-
western Medical liccord.
Angina Pectoris. — .Sir Benjamin Ward Richardson
{The Asclepiad) concludes, from a study of forty-three
cases, that the affection is a sympathetic neurosis,
bearing much the same relation to the sympathetic
nervous system as epilepsy does to the brain. Heart
lesions and coronary disease are often absent, and
when present are probably merely coincidental.
Unconsciousness from Constipation. — Very stout
women have suddenly become unconscious from a
long-continued constipation. .\ physician relates a
case in which unconsciousness, with stertorous breath-
ing in the night, simulated an apoplectic attack. By
the aid of mustard to the feet and abdomen, with ice
to the head, and a large enema of soap, water, and cas-
tor oil, a large evacuation was procured, with speedy
return to consciousness. The slow poison from the
retained facal matter probably brought on uncon-
sciousness.— Health Mai^azinc.
Etiology of Serous Pleuritic Effusion. — Dr. .\sch-
off, in the Zcitselirijt Jiir klinisclic ^J/iv/ZiV//, discusses
this subject, and considers the following three ques-
tions: I. Is every idiopathic pleurisy, /.<•., a serous
pleuritis without known cause, tuberculous in its na-
ture.' 2. Is there such a thing as an acute isolated
rheumatic pleurisy, which is to be looked upon as
equivalent to a preceding attack of acute rheumatic
arthritis? 3. Do serous pleuritic effusions ever contain
pyogenic organisms, without the latter becoming puru-
lent? Bacteriological examinations of two hundred
serous exudates gave the following results: Serous
effusions are nearly always free from pus-producing
micro-organisms. If the latter are present, the exu-
date will become purulent, except, possibly, when
pneumococci are present. Purulent pleuritic effusions
sometimes heal completely without operation. ^The
occurrence of isolated rheumatic pleuritis is question-
able— at least, it is very rare. Pleuritic effusions oc-
curring in rheumatism are usually the result of a car-
diac lesion. The administration of salicylic acid has
given no special benefit. The so-called idiopathic
effusions are almost always tuberculous. They may,
however, disappear entirely.
Phthisis — Dr. Tidey (British Medical Journal)
advises: i. In early phthisis (catarrhal stage) to
give comparative rest and relaxation to affected lung
tissue. 2. In the stage of consolidation, to secure
the same results, thereby limiting the risk of ex-
tension, and to promote elimination of the disease
products by improving the circulation in and about
the diseased area, and to facilitate expectoration. 3.
In the stage of cavitation, to promote closing of cavi-
ties by directing healthy lung to encroach on the dis-
eased area, instead of relying on natural processes of
cicatrization. 4. Diminished tendency to hemorrhage
by reduced tension on vessels and cicatricial traction
on vessel walls. 5. The ultimate object is to obtain
a smaller thoracic cavity filled with healthy lung, in-
stead of an enlarged thoracic cavity partly filled with
diseased lung.
Thyroid Therapy. — Dr. Herrick {Medicine, vol. ii.,
No. 8 ) reaches the following conclusions concerning
thyroid extract: i. It is curative in myxtedenia (idio-
pathic, cretinism, operative). 2. Many cases of obe-
sity are cured by it. 3. Simple hyperplastic struma,
particularly if in the young, is frequently cured or
improved. 4. In 1,2, and 3 the remedy has to be
continued for an indefinite time to prevent relapse.
5. It may prove of value in some ca.ses of tetany. 6.
In skin diseases it is of doubtful value, to say the
least. 7. The same is true of mental and nervous dis-
eases. 8. In exophthalmic goitre it is contraindi-
cated. 9. The results are practically the same,
whether fresh glands, extracts, or dried glands are
employed. 10. This is probably true also of the thyro-
iodine of Raumann.
Diet in Bright's Disease. — Dr. Elliot {North
American Practitioner, June, 1896, p. 248) says: "It is
agreed tiiat the most rational diet is a mixed one.
The estimate commonly given is that meat should
constitute one-fourth and vegetable food three-fourths.
This is often overstepped, and the proportion brought
to two to four. Such indulgence throws into the cir-
culation a large amount of nitrogenous waste, which it
is the office of the kidneys to remove from the system.
An increased amount of organic excretives, continually
demanding removal, throws a considerable tax upon
these organs, which is frequently rendered more se-
vere by a hyperacid co".centrated condition of the
urine, as these subjects seldom drink an adequate
amount of water. This irritation, if long continued,
eventually leads to functional and, finally, organic im-
pairment of the kidneys. To these sources of irrita-
tion must be added the deleterious effects upon the
renal .structure of the excretion of the by-products of
faulty gastric and intestinal digestion, frequently pres-
ent from the dyspepsia so common among those who
overindulge at table."
New Method of Diagnosis in Typhoid Fever
Dr. Widau {La Fresse Medicate, July 29, 1896) de-
scribes his method of testing the diagnosis of typhoid
fever, which has not failed in eiglity cases examined
The test is based upon the action of the serum of a ty-
phoid patient upon young cultures of coli bacilli grow-
ing in bouillon. It is performed in several ways.
From a finger tip, carefully sterilized by bichloride-of-
mercury solution and ether, a small quantity of blood
is drawn into a glass receptacle and allowed to clot.
If a few drops of the serum (one to every ten drops of
bouillon) are introduced into a young bouillon culture
of coli bacilli, they will in a short time gather them-
selves together into little balls, sometimes visible to
the naked eye, easily seen by the aid of the micro-
scope. The reaction may be seen in a few minutes,
but is more evident in a few hours. The culture used
should be only a day or so old, but if no fresh one is
at hand another method may be used. A tube of
bouillon is sowed with some of the old coli bacilli
culture and the typhoid serum is added, in the pro-
portion of one drop of serum to three cubic centime-
tres of bouillon. After twenty-four or forty-eight
hours at 37 "" C, the same reaction described alDove is
seen. .V control tube is recommended, the coli bacilli
being omitted, as the blood serum may not be sterile.
November 7, 1896]
MEDICAL RECORD.
681
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, &. 47 East Tenth Street.
New York, November 7, 1896.
THE LEPER COLONY.
At length New York can boast of being one of the
leper centres of the country. At least the public press
has within the last fortnight mentioned this city as
one of the three locations of leper colonies in the
United States. From the frequency with which cases
are reported as having been presented to medical soci-
eties, the number of lepers must at least be decidedly
upon the increase. A discussion took place at the last
meeting of the County Medical Society upon whether
the commissioners of health should be upheld in their
determination to turn out the few patients in their
charge. For live years this body has taken care of
such cases as other institutions wished to turn over to
it, but now for some reason it wishes to cease such
responsibility. The matter is an important one and
we agree with a correspondent, whose letter will be
found in another column, that the County Medical
Society would assume grave responsibility in taking
the step proposed. The public idea of the leprosy
question is erroneous, in spite of the oft-repeated
assurance that there is little or no danger in sitting
beside a leper in a street car or from shaking him
by the hand. We are not, however, in a position
to say that infection does not take place under much
the same conditions as those in which syphilis is dis-
seminated. This being the case, the leper must be
looked upon as a source of danger, aside from his
being an undesirable neighbor and an unappetizing
cook, as our correspondent puts it. W'e regret that
the board of health did not act upon the suggestion
which we threw out in our editorial comments upon
"The American Leper" in the Medical Record of
March 14th, and send its little colony down to the
new Louisiana Leper Hospital, which was anxious for
inmates. By the way, what has become of the resolu-
tions passed at the last meeting of the congress of
American physicians and surgeons in Washington
and entrusted to Surgeon-General Wyman of the
Marine Hospital service to bring to the attention of
President Cleveland and lay before Congress? Would
it not be well to have a national leprosy commission
appointed to determine what is to be done with the
leper here at home before we send delegates to an
international leprosy congress in London to decide
upon what to do with the lepers of the entire world?
It might be proper for those here who continually
preach the safety of this country from invasion to re-
member that New Orleans is located within the confines
of our possessions, and that the spread thereabouts
among natives of Louisiana is sufficient to occasion
comment if not alarm. It might also be well for these
gentlemen to remember that the Baltic provinces of
Russia considered themselves free and safe from in-
vasion until recently four hundred cases of leprosy
were found to have originated there, necessitating the
opening of three leproseries. No one can tell what
the future may have in store for this country if we
continue our present attitude of hospitality toward
foreign lepers. One of the speakers is reported to
have said at the meeting that within a week he had
seen a leprous patient who had just arrived in New
York from a foreign port. What of our laws covering
such cases? What of our quarantine inspection?
IMMORALITY IN CANADA.
We have been distressed and shocked beyond measure
to learn that large and increasing numbers of women
in Canada are giving themselves up to the vilest form
of immoral practices. The report that comes to us,
indeed, is such that, were it credible, we should be led
to despair of the future of the country, for, compared
to Canada, or at least to Toronto, Sodom and Gomor-
rah were as pure as Salvation Army shelters. It ap-
pears that cycling, which with us is adding so much to
the health and the beauty and the charm of our women,
is in Canada, or at least in Toronto, merely a means
of gratifying unholy and bestial desire. We hesitate
to believe such a report, but we have it on the author-
ity of the editor of the Doininion Aledical Alonthh\ and
he is on the spot and speaks as one with absolute
knowledge of the facts.
After referring to the advantages claimed for the
bicycle, whictT he refutes by the statement that the
average woman gets about all the exercise she wants
in looking after her home, our esteemed contemporary
says that "the consensus of opinion is increasing
overwhelmingly day by day that bicycle riding pro-
duces in the female a distinct orgasm . . . and even
if an orgasm is not produced the continued erethism is
decidedly more injurious and tends to the production
of nervous diseases and the general breaking down of
the system. The only contention that can be made is
that the orgasm or erethism is not produced. This
we know to be absolutely imtrue." The writer adds
more of the same kind, and pictures the mothers, wives,
and daughters of his neighbors as scorching through
the country, stooping low over the handle bars, and
"subjected to continued erethism as well as an occa-
sional orgasm."
There is but one of two conclusions to be drawn
from this statement. Either the wheelwomen of To-
ronto are the vilest of their sex, or they are the
victims of a contemptible slander. Unless our con-
temporary has a mass of facts sufficient to establish
beyond doubt the sweeping generalization contained
in the article from which we have quoted, he has
smirched the fair name of his countrywomen in a
682
MEDICAL RECORD.
[November 7, 1896
reckless fashion that calls for the strongest condemna-
tion. The question of the healthfulness of cycling,
for men as well as for worrien, is one that still admits
of discussion; but the man who can assert or even
suggest that the thousands, perhaps millions, of wo-
men throughout the world, who ride the wheel, are
giving themselves over to self-abuse, puts himself be-
yond the reach of argument.
POLITICS AND MEDICINE IN RUSSIA.
The organization of the Moscow Congress has met
with many trials during the past year. First it offered
what was by many regarded as a deliberate insult to
the English-speaking physicians of the world by ex-
cluding the use of their language in the scientific
meetings. Then this was hardly settled by the restora-
tion of English to its proper place, when Virchow
presented an ultimatum to the officers of the congress,
giving out that he would have nothing to do with it
unless Russia abandoned her discrimination against
Jews who wanted to enter the country. This danger
was averted by the publication of an order that all
physicians should be admitted to the country on equal
terms, no discrimination being made on account of
race or religion. Now the most serious blow of all
has come in the enforced resignation of Professor Eris-
mann from the position of secretary-general of the
congress. This is more of disaster than might be
supposed by those unacquainted with Dr. Erismann's
unusual ability as an organizer and executive officer.
His resignation has followed his dismissal from the
chair of hygiene in the University of Moscow. It
appears, from the account given by the St. Petersburg
correspondent of The Lancet, that Professor Erismann
was tainted with liberalism. He was one of forty-two
Moscow professors who, two years ago, signed a peti-
tion to the Russian government in which relief was
asked for certain wrongs under which the students of
the university were suffering. The result was the
u.sual one of such appeals in Russia. AH the signers
were formally censured and four, including Professor
Erismann, were severely reprimanded. The reasons
of Professor Erismann's enforced resignation of his
chair are not at present publicly known, The Lancet
correspondent says, but there is little cause to doubt
that the incident just narrated — or, rather, the " lib-
eral" leanings of Professor Erismann, of which the
incident was, perhaps, one out of many proofs — were
the real reasons. This explanation, which is the one
most generally accepted, is further supported by the
rumor that two of the other three professors who were
reprimanded at that time have also been requested to
resign their chairs. The circumstances of Professor
Erismann's resignation were the following: It is the
custom of the Russian government every summer to
send a certain number of professors to foreign coun-
tries to study foreign methods and systems and so to
keep in touch with the progress made in other coun-
tries. Among those sent this summer was Professor
Erismann. He visited Berlin and then went to Swit-
zerland. While there he was officially informed that
his services in the chair of hygiene were no longer
needed, the retirement to date from July 1st. No
reasons were given, but three days were allowed dur-
ing which a voluntary resignation would be accepted.
The loss is Russia's and not the deposed professor's,
for the latter's abilities will make him welcome any-
where; but the University of Moscow and the Inter-
national Congress can with difficulty supply his place.
DON'T DIE IN THE HOTEL.
The expense attending the misfortune of dying in a
foreign hostelry is such that it should be avoided
whenever practicable. In commenting upon this item
in the bill presented by a continental landlord, and
the difficulties encountered by the English consul in
securing its reduction to reasonable proportions, the
editor of the I''rcss and Circular suggests that the guide
books insert a schedule rate by which travellers could
be governed. This seems eminently fitting. Plain
deaths, so many pounds and so many shillings. Com-
plicated, ditto, etc. Or would it not be belter: death
of a plain person, so and so much ; of a person of title,
pro re nata (thereof course referring to the title)?
The Press puts the matter in a very apt and practical
manner. It says if the editors of guide books took
the matter up, "then travellers would only have them-
selves to thank if they deliberately placed themselves
within the clutches of unscrupulous and overreaching
landlords." This is quite right. Any man who
would deliberately pick out a hotel for this purpose
where the death rates, so to speak, were exorbitant,
would have only his surviving friends to thank him
accordingly. His only safety would be in finding the
rate actually prohibitory.
Bcivs jof the (121 cell.
Obituary Notes Dr. W. W. Palmer, of Keans-
burg, N. J., was instantly killed on October 27th. the
carriage in which he was driving with his daughter
and granddaughter and a friend having been run into
by a train as it was crossing the track. Dr. Palmer
was a graduate of the Albany Medical College in the
class of 1855. — Dr. George Harley, of London, died
on October 27 th, at the age of sixty-seven years. He
was M.D. Edinburgh in 1850, and was elected a mem-
ber of the Royal College of Surgeons, London, in 1850,
and a fellow of the Royal College of Physicians in
1864. He was well known for his writings on dis-
eases of the kidneys and of the liver. — Dr. George
W. Martin, of Augusta, Me., died at his home in that
city, on October 26th. Dr. Martin, who was born in
1830, was graduated from the University of New York
in 1858. At the breaking out of the war he went to
the front as assistant surgeon of the Sixth Maine Regi-
ment. He subsequently served as surgeon of the
Fourth Maine and the Second Maine Cavalry. Later
he became government medical inspector. In 1873 he
was made medical director of the military forces in
Maine, serving until 1879. — Dr. James B. Mcrdock,
late dean of the Western Pennsylvania Medical Col-
November 7, 1896]
MEDICAL RECORD.
683
lege of Pittsburg, and one of the best-known physi-
cians in Pennsylvania, died October 27th. He leaves
a widow and five children. He was born in Glasgow,
Scotland, in 1830. He graduated from the College of
Physicians and Surgeons, New York City, in 1S54.
For a time Dr. Murdock practised medicine in Oswe-
go, N. V. He settled in Pittsburg in 1877, and had
amassed a fortune. — Dr. Harriet W. Smith died at
Galveston, Te.x., on October 27th, at the age of thirty-
two years. She was a graduate of the Woman's Med-
ical College of Pennsylvania, and the wife of Dr. Al-
len J. Smith, professor of pathology in the University
of Texas. Both were formerly residents of Philadel-
phia, and they had been also resident physicians in
the Philadelphia Hospital. — Dr. Levi H. Thompson"
died on October 23d, at Reading, Pa., at the age of
seventy-three years, in the sequence of a carbuncle
upon the neck. He was a graduate of Jefferson Med-
ical College. After practising at Fleetwood and Ly-
ons, Dr. Thompson removed to Reading, where he had
lived for more than twenty years.
September's Death Rate in the State — The bul-
letin of the State board of health for the month of
September shows that there were five hundred fewer
deaths reported than in the corresponding month of
last year. The mortality from all diseases of the di-
gestive organs is diminished. There were eight hun-
dred fewer deaths under five years of age. Compared
■with the preceding month of August, the total reported
mortality is decreased by three thousand. The death
rate from all causes was 17.50, against 18.50 in Sep-
tember last year. The September prevalence of ty-
phoid fever is excessive in the Hudson and Mohawk
Valley districts, and in the southern tier and east cen-
tral districts. Diphtheria caused fewer deaths than
in September of any year for ten years.
The << Divine Healer." — He has come again. The
last glimpse the public had of August Schlatter, he
appeared scantily clad, mounted upon a snow-white
steed, and going toward the great Southwest. Now he
has turned up in Philadelphia, whose citizens were
not slow in recognizing his abilities, and by the con-
stant sending of handkerchiefs to be blessed and im-
portunities to renounce his seclusion finally induced
him to make this city of brotherly love his abiding-
place and field of labor. A chair of " spiritual thera-
peutics" is likely to be established for him in one of
the medical schools. His advent was unostentatious
and unobserved. Indeed, the modesty of the healer is
such that it is announced no one besides his landlady
knew of his presence until he had been in the city for
a considerable time. Were it anywhere but Philadel-
phia, there would arise a supposition that he had en-
tered by night. After his miraculous cures sufficiently
aroused Philadelphians, he distributed his benedictions
in Bayonne, N. J., and has now struck us here. We
trust he will not draw heavily on the clinics.
Photography of the Larynx was the subject of a
paper read by Dr. Thomas R. French before the sec-
tion on laryngology of the .Academy of Medicine, Oc-
tober 28th. The author demonstrated apparatus for
this kind of work, and gave a lantern exhibition of
photographs of the larynx in health and disease.
Among the cases shown was one of tuberculous tumor
of one vocal cord; also one of papillomatous tumor,
one of unilateral, and one of bilateral paralysis of the
cords; further, some photographs of the posterior
nares, representing hypertrophic and atrophic rhinitis.
The demonstration proved conclusively the value of
photography in studying the pathology of the larynx.
'<Dr." Walter May Rew, who was exposed some
time ago by the Herald as a manufacturer of physi-
cians' and nurses' diplomas, has just been convicted of
bigamy. He is said to have enjoyed the blessings of
having been five times wed.
Pjn'antin is the newest antipyretic. Piutti ob-
tained it by melting together hydrochlorate of phen-
acetin and succinic acid. It is extracted with boil-
ing alcohol, from which it crystallizes in colorless
prismatic needles. It is soluble in 1,317 parts of cold
water and in 86.6 parts of hot water, but insoluble in
ether. — La Med. Mod., October 14th.
County Medical Society. — In the election which
took place on the evening of October 26th, Dr. Lan-
don Carter Gray was elected President. The only
other candidate was Dr. Jacobus; Drs. Chapin, Peter-
son, Garrigues, and Van Santvoord having withdrawn.
Dr. Robert A. Murray was elected Vice-Preside7it ; Dr.
Nathan E. Brill, Second Vice-President ; Dr. Charles
H. Avery, Secretary ; Dr. William E. Bullard, Assis-
tant Secretary ; Dr. John S. U'arren, Treasurer.
The Pan-American Medical Congress. — It is esti-
mated that from three hundred to four hundred physi-
cians from the United States will take part in the con-
gress to be held in Mexico City, November 16-ig,
1896. Dr. H. L. E. Johnson, of the committee on
transportation, has obtained an offer from the rail-
roads throughout the countr)'. except in certain parts
of the East, of a one-fare rate for the round trip to
Mexico and return. From New York City to Mexico
and return direct the entire cost will be: Fare,
S78.50; berths in sleeping-car, $46 ; meals, $32; total
cost, $156.50. Living in Mexico, $2.50 per day extra.
A special train has been arranged for through the
American Tourist Association, with Reau Campbell,
manager, to leave Cincinnati on Tuesday, November
loth, 9 .A.M., via St. Louis and Eagle Pass, and make
a twenty-one day tour from there through Mexico and
return for $189 ; from Chicago and return, $190 ; from
St. Louis and return, $183.55. This will include rail-
road fares and all necessary expenses of the trip. The
Baltimore and Ohio railway will carry the delegates
from the North and East to meet the special train at
Cincinnati. From New York the trip can be made by
sea, in the boats of the Ward line, the total cost of
which will be, including meals and stateroom, $78.
Nine days are required each way for this trip. The
journey can be made by rail from this city to Mexico
in five days. The registration fee, $5, should be sent
to Dr. Francisco Bustillos, Calle de Tabuco, No. 7,
Mexico City, Mexico.
684
MEDICAL RECORD.
[November 7, 1896
The New York State Association of Railway
Surgeons will hold its sixth annual meeting at the
New York Academy of Medicine, on Tuesday, No-
vember 17, 1896. Several very interesting and prac-
tical papers are promised.
Small-Pox in Marseilles. — The P>esse\Medicale re-
ports that from January ist to July 30th there were
four hundred and sixty-eight deaths from variola in
the city of Marseilles.
The Pittsburg Dental College, a newly organized
department of the Western University of Pennsylvania,
opened its doors in September last, with one hundred
and twelve students enrolled. A three years' graded
course of instruction is offered.
Vaccination against Serpent Bites A gentleman
by the name of Oleta is reported to have arrived in
Paris from Guiana, with a vaccine against serpent
bites. The remedy has been known by the native ne-
groes, it would appear, for many years, but has only of
late received scientific study.
Pellotine is one of the latest hypnotics, an active
principle obtained from a Mexican cactus. The hydro-
chlorate is employed by the mouth or subcutaneously
in dose of from four to six centigrams. It is thought
that it may occasionally replace other hypnotics with
advantage.
The Hartford Medical Society. — The fiftieth an-
niversarj' of the Hartford Medical Society was most
appropriately celebrated in Hartford, Conn., October
26, 1896 (having been postponed from the anniversary
day, September 15th), by an afternoon meeting, at
which addresses were made by Dr. Gurdon W. Rus-
sell, one of the original fifteen members, of an histori-
cal character with incidents and reminiscences; Dr.
Horace S. Fuller, upon " Our Deceased Members and
Incidents Connected with the Later Years of the So-
ciety;" Dr. Henry P. Stearns, upon "Esprit de
Corps;" and the president, Dr. Melancthon Storrs,
upon "The Present and Future of the Hartford Medi-
cal Society." The present active membership is sev-
enty, and over sixty present and past members partook
of a banquet at Hotel Hartford in the evening. Dr.
P. H. Ingalls was toastmaster, and Drs. Russell, Hud-
son, Mayer, Jarvis, Page, Law, St. John, Cook, and
Storrs responded to the toasts. An improvised glee
club of twelve members varied the proceedings by se-
lections sung, some of which were original and ar-
ranged for the occasion. It is purposed to have the
proceedings published, marking as they do an impor-
tant epoch in the history of this flourishing society.
An Unwise Charity. — The Salvation Army has an-
nounced its intention to establish a number of shelters
in New York for homeless persons, and has thereby
aroused the fears of those who think it unwise to make
this city more attractive to tramps tlian it is at pres-
ent. The army proposed to provide not only beds
and a bath, but also a meal to the lodgers before let-
ting them go forth in the morning. The commander
of the army was recently waited upon by the commit-
tee on vagrancy of the conference of charities, and
was urged to recede from this plan, which was so cer-
tain to promote vagrancy, if not to spread disease.
The conference of charities has been working to rid
the city of vagrants, and one of its steps was to sup-
press those provisions for homeless persons where
there was no methodical scrutiny of the applicants.
They did succeed in having the police-station lodging-
houses abolished, and were just getting the city in a
state unattractive to tramps, when the Salvation Army
started this scheme. The leader of the Salvationists
promised to weigh the arguments presented to him by
Mrs. Josephine Shaw Lowell, but gave little hope that
he would act in accordance with them, for he said that
the Lord, who was with him, wanted shelters for the
homeless.
Dr. Tanner, for whom starvation had no terrors,
has perished by flame, according to a dispatch from
Akron, O., he having been burned to death in a con-
flagration in that city on the 21st instant.
Cremation in England is gaining ground. As we
have noted, Mr. George Du Maurier was cremated at
Woking, on October loth, and during the past few
weeks the remains of Dr. J. L. H. Langdon Down and
of Surgeon-General Sir William George Moore have
also been cremated.
Yellow Fever in Sugar. — In the latest issued re-
port of the Marine Hospital ser\ice. Dr. D. M. Bur-
gess, sanitary inspector at Havana, writes, under date
of October 17th : " I am informed that the government
here has appropriated, and is already using for hospi-
tal purposes, the extensive 'almacenes' or sugar store-
houses of Regia, which structures are situated contig-
uous to the wharf on the opposite side of the harbor
from this city. This measure, of course, will infect
these buildings and probably such sugar as may or
will be stored in them." Dr. Burgess adds that yellow
fever in Havana continues with all its malignancy,
and perhaps is increasing among the Spanish soldiers.
Passengers recently arrived from Havana say that
both yellow fever and small-pox are increasing in that
wretched city, and the Spanish authorities are abso-
lutely supine in the face of the spreading pestilences.
Maternal Impressions. — A hen in Vermont, after
looking at a tliree-pound potato grown by a neighbor
of her owner, went to the barn and laid an egg measur-
ing eight and one-half by six and one-half inches.
Another Office Fraud. — A young, middle-sized
man, with dark moustache, calls at the ofiice, sends
in his card as " Dr." Morton, informs the doctor in
waiting that he has recommended a case to him, that
the patient is a good one, pays promptly, and needs
an operation or other special treatment, and that said
patient will call on the morrow. The fraud then in-
forms the doctor tiiat he is about to take a vacation
in the Maine woods, and would like to purchase
some medicines. He asks the doctor to give him an
introduction to some neighboring druggist, which be-
ing done, the said stranger passes a bogus check and
gets surplus change. We have received several com-
plaints from friends in this city ivho have been vic-
timized, and publish this notice accordingly.
November 7, 1896]
MEDICAL RECORD.
685
Centennial Commemoration of the Paris Medical
School — Dr. A. Corlieu, assistant librarian of tlie
Paris Faculty of Medicine, has just completed a his-
tory of the faculty during the century of its existence
from 1794 to 1894. The work was published free of
expense to the faculty by a committee of the medical
publishers of Paris. It contains one hundred and
thirty portraits of eminent medical men who have been
connected with the medical school.
The Ship Captain as a Diagnostician. — A bill
has been introduced into the New Zealand legislature,
the object of which is to exclude all persons suffering
from tuberculosis. The bill provides that on the arri-
val of any ship in a port of New Zealand, the master
of the ship shall deliver to the health officer a true list
of all passengers and a declaration as to whether any
of them are suffering from tuberculosis, the penalty for
a false declaration being S250. No passenger suffer-
ing from that disease is to be allowed to land, and
should any such person do so both he and the master
of the vessel are liable to a penalty of $50. If within
three months of landing in New Zealand any passen-
ger is found to be suffering from tuberculosis, he shall,
until the contrary is proved, be deemed to have been
suffering from that disease when he landed in New-
Zealand, and the penalty will be enforced accordingly.
The master of a ship is liable to a penalty of $2 50 if
he allows a tuberculous patient to occupy the same
cabin as another passenger.
Hospital Management in Chili. — In an extract
from a letter from an English physician in Santiago
de Chile, published in the British Medical Journal,
the writer says, speaking of the local profession :
"Their notions of hospital management are the queer-
est in the world, though most of the professors have
been trained in Europe. The largest and most up-to-
date hospital in the republic, St. Vincent de Paul
(about one thousand beds), contains neither bathroom
nor watercloset. The bath is known only as an anti-
pyretic, and patients are brought into the operation
theatres (the one reser\-ed for abdominal surgery, by-
the-by, is next to the erysipelas ward) in all their na-
tive dirt, though they are placed on the brass table
without any covering whatever, because blankets are
too septic to come into the room. Stools, etc., are
kept for twenty-four hours in the locker at the head of
the patient's bed, togetlier with his food and wine.
After the physician's visit they are all emptied into the
open 'asequias,' which run through the hospital 'pa-
tios.' "
Pasteur Celebration at Alais.— A series of fl-h-s
have been celebrated at Alais, in the centre of the
great mulberry and silkworm district of France, in
commemoration of the services rendered by Pasteur to
sericulture. The silk industry covers an enormous
area, and its extension is owing to the studies con-
ducted by Pasteur at Alais, in 1865 and the following
years, into the diseases of silkworms and the method
of eliminating them. 'i\i& fetes lasted from September
25th to September 28th. The unveiling of a statue of
Pasteur took place on September 26th. Monuments
to Florian and the Abbe de Sauvage were also un-
veiled. On Saturday a solemn service was celebrated
in the cathedral, in commemoration of the first anni-
versary of Pasteur's death, which occurred on Septem-
ber 28, 1895. — British Medical Journal.
Dr. Montalvo, who has recently been arrested in
Havana as an insurgent suspect, has been hitherto
considered one of the most prominent members of the
Cuban autonomist party.
A Cardiac Tonic — Dr. M. C. Jennings, of Chicago,
writes to the Kc-io York Medical Journal, of October
loth, that he has employed a fluid extract of Cratagus
oxyacantha, or hawthorn fruit, in over forty cases of
failing heart from various causes, and always with
gratifying result. The force of the cardiac contrac-
tions is increased and the pulse rate is reduced in
frequency. The dose employed was from ten to fif-
teen drops after meals.
Experiments on School Children The filter in
the Chicago public schools has been a burning ques-
tion for the past few months between the health com-
missioner and the board of education. These latter
gentlemen have exercised an amount of discretion un-
worthy of a four-year-old, and, in view of the fact that
they probably all took precautions with the drinking-
water used in their own households, have knowingly
subjected the hundreds of thousands of school children
to the danger of intestinal disease, including typhoid.
They have finally permitted various filter manufacturers
to place their filters in some of the schools on a sixty
days' test. We trust that the children who are made
the unfortunate victims of these tests may look upon
it in a purely scientific spirit, and that their parents
may feel fully repaid for their loss. — Chicago Medical
Recorder.
The Late Dr. William Muir McLaury Whereas,
It has pleased divine Providence to take from us one
of our oldest members, a former president of this so-
ciety; and
Whereas, We, the members of the Northwestern
Medical and Surgical Society, desire to place upon
record our appreciation of the character of our de-
ceased brother; be it
Resolved, That in the death of William Muir Mc-
Laury this society has lost a devoted, able, and faith-
ful colleague, whose earnestness of purpose and lofti-
ness of motive peculiarly fitted him for the profession
which he adorned.
Resolved, That the loss, which we thus mourn, is
not limited to our society, or even to our city.
Resolved, That we most respectfully and sincerely
extend our heartfelt sympathy to his family, wishing
for them that consolation which is the outcome of his
noble life.
Resolved, That a draft of these resolutions be
spread upon the minutes of this society, and that du-
plicates be sent to the medical press, and that a copy
be transmitted to the family of our deceased friend.
Henry Ling Taylor, M.D., President.
Joseph Collins, M.D., Secretary.
686
MEDICAL RECORD.
[November 7, 1896
One Physician Shoots Another — Dr. Alfred Holt,
of Hayes, Miss., on October i6th shot and killed Dr.
P. S. Rhett, of Jonesville, La., at Natchez, Miss.
Philadelphia Polyclinic. — The faculty of the Phil-
adelphia Polyclinic and College for Graduates in
Medicine has established a lectureship on defects of
of speech and Dr. G. Hudson Makuen has been elected
to the position. Dr. A. O. J. Kelly has been elected
adjunct professor of pathology.
In Russia there are 18,334 physicians or i to about
every 6,000 inhabitants, while in Germany there is i
to each 3,000, in France i to 1,800, and in England i
to 1,600. In America they have not been accurately
counted of late, but there is a strong belief among
New York physicians just now that the proportion
must be somewhere in the neighborhood of i to 16.
Pathological Society of Philadelphia. — At a meet-
ing of the Pathological Society of Philadelphia, held
on October 22d, Dr. H. W. Cattell read the report of
a case of "Internal Strangulated Hernia of the Small
Intestine through the Omentum." Dr. John M. Swan
presented " Specimens from a Case of Arthritis De-
formans." By special invitation. Dr. Joshua M. Van
Cott, of Brooklyn, read a paper on "Malignant Endo-
metritis." Dr. J. P. Arnold presented "Tuberculous
Suprarenal Glands from a Case of Addison's Disease."
Dr. A. E. Taylor exhibited a specimen of conglome-
rate neoplastic involvement of the stomach and omen-
tum, of epithelial character but of obscure origin.
Dr. James H. McKee presented fragments of a mace-
rated four-months' foetus, the product of a criminal
abortion. Dr. A. Hand, Jr., demonstrated ulceration
of Peyer's patches in the small intestine from a young
child. Dr. J. Dutton Steele exhibited specimens of
carcinoma of the stomach and omentum. Dr. Alfred
Stengel presented a specimen of mitral stenosis with
pulmonary infarction; and one of primary carcinoma
of the head of the pancreas with secondary involve-
ment of the stomach, biliary obstruction, and gall
stones.
The Colony Treatment of Epileptics.— At the an-
nual meeting of the board of managers of the Craig
Colony, held at the colony on October 13th,- some in-
teresting facts were stated in the report of the medical
superintendent, Dr. William P. Spratling, bearing on
results obtained in the treatment of the patients and
the economy of the colony plan in caring for this class
of patients. The first fifty patients who were under
treatment five months and over before the close of the
fiscal year had collectively, during the first month of
their residence at the colony, seven hundred and eight
seizures. The same fifty cases, after five months'
treatment, had collectively, during the fifth month,
three hundred and fifteen seizures — a reduction of
SSff P^"" cent. During the first month each case aver-
aged fourteen attacks; during the fifth month, each
case averaged six attacks. The cost for maintenance
was more than half met in the value of the products of
the farm and garden and miscellaneous earnings, the
value of such articles being $14,230.20. The mana-
gers will ask a large appropriation of the coming leg-
islature, in order that they may meet, in a measure,
the demands made upon the colony for the admission
of hundreds of indigent epileptics in the State. There
are at present one hundred and thirty-five patients in
the colony. Dr. Frederick Peterson was re-elected
president of the board of managers, and Mr. H. E.
Brown secretary.
Diphtheria Spread by Rabbits. — A report comes
from Webster City, Iowa, that an epidemic of diph-
theria has been spread by rabbits in that neighbor-
hood. The disease is said to have recurred annually
in a school house in whi h the rabbits hibernated and
whence the disease was disseminated. The wise de-
cision was reached to destroy the building by fire.
Physicians Victimized. — A young and prepossess-
ing woman has been soliciting contributions, and
receiving them as well, from susceptible and unsus-
picious Brooklyn physicians for a hypothetic home or
some other charity. The lady has so far called her-
self Mary Cole, but it is probable that if she comes
across the bridge she may change her name as well as
that of the institution she claims to benefit.
Philadelphia County Medical Society. — At a busi-
ness meeting ot the Philadelphia County Medical So-
ciety, on October 21st, Dr. John Lindsay was elected
secretary, to succeed Dr. T. B. Schneideman, who had
resigned; and Dr. El wood Kirby was elected assistant
secretar}', succeeding Dr. Lindsay. Eleven new mem-
bers were elected, and nominations w-ere made for
officers for the ensuing year, as well as for delegates
to the AmericanMedical Association and the Medical
Society of the State of Pennsylvania.
College of Physicians of Philadelphia. — At a
meeting of the section on ophthalmology on October
20th, Dr. John T. Carpenter, Jr., read the report of
"A Case of Recovery from Unilateral Optic Neuritis,"
and exhibited the patient. Dr. H. F. Hansell read
for Dr. Charles A. Oliver the report of " A Case of
Probable Intra-ocular Growth in the First Stage of De-
velopment." Dr. Edward Jackson read a paper on
"The Corneal Reflex." Dr. B. A. Randall read a
paper entitled "Rhinitis as a Factor in Phlyctenular
Ophthalmia, with its Therapeutic Consequences."
Dr. S. D. Risley made a brief communication upon
" Defective Coquille Glasses," pointing out that many
of these e.xert disturliing refractive eftects.
Cumberland County (N. J.) Medical Society —
The Cumberland County Medical Society convened at
Hotel Cumberland, Tuesday, October 13th, with Pres-
ident Dr. D. H. Oliver in the chair. Dr. G. E. Day,
of Millville, was elected to active membership, after
whicii a very interesting address was delivered by Dr.
Theophilus Parvin, of Philadelphia. Addreses were
also made by Dr. O. H. Adams, of Vineland, on " Eye
Strains;" and Dr. A. W. Sullivan, of Shiloh, on " Dys-
entery." After the report of Dr. S. M. Wilson, as
delegate to the .•\merican Medical Association, and
the election of Dr. J. C. Applegate as reporter to the
State society, the society adjourned, to meet at Hotel
Cumberland, the second Tuesday in January, 1897.
November 7, 1896]
MEDICAL RECORD.
687
An Association of Urologists has been established
in France among the physicians interested in this
branch of medicine. Among the originators are Al-
barran, Audry, Chevalier, Desnos, and Malherbe of
Nantes.
International Exposition of Hygiene, of alimen-
tation, and of industrial arts will take place at Lille
in the months of March and April, 1897, under the
auspices of the municipality. The Rameau palace
has been placed at the disposal of the committee on
organization.
The Graefe Gold Medal of tiie German Ophthalmo-
logical Society has been awarded to Prof. Theodore
Leber, of Heidelberg, in recognition of his work on
inflammation. This medal is given every ten years,
in recognition of the greatest advance made in oph-
thalmological science during that time. The first one
to receive the medal was von Helmholtz, for his dis-
covery of the ophthalmoscope.
Yellow Fever has appeared at the New York quar-
antine. A patient, removed from the steamship }'ut-,r-
tan on the 21st, died the same night. All passengers
from Havana and other infected ports will be carefully
inspected. Dr. Doty reports that cold weather is too
near to admit of any fear of the disease gaining a
foothold here. It is said that four hundred new cases
were reported in Havana two weeks ago. Small-pox
was also prevalent.
The Green Cross In addition to the Red Cross
Society and the White Cross, which gives aid to sick
or convalescent soldiers, there has just been estab-
lished at Vienna a new order which will be known as
that of the " Green Cross." Its object and aim is to
give succor to Alp climbers and excursionists in
mountain regions. It originated in the Austrian Al-
pine club. The intention is to establish huts upon
high mountains and to keep supplies and relief stores,
or bo.xes containing articles apt to be required in
emergencies at conveniently located points. Besides
this guides are to be instructed in first aid to the in-
jured and trained in the application of splints and
antiseptic dressings. We wish the society with its
new-colored cross all success in its humane under-
taking.
Antivenin. — Dr. Fraser, of Edinburgh, has at-
tempted to render animals immune to the bite of ser-
pents by making injections of one-tenth the fatal dose
and gradually increasing the quantity of venom. The
serum of animals thus immunized is antitoxic and is
named antivenin. In case of poisoning by serpent
bite, he says, first shut off the circulation as much as
possible by ligature; increase the size of the open
wound; suck out with the mouth or better still with an
aspirating pump; inject antivenin into and about the
wound beneath the skin, and do not remove the liga-
ture for at least half an hour. To save a man's life
three hundred and thirty cubic centimetres of anti-
venin are required, provided it can be injected within
half an hour of the accident. The treatment has as
yet, so far as we know, not been tried on man.
A Chair of Massage has been established in the
University of Berlin with Dr. Zabloudovsky as profes-
sor. This is, we believe, the first instance in which a
great university has given such recognition to this
branch.
The Loomis Sanatorium for Consumptives, at
Liberty, Sullivan County, N. Y., is now open for the
reception of patients. The institution, which is a me-
morial to tlie late Dr. A. L. Loomis, is intended for
patients in the early stage of pulmonary tuberculosis,
who cannot afford to sustain themselves and pay for
medical attention at expensive resorts. The sanato-
rium is at an elevation of about twenty-two hundred
feet, and the buildings are substantially constructed
and beautifully located. Patients are received at a
nominal rate for board and medicines, but there is no
charge for medical attendance. There are no free
beds. Before patients can be admitted they must be
examined by either Dr. H. P. Loomis, 58 East Thirty-
fourth Street, or Dr. Charles E. Quimby, 44 West
Thirty-sixth Street, New York; or by Dr. J. E. Stub-
bert, at the sanatorium. There are at present twenty-
seven patients in the institution. The public dedica-
tion will take place in November.
Pruritus Vulvae The editor of The Medical Press
has been struck with the apparent frequency of this
complaint among American women, and says that one
hardly ever glances through an American medical
journal without coming across the most harrowing
accounts of its severity and refractoriness to treat-
ment. Every-day gynecological practice in England,
he continues, does not reveal pruritus vulvae as a
common or intractable affection, so that an explana-
tion of its greater incidence on this side of the Atlan-
tic "must be sought in ethnological or climatological
peculiarities, unless, indeed, there are more individual
reasons associated with the prevalence of a highly
strung, quasi-neurotic temperament." He throws out
the suggestion that this would be a profitable subject
of study by American gynecologists.
The Dispensary Abuse in London appears to be
as aggravated and aggravating as it is here, if we may
judge from the plaint of a correspondent of the Medi-
cal Times and Hospital Gazette. He writes : " A patient
of mine, who holds a good position, was thrown from
a trap when out driving recently, and received a severe
scalp wound. He was taken to the nearest hospital and
his injuries were attended to, and when sufficiently
recovered he was sent home in a cab. Instead, how-
ever, of being told to send for his regular medical
attendant as soon as he reached home, as he would
have been told when I was a hospital dresser, he was
requested to return to the hospital on the following
morning. He has continued to attend the hospital
almost daily since, being driven to the institution in
a cab, which waits to take him back to his place of
business. In order that he may not be kept waiting
for any length of time, he has, I believe, to tip the
porters, and it may be that he tips every one all round,
as he is mightily generous and liberal to everyone but
his poor outraged doctor."
688
MEDICAL RECORD.
[November 7, 1896
Treatment of Constipation. — i. W.ith regard to the
prophylaxis of constipation, we should abstain from
administering cathartics in slight transient disturb-
ances of digestion ; rather let nature take its own
course. Never put a patient on a one-sided diet for
too long a time ; the exclusion of vegetables, fruits,
and starchy foods in general, from the diet is fre-
quently the cause of marked constipation. A hygienic
mode of living, regular habits, less business strain
and worry, and more out-door life and exercise are of
greatest importance to prevent constipation. 2. The
treatment of habitual constipation will be composed
of the following factors: (a) Of the just mentioned
hygienic mode of living. (/>) Of correcting a faulty
diet; increasing the amount of vegetables, fruits,
starchy food, and also fats (butter), {r) Of impress-
ing the patient with the importance of not worrying
and not bothering much about his bowels, {d) Of
training the patient to have an evacuation once a day
at a certain time, either giving no drugs whatever, or
administering a very slight cathartic for a short pe-
riod, then gradually diminishing and ultimately
discontinuing its use. — Dr. Max Einhorn, J^osf-
Gradua/c.
Elixir of Peptonate of Iron. —
I^ Chloro-peptonate of iron loo gm.
Alcohol, 90;? 150 "
Simple syrup 450 "
Distilled water to make one litre.
.\romatize at discretion.
— -/?«'. J?itcnK lie Med. et de Chir., September 25, 1896.
Tellurate of Sodium ten to twenty centigrams, and
alcohol fifty grams, makes a solution of which a tea-
spoonful may be given in sweetened water morning
and night in the night sweats of phthisis. Dr. Joguet
says it was successful in sixteen out of twenty cases.
—Lyon Med., September 13, i8g6.
Typhoid Fever. — Dr. Bignami employed phenace-
tin to the exclusion of all other treatment in two
hundred cases of typhoid fever, out of which number
there occurred but six deaths. In the first week three
grams per diem were administered in six doses. In
infants and old persons the dose was reduced to two
grams. He considers that by this treatment the symp-
toms were reduced to those of a simple gastric fever.
— Gaz. d. Osped., No. 35, 1896.
Regime During Pregnancy. — Dr. Eichholz {La
Rev. Aled., May 16, 1896) believes many complica-
tions accompanying and following pregnancy are due
to errors of regime. While pregnant the woman should
avoid excesses of water and albumin; the one causing
excessive development of the fcetus, the other giving
rise to an excessive secretion of liquor aninii. Based
upon twenty-five observations he prescribes the fol-
lowing regime: Fresh meat once daily in small quan-
tity; green vegetables, salad, potatoes, bread and
butter. Avoid eggs as much as possible, peas and
beans. Wine, beer, and alcohol are forbidden, and
only enough liquids should be taken to allay thirst.
The advantages are: i. ."Vctivity is preser\'ed up to
time of delivery; sensations of fulness, fatigue, thirst,
and constipation disappear early. 2. Rapidity and
facility of deliverance even in cases in which previously
it has been difficult. 3. A limited quantity of amni-
otic fluid. 4. Possibility of nursing offspring, the
milk being of good quality and quantity. The me-
dium w'eight of the children was six pounds and the
circumference of the head thirty-three to thirty-four
centimetres.
Anal Pruritus, pure and simple, is treated by
Brocq in the following manner: i. An alimentary
regimen of the most strict order and avoidance so far
as at all possible of all overexertion. 2. Regulate
the passages, and before going to stool cover over
the margins of the anus with pure vaseline or cold
cream. 3. Wash the painful points morning and
night with a decoction of coca leaves as hot as can be
borne and to which has been added a solution of phe-
nic acid in glycerin. 4. Keep the anus constantly
powdered with a mixture of talcum and oxide of zinc.
5. Every third day apply a five-per-cent. solution of
nitrate of silver. 6. In case of ver}- severe attacks,
take at dinner time and on retiring fifty centigrams of
antipyrin. 7. Give hot sedative douches or apply
static electricity. — Jourtial des fratifieiis, March 21,
1896.
Obesity. — An obese patient consulted his physician
in reference to the treatment of his obesity, and was
given the following advice : " Eat three francs' worth
a day; but earn the money, and you will get thin."
— Lyon Medieale.
[An American physician of note gave similar ad-
vice to a dyspeptic: to saw wood for a living, and
live on the proceeds.- — Ed.]
Bromoform, in dose of half a gram in capsule, four
or six times daily, is found efficacious in chronic bron-
chitis, pneumonia, and especially in emphysema and
the attacks of asthma associated with this condition.
— Stepp.
Vomiting of Pregnancy, in three cases in which it
was severe and persistent, was quickly relieved by ich-
thyol tampon applied against the neck of the uterus.
— De la Torrk.
Pharyngeal Diphtheria. —
1} .\tropine sulphate O.045
Cocaine hydrochlorate 0.75
Bitter-almond water 300.00
M. S. One drop every hour for each year of the child's age.
For adults, according to the patient's constitution
and the severity of the disease, from ten to fifteen
drops every hour. The frequency of administration
is important, and at first it should be kept up even at
night; consequently great care is necessary on the
part of the nurse. — Elsaesser, Therapeutisehe Monats-
hejte.
Nervousness and General Malaise. — Especially
recommended at the period of the menopause:
'S, .^mmonii broniidi 3 ij.
Sodii bromidi 3 iv.
Spt. ammonii aromat 3 vi.
Aqua; camph 3 vi.
M. S. Tablespoonful every four hours.
— Parvin.
Balsamics should not be used in the acute stage of
bronchitis, as they can at this period only irritate the
already inflamed mucous membranes. Congestion of
the respiratory passages has often been seen to follow
a too free administraticn of syrup of tolu. — Gingeot.
Phthisical Sweatings may be treated by crystal-
Hied acetate of lead, of which one decigram is given
in pill form twice daily. This may succeed after atro-
pine, white agaric, tribasic phosphate of lime, cam-
phoric acid, and hydrastis canadensis have failed. —
Journ. des Fraiifiens.
Hydriodate of the lodate of Quinine has been
found by Assaky (La Presse Medieale, September 12,
1896) beneficially to influence in a brief period the
local condition and cause prompt disappearance of the
lesions in fourteen cases of syphilis associated with
paludism. The author does not know if it would be
prudent to subject such patients to a lengthy exclusive
November 7, 1896]
MEDICAL RECORD.
689
course of this drug, but that it is capable, probably by
reason of the iodide, of causing the secondary and
secundo-tertiary lesions to disappear seems positive.
It is administered in pills containing twenty-five cen-
tigrams, of which from eight to twelve are given daily.
Thyroid in Middle-Ear Disease has given Dr.
Vulpius (Zf 5'('(?<^67, September 27 th) such encouraging
results as to lead him to continue its use. He was
led to employ it by the favorable results upon the
hearing in myxtedema patients with sclerosis of the
middle ear, in whom the thyroid was being employed.
Gall-Stone Colic In one case nitroglycerin had
a promptly beneficial effect attributed to the paralyz-
ing action upon unstriped muscular fibre. — Turnbull,
Lancet, February 8th.
Methylene Blue, in daily divided dose of ten or
twenty centigrams, relieves, after three or four days,
hyperchlorhydria and other nervous troubles of the
stomach, such as gastralgia and hyperaesthesia of the
mucous membrane. — Bekthier.
Arterio-Sclerosis is itself improved by tepid baths,
as well as the affections which accompany it, such as
gout, chronic rheumatism of the muscles and joints,
arthritis deformans, and neurasthenia. — Groedel, Gaz.
hebd. dc A/ed. et de C/iir., September 13, 1896.
Paralysis Agitans. —
IJ Strychnina: sulphat : gr. i.
Acid, arseniosi gr. ij.
E.xt. belladonna gr. v.
Quininae sulphat 3ij.
Pil. ferri carbonat 3ij.
Ext. tara.xaci 3i.
M. et ft. pil. No. xc. S. One pill three times a day.
— S. W. Gross.
Sick Headache. —
I? Sparteine sulphate 0.02 gm. ( %gT.).
Caflfeine o. I gm. (1% gr.).
Antipyrin 0.5 gm. (7;! gr.).
Taken at inter\als of two hours until four have
been taken, even though the pain has disappeared. —
Aritzm.\n-, Presse Medicalc.
Antipyrin and Calomel — Dr. J- Schuh, of Mu-
nich, claims that the mi.xture of antipyrin and calomel
in the quantities usually prescribed causes in the
stomach juice the formation of corrosive sublimate in
suflRcient quantity materially to exceed the maximum
dose of this chemical.
Chronic Diarrhoea and Dysentery. —
V, .Sulphate of copper gr. i.
Sulphate of morphine gr. i.
Sulphate of quinine gr. xxiv.
Ft. pil. No. xii. S. One t. i. d.
— Aihintic Medical Weekly.
Chronic Pharyngitis.—
V, .Sodii grr. vi.
Potassii iodidi gr. xii.
Mentholis,
(Jlycerini aa q.s. ad S i.
M. S. Locally t. i. d.
Chronic Pyelitis — Dr. A. Robin uses the follow-
ing when pain is present :
V, Venice turpentine 3 iss.
Powdered camphor 3 iss.
Extract of opium gr. ▼.
Extract of aconite root gr. iij.
Mix and make into twenty pills. S. One pill to be taken
ever)' eight hours, and at the same time a small glassful of infu-
sion of uva ursi, slijjhtly sweetened.
— Le Progres Medical.
Ointment for Rheumatic Joints
\\ Salicylic acid.
Oil of turpentine,
Lanolin aa 3 iiss.
I-ard I iij.
— Journal des Praticiens.
Citric Acid in Diphtheria. — Ten-per-cent. solutions
are given every two hours in dose of teaspoonful
to dessertspoonful. Within twenty-four hours in
slight cases the false membranes cease spreading and
begin to detach themselves. In one hundred and
fourteen cases, thirty-one of which were severe, the
mortality was 9.6 per cent. Of the eleven patients who
died, five had been brought into the hospital from four
to seven days after the debut of the affection. — Block,
Deutsche tned. Zeit.
Heart Disease. —
B I'erri redacti.
Pulv. digitalis fol. (English),
Quininae sulphatis aa gr. i.
Pulv. scillae gr. x.
M. ft. massa et in pil. No. xx. div. S. A pill three or four
times daily. (In fatty heart, dilatation of cavities, and mitral re-
gurgitation with annemia. )
— Bartholow.
Epistaxis. —
B Hydrarg. chloridi corros gr. i.
.Acid, hydrochloric, dil.,
Tr. cannabis ind aa 3 ij.
Ergotin 3 ss.
Syrup, simp | i.
Infus. quassice amar | vij.
JL S. Three teaspoonfuls a day in a glassful of water.
— El Sigh Medico.
Dysmenorrhoea. —
V, Arsenite of copper gr. 1.60.
Tincture of Pulsatilla gtt. 15.
Tincture of nux vomica gtt. 8.
Distilled water § iij.
M. One tablespoonful every hour or half-hour until the
uterine pain is reliesed.
— W. Blair Stewart.
Bromoform in Phthisical Coughs. —
B Bromoform 30 gtt.
Alcohol 10 gm.
Syrup ipecac compound 100 gm.
Syrup opium 100 gm.
Syrup cherry-laurel 190 gm.
Mix in the order indicated to obtain a clear mixture. Dose,
three or four tablespoonfuls daily, between meals.
ROLLAND.
Vaginitis. — The following combination is made use
of at the Vanderbilt Clinic:
B Pulv. alum,
Zinci sulphatis,
Sodii biboratis,
Acidi carbolici aa 3 i.
Aq 1 vi.
M. S. A tablespoonful to a quart of lukewarm water as a
vaginal injection, twice daily.
Iodoform and Diiodoform are after all found to be
much more active than any succedaneum of the many
so far proposed, none of which can replace iodoform
completely. — Stokvls.
Borax does not seem sufficiently efficacious in epi-
lepsy to warrant its use, especially since, if long con-
tinued, it has an injurious action upon the kidneys. —
Claus, Belgique Med.
Simple Goitre. — In a case showing no improvement
from the iodine treatment a rapid cure was effected in
a man of forty-four years by the use of glycerin ex-
tract of the thyroid body. From one to one and a half
teaspoonfuls were given daily, each teaspoonful repre-
senting thirty centigrams of the fresh organ. — S.\-
BR.4ZES ET Cabann-es, Gaz. Hcbd., No. 28.
Syphilis Cured by Thyroid. — In a patient whose
condition did not improve under mercurial treatment,
but in whom ecthymatous and ulcerating lesions ap-
peared in the early secondary stage, destroying the
alai nasi and portions of the ear, Dr. (Jouladse ( Vra/c/i,
No. 30, 1895) administered two grams of beef thyroid
cut into small pieces and triturated, subsequently in-
creasing the daily dose to as much as fourteen grams.
690
MEDICAL RECORD.
[November 7, 1896
After the third day improvement was noted, and at the
end of five months all the phenomena had disappeared.
During the first days of administration there were nau-
sea, palpitation, trembling of the upper_ extremities,
and pulse running up to 120 beats. Just how the
thyroid is supposed to exert its beneficial action in
such a case is not stated.
Lichen. — In a girl of ten years thyroid tablets in
dose of two daily caused at first an increase in the
pruritus and desquamation, but the plaques became
paler. When four tablets per day were given, head-
ache and vomiting supervened. When six tablets
were given the eruption became less marked and
finally disappeared entirely. The urine contained
.some sugar but no albumin. — Kissel, Gas. Hebd.,
October 8th.
Gelsemium in combination with belladonna or mor-
phine, or both, greatly increases their anodyne powers.
As a relaxant, in rigidity of the os uteri and sphincter
perinaei, and in puerperal convulsions, dysmenorrhcea,
and nausea and vomiting in pregnancy, it will be
found of great value. In after-pains it will be found
a valuable substitute when opium is not tolerated. —
Roop.
Haemoptysis. — When blood is vomited it is impor-
tant to discover its source, but if large quantities are
being lost we may treat the symptom first and make
an accurate diagnosis afterward. Place the patient
in a quiet position and forbid movement. Raise the
head and place mustard plasters upon the lower ex-
tremities. Give pieces of ice to suck, and if it is
possible let the patient take a teaspoonful of ether in
a little sweetened water. Above all give a hypoder-
mic injection, deep into the muscle by preference, of
the following solution;
'B, Ergotin (V'von) 5 gm.
Morphine chlorohydr 0.04 cgm.
Antipyrin i. 5° g™-
Sparteine sulph o. 20 cgm.
Atropine sulpii 0.002 mgm.
At), dest q.s. ut ft. sol. 10 c.c.
This injection may be repeated, giving a syringeful
every half or quarter hour until four or five have been
given. If the patient can drink he may be given every
hour or every half-hour a soupspoonful of the follow-
ing potion :
I^ Ergotin ( Bonjean) 2. gm.
Acidi gallici o. 5 gm.
Syr. terebinthinas 120 gm,
— Capitan, La Frame Med., September 25, 1896.
Pilocarpine in Bright's Disease. — It has been
established, and cannot be controverted, that pilocar-
pine is a marked cardiac depressant and a dangerous
remedy to administer in uramia; that its sphere of
usefulness is but a limited one: that it should be ban-
ished from our therapeusis of Bright's disease, and
that its application should be relegated to another
sphere.— Proben, New York Medical Journal, July 18,
1896.
Ringworm in Institutions. — Strict isolation of
actti.il and suspected cases is called for. Clippers
should not be used for cutting the hair of any in-
mates. Ringworm patients should have the hair cut
close or the scalp shaved at frequent intervals. Scis-
sors should be sterilized after use. ?-pilation should
be done only in limited patches and then done thor-
oughly by a trained assistant. P)ichloride solution, i to
500 up to I to 100, can be used for washing the scalp
when it is free from open lesions. The best anti-par-
asitic remedy employed in this affection is chrysarobin,
which gives an efficient and prompt result. Care
must be exercised that the face and eyes do not become
irritated. A caoutchouc cap can be worn or the drug
can be incorporated in collodion or traumaticin.
Occlusive dressings have the advantage of shutting out
air, which would seem to favor the growth of the fun-
gus. Another formula used was nitrate of mercury
and ichthyol, each one drachm, and collodion, one
ounce. When seemingly well the patient must be
kept under surveillance for a time before being allowed
to mingle with the other children. Close cutting of
the hair and careful examination is recommended upon
admission to hospitals, asylums, etc. — Allen, fedia-
(riis, August 15, 1896.
Xeroform is a tribromphenol bismuth and is in-
tended to replace iodoform. It is not toxic, has nei-
ther taste nor odor, and does not irritate skin or mucous
membranes. It unites in itself the properties of phe-
nol and bismuth, being bactericidal, antipruritic, and a
moderator of secretions. It is not only an intestinal
antiseptic of great value but also a topical dressing
for wounds inducing cicatrization. Not decomposing
at 120^ F., it may readily be sterilized. — Heuss,
Thcrapeutisilie Monatshefti-, No. 4, 1896.
Lupus Erythematosus — Good results were ob-
tained by the local application twice daily of Fowler's
solution diluted four to six times. After six days
there was local reaction in the form of tumefaction, in
which case it is well to apply an indifferent ointment.
In nine cases thus treated cure was effected within
the space of eleven weeks.- — Schultz, Gaz. Hehd.,
October 8th.
J<ocietij Reports.
NEW YORK COUNTY MEDICAL ASSOCIA-
TION.
Stated Meeting, October ig, i8g6.
Joseph E. Janvrin, M.D., President, in the Chair.
The Treatment of Follicular Abscess of the Fossa
Navicularis with Attendant Fistula. — Dr. Charles
H. Chetwdou read the first paper of the evening. He
said the condition of which it treated was not infre-
quent, and was difficult to cure. The cases of folli-
cular abscess of the fossa navicularis could be divided
into three classes: i, those w'ith abscess and blind
internal fistula; 2, those with abscess and blind ex-
ternal fistula; 3, those with abscess and complete
fistula.
The etiology of all these varieties was the same,
being an extension of infiammation during an acute
urethritis or traumatism. There was a certain amount
of purulent di.scharge, especially on pressure upon the
meatus, the fluid escaping internally or externally ac-
cording to whether the fistulous opening leading to the
abscess was internal or external. The treatment com-
monly resorted to or recommended was surgical, open-
ing the fistula, packing, or scraping and suturing.
Hut this did not always effect a cure, and might make
a complete fistula which was difficult to heal. The
method which the author employed in all cases had
failed in none. It consisted of injecting a little of a
twenty-five-per-cent. ethereal solution of peroxide of
hydrogen, called pyrozone, into the abscess at inter-
vals of a few days several times until the secreting
surface healed. The injection was made with a glass
pipette having a bent and very fine opening. Cocaine
was used for local an.x'.sthesia at the first and possibly
subsequent sittings. Six to eight weeks was long
enough to effect a cure of the most obstinate case.
Dr. H. F. Nurdeman had seen all sorts of follicular
abscess of the fossa navicularis, had found it rarely
November 7, 1S96]
MEDICAL RECORD.
691
necessary to slit it up, and had been able to cure the
cases by what he regarded as a simpler method than
that described in the paper. It was to curette the
follicle.
Cardiac Disturbances from Gastric Irritation. —
Dr. He.nry Illow.^y read the histories of three pa-
tients, two women and one man, who had suffered one
or more attacks of cardiac embarrassment which he
suspected to be due to gastric irritation, the treatment
confirming his diagnosis. One of the women had at-
tacks of despondency, was pregnant five months, and
had been told by her physician that she had heart
disease. The apex was somewhat pushed up; at times
there was a blowing sound, which, however, he believed
to be extracardiac, or at least not valvular and not the
ordinary anaemic murmur. Like the other two patients,
she abused her stomach. On relief of gastric irrita-
tion her symptoms disappeared, she had an easy labor,
and subsequently no signs of cardiac trouble could be
discovered. In the case of the man it took longer to
overcome the gastric irritation and control his faulty
methods of eating, but after a time all symptoms at-
tributed by another physician to heart disease dis-
appeared. The explanation suggested was irritation
of the gastric fibres of the pneumogastric transmitted
centrally and back through the cardiac fibres, the
effect on the heart being the same as if there were
originally a central irritation.
Dr. Robert Newman was reminded by the paper
of some post-mortem examinations which he had made
in coroner cases as far back as 1867. They were four
in number, all had died suddenly, with a feeling of
uneasiness and the development of cyanosis. No
disease of the heart nor of the brain could be found —
nothing but a stomach filled with a large amount of
dtfbris of recent ingestion. If they had been given
an emetic and the stomach relieved of its contents
they might not have died.
NEW YORK ACWDEMY OF MEDICINE.
SECTION ON GEXER..\.L MEDICINE.
Stateii Electing, October 20, i8g6.
Reynold W. Wilcox, M.D., CHAIR^^'^N.
Effects of Treatment of Enteric Fever with Cold
Tub Baths Dr. W. GiL.\rAN Thompson read a paper
on this subject, based on a personal experience with
the bath in some two hundred and fifty cases. Every
three hours, if the patient's rectal temperature rose
over 102.5^^ F., he was lowered, covered with a cloth,
into water of a temperature of 72° Y., was rubbed
while in the water, removed after fifteen minutes, cov-
ered with a blanket immediately, dried, and rubbed.
It was sometimes best to omit the bath in the early
morning hours to avoid possibility of exhaustion.
The object of the rubbing was to apply friction over
a large cutaneous surface, stimulate the nerves, and
diminish the shivering and discomfort. It also served
to pass the patient's time and divert his attention from
the cold. Dr. Thompson said he had been familiar
with the old method of applying cold and was preju-
diced against the new or Brandt method until Dr. Pea-
body had taught him to carry it out systematically,
since which time he had been its advocate and had
submitted to it himself when he had typhoid fever.
The bath should be preceded half an hour by half an
ounce of whiskey. No time should be lost in drying
the patient on removing him from the bath, and the
limbs, back, and chest should be rubbed immediately.
He should then be allowed to sleep. Usually he
micturated after the bath, for the treatment induced
diuresis.
The bath was in nowise curative in the sense that
medicines were. It was a strong stimulant, mechani-
cal and thermic, to the nervous system, and, as was
well known, enteric fever was pre-eminently character-
ized by depression of the central nervous system. It
was not a question of reducing the temperature, for
there were many cases in which the temperature did
not fall more than half a degree after the bath, yet
delirium disappeared, the tongue became clean, the
pulse improved, the action of the kidneys and bowels
became more nearly normal — all in striking contrast
with what was seen when the expectant plan was pur-
sued. The average reduction of the temperature while
the patient was in the bath was from two to two and
a half degrees.
While in this country we did not get as good results
from the Brandt treatment as were claimed for it in
Europe, still they were very gratifying. Our patients
did not enter the hospital as soon as those did abroad.
The average death rate given by Osier, Wilson, and
others in this country was about 7.25 per cent. At
the Presbyterian Hospital in this city there had been
two hundred and eighty-four cases treated by different
methods since 1892, only one hundred and ninety-three
of them by the Brandt method. But many of these
were severe cases, and the death rate was nearly as
great as from other methods. But if the cases were
analyzed as they should be, then the death rate from
the Brandt treatment in the Presbyterian Hospital
would be about 7.25 per cent., corresponding with
that in other hospitals in this country. There had
been relapses in 13.5 per cent, of the cases, somewhat
more than under the other methods of treatment. It
had been objected that the bath tended to nephritis,
but he had seen nephritis as often when the bath was
not employed. One of his patients was put into the
tub one hundred and thirty-nine times, but the average
number of times was fifteen to twenty-five. Pregnancy
was not a contraindication. Dr. Thompson stated in
his conclusions that the cold-bath treatment caused
enteric fever to run a shorter and a milder course,
reduced the mortality by one-half, and did not interfere
with other modes of treatment. It did not prevent
relapses nor the occurrence of ordinary complications.
Treatment of Typhoid Fever by Antitoxin and
by Antiseptics. — Dr. Morris Manc.es was announced
to read on other methods of treating typhoid fever, but
for want of time confined his paper to the so-called
specific or antitoxin treatment and the antiseptic treat-
ment. Were we, he asked, in a position to pass final
judgment upon any treatment of this disease, whether
hydrotherapy, antiseptic, or antitoxin.' He thought
not. While it was generally believed that the cause
of typhoid was a bacillus, yet it was not settled wheth-
er it was due to the typhoid bacillus alone or what
part might be taken by the colon bacillus, whether it
was a local effect or whether toxic. One must distin-
guish between the bactericidal and immunizing power
of the blood. It had been shown that the blood serum
of persons who had had typhoid fever retained immu-
nizing properties a long time, but not beyond ten
years. Experiments had been made on animals with
sterilized cultures of typhoid bacilli and with the
serum of immunized animals and persons, but little
had yet come from it clinically. As to intestinal anti-
septics. Stern and others had shown that they were not
effectual even on micro-organisms less resistant than
the typhoid bacillus. Among those mentioned were,
after rectal enemata, the administration of calomel,
corrosive sublimate, salol, etc. The author had tried
corrosive-sublimate enteric pills, as recommended by
Waldstein, and which did not melt unless the intesti-
nal contents were alkaline. The use of the pills had
been followed by improvement of the general con-
dition, the stools became less offensive, and the amount
692
MEDICAL RECORD.
[November 7, 1896
of itidican in the urine was diminished: but this had
been only one part of the treatment.
Tubbing Preferred — Experience with Other
Methods. — Dr. Francis Delafield said that to his
mind the tubbing treatment of typhoid fever was alto-
gether the best which we now had. In employing it
one did so for the disease and not for the temperature.
Do not wait for an excessive rise of temperature. But
it must be admitted that the bath treatment was abso-
lutely impossible for a considerable number of pa-
tients. Therefore we had to look around for some
other method, and this was a good time while the
mortality rate from t)'phoid in New York was low.
His own experience during the past winter was limited
to thirty cases with the Woodbridge treatment, carried
out literally at first, afterward in modified form. The
modified form consisted in continuing only the calomel
and carbonate-of-guaiacol ingredients of the pill, and
of these he gave one-twentieth instead of one-sixteenth
grain of calomel, and five instead of three grains of
carbonate of guaiacol. Later, finding that calomel
given so frequently was producing sore mouth, he sub-
stituted for it drachm-doses of sulphate of magnesium
and continued the guaiacol. He could see no particu-
lar change in the patients under the difi'erent methods.
Of the thirty patients, four died, two of them at least
plainly from the disease and not from complications.
Seventeen were convalescent in three weeks, and none
had a relapse. While the figures seemed to speak well
for the treatment, yet, when at the end of the winter
he came to analyze them, he concluded that, although
•in the mild cases the duration of the disease might
have been shortened a little, in the severe ones there
had been no influence. It was not at all probable
that the drugs would at all diminish the mortality of
the disease.
Tubbing a Doctor Dr. A. B. Ball thought the
reason wliv the doctors at Bellevue, including himself,
had given up the bath treatment some years ago was
that they did not employ rubbing. Everybody who
had tried the more recent method, and for which we
were indebted to Dr. Simon Baruch, adding friction,
had been convinced that there was no other method at
command which was so valuable. When he had at-
tended I )r. W. G. Thompson he observed the gasping
for breath which the bath produced, and remarked then
that the influence upon the respiration, causing deep
inspiration, must be among the most beneficial effects.
With women he had continued the treatment during
menstruation, and it had received the approval of some
of his gynecological friends whom he had consulted
about it. With some patients it might be best to give
the bath at 85' or even go^ F. The great mistake
was to suppose that it was intended simply to reduce
the temperature. Some believed a high temperature
was beneficial in typhoid, tending to kill bacilli.
Dr. W. p. XoRiHRfP said the beauty about the
bath treatment of typhoid cases was, to quote Dr. Del-
afield, that they ran such a comfortable course. He
had applied it in all cases for three .successive autumns
at the Presbyterian Hospital, except in a few cases in
which at the strong recommendation of a doctor in the
city he allowed Fraenkel's toxin to be tried. These
patients, although recovering, suffered such great dis-
comfort from their disease as long as the baths were
withheld that he made up his mind, if he were for-
given for thus allowing them to suffer, never to repeat
the offence. He thought in some cases it might be
well to devise a means of applying warmth to the ex-
tremities during the cold bath, as they did when spong-
ing scarlet-fever patients at Willard Parker's.
May Typhoid be Aborted? — Dr. Louis Wald-
STEiN referred to the fact that Dr. Manges seemed to
doubt whether typhoid could be aborted. German
clinicians like Wiindelrich and Friedreich had insisted
for )ears that it was possible to abort this disease, and
they resorted to calomel. The difficulty was to say
that a patient who got well after three doses of half a
drachm of calomel had had the incipient stage of
typhoid. All of us had seen cases of continued fever,
with more or less coated tongue, headache, backache,
general malaise, with or without intestinal symptoms,
with or without indication of tumor in the splenic
region, cases which seemed to be tending toward ty-
phoid. He had seen quite a number of such cases,
had always thought it was possible they were cases of
beginning typhoid, and had at once put them upon
liquid diet and given them calomel. They were
closely watched, and within a week or less were well.
But a few cases, after remaining well two or three
weeks, became ill again and had real typhoid fever.
Was it not possible they had typhoid in the first at-
tack, that this was aborted, and that the second attack
was simply a relapse?
Dr. Newtun, of Montclair, N. J., had seen pneu-
monia rapidly clear up under large doses of calomel.
This was in accord with the teaching of the late Dr.
Learning. If pneumonia could be cleared up under
calomel, why might not some cases of typhoid fever.'
If we should live to see the diagnosis of typhoid made
as it was in diphtheria, we could tell more about the
eft'ect of treatment. In the army he had seen many cases
of so-called mountain fever, which autopsy proved
to be typhoid with intestinal lesions. The origin
was not clear. He had used calomel and thought he
had aborted an occasional case of typhoid, and he
had seen such favorable results as had been attributed
this evening to the cold bath^clearing up of the
tongue, disappearance of tympanites, etc. It was not
necessary for an antiseptic to kill all of the germs of a
di-sease to be of benefit.
Condemns the Cold-Water Treatment. — Dr. A.
P. DrDLKV had passed through two epidemics of ty-
phoid fever, and treated quite a number of cases, more
than ten, fifteen, or twenty ; he had lost none, but he had
not employed the tub bath. He held that this had no
anatomical or physiological basis relative to typhoid
fever. The disease depended upon germs in the in-
testinal tract, their multiplication, and the production
of a poison. The scientific treatment was elimina-
tive. The bath did not eliminate the poison: it sub-
jected the patient to unnecessary shock and endangered
the heart, whose muscular fibre was weakened by the
disease. It was well known tliat death in this disease
was usually attributed to heart failure. The treatment
which had pToven so successful in Dr. Dudley's hands
was citrate of magnesium, to wash out the intestinal
tract. He did not hesitate to move the bowel two or
three times a day if necessary. The patient took two
or three quarts of milk a day. and was given quinine
and nux vomica to keep the heart going, ^^'ithin a
year one of his friends died in a German town under
the Brandt treatment, he being one of two who died
out of twenty-four patients so treated.
Dr. Simon- Barixh upheld the Brandt treatment,
and pointed to the charts shown by Dr. Thompson as
proof that tlie bath was the best heart tonic. The
temperature fell and the heart's action always became
slower and stronger. Further, the bath was elimina-
tive, for the urinary secretion was increased and with
it the poisons in the circulation. The great bugbear
was shock, but there could not be reaction without
shock, and reaction was wanted for its stimulating
effect.
Dr. Thompson confirmed the statements made by
Dr. Baruch in response to Dr. Dudley's assertion that
the bath was not eliminative and was weakening to
the heart. Dr. Manges also made some closing re-
marks.
The Phonendoscope. — Dr. Manges presented a
November 7, 1896]
MEDICAL RECORD.
693
phonendoscope, the device of an Italian physician for
increasing the normal auscultatory sounds of the or-
gans of the body and also the percussion note.
MEDICAL SOCIETY OF THE COUNTY OF
NEW YORK.
Aiuiual Meeting, Oetoth-r 26. l8g6.
E. D. Fisher, M.D., President, in the Chair.
Report of the Treasurer. — Dr. John S. Warren
read his report as treasurer, by which it appeared there
was a balance of §1,745. The disbursements for the
year had been $5,894.
Report of the Committee on Ethics. — Dr. T. E.
Satterthwaite, chairman, read the report. Eight
cases of alleged violation of medical ethics had been
presented by members and others. In one case the
committee advised that the attorney prosecute the
offender, if satisfactory evidence could be obtained.
In one it was advised that the offender be disci-
plined by the society. In two it was recommended
that the consideration of the cases be deferred until
matters relating to them had been adjudicated in the
city courts. In four it was stated that the charges
were not sustained. The report stated that the com-
mittee's efficiency would have been greatly enhanced
and the labors of the co?nitia minora lessened, if the
chairman of the committee on ethics had been a mem-
ber of the lomitia minora. The committee unani-
mously recommended that the constitution of the so-
ciety be amended to that effect.
Report of the Counsel. — Dr. Seneca D. Powell
read the report of the board of censors, or that part of
it which embodied the report of the counsellor for the
society. The total number of persons arrested during
the year was seventy-three; the total number convicted
so far was forty-six; the amount of the fines imposed
was over S3, 000.
The committee on prize essays reported through its
chairman. Dr. W. H. Katzenbach, that but one essay
had been received, and, while it was deserving of fa-
vorable mention, the committee thought it was not
worthy the prize.
Report of the Committee on Hygiene. — Dr. J. W.
Brannan read the report. The committee had co-
operated with some of the city departments in promot-
ing the public health. It was thought that better ar-
rangements had been made for night lodgers, those
out of work, and tramps than had formerly existed.
Through the board of health an effort had been made
to stop e.xpectoration in cars and public buildings. It
was thought that within a year a building would be set
aside, on Blackw^ell's Island, for tuberculous patients,
thus separating them from others in public hospitals
and placing them where they could receive the advan-
tages of any improved methods of treatment. Dr. E.
S. Peck, a member of the committee, contributed that
part of the report relating to contagious ophthalmia in
the city. The State law bearing on the subject had
had a more or less wholesome effect.
Amendments to the Constitution Amendments
to the constitution were adopted, permitting the elec-
tion viva 'voce of members recommended by the coniitia
minora, except when three members asked for a bal-
lot. A two-thirds vote would elect. .Also the chair-
men of standing committees were made members of the
comitia minora, but the chairmen of the committee on
ethics and of the committtee on hygiene were to have
no vote.
Remarks on Some of the Practical Phases of the
Leprosy Question — Dr. Prince A. Morrow read a
paper with this title, and threw on the screen lantern
slides of leprosy and other diseases. The term lep-
rosy had crept into our literature as standing for all
that was most foul and unclean. If a leper were seen
at large, the public press set up such a clamor that he
must be immediately isolated. Quarantine of this dis-
ease meant imprisonment for life, as practised in this
city. Tuberculous patients were not quarantined, yet
they were far more numerous, and the danger of
spreading the disease was far greater than in the case
of leprosy. For a given number of years in New York
there had been sixty thousand deaths from tuberculosis
to two deaths from leprosy. There was no surveil-
lance of syphilis, yet the danger of its propagation was
immensely greater, and the number of cases, even of
repulsive external lesions, far exceeded those of lep-
rosy. Indeed, there were many other diseases, as was
shown by the photographs, which were more repulsive
than most cases of leprosy. In New York there was
no disease which granted its victims so long a lease of
life; there was no instance here in which it was known
to have been communicated to another person; yet be-
cause of the public clamor the board of health had
felt itself compelled to quarantine leprosy patients,
which really meant imprisonment for life. Dr. Mor-
row had three cases under observation, in one the dis-
ease being of twelve years' duration, in the other two
of seven years'. In one there had been apparent cure;
in the other two the patients were not worse than
when he first saw them. While leprosy was a conta-
gious disease, he believed the degree of contagiousness
was influenced by climate and other local conditions,
so that in New York there was no known instance of
contagion. What should be done with leprosy in New
York.' As it was almost exclusively a disease of ex-
otic origin, it might seem the easiest solution of
the problem to return the patients to the country
whence they had come; but this had been found im-
practical in most instances. As already stated, to send
them to North Brother Island was practically to im-
prison them for life — a punishment which was assigned
only to desperate criminals after due trial. If they
were isolated, it should be by the State or nation in
colonies, with such siuroundings and conditions as
were adapted to their needs, not imduly restricting
their liberty and gix'ing them the advantages of any
improvement in treatment.
Dr. G. H. Fox felt that it was imnecessary for him
to add anything to what Dr. Morrow had said. He
had expressed similar views some years ago, and they
had not changed. In New York the chances of lep-
rosy being conveyed to the healthy were extremely
slight. The danger in some other countries was much
greater. He would rather live in a hospital for lepers
here than to travel through certain countries where
leprosy was common, so far as the risk of contracting
the disease was concerned. Here the rights of lepers
should be maintained. He did not believe there was
any danger to the public from allowing them their
freedom.
An Outrage Dr. George B. Fowler said the
interest which he felt in leprosy dated from the mo-
ment that he took office as health commissioner, when
he found five lepers on North Brother Island, confined,
disfranchised, restricted in their mode of life, feeling
that they were going to die, in every way subdued.
Although knowing tiien but little about leprosy, he felt
that it was an outrage and wrote for information to
noted specialists in this country and abroad as to the
contagiousness of leprosy in our climate. Backed by
the answers received to those communications and by
the opinions expressed to-night, he felt that these men
ought not to be deprived of their liberty, and he pro-
posed to release them. They were an expense to the
city, and, since confinement meant imprisonment for
694
MEDICAL RECORD.
[November 7, 1896
life, it was a question whether the community had a
legal right to' quarantine them.
Drs. C. W. Allen, A. Y. Reid, and J. A. Irwin
asked some questions regarding the comparative con-
tagiousness of leprosy in New York and other coun-
tries, and expressed doubt as to the propriety of the
society adopting a resolution at once approving of
setting at liberty the lepers on the island, until a
committee had investigated and reported on the sub-
ject. It should be remembered that the action of New-
York would be looked to as an example for the rest of
the country. Dr. Reid made a motion, which was
amended by Dr. Irwin, providing for the appointment
of such a committee, with Dr. Fowler as chairman.
Dr. John A. Fordycf. gave a lantern-slide exhibi-
tion of some rare and interesting forms of skin lesions,
including rare cases of lupus erythematosus, multiple
epithelioma, multiple fibroma, papillomatous tumors of
various parts of the body, psoriasis, rupia, etc.
The annual dues were continued at $3.
HAS MACKENRODT ABANDONED VAGINO-
FIXATION?
To THR Editor of thk Medical Record.
Sir: I am so frequently asked the question: "Is it
true that Mackenrodt has abandoned vagino-fixation?"
and I am so frequently confronted with the statement
in print that he has done so, that I beg the indulgence
of a short space in your valuable and extensively read
journal to place the matter before your readers in its
true aspect.
To the question of the abandonment of vagino-fix-
ation by Mackenrodt, I will now give the same answer
I have given before, notably in a discussion before
the obstetric section of the Academy of Medicine, on
February 27, 1896, called forth by a series of papers
on the indications for .Alexander's operation, ventral
fixation, and vaginal fixation, by Dr. Paul F.
Munde, Dr. G. M. Edebohls, and the writer, respec-
tively. I stated then (not exactly in the same phrase-
ology) that Mackenrodt had not discarded vaginal
fixation any more than Edebohls, Cleveland, and Kel-
logg had given up .Alexander's operation because each
of them had changed the technique from time to time;
nor any more than Howard Kelly had abandoned ven-
tro-fixation because he had modified very materially
his method of operating. I stated that Mackenrodt
had not given up vagino-fixation, but had modified the
technique, baptizing the modification by a new name,
" vesico-fixation" which he considered an improve-
ment upon his former technique. The ventro-fixation-
ists have followed a similar procedure in labelling
their modification ventro-suspension of the uterus. I
am not finding fault with these actions, but merely
wish to draw attention to the analogy between the two
courses, and to emphasize the circumstance that,
though the name be changed, the underlying principle
remains the same — in the one instance the fixation or
suspension of the uterus carried out through a vaginal
operation, in the other through an abdominal one. Be
this as it may, let us hear what Mackenrodt himself
has to say in reply to a feuilleton by Flaischeln, in the
Monatschrift fiir Gehiirtshil/t- urn/ Gyiidkologic (Bd. II.,
Heft 5, November, 1895), in which it was stated that
vagino-fixation had been condemned by the Berlin
gynecologists. Mackenrodt's reply appears in the
same journal for January, 1896. (I5e it remembered
this was subsequent to the publication of the cases of
dystocia in vagino-fixation, in which a faulty technique
had been followed.)
"The gynecologists who took part in the discussion
(Berlin Gynecological Society) were divided in two
groups, one group consisting of men who discussed
the subject in a purely objective manner, from their
own experiences, and who, like myself, passed a favor-
able opinion upon the operation, and who would not
think of discarding it. To this group belonged A.
Martin, Wendeler, G. Winter, and Kossman, while
Olshausen assumed an entirely unpartisan attitude and
considered the technique of vagino-fixation as not yet
closed. Even J. Veit, on the whole, considered the
operation as a triumph {scgoisrekli), and that it
should not be allowed to fall into disuse. The second
group of speakers were those gynecologists who, from
the very first, expressed an unfavorable opinion of the
operation, and who had little or no experience with it.
To this group belonged Flaischeln, Paul Ruge, and
Bokelmann, whose remarks partook more of a per-
sonal attack than of a scientific discussion upon an
important subject."
To the unbiassed person the above must be conclu-
sive evidence that Mackenrodt has not abandoned
vagino-fixation, and that the operation has not met
with general condemnation in Germany. On the con-
trary, every one concedes its value, no matter which
technique is followed, in cases in which pregnancy
does not come into consideration: and tiiere is a
growing tendency in its fa\or e\en in fruitful bearing
women, when a certain technique is employed. Of
my own experience with the operation, and of the
modifications that I have from time to time adopted
and devised, I forbear to speak, as I have written of
them on former occasions. This much I may add:
that I have not as yet met with any accidents during
gestation and labor, and there have been five cases of
labor in my patients; that I am well pleased with the
results; and that the solicitude expressed by Fdei)ohls
for the welfare of the women in this city on whom
vagino-fixation had been done has thus far proven to
be a wa.ste of sentiment.
Hiram N. Vinebero, M.D.
127 East Sixtv-First Street, October 15, i8y6.
"A CASE OF HERMAPHRODISM."
To THE Editor of the Medical Recorp,
Sir; On my return from Europe I find in the issue
for August 8th letters from Dr. Paul F. Munde and
Dr. William Keller on the case of " Hermaphrodism."
reported by me on July 25th. When I wrote tliat arti-
cle I added an interrogation mark to the title; subse-
quent events, however, showed that I might have
omitted it and let the case stand as the second in liter-
ature of true hermaphrodism.
It is not surprising that so careful a searcher as Dr.
Mundii should have taken scientific exception to my
diagnosis, especially in view of the extreme rarity of
such blending of the sexes. But Dr. Mund^ labored
under the disadvantage of distance. Had I been
favored by his presence at the operation, his letter
would never have been written. He would then have
seen and felt the uterus, as did those of our colleagues
who were present at the removal of the testicles that
had been retained and which had undergone sarcoma-
tous degeneration.
Again must I deplore Dr. Munde's absence from
the laparotomy, as he would then not have said that I
missed the "glorious opportunity" more thoroughly to
examine the fem.ile reproductive organs contained in
tliis male (?) subject. Even had my colleagues not
urged me, I would have been driven by the hemor-
rhage, the pulseless condition, and the cessation of
respiration to close the abdomen as quickly as possi-
ble, after the removal of the testicles from their many
adhesions. I am more than confident that Dr. Munde
November 7, 1896]
MEDICAL RECORD.
695
would have justly reproved me for unnecessarily ex-
posing the patient's life, had I deferred acting for the
sake of scientific exploration. In my article these
facts were alluded to. The presence of the testicles
gives additional male asjaect to the penis, which in its
Haccid state measured more than two and one-third
inches.
The patient acquired pneumonia eighteen days after
the operation and died three days thereafter. The
autopsy not only corroborated my statement in regard
to the presence of the uterus, but showed also ovaries,
tubes, and ligaments. Unfortunately, I being absent
in Europe at the time of the autopsy, the attention of
the gentleman who made it was not sufficiently called
to this most important point and the ovaries were cut
off. The tubes and ligaments, however, are so well
preserved that even the mutilated specimen demon-
strates the facts. If the patient had not died, I would
have hesitated to say that I was positive in having
palpated the ovaries, appreciating the hiatus left by
the insufficient examination at the time of the opera-
tion. But had nothing but the presence of a uterus
been proven, this case would have been an extraordi-
nary one.
Dr. Munde's well-known sense of justice and cour-
tesy to his colleagues, is, I fear, put into a wrong light
through the shortness of my clinical report. Now,
having the specimen, I shall be able to write a fuller
description of the case.
As to Dr. Keller's letter, I heartily agree that a
much more extensive description would be of interest.
A vast number of observations could have been made
in fact, but I had intended to write only a clinical re-
port, the limits of which forbade this. The micro-
scopical examination was not only made by myself,
but also by a prominent pathologist, who would not
have been able to determine whether the tumors repre-
sented testicles or ovaries, as the tumor tissue had
taken up all the normal structure, were it not pos-
sible to regard them as testicles on the basis of the
facts described.
There was no enlarged clitoris, but a well-developed
penis, as described in my article. The arrangement
of the pubic hair was decidedly not feminine; it was
not continued up to the umbilicus. According to a
recent information, obtained through the kindness of
Dr. F. G. Lusk, the patient was treated last year in a
hospital of this city for syphilis, the initial lesion
having been under the observation of Dr. Lusk.
Carl Beck, M.D.
HOW SPECIMENS OF URINE MAY BE SENT
TO INDIA FOR DIAGNOSIS.
To THE Editor of the Medical Recokd.
Sir: The following letter which I received recently
from a native physician in Bombay, India, will inter-
est your readers. It presents gratifying evidence of
the progress that urinalysis is making in that country
in the interpretation of disease. But, more than this,
it throws the door wide open for the interchange of
professional courtesies between physicians in the
United States of America and India in a unique way,
by facilitating the safe sending of samples of urine
from one country to the other. Now that the only
difficulty in consulting Bombay experts has been re-
moved, I have little doubt that "close-packed and
properly sealed" bottles of urine will be exported from
this country to India in numbers to compete success-
fully with "bottled Bass" from England.
'I"he patient referred to in the letter was admitted
to the New York Hospital last spring. The case was
one of hysterical trance, and was well advertised in
the papers for some time before admission and after-
ward. It was a " bonanza" for reporters of sensa-
tional newspapers, and the grossly exaggerated and
absolutely false reports that appeared daily for some
time were a disgrace to modern journalism. I was
made to pose as an expert in the cure of hysteria by
removal of the ovaries; to cap the climax the case
was reported also in a Bombay newspaper, and then
came the following letter:
"Bo-MB.-vv, India, July 26, 1896.
"Dear Sir: I was surprised to read in one of the
local papers a report of a patient, Mrs. , who is
suffering from hysteria, and who is under your treat-
ment. I, belonging to the medical profession, am
naturally led to inquire into the details, and so I beg
you to put down all the particulars. I want to know
the real disease and to diagnose it properly if I can.
" I generally diagnose all the diseases by examining
the urine; so will you be kind to send the patient's
urine in a close-packed and properly sealed bottle to
nfy address? The whole quantity of urine passed early
in the morning just after getting up should be care-
fully collected and sent in the bottle.
"With this the history of the whole case will be
very useful, if you can conveniently send it.
" Let me remind you that the bottle should be kept
on ice in order to prevent decomposition.
" Hoping to be excused for the trouble
"I remain, sir, your obedient servant
New York.
A. Brayton Ball, M.D.
CORRECTION.
To THE Editor of the Medical Record.
Sir: In my recent article on "Preparation of Blood,"
etc., the formula for eosin solution should read one
gram instead of "one grain," as given. Since the ar-
ticle was published I have received a large number of
letters from different parts of the country, evincing a
deeper and more widespread interest in ha:-matology
than I had any idea of. Despite the fact that Hayem
has given us over a thousand pages about the blood,
what we don't know about the subject would make a
much bigger book than what we really do know.
Nearly a century and a half ago Henry Baker ("The
Microscope Made Easy," London, 1754) wrote as fol-
lows:
"We cannot employ the Microscope to any more
useful Purpose, than to view the natural Course of the
Blood within its Vessels, or examine the Contexture
of it when extracted from them : for the Preservation
or Restoration of the Health of Man may be greatly
advantaged by such Enquiries."
H. G. PiFFARD, M.D.
WHAT SHALL WE DO WITH THE LEPER?
To the Editor of the Medical Record.
Sir: I have already claimed a small portion of your
valuable space to discuss this question, and do so
now again because of my sincere belief that, hav-
ing strong convictions in the matter, it is my duty
to express them. At the last meeting of the County
Medical Society Dr. Fowler, commissioner of health,
expressed his determination to turn out the lepers con-
stituting the colony on North Brother's Island, believ-
ing that the disease is not contagious and hence not
dangerous to the health of the community, and for the
further reason that the New York board of health
had no funds to apply to the purpose of maintaining
a lazaretto. The commissioner asked the society to
endorse this proposed action. I opposed the motion
696
MEDICAL RECORD.
[November 7, 1896
made to this effect, because I did not think a leading
medical body, such as the County Medical Society is
known to be by the country at large, should endorse
the view so unqualifiedly expressed that the disease is
not contagious. No one more than myself recognizes
the slight degree of danger from contagion, and I quite
agree that there is more danger to-day from syphilis
and phthisis in the community than from leprosy; but
to give the impression to the profession at large, to the
public, and to the world that the New York County
Medical Society looks upon leprosy as a disease which
is not transmitted from person to person, that, in other
words, it is not a bacillary disease,
and that a new case depends upon
some other cause than a case of lep-
rosy which has gone before, is con-
trary to the belief of a vast majority
of the members of this society.
The only objection I raise to turning these five le-
pers out upon our streets is that, if they belong to the
pauper class and must therefore be cared for by tTie
people somewhere, we had better continue to care for
them where they are. If some have been taken from
occupations in the city to which they will return when
released, such as cooking and baking, I object upon
personal grounds that I prefer my bread kneaded by
healthy individuals, and, if we cannot compel or in-
duce syphilitics and consumptives to give up these
unappetizing pursuits, let us at least do what we can
by moral suasion and mild show of assumed power of
control over lepers, giving them always the privilege,
if they do not like the restraint placed upon them, of
returning to the country from which they came.
Why should we scatter these patients about among
the hospitals instead of keeping them where they are,
since I have been informed their surroundings are all
that is to be desired and not the prison or living tomb
which they have been represented to be? I have for-
merly opposed the assumed power of the board of health
in shutting up these unfortunates, because it has been
represented to me that the first man thus isolated was
treated in a barbarous and inhumane manner, being
confined in a tent without companionship and left
literally to die alone. I hope I have been misinformed
in the matter. The fate of one or two Chinamen, like-
wise isolated, as reported to me, seemed unnecessarily
severe. A local board of health cannot in my opin-
ion permanently give proper care to this class of
patients, but it can at least keep them under the con-
ditions mentioned, until the national government es-
tablishes suitable a.sylum homes in which to isolate
all lepers.
I have urged such a measure for thiij country be-
cause I believe we are so situated that the United
States can be made and maintained leper free. For
phthisis and syphilis it is futile to think of such a
thing, but because we cannot do it for all infectious
diseases there is no reason why it should not be done
for so loathsome a disease as leprosy, which is still so
limited in distribution that the proposition is practical.
Charles \V. Allk.v, M.D.
126 East Sixtieth Street.
Bew instruments.
A NFAV TRACHELORRHAPHY KNIFE.
liv D. TOD GILLI.\M, M.D.,
Cf»LfMIlL-S, OHIO.
This knife, devised by me some months since, has
proven most satisfactory. It not only expedites the
freshening, but enables one to do smoother work than
is usually obtained with the straight knife or scissors.
It consists of a handle, seven inches long, with a blade
The Population of the Earth. — The quinquennial
census of different nations was recently completed.
From 1874 to 1895 the total population seems to have
increased from 1,391,000,000 to 1,480,000,000. The
increase at the rate of five per cent, should give
1,549,000,000 in 1900, and 2,548,000,000 in the year
2000. The fear expressed in Malthus' essay on popu-
lation, that in course of time one portion of the popu-
lation will be reduced to famine, seems not incredible,
since the producing powers of the soil are limited,
while those of reproduction of species are practically
without limit.
at either end. The blades are set at an angle of 45°
to the handle, and are turned in opposite directions,
thus giving the instrument something of the appear-
ance of the letter S. One of the blades is narrow and
pointed, and intended to transfix the tissues up near
the angle of the tear and cut outward. The other is
bellied and used for clearing the angles. This blade
may often be conveniently used for the entire denuda-
tion of the right side. The accompanying cut is self-
explanatory. The knife is made by George Tiemann
& Co., New^ York.
piccUcal Jtcms.
Contagious Diseases — Weekly Statement — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending October 31, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis,
Measles
Diphtheria
Smallpox
Cases.
Deaths.
148
113
29
6
96
7
0
0
53 •
2
200
20
0
0
Thermal Baths ha\e a diagnostic worth, aside from
therapeutic results. In Wiesbaden, after six or seven
baths, rheumatic subjects are rendered worse, and
gouty subjects have a typical attack. After some
twenty baths, the quantity of uric acid excreted is re-
duced, in gout, to about one-half. In differcntiiil
diagnosis these almost constant results have an impor-
tance in distinguishing rheumatism and gout from
other painful affections simulating them. — Pfeifkek,
Berlin kliii. /F(v//., No. 12.
His Message The long, gloomy operating-room
of the hospital is hushed and .still; soft-voiced, gentle-
eyed nurses move quickly here and there, and a skil-
ful attendant arranges the cruel-looking instruments
upon a table. Before administering chloroform to the
patient, prior to the amputation, the kindly doctor
leans over and asks him if iie has any message for his
friends. "Naw!"' he murmurs wearily: "jest tell 'em
dat you .saw me. an' dat I'm losin' flesh.'" — Sun.
A Scaremosquito. — .-V New Jersey man has applied
the principle of the scarecrow to that other rapacious
bird, the native mosquito. He suspends two or three
imitation dragon flies by a fine cord from the ceiling
of his room, and claims that no mosquito will remain
within sight of them.
Medical Record
A Weekly younial of Medicine and Surgery
Vol. 50, No. 20.
Whole No. 1358.
New York, November 14, 1896.
$5.00 Per Annum.
Single Copies, loc.
COvir\inJil |tx*ticlcs.
RECENT AIDS IN THE DIFFERENTIAL DI-
AGNOSIS OF TYPHOID FEVER (DESCRIB-
ING THE AUTHOR'S MODIFICATIONS OF
EHRLICH'S TEST, WITH A PRELIMINARY
REPORT UPON THE SERUM TEST OF
WIDAL).
By CHARLES LYMAN GREENE, M.D.,
INSTRUCTOR IN PHYSICAL DIAGNOSIS AND CLINICAL MEDICINE IN THE INI-
VEBSITY OF MINNESOTA ; VISITING PHYSICIAN TO THE CITY AND COUNTY
HOSPITAL, UNIVERSITY FREE DISPENSARY, ETC., ST. PAUL, MINN.
The perennial interest in t\phoid displayed b)' our
profession is to be accounted for, not only by the fact
that we all meet it frequently in practice, but also
because we have learned that there is no acute disease
more insidious in its onset, more deceptive in its man-
ifestations, and more beset by troublesome and unex-
pected complications.
We ought, therefore, to welcome all tests which
seem to make clearer our way to a positive diagnosis,
and more particularlv those that aid us in early diag-
nosis.
The accurate diagnosis of typhoid is not always
easy, and is never to be made with certainty before
the end of the first five to ten days after the onset of
fever. Yet, in the discussion of this subject by a
medical society, we often hear of diagnoses made in
the first few days of the disease; and expressions
such as "the characteristic countenance," "the char-
acteristic pulse," or '■ the characteristic temperature,"
assail our ears, and make us wonder what early signs
are so truly characteristic or diagnostic as to warrant
these positive opinions.
In our student days all things were made so plain
to us that we were astonished, perhaps, to find in our
hospital practice after graduation that error in the
diagnosis of a disease so commonplace as tvphoid was
not uncommon, even in the practice of the most acute
clinicians. I have seen some of the greatest diagnos-
ticians refuse to commit themselves to a positive diag-
nosis in a certain case until the disease had nearly or
quite run its course — this conservatism being due to
the chastening effect of frequent autopsies and the
growth of caution in diagnosis which results from a
large clinical experience.
If we could trust the older text-books and if our
disease would be obligingly typical, we should have
no trouble. But the symptom complex of the text-
book is by no means common, and even its individual
components are often illusory or ubiquitous.
Allow me to pass .some of these symptoms in re-
view, with a running commentary upon their value.
Commencing with the prodromal and early first-week
symptoms, these are said to be: "Headache, nausea,
epistaxis, injected conjunctivae, lassitude, pain in the
back and legs, anorexia, tenderness and gurgling in
the right iliac fossa, diarrhoea, fever.''
The foregoing group contains the earlier symptoms
which, by their different combinations, constitute the
general malaise preceding the onset of fever, and are
the ones upon which the very early snap diagnoses
must, of necessity, be based. Collectively they are
important, as indicating an insidious onset; but the
individual symptoms are of little value, all being fre-
quently found in diseases other than typhoid, and no
one of them being at all characteristic of this disease.
For example, many of our cases in the city hospital
are constipated upon admission and give no history of
diarrhoea. Gurgling in the right iliac fossa may be
found in any diarrhoea. Tenderness in the right iliac
fossa may be due to appendicitis and many other con-
ditions. Epistaxis is lacking in a majority of our
cases, and the other symptoms are common to all gen-
eral infections.
If we pass on to the signs of the established disease,
there are :
First, fever. Much stress is laid by the text-books
upon the " characteristic temperature record," yet we
know that a case in St. Paul, with the step-ladder tem-
perature of the text-book, is a curiosity. The general
features are present and are important aids to diagno-
sis, but that is all.
Second, rose spots. These are important, and, if
found, are t)'pical. They are absent, however, in at
least thirty per cent, of our cases, and do not appear
until the eighth or tenth day.
Third, pulse. The pulse of typhoid is not neces-
sarily characteristic and certainly not pathognomonic,
though dicrotism is here more frequent than in almost
any other acute disease, and a disturbed pulse-temper-
ature ratio is often interesting (the pulse rate may be
only 100 to 110, with a temperature of 105' F".).
Fourth, enlargement of the spleen. This is a most
important sign. The spleen is palpable at the end of
the first week, if there is not too much tympanites,
and the engorgement disappears promptly as the fever
lessens. It is found, however, in malaria, septicaemia,
and miliary tuberculosis, and is far from being a
pathognomonic sign.
I will not prolong the discussion of symptoms, be-
cause my object is merely to indicate the somewhat
gauzy texture of ordinary diagnoses, and to point out
the fact that not one of the foregoing signs is pathog-
nomonic, that they do not permit of any positive early
diagnosis, and that it is only in their grouping that
they become important. Knowing that this is true,
it might be expected that the profession would grasp
eagerly at any new and important sign, even if it
were not pathognomonic; but such has not proven the
case with the diazo reaction of Ehrlich, a sign both
early and constant.
In a paper read before the Minnesota Academy of
Medicine, in 1893, I described both the original meth-
od of Ehrlich and my own modification of his method,
which seemed to me to yield more accurate results. I
intend to demonstrate this test to you to-night, and
beg that you will follow me closely at this point.
The formula; are as follows. I shall describe my
own method only, as I believe that it furnishes more
definite and less confusing results than in the original.
Solution A. — Hydrochloric acid, 50 ; distilled water.
1,000; sulfanilic acid, q.s. ad sat. This solution should
be most thoroughly saturated, allowed to stand some
days before being used, and shaken up from time to
time.
698
MEDICAL RECORD.
[November 14, 1896
Solution B. — P'ive-tenths solution of sodium nitrite
in distilled water. Should be kept in a cool place,
and black bottle, and renewed every week or ten days.
Solution C (test solution). — One part of solution
B: one hundred parst of solution A. This solution
should be freshly made for each day's testing.
Method of Applying Test. — Equal parts of the solu-
tion C and the susjsected urine are thoroughly shak-
en up together in test tube, and from one to two cubic
centimetres of ammonium hydrate allowed to tlowgen-
tlv down upon the surface. If the reaction be present,
a beautiful crimson or carmine band appears at the
junction of the ammonia with the mixture. Upon
sliaking, a pink tinge is imparted to the foam.
This test appears very simple, and no one would
suppose that any serious blunders would arise in the
hands of competent men. We find, nevertheless, one
of the greatest living authorities upon clinical diagno-
sis reporting it as valueless, and omitting all mention
of ammonia in his description of the test. The same
error occurred in the work of a very celebrated clini-
cian, who found it in normal urines. Another elabo-
rate report winds up with the reference to the yellow
color of the ring. Another used a live-per-cent. solu-
tion of sodium nitrite, and could not get rid of the re-
action. He found it in everything. Still another
used sodium nitrate. His results were naturally de-
plorable, and he cruelly condemned the test. Such,
sometimes, is the boasted accuracy of scientific medi-
cine.
As I test this typhoid urine, you will notice that
the color is not yellow, nor orange, but red. It must be
red, or there is no reaction. Now, here is tlie urine of
pneumonia and advanced tuberculosis. The color is
orange. In the first specimen, shaking produces a
pink foam ; in the second, no pink is to be seen. The
following rules are all important:
1. The urine must be fresh and filtered.
2. The urine must be acid.
3. The true color is red, and when the urine is shak-
en the foam should be slightly tinged witli pink.
4. The test solution C is to be freshly prepared
each day and accurately measured. A medicine
dropper and a marked test tube will insure this.
5. The sodium-nitrite solution must be accurately
made, and renewed at intervals of a week or ten days,
and be not stronger than 0.5 per cent.
6. The color band should be held against a white
background, the light falling upon it from behind tiie
oliserver. It must not be held against liie liglit.
7. The exact method of procedure must be conscien-
tiously carried out.
8. The test is to be made during the height of in-
fection.
Cases Tested. Tot.\u N<
Typhoid 64
Malarial fever 4
Tetanus 2
.'\cute miliary tuberculosis. . . 3
Joint tuberculosis 4
Pulmonary tuberculosis 16
Septicemia 4
Ulcerative endocarditis I
.Secondary syphilis 4
Krjsipelas -
Scarlatina 3
\le.isles 2
Carcinoma 4
Pneumonia 1 1
Rheumatism, chronic 10
acute 5
Diphtheria 3
Diarrhma 4
.Appendicitis 3
Albuminuria of pregnancy. . . 6
Chronic nephntis 19
Cystitis -
Urethritis, specific 7
DlAZO
Reaction.
Present.
Alxent.
61
3
0
4
0
2
0
3
0
4
2
14
3
I
0
I
0
4
0
2
0
3
0
2
1
2
I
10
0
10
0
5
0
3
0
4
0
3
0
6
0
19
0
2
0
7
(95^)
DiAZO Reaction.
Cases Tested. Total No. . •-;
Present. Absent,
Oxaluria and lithajmia 11 o II
Pleurisy 505
Pyamic abscess of lung i o I
Tuberculosis of prostate. ... 3 o 3
Necrosis of long bones 2 o 2
Rothein i o i
Syphilis, third stage 5 o 5
Alcoholic neuritis 3 o 3
Hysteria 6 o 6
Epilepsy 202
Leg ulcer, varicose 7 o 7
Fractures, long bones 5 o r
Fractures, skull 202
liurns, severe 2 o 2
(lunshot wounds, aseptic... 202
Morphine poisoning i o r
Sciatica 3 o 3
Cirrhosis, hepatic 2 o 2
.Simple enteritis 303
.Vngio-neurotic cedema 202
Endometritis 3 'o 3
Pericarditis i o i
Meningitis i o r
\'ulvitis and vaginitis, spe-
cific 2 o 2
Orchitis, gonorrhoea! i o i
Valvular heart disease 707
Quinsy and tonsillitis 3^3
Normal urines 30 o 30
Varicella i o I
Typhoid, relapse 3 3 o
Gastric ulcer 2 0 2
Acute bronchitis 3 o 3
Chronic constipation 7 o 7
Total cases 315
The urines of three hundred and fifteen cases, com-
prising over fifty diseases, have been tested. No one
of the three cases of supposed typhoid which failed to
show the reaction was, in other respects, a typical
case. In one the maximum temperature was only
100' F. ; in another the spleen was unaffected; and in
none of the three were there any rose spots. The re-
acition occured in only two of sixteen cases of pulmon-
ary tuberculosis, in one of which it was very faint. Both
were cases in wliich the element of sepsis predominat-
ed. Septica>mia, if profound, would seem to show it,
though, strangely enough, ulcerative endocarditis with
markedly septic temperature curve did not show it.
The single case of pneumonia in whicii it occurred
was an unusually rare and severe case of double pneu-
monia, witii involvement of both apices, seen in con-
sultation with Dr. H. P. Ritchie. Note that it did not
occur in our malarias, in appendicitis, nor in miliary
tuberculosis — a fact of the utmost importance i\\
differential diagnosis. It should be stated, however,
that these cases of malaria were of only moderate se-
verity, being the usual imported variety met with in
this region.
I shall also demonstrate to you the method proposed
by Widal ' to diagno.se typhoid, by adding to a pure
culture of Eberth's bacillus a drop of blood from a sup-
posed typhoid. The method is simple and has so far
proven to be reliable.
This patient is a convalescent, who, during his ill-
ness, presented a very typical group of symptoms. I
take two cover slips and a glass slide, place a large
drop of distilled water upon the slide, and stir in a
bit of the pure culture taken with liie usual precau-
tions ftom this tube. I now draw a drop of blood
from my patient, and, having sterilized my loop, take
up a little of the blood and stir into the mixture of
distilled water and typhoid bacilli, and drop on my
cover glass. I now go through the same process with
my own blood and a similar mixture placed upon an-
other slide. \\'e will leave them for a few minutes.
' Widal: La Presse Medicale. July 29, iSg6. iJieulafoy: Jour-
nal des Praticiens. July 11, 1S96. Ne\v York Medical Journal
.\ugust S. 1S96. Courmont, Achard, Widal, Hayem: La Se-
maine Medicale. July 29. 1S96. Medical Ne^vs, October 17, 1896.
November 14, 1896]
MEDICAL RECORD.
699
and you will see that the typhoid blood has seriously
interfered with the motility of the bacilli, which are
for the most part grouped and show but little move-
ment. The control slide will show the bacilli in rapid
motion and not grouped. \\'idal recommends that the
blood be allowed to clot and the serum used for the
test, but for rapid clinical work the blood itself is
more convenient and certainly proves satisfactory.
The colon bacillus is said to react in the same way,
and might, perhaps, be used if typhoid cultures were
not at hand.
The following tests were made at the City Hospital,
by Dr. H. P. Ritchie and myself, with the results as
here stated:
Case I.— W. J. M . Typhoid. Test of W'idal
made on twenty-fourth day after admission. Temper-
ature nearly normal. Reaction present.
Case 2. — J. N . Typhoid. Test on fortieth
day. Temperature normal. Reaction present.
Case 3. — F. D . Typhoid. Test on forty-sixth
day. Temperature normal. Reaction marked.
Case 4. — A. G . Typhoid. Test on sixteenth
day after admission. Reaction marked.
Case 5. — J. J . Typhoid (mild). Test on
twenty-fourth day. Reaction present.
Case 6. — R. Y . Typhoid. Test
eighth day. Reaction marked.
Case 7. — Mrs. C . Typhoid
day. Reaction marked.
Case 8.— M. P . Typhoid
twentieth day. Reaction present.
Case 9. — Lizzie . Typhoid.
day. Reaction present.
Case 10. — M. G . Typhoid.
eighth day. Reaction marked.
Case II. — L. F . Typhoid.
first day. Reaction marked.
Case 12. — D. D . Ulcerative endocarditis.
reaction.
Case 13. — Lama. Ulcerative endocarditis. No re-
action.
Case 14. — G. T —
action.
on twenty-
Test on thirtieth
(mild). Test on
Test on sixtieth
Test
thirtv-
Test on twenty-
No
No re-
Case 15. — Mrs.
H-
Broncho-pneumonia.
Pvloric stenosis. No re-
action.
Case 1 6
reaction.
Case 17. — Mrs. S —
No reaction.
Case 18. — Diphtheria.
Case ig. — Diphtheria.
Case 20.— E. W .
No reaction.
Case 21. — Phthisis.
Case 22. — Phthisis.
Case 23. — Phthisis.
Mrs. B . Lobar pneumonia. No
— . Septiccemia (abortion).
No reaction.
No reaction.
Gonorrhoeal bubo with fever.
No reaction.
No reaction.
No reaction.
Case 24. — Tuberculous pleurisy. No reaction.
Case 25.- — Erysipelas. No reaction.
This would indicate that the method has value,
though, of course, we must make many more tests be-
fore we can be entirely satisfied that the reaction is
constant, and further determine the question as to its
occurrence in other acute diseases. Widal states that
it may be present on the fifth day, and is quite con-
stant on the eighth or ninth.
I wish, in closing, to state what symptoms of ty-
phoid appear to me necessary to a diagnosis, and to
emphasize the importance of the two tests just de-
scribed. The important symptoms are :
(a) An insidious onset.
(i) Continued fever.
(c) An enlarged and palpable spleen.
((/) The occurrence of a well-marked diazo reaction.
(e^ Widal's test witii the typhoid blood, if this pre-
liminary report is verified by future work.
The occurrence of rose spots and the peculiar ochre
stool are, of course, important, though less constant.
.\bsence of leucocytosis is in favor of typhoid, and a
marked leucocytosis during the course of typhoid in-
dicates a complicating inflammation, such as pneumo-
nia. Malaria may usually be differentiated by the
finding of plasmodia in the blood of patients suffer-
ing from this disease.
The most important of these signs are the diazo re-
action and Widal's test. Our tables show that if
proper technique be observed, we have in the diazo re-
action not a pathognomonic sign, but
{a) A constant sign.
(6) A very early sign.
When any sign is found in ninety-five per cent, of
so large a number of cases as are here reported, it mav
certainly be called constant, and I, personally, believe
that all cases of severe typhoid will show it if the test
be made during the height of infection, i.e., tenth to
eighteenth day; and that when in a supposed typhoid
the reaction is lacking we have positive proof that we
are dealing with some other disease. The sign may
occur before the end of the first week, having been ob-
served upon the fourth day. The fact that it occurs
occasionally in other diseases has led most of those
who have reported upon the test to condemn it as val-
ueless. This position is certainly illogical and un-
tenable. We might as well deny the value of the
physical signs of consolidation of lung tissue or albu-
minuria as a symptom, because they are common to
many conditions; and the same argument applied to
the classical signs of typhoid would leave us no symp-
tomatology at all.
With regard to Widal's test, I can only say that if
the comparatively limited number of cases reported
can be taken as a fair indication, we have found some-
thing very nearly approaching the long-sought-for
pathognomonic sign.
Lacking space for any extended discussion of the
test at this time, I shall hope to report more fully at
a later date. I am under great obligations to Drs. E.
J. Batchelder, H. W. Knauft", and H. P. Ritchie, who
have materially assisted me in making these tests, and
venture to express the hope that this paper will serve
in some slight degree to bring about the wider recog-
nition and more general use, in this Northwest, of
these clinical tests, which have to me proven both in-
teresting and useful.
150 LowRY Arcade, October, 1896.
THE TREATMENT OF STRICTURE OF THE
MALE URETHRA.'
By R.\.M0N GUITERAS, M.D..
PROFESSOR OF ANATOMY AND OPERATIVE SLRGEBV, NEW YORK POST^iRADU-
ATE MEDICAL SCHOOL ; CONSLLTING SL RGEON, FRENCH HOSPIT,\L ; VISIT-
ING SURGEON, COLL'.MBUS HOSPITAL AND CITY HOSPITAL.
The object of this paper is not to give a treatise on
the treatment of stricture, with a review of the current
literature, but to describe the methods that I am in
the habit of pursuing in the cases which come under
my care, and to mention a few of the various other
methods now in vogue. The treatment of strictures
depends entirely upon the varieties presenting them-
selves.
These are classified by different authors in a num-
ber of ways, as, for example, organic, inflammatory,
spasmodic, traumatic, congenital, etc. It is my object
in this paper, however, to simplify as much as possi-
ble, and I will therefore speak of them only as organic
and functional.
By far the greatest number of strictures are organic,
and under this head I include congenital, which are
' Read before the .Medico-Surgical Society at September meet-
ing.
700
MEDICAL RECORD.
[November 14, 1896
narrowings of the canal, usually at or near the meatus;
traumatic, due generally to a blow on the perineum,
by which the bulbo-membranous urethra is caught be-
tween the impinging body and the lower border of the
subpubic ligament; and the so-called inflammatory
strictures, due to acute urethritis and inflammations
about organic strictures.
These vary in consistence, size, position, and re-
sistance.
In consistence they varv from an induration and
thickening of the mucous membrane, with connective-
tissue proliferation occurring in its depths, to the
formation of a dense mass of cicatricial tissue occupy-
ing the submucous region and extending into the
meshes of the corpus spongiosum.
In size, they are spoken of as being of large calibre
when they admit more than a 15 F. sound: of small
calibre when they admit a smaller size, and imperme-
able when nothing can pass through them.
As to position observers differ, many believing them
to be more frequent in the bulbo-membranous region.
My own e.xperience, however, leads me to think they
most frequently occur in the pendulous portion. In
the bulbo-membranous region, however, they are the
most serious. In fact, the gravity of a stricture is in
direct proportion to its distance from the meatus.
In resistance strictures of the urethra vary greatly,
some of the soft and recent ones being very amenable
to dilatation, while others are so hard or unyielding
that not much headway can be made without resorting
to the most radical measures. The most unyielding
of those in my experience have been the congenital,
the traumatic, and those of long standing.
Funtional strictures are simply spasmodic, and will
be considered later.
When a patient who has had frequent attacks of
^^rethritis presents himself to me, with symptoms of a
chronic urethral discharge (gleet), a feeling of pain or
heaviness in the perineum or back, frequent desire to
urinate, dribbling after urination, a stream twisted or
small, or a condition of hypochondriasis or depres-
sion, I at once suspect stricture and advise an exami-
nation of his urethra.
Examination for Stricture. — At this examination
I am in the habit of directing him to pass his urine
in two glasses, which is then examined for threads
and to observe the clearness of the two specimens,
cloudiness in the first specimen indicating urethral
discharge, in the second cystitis. I then direct him
to lie at full length on the table, \vith his shoulders
■elevated, and wash out his urethra with warm boiled
water. After this I insert the Otis bulbous sounds,
usually commencing with a i 5 F.
If this passes easily, 1 continue to increase the size,
■noticing the location of the strictures, if any be pres-
-ent. If the meatus is too small for a complete exami-
nation and the organ is a well developed one, it would
seem probable that the average calibre of the canal is
greater than that of the meatus, and therefore, to make
a thorough exploration, the meatus should be cut.
Meatotomy. — In performing this operation, it is
•my custom to use a blunt-pointed bistoury or a blunt-
pointed tenotomy knife, and to cut downward, en-
•deavoring to enlarge the opening until it can admit a
30 French sound, or even one of larger size. The
incision should be exactly in the median line toward
the fraenum. In this operation one must cut steadily
and avoid a quick, sharp cut, which might prove to be
too free, thus producing a condition of artificial
balanic hypospadias.
If the bleeding is slight, I at once make an exami-
nation of the anterior urethra, postponing that of the
deep urethra until the next visit. ']"he patient is
directed to wear a plug of oakum or absorbent cotton
ior the next three days, inserting a fresh one after
each act of micturition, and is requested to return
again at the expiration of that time. At the second
visit, an examination of the entire urethra is made, as
at the first visit in cases in which the meatus is of
ordinary size.
If strictures of moderate calibre are found, gradual
dilatation is attempted.
Gradual Dilatation.— For this purpose the best
method that we have appears to me to be by means
of the Oberlander dilator and sounds.
The Oberlander dilator affords the best-graded in-
strument of dilatation which we have at present. It
is constructed after the model of the curved Otis ure-
throtome. It is inserted with a rubber covering, and
is capable of dilating strictures both of the pendulous
and bulbo-jnembranous portions of the canal. The
dial at the handle end on the upper surface registers
the amount of dilatation, each point corresponding to
a millimetre. The dilatation is usually from one to
three millimetres at each visit. It is well to alternate
with sounds, the patient calling for treatment every
second day.
During a course of dilatation in these cases the
utmost care should be taken to have the bladder, the
urethra, and the instruments as clean as possible.
The instruments should be boiled in a soda solution
before being used, and should be lubricated with
borated glycerin before they are introduced.
The patient should be directed to take internally
the so-called urinary antiseptics while under treat-
ment, such as salol, boric acid, or oil of wintergreen,
to abstain from liquor, and to avoid exposure to cold
and wet. Tobacco is also bad, as it tends to produce
general irritability and hvperasthesia. Oil of euca-
lyptus in ten-minim doses is considered one of the
best urinary antiseptics. If there is a spasm or con-
gestion after the passage of sounds a hot sitz bath
should be taken then, or just before retiring.
The patient should always urinate immediately be-
fore each treatment, after which his urethra should be
washed out with boiled water. If moderate dilata-
tion has been accomplished in this way, or the stric-
tures are more than i8 F. and not much progress can
be made by dilatation, I am inclined to cut them if
they are situated anteriorly.
If they are deep, however, I should not recommend
an operation until symptoms of an annoying character
develop. In this latter class of cases, I should rec-
ommend the passing of sounds at intervals, to prevent
any further contraction. It quite frequently happens
that after cutting an anterior stricture the deep one
can be dilated. The operations for internal and ex-
ternal urethrotomy will be considered later. If the
introduction of sounds causes irritation, the French
rubber or silk bougie will often irritate less and ac-
complish more.
Bougies may be disinfected by soaking them in a
1-1,000 bichloride solution.
If the strictures are small, that is, less than 15 F.,
more care is necessary. Strictures of this size are
usually of some years' standing and are often very
unyielding. All strictures will, however, yield some-
what to dilatation if it is proix;rly performed. They
are, of course, too small for dilatation with the Ober-
lander, wiiich is ecjuivalent to a 19 F. sound, and
therefore must be treated with either sounds or bou-
gies. Of these the latter are preferable, as they are
much less liable to lacerate the tissues, and should
always l)e used if the strictures are smaller than 10 F.
By the passage of the bougies, the strictures can gen-
erally be stretched enough to admit a dilator or a
urethrotome, when further treatment may be carried
out as with strictures of a larger calibre.
In other cases strictures of this size are unyielding,
and operative procedures have to be resorted to, either
November 14, 1896]
MEDICAL RECORD.
70 r
an iiitenial urethrotomy, with a Maisonneuve, or an
external upon a Gouley tunnelled sound or catheter.
Instrumentation in irritable strictures, which usu-
ally occur in the nervous and hyperassthetic, some-
times give rise to pain and spasms, followed later
by chills and fever. The urethral fever in these cases
is often obviased by irrigating the urethra with a hot
bichloride solution before and after passing the
sounds, or before cutting, if urethrotomy should be
decided upon. This prevents the septic element
present from causing urethral fever. Eucalyptus
taken internally is a valuable agent in preventing
chills in these cases. A great deal of time is saved,
and suffering and distress are spared if an internal
urethrotomy is performed in such conditions.
Continuous Dilatation. — We now come to a class
of strictures nearly impermeable, in which all the skill
and ingenuity of a surgeon is brought into play, as
apparently nothing can be passed through them, and
yet by a little careful manipulation the passage of an
instrument may be effected. In these cases the ure-
thras are distorted by strictures, and often by pockets
and false passages as well. Here the smallest instru-
ments are brought into play, namely, the iiliform
bougies. If one of these can be passed into the blad-
der, it should be left there during the night, as thus a
certain amount of dilatation is accomplished by the
continuous action of the bougie and the flowing of the
urine beside it, and on the following day one or two
more can usually be slipped in beside it, or perhaps a
small French catheter may be introduced in its place.
In either case, whatever is passed on the next day,
whether it is one or two additional filiforms or a small
French catheter, should be allowed to remain in for
another twenty-four hours. By increasing the size of
the catheter or the number of filiforms daily for a few^
days, a sufficient dilatation will be accomplished to
allow the passage of small bougies and a continuation
of the treatment by gradual dilatation.
The passage of a filiform bougie through the urethra
is not always an easy thing. When it is found to be
difficult, if a little warm sweet oil is first injected
into the canal and held for a few minutes, the filiform
can usually be worked through. In case it cannot be,
it should be left in place and others slipped in beside
it. When half a dozen or more of these are in the
canal, they should be worked about gently for a few-
moments, when it will be found that one will slip by
into the bladder. This should be allowed to remain
in over night, as just referred to. If one cannot be
made to pass through the stricture in this way, but
engages, it should be allowed to remain in this posi-
tion for the night, as on the following day it may
possibly be worked into the bladder.
In other ca.ses, in which a filiform cannot be passed
and in which the stricture is considered impermeable,
but in which the patient is able to pass his urine, I
am in the habit of directing him to remain in bed for
a few days in the dorsal decubitus, arising only to
take hot sitz baths night and morning. During this
time I give him a preparation of the acetate of potas-
sium and sweet spirits of nitre three times a day. .\
few days of this treatment usually reduces the conges-
tion of the urethra sufficiently to allow a filiform to be
passed.
In all these cases of so-called impermeable stric-
tures and strictures of small calibre in which a filiform
can be passed through into the bladder, the pressure
of the retained bougie and the urine passing along its
sides will dilate it sufficiently to allow something
larger to be introduced at the next visit. If, however,
it seems advisable to operate at once, a Fluhrer's
modified Maisonneuve urethrotome can be passed over
it and the stricture cut if it is in the anterior urethra;
or a Gouley tunnelled sound can be passed over it
into the bladder upon which an external perineal ure-
throtomy can be performed if it is in the deep urethra.
I do not think that P'luhrer's modification of the
Maisonneuve is so good as the original instrument
which is attached to a guide. This guide is, how-
ever, the size of a No. 4 or No. 5 French bougie, and
is therefore a little larger than a filiform over which a
Fluhrer's modified instrument can be passed. A
Maisonneuve urethrotome cuts up to 20 F., which is
sufficient to allow gradual dilatation by sounds of a
considerable size, or a further cutting operation by
means of an Otis urethrotome, which cannot be intro-
duced into a canal smaller than 18 F.
I may here say that I do not believe in a Maison-
neuve urethrotome, as I think that it lacerates the tis-
sues, and I feel that it cannot be used safely, excepting
in connection with an external urethrotomy. Perhaps
an ideal case for this double operation is when there
are a number of very small resisting strictures along
both the anterior and deep urethra.
To reconsider what has just been said, we may as-
sume that all soft and yielding strictures, whether an-
terior or deep, large or small, should be dilated; re-
sisting strictures of large size in the pendulous portion;
should be cut, while similar ones of the deep urethra
should be kept open and observed carefully; resisting
strictures of small calibre of the pendulous urethra
should be cut by a Maisonneuve urethrotome, if very
small, or by an Otis urethrotome if they can be di-
lated sufficiently to admit it, or by both; while re-
sisting strictures of small calibre in the deep urethra
should be treated by an external perineal urethrotomy.
The so-called impermeable strictures should be opened
sufficiently for operation by instruments on a guide,,
if possible; if not, by perineal section.
Internal Urethrotomy In all anterior urethroto-
mies, my preparation of the patient is the same. He
is put on salol, ten grains, three times a day for three
days before the operation, to be continued until three-
days after. A cathartic is given on the evening pre-
ceding the operation, and the bowel is washed out just
before the patient is brought to the operating-room.
When he is upon the table his urine is drawn by catheter
and his bladder is washed out with a saturated solu-
tion of boric acid, about six ounces of which is
allowed to remain in the bladder. A syringeful of a
four-per-cent. cocaine solution is then injected into-
the urethra from a hand syringe holding about three
drachms, and is held there for fi\e minutes to allow
perfect anaesthesia of the urethra to be produced. The
choice of instruments now takes place. The two in-
struments of to-day are the Otis and the Maisonneuve
urethrotomes. The numerous others which have been,
invented are now in disuse. As we have observed,,
the Maisonneuve is the smaller of the two, and is there-
fore used in the cases in which the Otis cannot be made
to enter.
Operation by the Maisonneuve Urethrotome. — A
Maisonneuve urethrotome is shaped like an ordinary
small sound, with a groove running along the entire
length of its concave aspect. In this groove a small
wire shaft with a triangular blade on its end is in-
serted, which can be slid at will backward and for-
ward in the groove. The instrument, which is of the
size of an 8 or 9 F., is attached by a screw to a guide
of the size of a 4 or 5 F. bougie.
The guide is pushed gently into the bladder, fol-
lowed by the staff' which is attached to it until its end
has reached the prostatic urethra. The penis is then
held steadily in the median line slightly on the
stretch, while the urethrotome is carefully and firmly
held in the urethra in such a way that the groove on
the upper surface of the urethrotome corresponds ex-
actly to the space between the two corpora cavernosa.
Everything being in readiness, the blade is introduced
702
MEDICAL RECORD.
[November 14, 1896
into the groove and is then pushed down through the
strictures. The blade of the Maisonneuve is triangular,
with a guard on the apex of the triangle, and a cutting
edge in front and behind. The object of this guard
on the ape-x of the cutting blade is to prevent the nor-
mal tissues along the canal from being cut, :..i it glides
along the upper wall of the urethra and only stops
when it comes in contact with the stricture through
which the knife passes, when the guard again slides
along the smooth urethra until anotlier stricture is en-
countered. It is my oi)inion that the Maisonneuve is
not a good cutting instrument, as it is difficult to keep
sharp and the guard hinders the progress of the blade.
It has frequently happened in my cx]Derience with this
instrument that the force used in pusiiing the blade of
the instrument has been sufficient to push the organ
out of my grasp instead of sending the blade through
the stricture. It is thus easy to see that the force
used would be sufficient to lacerate and contuse the
mucous membrane and soft tissues about a tough
stricture. When there are one or two small strictures
of the pendulous jsortion to be cut the Maisonneuve is
of undoubted service, but when the strictures are in
the bulbo-membranous region it is safer to associate
this operation with an external urethrotomy. In cases
of anterior strictures, after cutting them with the
Maisonneuve, I frequently insert an Otis and cut to a
larger size.
In almost every case anterior strictures can be
dilated with patience and care to a size sufficient to
allow the |)assage of the Otis luethrotome.
Operation by the Electrolyzer — Professor Fort,
of Paris, has recently devised a means of performing
urethrotomy by an instrument known as the electro-
lyzer. This instrument is about the size of the Mai-
sonneuve urethrotome and very similar to it in shape.
It has a guide of about the same size as that of the
Maisonneuve, and the staff to which it is attached also
corresponds in shape and size. The blade of the
electrolyzer corresponds to that of the Maisonneuve in
shape, but it differs in material, as it is made of plati-
num instead of steel; and in edge, as it is dull on all
sides, while that of the Maisonneuve is dull at the apex
where the guard is situated and is sharp in front and
behind. An electrolyzer, in fact, resembles in outline
a Maisonneuve with the guide and staff joined and the
blade pushed well down into its concavity. The
blade of the electrolyzer is connected through the
shaft and handle end of the instrument with the nega-
tive pole of a galvanic battery, while the positive pole
is connected with an electrode, covered with chamois,
which is placed over the pubis or on the adjoining
thigh.
The guide is then pushed in until the platinum
blade comes in contact with the stricture, against
which it is gently pressed. The current then being
turned on, the dull lilade glides easily through the stric-
ture, dissolving a furrow through it in the median line.
The current is then discontinued and tlic instrument
is withdrawn or pushed in until the next stricture is
encountered, when the same process is again adopted.
In this way, without using any force, the platinum
blade gently slides through all the strictures present
into the bladder. During the entire operation the
blade remains jierfectly cold, and very little pain is
experienced, even if no cocaine is used. The strength
of the current necessary successfully to oix-rate on
these strictures is from ten to twenty milliamperes,
and the time required to go through a stricture is usu-
ally from thirlv seconds to four minutes. The lumen
of the strictured portion of the urethra is thus brought
to the size of an 18 F. sound. Afterward the stricture
can be still further enlarged by sounds or by a ure-
throtomy with the Otis urethrotome if the stricture is
an anterior one.
This operation has been performed several times in
this country by Dr. Fort and also by Dr. Chassaignac,
of New Orleans. It has several advantages over the
Maisonneuve, namely, it does not bruise and lacerate
the tissues .so much ; it is less painful at the time and
on urination afterward; there is almost no hemor-
rhage, and consequently very little danger of infec-
tion, as the blood-vessels in the urethra are not left
open.
Operation by the Otis Urethrotome An Otis ure-
throtome consists of a shaft made of two pieces of
steel, with a groove along its upper surface; a wire
shaft with a small cutting blade on its end, which is
pushed along the groove until the blade disappears
from sight near the end of the shaft of the urethrotome;
and a dial on the upper surface near the handle, on
which the amount of dilatatipn is registered. The
dilatation is accomplished in this way: A small wheel
at the end of the handle is turned. This turning sep-
arates the two pieces of the shaft, thus dilating the
urethra to a size corresponding to the circumference
of the opened halves of the shaft, the amount of which
dilatation is registered in millimetres on the dial of
the instrument. There are two forms of the Otis
urethrotome, the straight and the curved. The
straight is of service only in cases of anterior stric-
tures, while the cur\'ed one could be used in cases of
deep strictures in the same way as the Maisonneuve,
although I do not consider it safe unless combined
with an external urethrotomy.
The steps of the operation are as follows: The point
of the urethrotome is jnished about an inch beyond
the stricture, when the screw at the handle end is
turned until the degree determined upon as that
of the average size of the urethra has been regis-
tered upon the dial of the instrument, when the
knife is pulled up through the stricture and then
pushed back again into place. The other stric-
tures are then approached in the same way and
.severed. The canal is then tested with the sounds,
to see if it admits with ease the size required. I
do not believe in inserting the urethrotome into the
penis at right angles to the body as far as it will go,
then screwing it up to the highest point possible and
pulling out the blade along its entire length, as I have
frequently seen done by surgeons of good standing.
Otis determines the size of the urethra in two way.s,
first by his urethrometer, and second by measuring the
circumference of the penis. His rule of comparison
is as follows:
Circumference of penis 3 inclies, urethra ^o millimetres.
•• •• 3'4 '• •■ 3=
" " 3,'i' ■■ " 34
.. .. 33_/ .. ., 36
4X
</
38
40
As each degree upon the dial of his urethrotome
corresponds to one millimetre, it is easy to see how
exactly he can make the size of his urethrotome corre-
spond to that up to which he has determined to cut.
These figures of Otis are the result of careful study
and long observation, and yet I am afraid to be gov-
erned by them, although I do not doubt their accuracy.
The reason why I consider the.se figures difficult to
be accepted as a standard are: ist. Because in turn-
ing the screw of the urethrometer it is very difficult to
tell when we have arrived at the exact size of the
urethra or when we have it on the stretch. 2. Because
the circumference of the organ varies so much when
flaccid. 'I'his depends on the amount of blood in the
organ at the time and is influenced by the temperature
of the room, the feeling of fear or nervousness, and
many other causes.
In my own practice when a patient's urethra will
November 14, 1896]
MEDICAL RECORD.
703
admit a 32 F. with ease, it appears to me tliat lie has
a sufficiently good canal for all practical purposes,
and cases of stricture of very large calibre seldom
present themselves.
After-Treatment in Cases of Internal Urethrot-
omy In several cases that have come under my
observation severe rigors and a rise of temperature to
103° or 104° F. have followed. These elevations of
temperature usually began after the first urination.
They are not nearly .so frequent now, however, as thev
were formerly, and this improvement I attribute to
my present system of urethral antisepsis already al-
luded to, namely, the administration of salol for some
days before the operation and the injecting the blad-
der with a saturated solution of boric acid just before
the urethrotomy, as the urine mi.xed with the boric-
acid solution and influenced by the salol is much less
irritating and more antiseptic.
After the operation sounds should be passed on the
second day if there is no fever, but if fever is present
this treatment should be postponed until it has sub-
sided. I am in the habit of passing sounds every day
for the first week, every other da)- for the second week,
and every third day for the third week.
The patient should remain in bed for two days, or
longer if necessary. The results of the operation in
this country are very favorable and personally I have
never had a fatal case. Other observers, however,
claim a mortality of two per cent.; while in England
and on the continent as high as four per cent, is
claimed.
Hemorrhage sometimes occurs after the operation,
causing a great deal of alarm. It can be controlled
by simply bandaging the penis. If it is very severe,
a catheter may be introduced and pressure made by
bandaging the organ, thus pressing the cut urethra
against the catheter.
Fever, if it does occur, is benefited by quinine, grs.
X., or Dover's powder, grs. x.
Gleets accompanying stricture usually disappear
after a urethrotomy, as the source of irritation has
been removed.
External Perineal Urethrotomy This operation
is usually performed for strictures of the bulbo-mem-
branous region which require operative interference.
An internal urethrotomy with a Maisonneuve could be
performed in these cases, but the drainage would not
be so good and tiiere would be more danger of infec-
tion. A perineal section might also be performed.
The only real dift'erence between a perineal urethrot-
omy and a perineal section, as they are understood
to-day, is that the former is performed with the aid of
a guide, and the latter without. You will frequently
hear a surgeon say he is going to do a perineal sec-
tion, but if you see the operation you will find that it
is really an external urethrotomy, and not a Cock's
operation.
The usual indication for an external urethrotomy is
the existence in the deep urethra of a stricture of
small calibre not amenable to dilatation. White, of
Philadelphia, has enumerated these conditions very
carefully, in Morrow's "System of Genito-Urinary
Diseases," the following varieties of which I may here
mention briefly: Tough, fibrous strictures which will
not permit of dilatation; resilient strictures, which
rapidly recontract after dilatation; hard, narrow stric-
tures, associated with perineal indurations; strictures
complicated with fistulas, in which dilatation has failed ;
traumatic strictures, which are almost always dense;
strictures with extravasation of urine behind them;
strictures complicated by perineal abscesses; strictures
associated with intense cystitis; strictures in which
retention of urine is present.
The preparation of a patient for external urethrot-
omy is practically the same as for an internal. Have
the patient on salol, ten grains, three times a day for
two days before the operation, and ha^•e the bowel
well emptied before he is brought upon the operating-
table. When he is upon the table, if the stricture is
permeable, his urine should be drawn, and he should
have eight ounces of boric acid left in his bladder.
If it is not permeable to an instrument and he can
urinate, he should be directed not to pass his urine
for five hours before the operation, as it is much easier
to perform a perineal urethrotomy when the bladder is
full than when it is empty. Always pass the guide
before placing the patient in a position for operation.
The two best positions are the lithotomy and the Ede-
bohls'. I generally use the latter, and find it perfectly
satisfactory. Instruct the assistants carefully how to
hold the thighs and be sure that they attend to the
support of the limbs and not to other matters. Direct
the assistant holding the guide to stand on the left of
the patient near his waist, that he may control it in
the median line in a steady manner. Do not have the
buttocks and thighs so covered with towels that you
cannot see whether the patient is in an even position
or not, as it is most important to have him held
squarely in an even position.
The Various Operations — There are a number of
methods of performing perineal urethrotomy which I
will review hurriedly.
Boutonniere, that is, the simple opening of the
urethra behind the stricture as a palliative measure,
or for bladder drainage. It consists merely in pass-
ing a guide through the urethra into the bladder and
cutting down on it through the perineum, after which,
if for bladder drainage, a tube is introduced into the
bladder by way of the perineal incision.
Syme's Operation. —In this method a staff can be
pushed through the stricture upon which it can be cut.
This staff is called a Syme's staff. It resembles in
shape an ordinary sound with a generous curve, but
with the peculiarity that the lowest third is much
smaller than the remainder of the instrument. It has
a groove running along the convex surface of the
smaller part of the statT up on to the larger part. The
junction of the smaller and larger parts form a shoul-
der, and it is this shoulder which comes up against
the distal side of the stricture after the smaller part
lias passed through.
Steps: The patient is placed in the lithotomy
position and the staff' is introduced. An incision is
then made in the median line of the perineum down
on to the shoulder of the Syme's staff. The point of
the knife enters into the groove above the shoulder
and cuts down through the stricture in the groove
toward the neck of the bladder. A director or Teale's
gorget is then introduced along the staff' into the blad-
der, after which the staff can be withdrawn. A cathe-
ter is passed into the bladder through the penis along
the director. If the bladder is too irritable to retain
the catheter, a tube should be passed into the bladder
through the perineum and held by tapes.
Gouley's Operation. — In this method a Gouley's
tunnelled sound or catheter is used. The Gouley
tunnelled sound is an instrument shaped like any
other sound, the latter half of it being grooved on its
convex surface. At the end of the sound is a bridge
about one-fourth of an inch long, extending over the
concavity, thus making it round in circumference, with
a passage for the transmission of the filiform bougie.
It is thus easy to see how the tunnel or canal of the
instrument can be slipped over the filiform and the
instrument can then follow it down to the stric-
ture.
A Gouley catheter is built with the same curve as
the round, with the difference that the concave side
has a canal running along its entire extent, through
which the fluid may escape from the bladder The
704
MEDICAL RECORD.
[November 14, 1896
handle end of the instrument is not solid, and there-
fore not so easy to steady as that of the sound.
The urethra is filled with olive oil, and a probe-
pointed whalebone bougie is passed through the ob-
struction into the bladder. Gouley's grooved metallic
catheter staff is then passed over the whalebone bou-
gie until its point comes in contact with the stricture,
when the patient is brought into the lithotomy posi-
tion and the guide held in position by an assistant.
The surgeon then makes an incision through the me-
dian line of the perineum and brings the urethra into
view, which he incises upon the bridge of the catheter
and a short distance along its groove. Sutures are
then passed through each side of the incised urethra
close to the stricture, which are held apart by assist-
ants. The catheter is then withdrawn sufficiently to
bring the filiform into view. The beaked bistoury is
then introduced beside the filiform, and an incision is
made well through the stricture, after which the guide
is pushed through into the bladder, when the operation
is complete.
Wheelhouse's Operation. — Lithotomy position.
The Wheelhouse staff is then passed up the urethra
with the groove away from the pubes until its end
touches the stricture. A Wheelhouse staff is like a
straight sound with a groove on one side, the other
side being intact as far as the end, where it turns up
in a little knob called a button.
.Steps: This is held in position by an assistant
while the surgeon makes an incision down on to
the groove of the staff. The urethra being opened,
its edges are grasped on either side by straight-
bladed nibbed forceps and held apart. The staff
is then drawn up and turned so that the button
end catches the upper part of the uretiiral inci-
sion. The incision into the urethra is then held
open from three different points, and the operator
passes a grooved director through the stricture into
the bladder. The director is then turned so that the
groove is toward the surface of the perineum, and the
stricture is divided along it to its full e.xtent. .\
blunt-pointed bistoury is then run along the groove to
complete the division of the tissues. After this a
Teale's gorget is passed along the director into the
bladder and a catheter is introduced through the ure-
thra into the bladder, where it is fastened for drainage
for a number of days.
Cock's Operation. — This consists in opening the
urethra behind the obstruction at the apex of the pros-
tate without the aid of a guide. It is spoken of as
perineal section or external urethrotomy without a
guide.
Steps: Lithotomy position. The operator's left fore-
finger is inserted into the rectum and its tip pressed
against the ape.x of the prostate. The knife, having a
double-edged i)lade, is then thrust into the perineum
in the median line of the perineum and carried toward
the tip of the forefinger at the ape.x of the prostate
until it is felt to be close to it. The incision is at
times made somewhat obliquely to be sure of cutting
through the urethra. It is important that the knife
should not at any time be withdrawn from the wound
until the posterior urethra has been opened. The
probe-pointed director is then passed through the in-
cision into the bladder, and along this a perineal
drainage tube, which is Jield in place by means of two
tapes.
Observations on the Various External Urethrot-
omies.— It appears to me, after reviewing the various
methods of performing e.vternal urethrotomy which I
have just described, that each method has been formu-
lated to fit some particular new instrument which the
surgeon has designed. I consider the Gouley tun-
nelled sound or catheter by far the most ingenious
and practical instrument which has been devised for
operative work in the deep urethra. Compared with
the Syme's staff", a Gouley tunnelled sound No. 8 is
smaller than any portion of it and far more practical.
It is very convenient to know that a particular stric-
ture of the deep urethra has the shoulder of the staff"
engaged in it; but if we have e.\amined the urethra
carefully, we know exactly where the stricture is, and
it is as easy to cut through it in the groove of a Gou-
ley as in that of a Syme. Again, suppose that there
are one or two small anterior strictures present. In
such a case, unless an anterior urethrotomy were first
performed, the shoulder of the Syme's staff would stick
in one of the anterior strictures, far away from the seat
of operation.
Again, comparing the Gouley tunnelled catheter
with the Wheelhouse staff.: In the Wheelhouse opera-
tion the staff is passed down to the stricture. This
could be done as well with the Gouley. An incision
is made into the groove of the staff through the urethra
and its edges are seized with straight-bladed nibbed
forceps and held apart while the staff' is turned and the
button end is caught in the upper part of the incision.
It appears to me that it is much easier to cut down
into the groove of the Gouley sound, pass retraction
sutures, and then turn the beak of the sound out through
the perineal opening; while regarding the other steps
of the operation, passing a grooved director through
the stricture and cutting upon it, with the Gouley
method there would already be a guide present in the
filiform, along wiiich the incision could be made; or
if a grooved director could be in.serted through the
stricture, the Gouley sound could be pressed through,
as they are of about the same size, the No. 8 Gouley
being smaller than the average director, in which case
the incision of the stricture could be made in the
groove of the Gouley instrument. Another point
which I should like to criticise is the method of pre-
paring for drainage in the Syme and Wheelhouse ope-
rations, which is by a catheter through the urethra, as
it appears to me that the u.se of the perineal tube is
the preferable one.
Author's Method of Operating on the Urethra
through the Perineum After the comparative study
of the various methods of performing external perineal
urethrotomy, I should like to outline the one which I
am in the habit of teaching. I find that most men
who are practising medicine do not know the difl'er-
ence between the methods here described, and ha-.e
not the various instruments which characterize them.
It is necessary, therefore, to recommend one instru-
ment, if possible, as the most important one, and to
show how it can be best used in all cases. The in-
strument that I recommend is the Gouley tunnelled
sound. The only advantage that the catheter has is
that the stylet can be withdrawn and one can tell
whether or not he is in the bladder by the appearance
of urine. The Gouley sound, on the other hand, is
stronger, has a handle more like an ordinary sound,
and can be held more steadily and firmly in place,
and is therefore preferable.
In most cases of stricture of small calibre in the
deep urethra not amenable to dilatation, the small
sizes of the Gouley sound can be passed. The patient
then having been prepared as already described, an-
esthetized, and the Gouley tunnelled sound passed,
he is brought into the lithotomy or Edebohls' position.
There should be four assistants, if possible, one at
each corner of the table to support the legs, another
standing at the waist of the patient to steady the
sound, and another to pass instruments and sponge.
If the instrument has passed through the stricture into
the bladder, it is only necessary to cut down into the
groove on the convex part of the instrument. The in-
cision should be made exactly in the median line of
the perineum from the base of the scrotum to within
November 14, 1896]
MEDICAL RECORD.
705
half an inch of the anus; as the tissues retract and
the superficial perineal fascia is cut through, the
sound with its groove can be easily felt. Care must
be now taken not to wound the bulb of the urethra, as
its bleeding obscures the field of operation. This can
be caught by a tenaculum and held up by an assistant.
The point of the knife can now be pushed gently into
the groove and a small incision made, after which it
can follow the groove down into the prostatic urethra,
the sound being taken by the operator and pushed
along with it. The knife should then be withdrawn
and the grooved director pushed along the sound into
the bladder. The gush of urine along the director
shows that its end is in the bladder. The forefinger
should then be inti'oduced along the director, when
the characteristic feel of the neck of the bladder will
be noted. If the opening is not large enough to ad-
mit the end of the finger, a scalpel should be run
along the groove of the director, first above and then
below, enlarging the opening sufficiently to admit the
finger. The gorget should be introduced along the
director, and a large rubber velvet-eyed catheter, with
thick walls, from 17 to 19 English, should be inserted
into the bladder along the hollow of the gorget. The
gorget should then in turn be withdrawn and the
drainage tube shoidd be drawn down to the lowest
point at which it will drain the bladder, and should
be pinned by an ordinary safety pin to the skin of the
perineum. A little iodoform gauze should be packed
into the wound around the drainage tube, and the
tube should be connected by a glass coupling with a
larger rubber tube which passes down into the bottom
of a wide-mouthed jar, about one-quarter full of car-
bolic-acid solution, on the floor by the bedside. In
this way, siphon drainage is established.
If the Gouley sound cannot be introduced alone
into the bladder, but a filiform may be made to enter,
in almost every case the tunnelled sound can be forced
along it into the bladder. I do not believe in forcing
a sound ordinarily, but when it is my intention to cut
into the area that has been forced and drain it almost
immediately afterward, I do not think that a slight
laceration will do any harm, and we are sure the sound
has been forced in the right direction, as it has been
pushed over a guide. When, however, the sound can-
not be pushed over the guide without exerting a great
deal of force, if the filiform is left in the uiethra and
continuous dilatation is resorted to for a fev,- days, the
Gouley sound can generally be made to pass. In
either of the cases, the sound having been passed into
the bladder, it can be cut down upon through the peri-
neum in the manner just described. In case, how-
ever, that the tunnelled sound cannot be made to
follow the guide into the bladder, the operation can
be performed by passing it down to the distal end of
the stricture, opening the urethra anterior to it through
the perineum along the groove in the sound and then
cutting through the stricture along tlie filiform with a
beaked bistoury, as already described under the head
of the Gouley operation.
If a filiform cannot be passed through the stricture,
the tunnelled sound should be passed down to the dis-
tal end and an incision made down into its groove
through the perineum. Traction sutures should then be
passed through the walls of the urethra on either side
and the beak of the sound should be turned and brought
out tlirough the opening in the perineum and held in
the median line, thus keeping the urethra open from
three points. A small silver grooved director should
then be inserted into the stricture, which, if it passes,
can be cut down on to. If this small director cannot
be made to pass, a filiform may be tried. If nothing
can be made to pass through, insert the left forefinger
into the rectum, with its tip against the apex of the
prostate, and inake an incision toward it from the dis-
tal end of the stricture. If the point of the knife is
inserted into the stricture from the opening just an-
terior, and a sharp, quick cut downward and outward
made, it will often sever the stricture so that the sound
may be slipped through. If it does not, however, the
incision should be made steadily toward the ape.x of
the prostate, .\fter cutting a little way the prostatic
lu-ethra will be entered, and a little urine will be seen
escaping. Pass a director up along this stream, and
it will be found to enter the bladder. The opening
can be enlarged in the manner already referred to, and
the operation finished as in other cases of perineal
operation. This last operation is really a perineal
section. In these cases the e.xact position of the ure-
thra must be known, and it is important to remember
that the membranous urethra passes one inch below
the symphysis and three-fourths of an inch above the
perineal centre.
In all operations on the perineum, hot water is of
the greatest value to stop the general oozing, and
should be freely used. Unless the bulb or perineal
arteries are cut into, there will not be much real hem-
orrhage. It is thus easy to see that it is not necessary
to have many special instruments to do operative work
on the deep urethra. A few filiforms and a Gouley
sound are absolutely necessary, while a Teale's gorget,
a Gouley's beaked bistoury, and a fine silver grooved
director are lu.xuries which are much appreciated.
Perineal operations are at times very difficult. I
ha\e often spent an hour over a difficult case, and
have at times been obliged to begin an operation on
one day and finish it on the ne.xt. In cases in which
considerable hacking has been done without opening
the strictured urethra, and in which there is quite a pro-
fuse hemorrhage, I think that it is justifiable to open
the bladder suprapubically and to pass an instrument
through to the proximal end of the stricture, since with
guides against both its distal and proximal ends it
will be an easy matter to cut through it.
These perineal operations, although at times very
difficult, are usually not dangerous, and the only fatal
cases that I have ever seen were those in which there
had been quite an extensive urinary infiltration exist-
ing for a few days and gangrene had already set in.
Bryant estimates the mortality in external urethrotomy
at five per cent.
After-Treatment. — The salol, ten grains, three
times a day, should be continued for three days after
the operation, and the patient should be kept upon a
milk diet. The dressings should be changed on the
following day and on every succeeding day. The
bladder should be washed out twdce a day with a boric-
acid solution. Forty-eight hours after the operation
the tube may be withdrawn, and the bladder, wound,
and tube all thoroughly cleansed with the boric-acid
solution, after which sounds should be passed through
the urethra into the bladder. The tube is then re-
inserted and allowed to remain in place for two days
more, when it is again withdrawn and sounds are
passed as before. The perineal tube should be left
in for from four to fourteen days (generally six).
After the perineal tube has been discontinued, sounds
should be passed every second day for three weeks,
but if the deep urethra is much distorted a catheter
may be passed through the penile urethra into the
bladder and allowed to remain in for a few days
longer.
If hemorrhage takes place after the operation, it can
usually be controlled by packing gauze into the open-
ing about the catheter. If this does not succeed,
attach a piece of gauze to the tube in the manner
known as a catheterc en chemise, and then pack the
gauze with cotton within it into the wound.
The patient should remain in bed for two weeks
after the operation, and after the tube is withdrawn
7o6
MEDICAL RECORD.
[November 14, 1890
should always urinate with ills legs pressed tightly to-
gether until the perineal wound has healed.
Functional Strictures (Spasmodic). — These are due
to spasmodic contractions of the striped or unstriped
muscular fibres. They are generally situated in the
membranous urethra, as spasmodic contractions of the
compressor urethree muscle, in which case they closely
resemble deep organic strictures. They are due to
retie.x and psychical causes, the former of which are
by far the most frequent and important. The refle.x
causes are generally situated along the genito-urinary
tract, and are usually anterior strictures, contracted
meatus, localized areas of urethral inflammation, vesi-
cal calculus, retention of urine, excessive coitus, etc.;
but they are sometimes situated about the lower end
of the bowel, as in cases of hemorrhoids, fissures, and
the like. Spasmodic strictures are sometimes so se-
vere as to cause retention of urine.
The treatment in all these cases consists in deter-
mining what the source of the irritation is and treat-
ing it by some radical means.
It is quite common to find a urethra with anterior
strictures of moderately large calibre and a deep one
through which a very small bougie can be passed with
difficulty, in which an external urethrotomy is con-
templated, and in which after a division of the an-
terior strictures a sound of large size can be passed
through the deep one.
Remarks. — On all occasions when the urethra is
under treatment for stricture, whether by methods of
dilatation or cutting, urinary antiseptics should be
given until the treatment is at an end.
If the meatus is much smaller than the rest of the
canal, meatotomy should always be performed at the
start.
Dilatation is always to be preferred to cutting ope-
rations, if the strictures will yield to this measure.
In continuous dilatation in very small strictures we
have a method which produces the most satisfactory
results if used with patience and care, and it should
always be tried in the beginning either to enlarge the
urethra sufficiently for gradual dilatation or for the
introduction of a good-sized guide if an operation is
contemplated.
In performing gradual dilatation, an Oberlander
dilator is the best instrument that we have, and I do
not think that its use is sufficiently appreciated in this
country.
The surgeon should never promise to cure a stric-
ture by dilatation, as there is always a possibility of
his failing, in which case a urethrotomy must be re-
sorted to.
In cases in which a filiform has been passed through
the urethra with difficulty, it is not advisable to pass
a tunnelled sound over it unless it is to be followed
by an operation, as the tissues are liable to be lace-
rated by such a procedure.
When an operation must be performed on an ante-
rior urethra, if the stricture is very small a urethrotomy
with a Maisonneuve urethrotome is usually advocated.
This is a method that I am not particularly in favor
of, for reasons already mentioned, and I believe that
an operation by means of a Fort's electrolyzer in such
cases will be found much safer and less harmful. It
is argued that the formation of cicatricial tissue fol-
lows an operation by this instrument, but, as cicatricial
tissue is present in the stricture before the operation,
I do not see that the argument has any force. At any
rate, the object will have been accomplished, that is,
the urethra at the strictured portion will have been
made to admit an 18 F. sound, whereas before the
operation it could perhaps have admitted onlv a 4 or
If the anterior stricture is larger than an iS F. in
size, I should recommend the Otis urethrotome as a
safe and useful cutting instrument, as the results of
an internal urethrotomy by this means are usually very-
gratifying.
In operating by the perineum, a Cock's operation
should be avoided, if possible. Regarding the vari-
ous perineal urethrotomies that have been alluded to,
I do not think that any one of the methods by the
different instruments described will be found useful
in all cases, and I believe that the general advice
given by me in this arti le will be of great value, that
is, of using the tunnelled sound or catheter as a guide.
The other instruments are useful, and in the hands of
a specialist may be employed in various cases, but for
the general surgeon who is called upon to perform an
operation of this nature the tunnelled sound and a few
filiforms will be of the gf^eatest value.
I do not believe that in the very small strictures of
long standing in which a dense mass of cicatricial tis-
sue is present anyone operation will cure the case, and
think that in such cases after an operation the urethra
should be kept under constant observation for the re-
mainder of the patient's life, to prevent a recurrence
of the gradual chain of bladder and kidney complica-
tions which are apt to follow. One of the most im-
portant pieces of advice that I can give is never to
perform a perineal section without a guide unless
absolutely forced to do so; and when a guide is em-
ployed, the larger the better. It ajipears to me that
the surgeons of to-day are too anxious to cut. There
seems to be a certain fascination about doing a sec-
tion. But we should not be governed by this, but
should at all times perform the quickest, surest, and
best operation for the patient, whether in a hospital or
in private practice.
23 Wks'i Fiftv-Third Street.
THK HIGHER AIMS OF DERMATOLOGY.'
B\ A. K. KOBIN.SON, .M.D.,
NEW YORK.
Gentlemen : My first duty after welcoming you to
this meeting is a sad one. Since our last meeting
this association has suffered the loss of one of the old-
est, ablest, worthiest, most active, genial, and cour-
teous of its members; ^ and, judging from report and
conversation, each one of us, I am certain, regards and
feels our general loss as a distinctly personal one
also. To some of you he was an old and well-known
and well-pro\en friend; to all of us he was an honored
and admired colleague, whose absence from our meet-
ings will be sadly felt. As your president I have
asked one of his closest friends, Dr. Duhring, kindly
to prepare such an obituary notice as could form
a part of our proceedings and be incorporated in the
printed transactions. It is for the association to de-
cide what further action shall be taken concerning our
late friend and colleague. Dr. Wigglesworth. Let us
hope many meetings will be held before another such
a loss occurs in our ranks.
Gentlemen, the honor you have conferred upon me,
by electing me to the presidency of the American Der-
matological Association, is, I assure you, fully ap-
preciated by me; and it was my intention to give
a token of that appreciation by carefully preparing,
according to my ability, an address suitable for this
occasion and worthy of your attention. With that
object in view, I read, several weeks ago, all the ad-
dresses given before this association since its founda-
tion, but found the ground had been so well covered
by my predecessors that no untrodden, unworked area,
' President's address delivered at the annual meeting of the
.\merican Dermatological Association, held at Hot Springs. \'a.,
September 8. g, lo. i3g6.
- Dr. Edward Wigglesworth.
November 14, 1S96]
MEDICAL RECORD.
/"-"/
iiuiting or requiring consideration, arose before my
mental vision.
After furtlier consideration, and especially after
thinking over the brilliant address of our late la-
mented member, the idea was formed that to continue
the historical description up to date of the struggle
of dermatology for due recognition in America, as
given by Dr. \\'iggles worth: to describe its present po-
sition among the other branches of the medical tree ;
and also, peering into the future, to consider the lines
of study and action most suitable for a proper increase
and extension of our influence in territory rightfully
belonging to us — territory we have not only discovered
but in which we are the active workers, and have set-
tled and cultivated almost everything that has been
settled and cultivated — would be acceptable to you.
I hope to make it clear, not to my colleagues, for you
all know it already, but to the rest of the medical pro-
fession, that this territory is of much significance to
the human race; that cutaneous diseases are much
more numerous, complicated, and serious than is gen-
erally belie\ed; that not a few of them are not alone
annoying or humiliating, but dangerous to the life of
the subjects of them; and that only those who are
able to diagnose and understand their nature and
course, as far as our present knowledge permits, should
undertake their treatment.
At the present time dermatology as a specialty does
not, in my opinion, hold the position it should in the
eyes of the general profession, considering the magni-
tude of the subject and the importance of a knowledge
of cutaneous diseases. There are reasons for this con-
dition of sentiment, and I hold it possible for derma-
tologists to bring about a great change in this matter.
One reason is the " dark-age" position of the medical
schools toward the subject of diseases of the skin, as
well as toward other important subjects — as diseases
of the eye, etc. Almost every medical school ' acts on
the absurd plan that internal medicine, obstetrics, and
general surgery are the only subjects, from a clinical
standpoint, worthy of serious consideration and study,
and necessary for a student to know something about
in order to obtain a diploma entitling the recipient
to practise medicine and surgery in all its branches
and certifying to his ability to do the same. It is
necessary (sometimes) for graduation that the can-
didate should know the names and mutual relations
of the deep muscles of the back; that he should be
able to give the surgical anatomy of the parts con-
cerned in the operation of oesophogotomy, and to de-
scribe the several steps of the operation; to give
symptoms and pathology of Addison's disease, of
Asiatic cholera, or of some disease limited to a
foreign country. He is required to study diseases
he will probably never be called upon to treat, and
if he should would have plenty of time to read about —
and yet he is not required to know the diagnosis and
treatment of purulent ophthalmia, cutaneous epitheli-
oma, or syphilis! Does it not seem strange that the
plan of medical education has not yet reached a com-
mon-sense, economic .basis? In no other branch of
science is such a defective, absurd, and morally wrong
method followed. If it be true that the diligent and
bright student should have a degree at the end of four
years of study in a medical college, a view with which
I entirely disagree, his training should be so regulated
as to give the best basis for independent study after
graduation. As far as the practical subjects are con-
cerned, he should be drilled in those diseases only
with which he is most likely to be brought in contact,
and particularly in those of such serious character as
to demand active and correct treatment. He should be
informed beforehand of the subject he is expected
' Har\'ard is an exception, and the University of Pennsylvania.
I understand, intends to follow in Harvard's footsteps.
thoroughly to study and will be examined in, in-
stead of requiring him to grind into his inexperienced
and confused head the contents of a large volume or
of two volumes on internal medicine — an utter impos-
sibility; there is even great probability that the author
himself, if subjected to the usual '• catch" examination,
would not receive a fifty-per-cent. marking for his
attempts to answer the questions. By such a curricu-
lum he could study properly such subjects as auscul-
tation and percussion, diseases of the heart, lungs, kid-
neys, digestive tract, etc., and establish a basis in that
department upon which he could build after receiving
his diploma. The same method in the selection of
subjects would be proper as regards surgery and the
other departments of medical science. No graduate in
arts, not even the honor graduate, is expected to know-
all of mathematical subjects that is known; but his
studies are so arranged that he can subsequently con-
tinue the study of his subjects without the aid of a per-
sonal teacher. So, also, the medical student who re-
ceives a degree entitling him to practise medicine and
surgery in all its branches should pursue selected
subjects and have such a basis of knowledge in all the
branches that he can with advantage continue unaided
to study for the rest of his professional life; at the
same time his first patients in special departments
would be likely to receive more or less correct treat-
ment. If this result cannot be accomplished with four
years' study, then no medical college has the moral
right to graduate its students at the end of that period.
It has no right to declare under seal a person to be
fairly capable of treating serious diseases of common
occurrence, unless he has been taught and has learned
to recognize and treat with more or less skill such
cases.
To return to the subject of dermatology: It is a
glaring fact that, with the exceptions already noted, in
no college in this country do the students devote the
time they should to obtain any useful knowledge of
the subject of skin diseases. It is true that many of
the colleges have professors or lecturers of dermatol-
ogy; but the classes are too large to be handled to ad-
vantage, the lectures are too few in number, and the
students rarely devote any time to the study of the
subject, as even a smattering knowledge of it is not
necessary in order to obtain a diploma. The conse-
quence of all this is that the )"oung graduate does not
know how to diagnose the most common skin disease,
and, therefore, is unfit to treat it, and certainly is not
justified in any sense in accepting a fee from a patient
for treatment, especially when there are other physi-
cians within easy reach who, from study and experi-
ence, can diagnose the disease and treat it according
to recognized proper methods.
These remarks are meant to apply especially to phy-
sicians in cities, where specialists can be consulted,
either at their private offices or at the clinics or dispen-
saries. If practising in the country, I think the physi-
cian should tell the patient that his knowledge of skin
diseases is limited, but that he will treat the case, as
he thinks he can benefit him, and certainly can do
better for him than if he resorted to advertised " cure-
all-skin-diseases" nostrums. Even in this case, if the
physician cannot exclude in his diagnosis such diseases
as epithelioma, lupus vulgaris, etc., he should write or
send the patient to some specialist for assistance. If
he writes, and the patient is not a pauper, but one
from whom he receives money for his services, he
should not forget to enclose a proper consultation fee.
I mention this, as it is a notorious fact that physi-
cians very rarely think of rewarding a specialist for
advice obtained by letter; and this is most unfair, as
the task of answering such letters usually consumes
considerable time, and is, furthermore, a consultation,
and should be regarded as such. I have no doubt you
7o8
MEDICAL RECORD.
[November 14, 1896
all, like myself, receive a great many such letters
every year, and much time is taken up in considering
and writing a suitable reply. This complaint is di-
rected more to the older, so-called established physi-
cian, tiian to the one who has just hung out his shingle.
Of course, if the case is one of charity, we are always
willing to contribute to the relief of such sufferers,
■without money and without price.
I do not believe that dermatologists make known
through the proper channels — the medical profession
— our convictions upon this subject of the moral duty
of the physician toward himself and his patients in the
practice of medicine. A physician should appreciate
the fact that, if he intends to practise the art in any
special department in addition to internal medicine
or surgery, he is not qualified to do so unless he has
studied the special subject, under a capable teacher,
a sufficient length of time to acquire a fair knowledge
of it. That this knowledge is not obtained at the reg-
ular undergraduate schools, is easily demonstrated, as
far as the subject of dermatology is concerned. Since
the opening of the New York Polyclinic I have lec-
tured to at least three thousand physicians, who have
•come from different parts of the country to take a post-
graduate course. Of this number, not one per cent,
■were able to diagnose the different cases of eczema
presented at the clinics, and such diseases as lupus
vulgaris were an enigma. In England there is a spe-
•cial diploma in medicine and a special diploma in
surgery. This, I believe, was a step in the right direc-
tion, and sufficient for the time when it was instituted.
At the present day the subject of medicine is too large
for the mental grasp of a single individual, especially
if he has to earn his daily bread by the practice of his
profession. The time has come, I believe, when col-
leges should separate, to a certain extent, the differ-
ent well-recogni/ed branches of medical science, and
grant special diplomas or certificates to those who have
given special attention to and shown special knowl-
edge in a particular branch, in addition to the ordinary
degree of doctor in medicine. Of course, a fair knowl-
edge of general medicine and surgery should be re-
quired, just as the graduate in surgery in England
must also pass an examination in internal medicine.
As the country is greatly overstocked with physicians,
■necessitating considerable " hustling" with a large
percentage of them in order to increase their incomes,
and the colleges continue to manufacture them in in-
creasing numbers each successive year, such a system
-would, in time, result in benefit to the afflicted, as they
would probably learn to seek the advice of a physician
according to the character of his e.xtra diploma and
the supposed nature of the disease. As a final result,
owing to the increased attention given to special sub-
jects, the poor and middle classes would probably
■cease flocking to dispensaries and clinics, as they could
receive private treatment by a partial specialist for a
fee within their means — and that, up to the present
time, they cannot get, and .so should not be blamed for
seeking free advice at a clinic.
Until the above-sketched plan of teaching and grad-
uating is followed, or dermatology accorded its proper
place in medical schools, we must not without protest
allow the recent graduate to imagine that he is justi-
iied in treating any skin disease except those he has
learned to diagnose. By such action we might en-
courage him to pursue his studies further before
commencing private practice, or combine both prac-
tice and post-graduate studies.
While we can quietly and honestly impress upon
the recent graduate the necessity for further study,
and the fact that he should regard the four years of
under-graduate study as only preparatory to studies
necessary to enable him to do justice to his patients,
we must be more aggressive with the "old practition-
er," the "established" physician, especi.illy in a
city — he who grasps all but refuses to devote the time
to such post-graduate instruction as would enable him
to treat the ordinary run of office cases. I have al-
ways strongly advised the general practitioner in the
country to take a six-weeks' course every second year,
at one of our post-graduate schools, upon one or two
special subjects each time. There is statistical proof
tliat many physicians have followed this plan within the
last few years, and they are a credit and a worthy ex-
ample to the profession. They learn the difficulties of
diagnosis, in skin diseases for instance, and to appre-
ciate more fully the importance of the subject and the
value of an e.xpert opinion in many cases before resort-
ing to that reputation agent, the knife. Post-graduate
schools are the great "teachers of the importance of
the special departments in medicine. Under post-
graduate instruction is included, of course, instruction
from whatever source, whether in schools founded for
that purpose, or in connection with an undergraduate
school, or from a private teacher, such as our old
friend, the " decent" in Vienna, or from medical
books and journals. The '"complete" specialist must
draw from every source, and should not only study in
America, but also in Europe; and the "would-be"
dermatologist must remain long enough at the medical
centres to learn the views of the different teachers,
as well as see a large number of cases of skin dis-
eases. In addition, he should not fail to devote for
subsequent aid considerable attention to internal med-
icine and nerve diseases, even if he does not practise
outside of pure dermatology.
The surgeon invades our territory almost as much
as the general practitioner, and if he has not shown
us as much consideration as we feel he should,
it is, to a great extent, our own fault. We ha\e
not impressed him as much as we should with the
real value of our opinion in consultation in a wide
range of cases. He treats a good many diseases which
we think belong more properly to dermatology, al-
though the border line is often not well marked. Be
that as it may, I think the surgeon should recognize
the fact that unless he is thoroughly familiar with all
the manifestations of syphilis, for instance, he should
have a consultation with a dermatologist rather than
with a surgeon, if he be in doubt as to whether a cer-
tain case be one of sarcoma, lupus, tuberculosis, or
syphilis. We are all liable to make an incorrect di-
agnosis sometimes, but I have seen — we all have seen
— a goodly number of unnecessary surgical operations
and much mutilation produced in cases easily to be
diagnosed by a skilled dermatologist. Most excellent
and learned surgeons have performed serious opera-
tions with the view of removing a malignant growth,
when iodide of potassium would have ver)- quickly
accomplished the same result. As the internal-medi-
cine expert should be called in consultation by the
surgeon in a suspected case of appendicitis, so the der-
matologist should be consulted by him before operating
upon a rectum for a supposed sarcoma, or removing a
jaw for suspected cancer, or a testicle for supposed
tuberculosis. A small lesion situated upon some
other part of the body, a lesion to be diagnosed, per-
haps, only by a skilled dermatologist, will often give
a clew to a correct diagnosis of a tumor situated, say,
in the jaw, tongue, or rectum. Who should be so
capable of diagnosing a cutaneous epithelioma at its
earliest .stage, at a period when correct treatment offers
such excellent results, as the physician familiar with all
the forms of cutaneous disease? -And who should be
able to treat such a case more efficiently and with less
resulting deformity than he? The dermatologist, with
his knowledge of the anatomy and intimate structure
of the skin, should usurp his real province in all cu-
taneous diseases, and obtain the legitimate results of
November 14, 1896]
MEDICAL RECORD.
709
his special studies and knowledge therein. 'I'lie
general profession should learn, through our dis-
cussions and publications, that the study of cutaneous
diseases is a large subject, and a comprehensive
knowledge of it is obtained only after many years of
diligent study and observation. Few physicians in a
city think of invading the field of ophthalmolog}',
and the same should be the case with our specialty,
for it is an equally important one from every point of
view. If we do justice to ourselves and our subject,
the medical schools must and will, finally, give us
rightful recognition, and the general physician and
surgeon will cease thinking that any one can treat skin
diseases and that a consultation with a dermatolo-
gist is only necessary " after all other means have
failed."
By the term specialist, as used in this address, I
mean a physician specially skilled in dermatology.
A specialist — that is, one who devotes himself to the
practice of only one subject — is not necessarily a spe-
cialist in the sense of the term as used by me, for such
a one may, after all, not possess special knowledge of
the subject. A physician, also, may be a learned
specialist in more departments than one. That is not
unusual, and even in widely separated subjects, such
as dermatology and ophthalmology, or surgery. So,
also, one may be an expert in the treatment of a lim-
ited number of diseases in a special department,
without being a specialist in the whole subject; for
instance, a surgeon may be an expert in abdominal
surgery, and not in brain surgeiy or surgical diseases
of the rectum.
It is, in reality, a question of brains, time, and op-
portunities; but there is a limit, and, as a rule, two
special departments make the limit. And they should
be somewhat related subjects, as internal medicine and
dermatology, and not genito-urinary surgery and der-
matology. In some places of study, one can see more
dermatological cases in three months than in others in
a year; and many physicians live a much longer med-
ical life than others during the same number of years,
by sticking closely to their studies and avoiding en-
gagements, and limiting the hours devoted to sleep and
meals to a physiological number. A great deal of
time can be saved and utilized in this way, and if de-
voted to a second subject may lead to special knowl-
edge of it. Personally I believe - every physician
should devote several years to post-graduate studies
before commencing private practice on his own respon-
sibility.
The time is long past when it was thought there
were only three kinds of skin diseases — one sulphur
would cure, another arsenic would cure, and a third
the devil couldn't cure. The time should now be past
when any physician is entitled to think he can treat
any case of so-called eczema. The profession should
learn that only a skilled expert can diagnose correctly
the kind of eczematous inflammation present in a given
case, and understand the cause and processes at work,
and treat them intelligently and in a manner the patient
has a right to expect. When all these things are
learned — and we are the individuals who should teach
them — then those afflicted with cutaneous disease, in-
cluding syphilis, will receive proper treatment from
skilful hands. Then we will see students anxious to
attend colleges where dermatology can be learned;
there will be special wards for cutaneous diseases in
our public hospitals and private hospitals will be
erected, such as now exist for other special branches,
such as diseases of the eye; our not over-ethical nor
over-scrupulous medical journals will not contain ad-
\ertisements of some preparation warranted to cure all
skin diseases, or be filled with formula,- for the treat-
ment of eczema, pruritus, etc., for such advertisements
on their very faces would bear the stamp of humbug
to the educated physician. To bring about this result,
we must simply be properly aggressive in our writings
toward notorious offenders, and by our studies and
works show the great importance of a knowledge of
our specialty for the relief of human suflering.
The above outspoken remarks are not intended to
apply to all physicians, as they would not be true as
regards the very considerable number of the profes-
sion who make a point of referring to some specialist
all cases they do not feel fairly competent to treat.
All I have said is intended to aid the advancement of
medicine, both in its moral and scientific aspects.
I believe all publications representing original
work,, and equivalent to a contribution to existing
knowledge, should be published only in a journal de-
voted to the specialty. The same is true of reports of
meetings of dermatological societies and reports of
unusual cases of skin disease. If this were done, it
would, at a small expense, be possible for the der-
matologist to keep track of the only literature upon the
subject worth reading. Other articles, not representing
contributions to existing knowledge, but intended to
teach the general practitioner, should be printed in
journals devoted to general medicine and not to der-
matology. Such papers, when written, should be de-
voted to a discussion of diseases with which the gen-
eral physician supposes himself to be capable of
diagnosing and treating, as acne vulgaris, etc. : and
even then the difliculties of diagnosis should be em-
phasized. Papers of this kind, or such as deal in a
general manner with cutaneous diseases, may and
should be written with the object of drawing attention
to the knowledge and experience required for the
proper recognition and treatment of these aft'ections;
and, as they can reach the general profession only
through the columns of a general medical journal, that
is the proper organ for their publication. At no time
and on no occasion should a paper be read or published
for the purpose of advertising the author, and yet I
am afraid such things have occurred and will occur
again. We should keep a lookout for such '" derma-
tologists"— they may some day apply for admission
to our association.
I believe it to be the duty of this association to
guard the interests of dermatology in America and
to maintain a membership herein. A membership
should be the goal of every true dermatologist in this
country, and when such a one has earned by his labors
and character a fellowship with us he should be ad-
mitted, irrespective of personal feelings. We should
watch the medical course of possible aspirants, read
their articles, and observe if the quantity and quality
are proportionate to the subject or subjects discussed.
A scribbler who writes for notoriety and keeps the
printing-machine busy is not likely to bring us much
credit, and should not have a 16 to i chance for ad-
mission. I would suggest a very careful consideration
of all candidates proposed for membership, and trust
no one will propose a name merely because he was
asked to do so or because he is a personal friend of
its bearer. The more select the membership, the more
honor to be admitted a member. I see danger ahead
if nnich caution is not exercised.
I hope the innovation this year, of devoting consider-
able time to an exhibition of drawings, colored and
uncolored photographs, instruments, microscopical
sections, will be regarded favorably by the members.
I am a warm believer in great mutual benefit from
such exhibitions, and think that the reading of papers
upon subjects specially adapted for general discus-
sion and requiring only clinical obser\-ation, together
with these exhibitions, should be the leading features
of our annual meetings. Such an arrangement would
make our meetings have more the character of clinical
demonstrations than of didactic lectures, and more in
7IO
MEDICAL RECORD.
[November 14, 1896
accordance with modern ideas of teaching; for, after
all is said, we meet not alone to enjoy each other's
fellowship and guard the dignity of dermatology, but
also to learn anything that is new and worthy of
knowing.
THE EFFECT OF EARLY OPTIC ATROPHY
UPON THE COURSE OF LOCOMOTOR
ATAXL\.
By PEARCE BAILEY, .M.D.,
ASSISTANT IN NEUROLOGY, COLUMBIA COLLEGE ; ATTENDING PHYSICIAN TO
THE ALMSHOUSE AND WORKHOUSE HOSPITAI.S AND HOSPITAL FOR IN-
CURABLES, NEW YORK CITY.
It has long been observed by neurologists and oph-
thalmologists that individuals who develop, without
assignable cause, an atrophy of the optic nerves may,
after a considerable period of time, begin to have
lightning pains, or may become ataxic, or present other
of the classical symptoms of locomotor ata,\ia. Al-
though typical tabetic symptoms have been delayed
for as long as nineteen years, the failure to discover
any other cause for the optic atrophy and the fre-
quency of occurrence of this symptom in tabes lend
probability to the assumption that in such cases the
atrophy was the first manifestation of the systemic de-
generation, and that during the interval between the
occurrence of atrophy and the beginning of the spinal
symptoms the disease was quiescent.
The following case, which recently came to the Yan-
derbilt Clinic, has no symptoms of locomotor ata.xia,
except blindness and loss of knee jerk, although other
tabetic symptoms will undoubtedly develop eventually :
Man, aged thirty-six; syphilis denied. One year ago
he became blind in the left eye and soon after in the
right. Knee jerks absent; double optic atrophy; no
pain; no Romberg symptom ; no sensory changes; no
crises; no oculo-motor paralyses.
The proportion of these '" primary" optic atrophies
which eventually develop tabes to those which do not
is not accurately determined. Cowers states it to be
about fifty per cent. The fact that optic atrophy may
be an early symptom in general paralysis of the insane
was illustrated by a case which recently came to my
notice. There was nearly complete blindness, but
the mental and physical symptoms of paresis, though
unmistakable, were not far advanced.
Benedikt was the first to attribute to an initial optic
atrophy a postponing influence upon the development
of the other symptoms of locomotor ataxia; and he
went further, and formulated the statement that in
many cases of tabes in which atrophy of the optic
nerves was an early symptom the character as well as
the course of the disease would be changed. Symp-
toms sufficient for a recognition of the trouble might
develop, but ataxia and pain would not occur. He
also maintained that if the atrophy took place after
the disease had become symptomatically characteristic
the occurrence of blindness would be accompanied by
an amelioration of tlie spinal symptoms. Dcjerine
indorses Benedikt's first proposition, but does not
agree that optic atrophy, occurring after the disease is
developed, will he followed by any improvement of
the spinal symptoms. Since the appearance of these
earlier articles, the subject has received attention from
Berger, Walton, Martin, Pershing, Buzzard, and De-
jerine. Martin's is the most valuable of these contri-
butions, as it embodies the results of careful examina-
tion of twenty-one cases in which locomotor ataxia
was surely present, and in which optic atrophy was the
first (in six cases) or among the first symptoms. In
three of these patients the pains did not appear until
seventeen, eighteen, and nineteen years, respectivelv,
after the blindness. In eleven cases the pains were
diminished after atrophy occurred; ataxia was present
in six cases, but developed in one only, after the atro-
phy was established. But it will be seen from these
studies that optic atrophy, as an early symptom, may
be speedily followed by ataxia, and that the pains do
not necessarily disappear when the blindness comes.
Thus the position that initial optic atrophy will inva-
riably retard the appearance of spinal .Mmptoms is no
longer tenable.
These results of Martin's accord in many ways
with observations of my own ; but as the subject,
which is of considerable importance to neurologists,
has received little attention, I have been led to record
the cases of locomotor ataxia which are accessible to
me, and most of which I have personally examined, in
which optic-nerve atrophy was the initial or an early
symptom. I am indebted to Professor Starr for his
kindness in permitting me to utilize the records of the
Vanderbilt Clinic for this purpose. Of the one hun-
dred and twelve carefully recorded cases which have
come to the clinic in the past few years, seven have
given symptoms of optic atrophy as an early symptom.
It is greatly to be regretted that in three of these an
ophthalmoscopic examination was not made, but, as
the examination of the pupillary reflexes necessitates
close observation of the eye, I think it fair to assume
that in these cases the blindness which in\olved both
eyes was due neither to cataract nor to corneal opac-
ities, of wiiich no mention is made in the history, but
in all probability to an atrophy of the optic ner\'es.
In addition to the seven clinic cases, five of the
eighteen cases of tabes at present under my care at
the Hospital for Incurables, give a history of early atro-
phy, which has been verified by ophthalmoscopic ex-
amination.
I have to thank Dr. Gomez for his kindness in un-
dertaking the ophthalmoscopic examinations.
The cases are as follows:
C.4SE I. — Male, fifty-three years; has had syphilis.
The first symptom was a failure of sight, which came
on five years previously. There never were any pains.
Knee jerks absent ; inco-ordination : girdle sensation.
Eyes: Pupils do not respond at all; totally blind in
the left eye; can distinguish light only in the right.
Case II. — Male, aged thirty-eight; syphilis denied.
The first symptom was failure of sight, which came on
two years previously. Never any pain or ataxia.
Numbness of hands and feet; knee jerks absent.
Eyes: Argyll-Robertson pupils; left eye totally blind;
right eye very much impaired.
Case III. — Male, forty-seven years; probably has
had syphilis. The first symptom was failure of sight,
which came on one year previously. Knee jerks ab-
sent; ataxia of arms and legs. Never any pain.
Eyes: Advanced optic atrophy.
Ca^e IV. — Male, forty-five years; syphilis denied.
The first symptom was dimness of sight, which came
on three years previously. Ataxia began in third year
of disease; there were very slight pains at first, none
since. Knee jerks absent. Eyes: Right, pupil wider
than the left; left, external strabismus, totally blind.
Case \'. — Male, aged forty-two; syphilis denied.
The first symptom was dimness of vision. No pain;
no inco-ordination. Knee jerks: Left, absent; right,
present. Eyes: Argyll-Robertson pupil; doubleoptic
atrophy.
Case VI. — S. D •, female, aged fifty-five: syphi-
lis denied. The first symptom, six years ago, was
paresthesia in legs and feet, followed by sharp shoot-
ing pains in the back and legs, which lasted one year.
One year ago sight began to fail, and she became to-
tally blind in six months. No ataxia; no Romberg
svmptom : no loss of sense of position ; knee jerks ab-
sent: areas of cutaneous ana-sihesia. No severe pain
now, but parai-sthesia in legs and back. Slight incon-
tinence. Eyes: Pupils unequal; respond slightly
November 14, 1896]
MEDICAL RECORD.
711
■during efforts at accommodation, but not to light;
almost totally blind; double optic-nerve atrophy; no
oculo-motor palsies.
Case VII. — G. K , aged forty-nine; syphilis
denied. The first symptoms, seven years ago, were in-
terference with gait and shooting pains in the thighs
and legs. Si.x and one-half years ago eyesight began
to fail in the left eye, and about one month later the
right eye became affected; was totally blind in si.x
months. At present, ataxia of legs and hands; cannot
walk; loss of knee jerks; retention of urine. Pains
less severe than before and trouble the patient very
little. Eyes: Paralysis of the left internal rectus;
pupils unequal; loss of pupillarj' reflexes; double
optic-nerve atrophy.
Case VIII. — A. M , aged fifty-six; syphilis un-
■certain. The first symptom, twenty-four years ago,
was swelling of the right knee-joint, which was oper-
ated upon for "dropsy." This knee is now a typical
<Jharcot joint. Sixteen years ago sight began to fail,
and total blindness was established in one year.
•Could work very well until six or seven years ago,
since which time ataxia in legs became so marked
that walking was impossible. Never any pain, except
local pain in the right knee-joint. The patient is now
a perfect example of advanced locomotor ataxia— -
blind and bedridden, with retention of urine, loss of
all reflexes, and areas of cutaneous anresthesia. Eyes:
Totally blind; pupillary reflexes, absent; bilateral
third-nerve paresis, with double external strabismus
and atrophy of both optic nerves.
Case IX. — W. W , aged fifty-five: syphilis
thirty-six years ago. The first symptom, three or four
years ago, was inco-ordination of legs. One year ago
he began to lose sight, and now is totally blind. Never
any pain. Gait very ataxic. Loss of sense of posi-
tion; hands not involved. Knee jerks absent; sphinc-
ter control retained; no changes in sensation; Rom-
berg symptom. Eyes: No pupillary reactions; totally
blind; double optic atrophv; no oculo-motor palsies.
But no rule is without its exception, and that an ini-
tial optic atrophy may very speedily be followed by
other characteristic and serious symptoms of locomo-
tor ataxia is positively proved by the three cases
which follow :
Case X. — W. F , aged fifty-five; syphilis prob-
able. The first symptoms, in 1891, were sharp shoot-
ing pains in the back and legs and difficulty in walk-
ing. About one year later, began to lose sight; the
left eye was first affected, and was totally blind in
one year. Pains increased in severity with the occur-
rence of blindness. Now very ataxic; cannot walk.
Pains not very severe. Eyes: No pupillary response:
double optic-nerve atrophy; bilateral third-nerve par-
esis, with double external strabismus.
Case XI. — Male, forty-nine years; has had syphi-
lis. The first symptom, occurring three years pre-
viously, was dimness of vision. This was soon fol-
lowed by sharp shooting pains i.nd ataxia. Knee
jerks absent. Eyes: Argyll-Robertson pupil; begin-
ning optic atrophy.
Case XII. — Male, aged thirty-two; has had syphi-
lis. Symptoms, consisting of dimness of vision,
pains, and ataxia, came on simultaneously one year
previously. Knee jerk absent. Eyes: Optic atrophy.
A summary of these twelve cases shows that in nine
the early development of optic atrophy had an appar-
ent inhibitory influence upon the e\olulion of the dis-
ease, especially as regards pain, which either developed
not at all, or was slight, or became less severe when
the atrophy began. Ataxia failed to de\elop in three
of these nine, hut was present in the rest, and in some
was very marked. When pain and ataxia both were
absent, there were, in addition to the optic atrophy,
sufficient symptoms to justify the diagnosis of tabes.
In four of the cases cited there were present oculo-
motor palsies, affecting chiefly the third pair.
The last three cases of the series demonstrate \ery
positively that locomotor ataxia may develop in its
characteristic form in spite of optic atrophy as the ini-
tial symptom.
It is unquestionable that in some but by no means
all cases of tabes early optic atrophy exercises an ap-
parently inhibitory influence upon the evolution of the
disease. Why this should be so it is impossible to
conjecture, and we are obliged to be content with the
ability to hold out to patients in whom optic atrophy
is an early symptom the hope that the disease will
pursue a mild course in other directions. It is possi-
Ijle that more extensive statistics, based upon the sys-
tematic observation of patients who de\elop primary
optic atrophies, will alter our present views on this
subject. Widely different results have been obtained
by different investigators in regard to the symp-
tomatology and etiology of this sensory systemic
disease.
As an example of the latter fact may be cited the
assertion, made by high authorities, that aortic insuffi-
ciency, directly dependent upon the syphilitic or tabet-
ic process, is the commonest complication of the
disease. Some investigations of my own tend to con-
tradict this opinion; and in tliree hundred cases of
Erb's, reported by Leimbach, in which the heart was
carefully examined, only three presented any evidences
of aortic leakage.
Again, Erb's statistics show that optic atrophy oc-
curs in 6.75 per cent, of the cases, while Dejerine says
that of one hundred tabetic patients under his care
eighteen were completely blind from an early atrophy
of the optic nerves.
Thus more extended attention than the influence of
the optic-nerve atrophy has obtained will be neces-
sary before it can be definitely determined just how
far and how frequently the disease may be modified
by the occurrence of any initial individual symptom.
There is at present a man, aged thirty- five years,
syphilitic, under my observation, who for two years
has had retention combined with occasional inconti-
nence of urine. He has the Argyll-Robertson pupil
and no knee jerks, and there is no discoverable local
cause for the urinary symptoms. The man, in my
opinion, has had locomotor ataxia for two years, yet
he never has had either pain or ataxia. It would not
be justifiable to infer that the bladder trouble had
caused a delay in the evolution of other symptoms.
So it may be with any indi\'idual initial symptom.
And with early optic atrophy we would be on the safe
side if we limited ourselves to stating that, from the
present knowledge of the subject, in a considerable
proportion of the cases of locomotor ataxia in which
atrophy of the optic nerves is an initial or early man-
ifestation some of the spinal symptoms may be late
in appearance or may not develop at all. So that the
onlv justifiable conclusions from present data are
that .
1. In about seventy- five per cent, of the cases of
tabes in which optic atrophy is an early symptom
some of the other tabetic symptoms may be late in ap-
pearing or may not develop at all. This is especially
the case in respect to the lightning pains and the inco-
ordination of movement. 'Phe loss of knee jerk in
such cases is very constant.
2. The most distressing syni])tonis may develoj)
simultaneously with or immediatelv succeed the blind-
ness.
3. The association with the optic atrophy of Ciculo-
motor palsies is without prognostic significance.
4. The subject will receive its best elucidation by
the observation, over long periods of time, of patients
with "primary optic atrophy."
■I 2
MEDICAL RECORD.
[November 14, 1896
BIBI.IOGKAI'IIV.
Bailey: Jour. Nerv. and Ment. Dis., May, 1S95.
Benedikt; Wien. med. Presse, 1S81, p. 102; also 1807, p. 1,130.
Berger: Arch. f. .\ugenheilk., 18SS, 3, p. 30;; also 4, p. 391.
Buzzard: Br. Med. Jour., 1S93, October 7th.
Dejerine: Soc. de Biol , 18S9, p. 431. Also Med. Mod., 1S95,
p. 177.
Gowers: Dis. Nerv. .System. Also Med. Opthalmoscopy.
Martin: Kef. Schmidt's Jalirb., 1892, 233. p. 77.
Pershing: Med. .Xews, 1892, 60, p. 337.
Walton: Bost. .Med. and Surg. Jour., 1S89.
60 Wf.st Fiftieth .Street.
^'roorcss of |3tXcdical Science.
Magnan's Sign in Chronic Cocainism — Dr. Ri-
bakolT (6',7.';. J. Osp. e d. Clin., August 4th) has had
occasion to observe a couple of cases of severe chronic
cocainism, in which Magnan's sign was the predomi
nant symptom. This is a hallucination of the cuta-
neous sensibility, characterized by the sensation of a
spheric foreign body under the skin, varying in size
from a grain to a nut. This sensation is peculiar to
this into.xication, and its differential value should be
more generally recognized.
Chlorosis no Contraindication for Marriage. — Dr.
Grosset ['J'/irsi- lit- raris, 1896) discusses tiiis subject,
and concludes as follows: 1. The physical and spiri-
tual e.xcitement which marriage offers a chlorotic girl
can have only a favorable effect upon her disease. 2.
The sterility of chlorosis is only a temporary one in
most cases, the rare instances of infantile genitals be-
ing excepted. 3. Chlorosis does not predispose to
abortion. 4. The children of a chlorotic woman are
likely to be chlorotic, but they seem to show little
tendency to become tuberculous.
Etiology of Peritonsillar Abscess. — Dr. Logueki
(" Beitrage zur Aetoil.," etc., ^/r/;. /. Laryii. 11. Rhin.,
Bd. IV., Heft 2 ) says that abscess in this region presents
itself usually under two distinct clinical forms. In the
first the pus collection is situated between the gland and
the anterior pillar, which is decidedly bulged forward.
There is likewise prominence of the vault of the pal-
ate and considerable cedema of the uvula. In the
second the abscess is located between the tonsil and
the posterior pillar. In this variety the affection lasts
longer and presents more pronounced symptoms than
in the first variety. The author has examined eleven
cases from a bacteriologic standpoint. In a recently
opened abscess about the tonsil streptococci are es-
pecially found; at a later period streptococci and
staphylococci; in a still later jjeriod only staphy-
lococci. Now it is well known that all these micro-
organisms are found in crypts of the tonsil even in
healthy persons. If an acute amygdalitis comes on,
this always occasions an adhesion between the surface
of the tonsil and the pillars of the fauces: the contents
of the crypt, not finding any external exit, set up an
irritation of the peritonsillar tissue and determine in it
an inflammation and an infection by the above-men-
tioned microbes, which suddenly acquire virulent
properties.
Venereal Buboes. — In an article on their etiologj'
and treatment. Dr. Perry, of the Marine Hospital ser-
vice concludes as follows [The Ameikan Journal of
the Mulinil Sciences, November. 1896) : i. That buboes
are probably caused by the absorption of chemical
poisons, the result of the action of the micro-organisms
in the chancroid, and not to the entrance of the micro-
organisms themselves into the lymphatics. 2. That
the benzoate of mercury yields such satisfactory re-
sults that it should be emploved i'l the treatment of
non-suppurating buboes, and excision reserved for
those cases in which benzoate has failed. 3. The in-
jection of iodoform ointment should be used in the
treatment of all freely suppurating buboes, since sta-
tistics sliow that it yields mucii more satisfactory
results than the other methods of treatment appli-
cable to this variety. 4. Incision and curettage
should be used in a few cases in which the skin has
been destroyed and the ulcer presents an unhealthy
granulating surface. 5. Excision should be reserved
for cases that have not yielded to other treatment, and
for those in whicli there are several foci of suppura-
tion.
Results of Hydatids. — Dr. Frank {American /our-
nal of the Me.lical Sciences, October, 1896) writes that
hydatids of the liver may cause no trouble what-
ever or the following results may transpire: i. By
pressure interfering with the functions of some or-
gans of the body, and by attaining a large size caus-
ing ascites and dropsy. 2. Forming adhesions with
the diaphragm and ulcerating through, either into
the pleura, causing pleuritis; or further ulceration
may take place in the lung, and the contents, com-
ing originally from the liver, may by this channel
be expectorated and lead to a spontaneous cure. 3.
\ fistulous opening may be formed into the lumen
of the bowel and lead to a cure. 4. If they open
into the stomach and the fluids and cysts be vom-
ited, a cure is the result. 5. If a simple cyst rup-
tures into the kidney or bladder, a spontaneous cure
is possible. 6. If they empty into the pericardium,
the peritoneal cavity, bile ducts, or gall bladder, the
result is disastrous. 7. Cases arc on record in which
hydatids have invaded the trachea and produced death
by suffocation. 8. Nature's best cure, without any
surgical aid, is the formation of adhesions to the
parietes. Cases are on record which have emptied
themselves externally, but this favorable result is not
often met with. 9. Finally, a calcareous degenera-
tion may take place within the cyst, and thus lead to
a very satisfactory termination.
The Cause of Sudden Death after Antitoxin
Injections Drs. .A. Seibert and 1'. Schwyzer (Medi-
cal Journal, May 30th) publisiied the following con-
clusions: 1. .Antitoxic serum does not seem to be
capable of causing threatening symptoms and speedy
death, even when brought quickly into the blood cur-
rent in very large doses. 2. The carbolic acid used
in preserving the anlidiphtheritic serum must be in
such a weak solution as to be entirely unable to cause
the characteristic carbolic convulsions produced in
every one of our second series of experiments. The
absence of these convulsions in patients in the cases
of sudden death, the entirely different group of symp-
toms reported in tiiem, and the fact that guinea-pigs
and rabbits will survive even very large and concen-
trated doses of carbolic acid injected into a vein, lead
us to discard the possibility of this drug having caused
the reported deatlis. 3. Even very small quantities of
air will cause severe disturbances and ultimate cessa-
tion of breathing in every animal experimented upon.
These disturbances are entirely analogous to the
symptoms reported as preceding the sudden deaths
after antitoxin injections. .Air is found alongside of
the fluid in every syringe used for hypodermic injec-
tions, and being pressed under the skin with the fluid
mav readily come in contact with a punctured cutane-
ous vein and so may enter the blood-\essel and the
right heart, even before the serum has been absorbed.
In view of these facts and of our experiments, we here
express our firm opinion that the sudden deaths re-
ported after antitoxin injections were caused by in-
jected air and not by the antidiphtheritic serum.
November 14, 1896]
MEDICAL RECORD.
713
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO , 43, 45, &. 47 East Tenth Street.
New York, November 14, 1896.
THE TREATMENT OF PERNICIOUS AN.«-
MIA.
Our notions concerning the nature of pernicious ana-
mia have undergone various modifications since its
recognition by Addison in 1855, and by him desig-
nated idiopathic, and its subsequent description by
Biermer, in 1868, as an independent affection. A
final decision cannot yet be given as to whether the
disorder is dependent principally upon excessive blood
destruction or upon deficient blood production, but the
statement can be safely made that the affection is no
longer looked upon as primary or idiopathic, and
doubt may exist in some cases as to its progressive
and perniciov<s character, in the sense in which it has
been customary to employ these terms.
A growing experience has taught that profound
and fatal anemia may result from a variety of causes,
sometimes perfectly obvious, but at other times so ob-
scure as to escape detection at the hands of the
keenest clinical observer. .Sufficient evidence has
accumulated to justify the conclusion that in a not
inconsiderable proportion of cases the blood deprav-
ity results through the gastro-intestinal tract, perhaps
in consequence of poisonous products there generated,
or by infection, or from the presence of parasites of
other character. These advances in our knowledge
of the etiology of the disease have not been without
their influence upon a selection of the means employed
in its treatment. Thus, whenever a source of hemor-
rhage or other wasting discharge can be discovered,
the first essential step is to secure its control. When
animal parasites are found to be present in the intes-
tinal tract, their extrusion must be effected by appro-
priate means. When it is suspected that the condi-
tion arises in consequence of intoxication, resulting
from some failure in the normal digestive and assim-
ilative processes, measures calculated to aid gastro-
intestinal digestion and disinfection will be indi-
cated; if the intoxication be dependyit upon the
retention of metabolic products intended for excretion,
laxatives — and especially calomel and salines — may
be used with advantage.
Upon the assumption that the excessive haemolysis
is supposed to take place in pernicious anamia as a
result of the presence of toxic matters in the gastro-
intestinal tract, Gibson ' was led to use two-grain
' Edinburgh Medical Journal, October, 1S92, p. 329.
pills of beta-naphthol, given twice or thrice daily, in
the treatment of a case of that disorder, with the hap-
piest results. Acting upon the same thought and
adopting a suggestion of Fraser,' Dieballa " employed
successfully salol in a case of similar kind, in which
the usual remedial agents had been previously em-
ployed without avail. The patient was a laborer, fifty
years old, who suffered greatly from weakness, and
presented a yellowish discoloration of the skin and
conjunctiva, and pallor of the lips and mucous mem-
branes, with a reduction of the red blood corpuscles to
1,120,000 per cubic millimetre, of the white to 2,600.
and of the haemoglobin to 43 per cent. At the age of
thirty-one he had had a like attack, from which he re-
covered in the course of six months, and again at the
age of forty-five. The red blood corpuscles varied
greatly in size and shape, and some were nucleated.
Of the colorless corpuscles, 55 per cent, were polymor-
phous neutrophile, 21 per cent, lymphocytes, 13 per
cent, large mononuclear cells, 8.5 per cent, transitional
forms, and 2.5 per cent, eosinophile cells, .\fter ar-
senic, bone marrow, iron, inhalations of oxygen, and
quinine, singly and in combination, had been employed
for more than four months w ithout appreciable benefit,
salol was given in doses of fifteen grains five times a
day. Unpleasant symptoms arising, the frequency of
administration was reduced to three times a day.
The treatment was continued thus for three months, at
the end of which time the red corpuscles had increased
in number to 4,200,000 per cubic millimetre, the col-
orless corpuscles to 7,000, and the hjemoglobin to 60
per cent., while a gain in weight of thirty pounds had
been made. Of the colorless corpuscles, the polynu-
clear neutrophile were increased to 68 per cent., and
the large mononuclear and transitional forms to 8 per
cent., the others undergoing practically no change.
The presence of eosinophile cells in about normal
proportion was looked upon as indicative of maintained
functional activity of the bone marrow in the process
of hamogenesis, and to this extent of favorable prog-
nostic omen.
In cases in which the blood-forming organs are be-
lieved to be at fault, bone marrow may serve a useful
purpose. The influence which this substance is capa-
ble of exerting is still undecided, but in a disease like
pernicious ana_-mia, in which no measure can be ex-
pected to act with certainty for good, the patient
should be given the advantage of every doubt, and no
remedy should be neglected which may even doubtfully
render a service. In the way of agents that aid in
blood making, the first place must be given to arsenic,
given in doses as large as the patient will bear and
for a long period of time. Iron is not capable of the
same good, but may find a useful place in the treat-
ment. Inhalations of o.Kygen have at time proved a
valuable therapeutic adjunct.
It goes without saying that the diet should always
be the most nutritious possible, special care being
observed to maintain digestive integrity and activity,
while no general hygienic precaution should be neg-
lected. Moderate and gentle exercise in the open
' Uritish Medical Journal, N'o. 1,744, P- '.1/2.
'Zeitschrift fiir klinische Medicin, H. .\x,xi., U. i, 2. p. 47.
714
MEDICAL RECORD.
[November 14, 1896
air, within the limits of fatigue, and exposure to sun-
shine, should be judiciously indulged in. Sympto-
matic indications must be met as they arise. Strych-
nine in moderate doses will almost always serve a
useful purpose.
In attempting to reach a decision as to the efficacy
of any plan pursued in the treatment of pernicious
anamia, it is to be borne in mind that periods of
transitory improvement, of varying duration, are often
a part of the natural course of the disease, so that too
much importance must not be attached to the favora-
ble results that may follow the special line of medi-
cation employed. Even if such improvement continue
for a long time, the conclusion must not be too hastily
reached that the disease is cured.
THE SIGNS OF LONGEVITY.
Every one is interested in the question of long life
as applied to himself, and all facts bearing on it are
noted with becoming feelings of self-congratulation
or otherwise. It is the staying power that is in de-
mand, backed by an inherited and reserved vitality
of resistance against the usual evils to which all flesh
and other perishable things are subject. The law of
heredity, which our life insurance companies under-
stand so well, is at the bottom of all calculations as
to whether a particular man or woman is wound up for
seventy years or will run down at twenty or forty years.
-Aside from this testimony, there are certain physi-
cal qualities which have great weight in determining
the result of the struggle against a conspiring envi-
ronment. An oak has one configuration, and a cedar,
pine, or mullein stalk another. It is the proper recog-
nition of such distinctions that aids physicians in their
prognosis and turns the balance against apparently
desperate chances.
At a recent meeting of the Academy of Science, Mr.
F. \V. Warner, in speaking upon the subject of biom-
etry, offered some very interesting data, which are in
the main true.
" Every person," said he, " carries about with him
the physical indications of his longevity. A long-
lived person may be distinguished from a short-lived
person at sight. In many instances a physician may
look at the hand of a patient and tell whether he will
live or die.
''In the vegetable as well as in the animal king-
dom, each life takes its characteristics from the life
from which it sprung. Among these inherited charac-
teristics we find the capacity for continuing its life
for a given length of time. This capacity for living
we call the inherent or potential longevity.
■' Under favorable conditions and environment, the
individual should live out the potential longevity.
With unfavorable conditions this longevity may be
greatly decreased, but with a favorable environment
the longevity of the person, the family, or the race
may be increased."
Herein are presented the two leading considera-
tions, always present and always interdependent — the
inherited potentiality and the reactionary influences
of environment.
" The primary conditions of longevity," he contin-
ues, ■■ are that the heart, lungs, and digestive organs,
as well as the brain, should be large. If these organs
are large, the trunk will be 'long and the limbs com-
paratively short. The person will appear tall in sit-
ting and short in standing. The hand will have a
long and somewhat heavy palm and short fingers. The
brain will be deeply seated, as shown by the orifice
of the ear being low. The blue hazel or brown hazel
eye, as showing an intermission of temperament, is a
favorable indication. The nostrils being large, open,
and free indicates large lungs. A pinched and half-
closed nostril indicates small or weak lungs."
These are general points of distinction from those
of short-lived tendencies, but, of course, subject to the
usual individual exceptions. Still, it is well acknowl-
edged that the characteristics noted are expressions of
inherent potentiality, which have been proven on the
basis of abundant statistical evidence.
.•\gain, he says truly:
"In the case of persons who have short-lived paren-
tage on one side and long-lived on the other side, the
question becomes more involved. It is shown in
grafting and hybridizing that nature makes a supreme
effort to pass the period of the shorter longevity and
extend the life to the greater longevity. Any one who
understands these weak and dangerous periods of life
is forewarned and forearmed. It has been observed
that the children of long-lived parents mature much
later and are usually backward in their studies."
Such obser\'ations are of the highest importance,
especially to the physician, and it is on this ground
we commend them to his thoughtful consideration.
CHARCOAL AS A SURGICAL DRESSING.
KiKUZi, a Japanese army surgeon, as our readers al-
ready know, has introduced, with great success, char-
coal, freshly prepared by burning rice straw, as a
dressing on the battlefield and in military hospitals.
A qualitative analysis shows the presence of potas-
sium, sodium, aluminium, magnesium, lime, iron,
chlorine, sulphur, phosphorus, silicates, and organic
substance. Its absorbent qualities are but slightly in-
ferior to that of gauze, and it makes even pressure.
Dr. Matignon, an attache of the French legation in
(liina, has been most favorably impressed with this
dressing, and gives, in /.a Makcine Motkrne, May 6,
1896, the following risume of its advantages:
■■ I. Its elasticity and its absorbent powers are equal
to those of gauze.
"2. It is found everj'where, and can be obtained
quickly in large quantities.
"3. Its price is minimum, being a twentieth part of
that of gauze.
"4. It may be employed at once, its disinfection re-
sulting from its preparation.
"5. It is not necessary to transport it."
In this connection we would refer to an article upon
the uses of charcoal as a dressing in military surgery.
November 14, 1896]
MEDICAL RECORD.
715
based upon an experience in the Franco-Prussian war.
Dr. Samuel Sherwell, of Brooklyn, published in the
New York Midical Journal and Obstetrical Review for
October, 1882, a paper which he had written in 1876,
just after the battle of Plevna, and which he read in
the surgical section of the International Medical Con-
gress in London, in 1881.
.As surgeon in the Anglo-American ambulance, the
writer saw considerable field-hospital practice at -Se-
dan, Orleans, and other places, and was only too fa-
miliar with the ravages of septicemia and pyaemia
after amputation and important operations. In his
article, which is entitled " A Ready and Convenient
.\ntiseptic Dressing for Amputations and Other Open
Wounds in Field Hospitals," he says: " .Among almost
all continental nations charcoal is largely used and
everywhere available or easily obtained. I would
suggest, then, after operation, the instant envelopment
of the wounds, particularly those of the limbs, and
more especially, as I think, those of the lower limbs,
in a sack or bag (a common small pillow slip would
serve) of charcoal finely pulverized, a fair excess of
this to be used so as to shield and envelop the tissues,
the charcoal to be either directly laid on the wound
or mediately, a fold of gauze being applied ne.xt the
surface ; this not to be removed for days at a time,
except under pressing necessity, and then preferably
by a jet of water from some clean source."
It should be a source of gratification to Dr. Sherwell
to know that, after all these years of Listerism and an-
tisepsis and aseptic treatment, which can never be
properly carried out in a busy field of carnage, his ex-
cellent and original suggestion has been put into
practical use on a large scale, and with such favorable
results.
Illness of Sir William MacCormack. — Sir William
MacCormack is very ill with pneumonia following
influenza. His numerous friends are very anxious.
Surgeon in Ordinary to the Lord Lieutenant. —
Mr. Thompson, president of the Royal College of Sur-
geons in Ireland, is the new surgeon in ordinary to
the lord lieutenant.
The Widow as Partner. — The tribunal of the
Seine has just handed down a decision of interest to
French relicts of medical men, who may wish to dis-
pose of their husbands' clientele or to enter into co-
partnership (professional) with another physician who
succeeds to the practice. The court holds that the
doctor's knowledge and experience cannot be made
the object of a contract, and a copartnership between
the widow and a practitioner of the art of her defunct
husband is void.
Rabies. — The city of Lyons, France, continues to
give a large percentage of this affection, ninety per-
sons having been bitten during the past year. There
have been observed one hundred and three dogs, ten
cats, and one horse showing manifestations of the dis-
temper.
Obituary Notes. — Dr. John Russell McClurc;
died at West Chester, Pa., on November 3d, at the age
of seventy-six years. He was graduated from Jefferson
Medical College, and in 1864 was commissioned major
and surgeon. United States volunteers, retiring at the
close of the war with the brevet rank of colonel.
Vital Statistics of Philadelphia — For the week
ending October 31st there occurred in the city of Phil-
adelphia 362 deaths — 114 in children under five years
of age. The largest number of deaths from any one
disease resulted from pulmonary tuberculosis, 44; the
next largest number from pneumonia, 33 ; and next,
diseases of the heart, 22. There were reported during
the week new cases of diphtheria, 59 ; of typhoid fe-
ver, 38; and of scarlet fever, 20.
The New York Obstetrical Society — At the an-
nual meeting of the New York Obstetrical Society,
held October 20, 1896, the following officers were
elected: Dr. Robert A. Murray, /V£'i/V/<?«/,- Dr. C. A.
Von Ramdohr, First Vice-President ; Dr. George W.
Jarman, Second Vice-President ; Dr. Arthur M. Jaco-
bus, Recording Secretary ; Dr. Le Roy Brown, Assistant
Recording Secretary; Dr. H. J. Boldt, Correspotiding
Secretary; Dr. J. Lee Morrill, Treasurer ; Dr. G. C.
Freeborn, Pathologist.
A Novel Enterprise. — The announcement is made
that articles of incorporation have been filed in the
Camden County (N. J.) clerk's office by the Pennsyl-
vania Medical and Burial Company, whose avowed
objects are the entering into contracts with parties for
the purpose of providing them with funeral and mourn-
ing supplies, drugs, medicines, and medical services.
It would seem that the enterprising incorporators of
this novel commercial scheme have reversed the order
in which it would naturally be supposed their services
might be useful, as one would scarcely have need for
medical attendance after having been provided with
funeral and mourning supplies;
College of Physicians of Philadelphia. — .At a
stated meeting of the College of Physicians of Phila-
delphia, on November 4th, Dr. Guy Hinsdale presented
a communication entitled "' Case of Foreign Body in
the Larj-nx; Death from Suffocation; Exhibition of
Specimen." Dr. A. A. Eshner read a paper entitled
" A Graphic Study of Tremor." Dr. Frederick A.
Packard read a paper entitled " Movable Liver, with
Report of a Case." Dr. John Ashhurst, Jr., read a
notice of the late Dr. W. S. W. Ruschenberger. It is
announced that the Mutter course of lectures for 1896
will be delivered in the Miitter Museum of the col-
lege, by Dr. Oscar H. .Allis, on November i8th, 20th,
24th, 27th, 30th; December 4th, 7th, 8th, r4th, and
16th, at 8 P.M. The subject of these lectures will be
"Luxations; the Traumatisms Present in the Major
Articulations."
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
November 7, 1896: October 31st. — Medical Inspector
J. L. Neilson detached from the Maine, November
loth, and placed on waiting orders; Surgeon L. G.
7i6
MEDICAL RECORD.
[November 14, 1896
Heneberger ordered to the Maine, November loth;
D. N. Carpenter and F. L. Pleadwell appointed assis-
tant surgeons from October 24th. November 2d. —
Surgeon G. P. Lumsden detached from the Yorktown,
ordered home, and granted three months' leave;
Passed Assistant Surgeon J. E. Page detached from
the Boston and ordered to the Yorktown; Passed
Assistant Surgeon G. Rothganger detached from the
Oregon and ordered to the Patterson ; Passed Assis-
tant Surgeon R. M. Kennedy detached from the Pat-
terson, ordered home, and granted three months' leave ;
Assistant Surgeon R. S. Blakeman detached from the
Vermont, November 12th, and ordered to the Boston,
per steamer of November 21st; Assistant Surgeon W.
M. Wheeler detached from the Franklin, November
12th, and ordered to the naval hospital, Mare Island;
Assistant Surgeon A. Farenholt detached from the
Mare Island naval hospital and ordered to the Ore-
gon; Assistant Surgeon S. B. Palmer detached from
the naval laboratory, Nevif York, and ordered to the
Vermont. November 5th. — Assistant Surgeons D. N.
Carpenter and F. L. Pleadwell ordered to the naval
laboratory and department of instruction. New York.
Killed by His Patient. — Dr. J. S. Wintermute, of
Tacomah, Wash., was shot and killed November nth
by a patient whom he was treating for melancholia.
Tuxedo Quarantined. — An epidemic of diphtheria
of virulent type has recently occurred at Sloatsburg,
Rockland County, N. Y., in which out of fifteen cases
there occurred five deaths. For some time Tuxedo
was quarantined against Sloatsburgers.
Department of Charities. — A contract has been
given out for uniforms for all employees of the depart-
ment and they are now having their measure taken.
Physicians, we understand, are exempt from the work-
ings of the rule.
Bellevue Hospital Dispensary has been renovated
in several important particulars. Wooden floors have
been wholly done away with and replaced by asphalt
with automatic central drainage. The whole interior
has been repainted.
Medical Examination by Civil Service. — The
New York City civil service commission will hold
the following examinations at its office, in the new
criminal court building (corner of Franklin and Cen-
tre streets) at 10 a..m. on the dates given. Applicants
must be citizens of the United States, residents of the
State of New York, eighteen years of age and over.
Applications may be obtained from S. William Bris-
coe, secretary, new criminal court building. New
York City. November 24th, assistant bacteriologist,
health department. Candidates must hold degree of
M.D. and possess knowledge of general bacteriology.
Salary, $1,200 per annum. November 24th, assis-
tant bacteriologist, health department (temporary).
Candidates must hold degree of M.D., and possess
knowledge of general bacteriology. Salary, $600 per
annum. Medical chief of staff, department of public
charities. Candidates must hold degree of M.D. and
have had experience in hospital organization and
management. Salarj', S3, 000 per annum.
Marine Hospital Service. — A competitive exami
nation will be held in Washington on P'ebruary 3,
1897, for the position of assistant surgeon in the
United States Marine Hospital service. After four
years of service a second examination is held for pro-
motion to the grade of passed assistant surgeon. The
salar}' of assistant surgeon is $1,600, quarter.s, light,
fuel. That of passed assistant surgeon Si, 800, and that
of surgeon $2,500. Information can be obtained from
the surgeon-general of the Marine Hospital service.
Cleveland Medical Society — It appears that an
Ohio man was elected as a member of the judicial
council of the American Medical Association at its
last meeting who was objected to by the Ohio member
of the nominating committee. In his official capacity
the gentleman elected seems to have prevented the
recognition of delegates from the Cleveland Medical
Society and thus returned the compliment. Now the
members of the Cleveland Medical Society have
agreed among themselves to keep away from the next
meeting of the American Association. It is said that
the Ohio State Society approves of the Cleveland So-
ciety's action.
Contract Practice. — Resolutions have been signed
by nine-tenths of the Santa Clara, Cal., physicians
pledging themselves not to enter into any agreement
or contract to render medical or surgical service at
reduced rates to any association or organization.
A Hospital Reform Association, having for its ob-
ject the correction of abuses which exist in the out-
patient departments, has been organized in London.
While wishing the association all success, we would
state that an attempt has been made in this direction
here, and unless London hospital managers and phy-
sicians differ greatly from our own, little or nothing
will be accomplished. There are a few things in the
world which seem beyond reformation, and the dis-
pensary physician who once acquires a taste for large
classes of well-to-do patients is one of them, and an-
other is the ''professor" who boasts that his interests
have nothing in common with those of the young and
struggling practitioner, and that abundant material
must be provided for his clinics, no matter from what
source the patients are drawn or who is injured.
London, too, has her noises of unnecessar)' nature
of wliicli to complain, but there they do something at
least looking to their abatement. The county council
have just resolved " that the local government and
taxation committee should further consider the matter
and report with a view to the mitigation or suppres-
sion of such street noises as constitute a public nai-
sance.'" Will our honorable board of aldermen allow
the London gentlemen to outdo it?
Errata. — In Dr. Craig's article on the "Plasmodium
of Malaria," published in the issue of November 7th,
the authorities quoted as " Doch" and " Dambewsky"
should read Dock and Danilewsky. In Dr. Louis
Fischer's remarks on "Weaning of Infants," p. 612,
the amount of salt used in the cow's milk should
be from ten to fifteen grains, instead of ten-fifteenths
of a grain, as printed.
November 14, 1896]
MEDICAL RECORD.
717
Philadelphia Neurological Society. — At the open-
ing meeting of the Philadelphia Neurological Society
on October 26th Drs. De Forest Willard and William
G. Spiller presented a communication entitled "Con-
cussion of the Spinal Cord (Railway Spine)."
Northern Medical Association of Philadelphia. —
At a meeting of the Nortliern Medical Association of
Philadelphia, on October 23d, Dr. Samuel Wolfe read
a paper on '"Puerperal Convulsions." The associa-
tion will shortly celebrate the fiftieth anniversary of
its organization. It is thus a little older than the
American Medical Association and by several years
the senior of the Philadelphia County Medical Society.
Philadelphia County Medical Society. — At a meet-
ing of the Philadelphia County Medical Society on
October 28th Dr. Joseph Price read a paper entitled
" Surgery for Typhoid Perforation,'" in which he re-
lated three cases of intestinal perforation, probably of
typhoid origin, in which recovery followed operation.
Dr. J. T. Rugh read a paper entitled " Profound To.xic
Effects from Drinking Large Amounts of Strong Cof-
fee." Dr. John B. Roberts read a paper entitled " The
Perfect Surgical Needle; with Remarks on Common
Defects in Needles." The needle recommended was
the ordinary glovers' needle properly polished and
sharpened.
Additional Laboratory of Bacteriology at the
University of Pennsylvania. — A laboratory of bac-
teriology has been established at the University of
Pennsylvania in connection with the courses in veter-
inary medicine, to be under the supervision of the
State live-stock sanitary board and in direct charge
of Dr. M. P. Ravenel, instructor in bacteriology in the
medical department of the university. Special atten-
tion will be given to the study and investigation of
the diseases of poultry and cattle. Arrangements
have also been made for the preparation of tuberculin
for employment in the treatment of tuberculosis in
cattle. This laboratory work is independent of the
course in bacteriology already offered to students in
the medical department of the university.
Medical Students at Vienna. — During the last
summer semester there were 2,228 students of medi-
cine at the University of Vienna, 1 10 fewer than there
were the corresponding semester of 1895. According
to the university calendar, recently issued, there will
be held during the present winter 271 courses by 29
ordinary professors, 36 extraordinary professors, and
94 Privatdocents and assistants. The number of
courses in the various subjects is as follows: histor\
of medicine, 2; anatomy, 8: physiology, 13; pa-
thology, 16; pharmacolog)', 6 ; medicine, 63; surgery,
47; otology, 13; ophthalmology', 28: midwifery and
gynecology, 29; syphilis, 17; mental pathology, 8;
public health, 10; chemistry, 9 ; and veterinary med-
icine, 2.
Moral Turpitude in a Physician. — The medical
board of Oregon was recently requested to revoke the
license of a physician for getting drunk and using
forcible language. The board agread, however, with
the counsel of the accused that getting drunk was only
a violation of a city ordinance, and even when fre-
quently repeated did not involve any inherent base-
ness of character. It was established that a phy-
sician may get drunk and indulge in loud language
occasionally without his conduct being held to indi-
cate moral turpitude.
Hygeia Medical College of Cincinnati has had its
diplomas refused by the Ohio State board.
Dr. Black on English Hypocrisy Dr. D. Camp-
bell Black, of Glasgow, who must know whereof he
speaks, writes to The Medical Fnss that '" our moral
censors of the British Medical Association, who object
so much to advertising, take good care that their lucu-
brations at the annual meetings are reported in as
many ' lay ' papers as possible; and if this did not
happen, the association would not long be favored
with the e.xalted light of their countenances, and the
British Medical Association itself would collapse (no
great loss!) in twenty-four hours.'"
Non-Toxic Properties of Aluminium. — Recently
two healthy and robust physicians, aged twenty-six
and thirty-five, were selected by the imperial German
health bureau to undergo an interesting experiment
to ascertain whether aluminium is poisonous or not.
These two gentlemen, in order to test the non-poison-
ous proi^erties of aluminium, volunteered to swallow,
every morning for one month, fifteen grains of alumi-
nium tartrate with their lunch. At the end of the trial
neither of them had lost flesh or appetite nor experi-
enced the slightest discomfort during the entire period
of their metallic lunch. It was found that the metal
is not adapted, however, to contain for a long period
brandy, whiskey, or wine. After a time these liquids
turn turbid, and, although perfectly harmless, are not
inviting, to say the least, although for two or three
days' journey they are not appreciably acted on when
carried in aluminium flasks. — College and Clinical
Record.
The Rush Monument Fund.— Dr. Albert L. Gi-
hon, who will deserve a monument himself for his
indefatigable advocacy of every good cause which he
takes up, has issued another appeal for subscriptions
to the Rush monument fund. He calls attention to
the fact that the homoeopathic physicians of the coun-
try have raised $75,000 for a monument to Hahne-
mann, a foreigner, while less than $4,000 has been
subscribed for a monument to the American patriot.
Benjamin Rush. The navy department has already
generously designated a commanding site in the park
fronting the LTnited States Naval Museum of Hygiene,
where it will be one of the most conspicuous features
of the national capital, but there is as yet nothing to
place on this site. The American Medical Associ-
ation will meet next year in Philadelphia, and it would
be a graceful and grateful act on the part of the phy-
sicians of that city to raise among themselves the
modest sum necessary- to honor the man who brought
so great honor to their city. That would no doubt
stimulate others to give, and then there would be a
monument to the great man of which all physicians
and all Americans could justly be proud.
7i8
MEDICAL RFXORD.
[Xovember 14, 1896
Cremation of Paupers. — A petition is in circula-
tion in \\'ashington asking tiiat a crematory be sub-
stituted for the I'otter's Field.
The American Laryngological, Rhinological, and
Otological Society will hold its next meeting in New
Orleans, March 3 and 4, 1897, this being in the car-
nival season.
Sir Andrew Clark's house, which is in reality some-
what of a mansion, in Cavendish Square, vacant since
the death of its illustrious occupant, has now been
lea.sed to a manufacturing dental firm, and will be
used in part for a post-graduate dental school.
Intellectually Enfranchised, the woman physician
of Kngland now shows lier gratitude to her professional
brothers, according to The Medical Press and Circular,
October 21st, by opening an obstetrical dispensary, at
which for the sum of five shillings confinements are
undertaken.
Surgeon to the Queen. — Succeeding the late Sir
John Erichsen, Mr. Bryant, ex-president of the Royal
College of Surgeons, has been appointed surgeon-
extraordinary to Queen Victoria. The appointment
seems to have given general satisfaction in English
professional circles. Can there be anything in the
name which is attractive to English-speaking crowned
heads ?
The International Congress of Criminal Anthro-
pology, which held its fourth session in Geneva on
August 25th to 29th, will meet again at The Hague in
1901. The most practical outcome of the Geneva
congress was the unanimous adoption of a resolution
calling for legislation in all countries restricting the
sale of alcoholic liquors, and declaring it to be the
business of the congress to further such restrictive
legislation of a stringent kind.
San Francisco is to have a college of physicians
and surgeons. Articles of incorporation were filed in
June last. S. M. Mouser is president and S. C). L.
Potter secretary. The Pacific coast is fast supplying
facilities for medical instruction. San Francisco
already has the University, the Cooper Medical Col-
lege, and the Polyclinic. Los Angeles has two schools
and Portland, Ore., two.
Boston Public Institutions. — Mayor (^)uincv has
dismissed Dr. A. B. Heath from the position of com-
missioner of public institutions after asking for his
resignation, which Dr. Heath declined to hand in.
The charge against the commissioner, who was ap-
pointed by Mayor Curtis to succeed Dr. lenks, is that
the expenditures have exceeded those of his predeces-
sor by So.; ; 5140,000 per annum, leaving at the pres-
ent time a deficit in the treasury. Dr. Heath has
many friends in New York who will regret to learn
th.it, however much his free use of funds has been
pleasing to the patients and paupers under his care, it
has not had the same effect upon the tax-paying public
whom the mayor represents. Bosto:. has had the repu-
tation of caring for the citv's poor and needy in a
handsome manner, but it evidently does not like to
foot the bill.
(TUuical tlcpavtmcnt.
REPORT OF A CASE OF XASAL POLYPUS
IX A FEMALE INFANT FOUR WEEKS
OLD.'
By .ADOLPH RUPP, M.D.,
NEW VOKK,
FOKMEKLV PHYSICIAN TO THE NOKTHERN DISPENSABV AND FOR.MBKI.V AIRAL
SrRGEON, NEW \f)RK EVE AND EAR INFIRMARY.
Cases of nasal polypi in infants and young children
are so rarely observed by both pediatrists and laryngo-
rhinologists as to make the following observation
almost unique. Considering the frequency with which
catarrh of the nose is met with in children, it is re-
markable how rarely neoplasms are observed before
the age of puberty. Thus, Moritz Schmidt, in his am-
ple experience, saw and operated upon only one case,
the child being a girl six months old. Schmidt and
other specialists cjuote Cardonne, wJio saw a polypus
in the nose of a child two days old. Boswortli states
that Krakauer removed twelve polypi from the right
nasal fossa of an infant four and one-half months old.
My neighbor. Dr. Traugott Roediger, told me he has
seen one case in his extensive general practice. This
child, when two weeks old, had the polypus removed
by Dr. Simrock, of this city.
My own ca.se is a girl baby, N , four weeks old.
I was consulted because since its birth nursing had be-
come gradually more difficult, and the snufiling breath-
ing had also become gradually more marked. This
breathing difficulty had been attributed by the mid-
wife and parents to a slight '"cold in the head," until
the father thought he dis overed the real cause, in
'■ something which flapped up and down'' in the left
nasal fossa. Examining the infant's nose, I found a
pinkish pedunculated polypus, large enough almost to
occlude the left nasal air passage in the vestibule of
the nose. Its consistency was neither soft nor hard,
but friable. The attachment of the little tumor was
high up, possibly on the upper jiortion of the middle
turbinate. There was only si ight nasal catarrh present,
but in no sense was it obstructive. The rest of the nasal
passages of both fossa were clear. There was a slight
conjunctivitis of the left eye, which may have some
pathological interest but was clinically insignificant.
Neither of the parents have catarrhal affections, and
from neither coidd a svphilitic history be obtained, nor
were there any signs of syphilis about the infant.
Part of the little tumor was removed with a wire
snare (cold), and the remainder by means of a blunt
ring curette (Buck's). Very little hemorrhage ensued.
The operative results were all that could be desired —
the child was able to breathe and nurse satisfactorily
and with comfort, and slept better than it had before
the removal of the tumor.
4ot/ West Thiki^-Fulri h Street.
AP.SEXCE OF LEFT KIDNEY.
llv .1. II. SMITH, M.I) ,
M.ATTSBfKG, N. ^.
The article "Congenital Absence of Kidney," on
page 550 of the Mehicvl Record of October 17th,
brings to mind a case of the same kind in my prac-
tice: A. M , male, an inmate of Clinton Prison,
aged thirty-three, French Canadian, died in the prison
hospital on April 24, 1881, of diabetes mellitus.
Post-mortem examination showed an entire absence of
the left kidney. The right kidney was enlarged,
weighing a little more than seven and one-half ounces.
' Reported October 2S. iSq6. at a meetinK ')f ihe larynjjologi-
cal section of the -New Vork Academy of Medicine.
November 14, 1896]
MEDICAL RECORD.
•19
A COMPLICATF.I) CASE OF
POISONING.
lilCHLORIDE
By WIU.IAM EDGAR UARXALL, .M.D.,
ATLANIIC CITY, N. J.
Mrs. a , priinipara, consulted me a few clays be-
fore her labor, complaining of dysentery. Her hus-
band being sick, she had not taken proper care of her-
self; the gravid uterus, by pressure on the rectum,
had therefore set up irritation. Little could be ex-
pected from treatment under such circumstances un-
til the child was born. Two or three days later
■came the call for confinement. The process was un-
eventful; the labor was a little slow on account of its
being the first child. The exciting cause of the dys-
entery being removed, rapid improvement took place
for a day or two. The labor had been conducted with
■every care, and the uterus thoroughly emptied of its
<;ontents. No alarm was felt, therefore, for the moth-
er's safety.
On the morning of the third day after labor, how-
ever, I found the patient restless, with chilly sensa-
tions, etc. ; lochia slightly diminished and foul ; a
temperature of 102° F. ; pulse, no; and her expres-
sion anxious. The only discoverable source of infec-
tion was that she must have carried the poison from
the rectum to the vagina by carelessness during her
frequent stools. A half-gallon of i in 40 carbolic-acid
solution, with iodoform suspended, was promptlv in-
jected into the uterine cavity by means of a fountain
syringe. The temperature at once fell to normal.
About 10:30 P..M. the same day, I received an ur-
gent call to the house, the messenger stating that the
patient had been poisoned by taking the wrong medi-
cine. On my arrival I found she had been given by
mistake a bichloride tablet of one and three-fourth
grains, which had been left with careful directions for
bathing the parts. Fortunately she discovered, as soon
as she swallowed it, that it was not one of the morphine
tablets which she .vas taking 5or after-pains and called
her mother's attention to the fact. Mustard and other
household emetics were given as soon as they could
be gotten ready, and vigorous vomiting was produced
before my arrival. The whites of eggs and milk were
then ordered. Her excitement quieted, and I left her
fairly comfortable.
Next morning her temperature was 100' F., and for
seven days it dodged about from 99^ to 102.5° F., be-
ing unaffected by intra-uterine treatment. The pa-
tient, meanwhile, became worse daily. She had in-
gested enough of the bichloride to set up a severe
gastro-enteritis and relight the old flame at the lower
end of the alimentary canal. The most distressing
feature, perhaps, was the violent paroxysms of griping
abdominal pain, which constantly occurred two or
three times an hour. These dated from the poisoning,
and continued throughout the sickness. All the anal-
gesics available were tried in turn, but after a few
doses the effects of each wore off and they became
useless. Morphine did not give any relief. Turpen-
tine stupes were applied to the abdomen. Hoffman's
anodyne gave the stimulation the weakened body
needed, and kept the cramps in check longer than the
others; but it did not wholly meet the emergency.
The inflammatory condition seemed to extend from
one end of the alimentary cpnal to the other. Large
doses of bismuth with powdered acacia were adminis-
tered every four hours, with good effect. The diet
was restricted to milk and albumin water. On the
ninth day the temperature remained at normal, and the
bowel symptoms were mitigated a little. The patient
was in a precarious condition, at times almost col-
lapsed. Hot bottles and judicious stimulation were
applied. The following day she was a little brighter.
Mild a.stringents were ordered as soon as the acute
stages of inflammation were passed. From this time
on she gained strength, her acute symptoms gradually
subsided, and her recovery took place uneventfully.
Here was a case of acute dysentery complicating
labor, associated with septic infection and poisoning
with bichloride of mercury. Had emesis been de-
layed till I arrived, I feel sure the patient would have
succumbed. The case was critical enough as it was.
The continued abnormal temperature, in my opinion,
was kept up more by reason of the intestinal inflam-
mation than from septic processes in the uterus, for
it must be borne in mind that it often takes very little
to throw a puerperal woman into a fever, when there
is no sign of any septic process present. This view
is strengthened by the fact that the mild infection
present just before the poisoning occurred seems to
have been completely removed by the intra-uterine
douches, and that after the poisoning intra-uterine
treatment had no effect whatever upon the temperature.
PLASTIC OPERATION FOR MALFORMATION
OF THE NOSE CAUSED BY SYPHILIS,
WITH ILLUSTRATION.'
Bv K. L. FORKER, M.D.,
BINGH.AMTON, N. Y.
The case which I present is one made interesting
principally by the transforming effects of plastic sur-
gery. Plastic surgery was originally restricted to the
repair of the nose, but during the present century has
busied itself in different ways with the emendation
of various organs, and has thus greatly enriched the
domain of genera! surgery. It has been a field of
conquests, and the perfection to which it has attained
constitutes some of the proudest triumphs of the human
mind in modern times. I will first give you a brief
description of the case and then show you the result.
H. Y , aged twenty-two years, came under my care
at the City Hospital, May 13, 1896, and gave the fol-
lowing history: Family history good; personal health
good until fourteen years of age, when ulcers began to
appear in the mouth, nose, and throat. The end of
the nose became very red and painful, and at the end of
two weeks the tissues began to break down, the proc-
ess continuing until the nasal septum and floor of the
nasal cavities, including the central portion of the supe-
rior maxilla with the incisor teeth were carried away.
The nose continued for sometime afterward to diminish
gradually in size; after being treated for some time
this ulcerating process discontinued, and she enjovtd
comparatively good health until January, 1894, when
her right leg began to ulcerate, and in spite of treat-
ment the process had extended at the end of one year
entirely around the limb and destroyed three-founhs
of the integument below the knee, in places laying the
bone bare. All I am able to learn in regard to the
treatment received is that she was in the care of a
regular physician, who advised her to enter the hos-
pital and have her leg amputated, since it was entirely
useless. She accordingly entered the hospital, but
the surgeon-in-charge did not deem amputation neces-
sary, so after three months' treatment she was dis-
charged improved. After leaving the hospital the
ulcer again extended, and she returned in May of the
present year for further treatment. On admission her
general condition was very poor, the extensive ulcera-
tion had exhausted her strength to a marked degree,
digestion was disturbed, severe pain was felt in the
left iliac region, and a large gangrenous ulcer extended
over nearly one-half the surface of the right limb below
the knee. The external nasal tissues were too small
' Read at the annual meeting of Broome County .Medical
Society, October 6, iSyO.
720
MEDICAL RECORD.
[November 14, 1896
to cover the nasal cavities, being only three-fourths of
an inch in length and much distorted, the nasal septum
being absent, as were also a portion of the superior
maxilla, and four incisor teeth, leaving an opening be-
tween the nasal cavities and the mouth about one inch
square. The uvula and palate on the right side were
closely adherent to the posterior wall of the pharynx.
As a result of these deformities, she had a very marked
nasal voice and her sense of smell was almost entirely
destroyed. Treatment consisted of rest in bed, milk
diet, tonics, and potassium iodide. The latter was be-
gun in dose of five grains, t.i.d., and gradually in-
creased to fifteen grains. The ulcer was first thorough-
ly cauterized with nitrate of silver, and tlien antiseptic
dressings were applied daily for one montii, at which
time Thiersch's operation of skin-grafting was done
with very gratifying results, and two months from the
patient's admission to hospital tjie ulcer was entirely
healed.
The deformity in this case had not only destroyed
the normal functions of this important organ, but had
rendered the patient so repulsive in appearance tiiat
she was unable to earn a livelihood; accordingly a
successful repair of this deformity was a very impor-
tant matter to her. After consulting with various
members of the hospital staff, and receiving practically
no encouragement, I performed the following opera-
tion, after the usual preliminaries were attended to.
The first step consisted in detaching the nose at its
root and sides by two incisions, and folding it down
over the upper lip one inch; the second step consisted
in dissecting up two triangular flaps, one from each
cheek, and turning them around to fill in space created
by the first step. These flaps were composed of integu-
ment and cellular tissue about one-quarter of an incli
in thickness, and were left attached at the angle of the
space by a pedicle about one-fourth inch in diameter.
The third step consisted in suturing the flaps in their
new position and bringing together the borders of the
space left in the cheeks by means of silk and worm-gut
sutures. Iodoform along the line of suture constituted
the only dressing applied. Primary union followed
throughout and the sutures were removed on the second
day.
Considering the diseased constitution of my patient,
it was a question what would happen to the cellular
tissue covering the under surface of the flaps which
was left uncovered, but by the aid of a solution of per-
oxide of hydrogen used daily a form of mucous mem-
brane gradually crept out from the border, and at the
end of two weeks this exposed surface was entirely
covered over.
The adhesions of the uvula and soft palate were
separated at a second operation, by means of a knife
constructed for the purpose.
I next took my patient to a dentist and had a plate
constructed to fill in the cleft in the superior maxilla
and to restore the lost teeth.
.\nd now as a result of three months' treatment I
am able to report the following condition: First, a
gain of integument and healthy tissue over the right leg
of about ten inches square; second, a gain in weight
of twenty pounds; third, a gain in voice production
from a marked nasal to an almost natural tone:
fourth, a gain in sense of smell which is quite
marked, and fifth, a gain in length of nose of one
inch, which, taken together with changes produced in
my patient's cheeks by removal of flaps therefrom,
amounts to little less than a complete transformation
in her appearance.
In Memory of Pasteur The municipality of
Paris has changed the name of the Boulevard de ^'au-
rigard to that of Boulevard Pasteur.
J>ocictu[ Reports.
NEW YORK ACADEMY OF MEDICINE.
Stah'ii iVIc-etirig, Novemhir j, l8g6.
JiKSECH D. Bkv.\nt, M.l)., President, in the
Ch.mk.
Wesley M. Carpenter Lecture — The Etiology and
Classification ol Infectious Diseases. — Dk. Geukce
M. SrEkNw.kii, U. S. A., delivered the lecture. What
he should present was not claimed to be new. Etio-
logical studies had always possessed special attraction
for him, and he thought a general view of the etiology
and classification of infectious diseases might not be
out of place on the present occasion. By infectious
diseases were meant those which resulted from the in-
troduction into the body of some disease-producing
agent, and he thought we were justified in saying that
an essential condition of infection was that the disease-
producing agent must be capable of reproduction in
the body of the infected individual; in other words,
that it was a living organism. It was indiflerent
whether it was large or small ; whether it belonged to
the animal or to the vegetable kingdom ; whether is was
located in the skin, as in scabies, or in the blood, as
in relapsing fever. The introduction and multiplica-
tion of the infecting agent constituted infection.
We were now including among infectious diseases
many disea.ses which a few years ago were not recog-
nized as being due to infection — for example, tetanus,
pneumonia. The number was constantly being in-
creased. It was true, we miglit have inllammalion in-
dependent of infection, as a gastritis from the intro-
duction of a chemical poison, or in a wound from
mechanical cause; but this form of irritation did not
give rise to suppurative inflammation. It was only a
potent predisposing factor, inasmuch as the injured
tissues were thereby rendered liable to infection.
The stone in the bladder and the surgeon's instrument
did not produce cystitis, but the bacteria which caused
cystitis would be impotent without such predisposing
cause, i.e., injury. The difierence between infectious
and non-infectious inflammatory irritation from me-
chanical cause was well illustrated by some experi-
ments which he had made in 1884. Under antisep-
tic precautions he introduced finely broken sterilized
glass into tiie abdomen of rabbits, without producing
fatal peritonitis. The inflammation which occurred
was of a conservati\e kind, walling in the powdered
glass and forming nodules of various sizes. The ani-
mals remained in good health, and even gained in
weight until killed. Similar results were obtained
from introducing sterilized bodies into other tissues.
But let the foreign body carry bacteria, and we would
find a localized septic process established, if not in-
fection of the blood and pyemia.
In many diseases the infectious agent was constantly
present, awaiting an opportunity to enter the tissues or
the circulation through a broken mucous membrane or
skin. No doubt this was true of croupous pneumonia
and associated diseases. But other conditions besides
a wound for their entrance might be necessary to
favor production of the disease by the germs. One of
the objects of the address was to call attention to these
other factors. Among them was natural susceptibil-
ity to the disease, which might be increased by de-
pressing agents, such as alcoholism and unsanitary-
surroundings. Local congestion from '' taking cold'"
was a frequent factor in diphtheria, tonsillitis, pneu-
monia, etc. It had been demonstrated that a person
might carry the bacilli of diphtheria in the throat
without developing diphtheria. The same was true
of cholera germs. Further, the germs might be pres-
November 14, 1896]
MEDICAL RECORD.
721
ent and cause a mild attack of diphtheria or cholera,
which might not be recognized from the clinical symp-
toms alone, as these might seem those of a simple ton-
sillitis or a simple intestinal catarrh. Thus it became
apparent that a diagnosis based upon symptoraatolog)'
alone was not always reliable. Sometimes the most
prominent symptom depended upon a mixed infection,
and not upon the specific germ of the disease. The
laity and some physicians committed the error fre-
quently of attributing the infectious disease to the
exciting factor, as cold or injur}', instead of to the in-
fecting germ. The prevalence of certain infectious
diseases at certain seasons was to be accounted for by
the favorable atmospheric conditions for the develop-
ment of the infecting germs, or by the depression of
the patient's system and confinement within doors.
Regarding influenza, Dr. Sternberg was surprised
that so few physicians recognized its distinctly infec-
tious nature, and that its germ had been discovered
(in 1892). The impression which many had ex-
pressed, even of comparatively recent years, that it
was wafted long distances — say across a continent or
ocean — by the air, was quite without foundation.
The author mentioned only one disease whose infec-
tious agent was carried to any considerable distance
— malaria. But even in this instance, it was only
in the neighborhood of the marsh whence the wind
came. Doubt was expressed whether true malaria was
conveyed through water or mosquitoes. There were
questions of uncertainty in all reported cases. Many
of them were cases of typhoid or some fonn of infec-
tious fever different from typical malaria. The Plas-
modium of malaria was frequently reported as present
when it was not, as there w-ere other conditions of the
blood which resembled it more or less. Continued
absence of the malarial parasite from the blood and
failure to respond to quinine was pretty positi\ e evi-
dence that the case was not one of malaria.
Classification of Infectious Diseases. — Dr. Stern-
berg said, regarding the classification of infectious
diseases, that any attempt in this direction, based on
present knowledge, must be more or less incomplete
and provisional. One classification might be as fol-
lows, based on the channel of contagion : (a) Trau-
matic infections; (/') infection by contact or direct
contagion: (() infection through ingesta; (</) infection
through the respiratory tract. Another classification
might be based on the nature of the infectious agent:
I, Diseases due to infection by vegetable parasites, of
which there were several subdivisions; 2, diseases due
to animal parasites, of which there were several subdi-
visions. Further, a classification might be made
which was based on the special tissues involved, as
the blood, the skin, mucous membranes, serous mem-
branes, glands, lungs.
The academy extended to Dr. Sternberg a vote of
thanks for his instructive address.
The Physical and Schott Treatment of Chronic
Cardiac Disease. — Dr. H. Newiox Heineman read
this paper. Contrary to the opinion which he had ex-
pressed in a paper read before the academy seven
years ago, he now believed the physical and Schott
treatment of chronic heart disease gave the best re-
sults. This conclusion was based on observation and
experience with the method, as carried out at Bad
Nauheim and elsewhere in Europe. The waters at
Bad Xauheim were chalybeate, but also contained a
high percentage of chloride of sodium, calcium chlo-
ride, etc., and were strongly impregnated wdth carbonic
acid gas. The temperature was from 83° to 93 F. in
the baths, which were taken either in the sprudel bath
{Sprudelstrom) or after more or less of the gas had
escaped, as it did when the water was allowed to
stand in the open tub. The longest stay in the bath
did not exceed twenty minutes. It should be followed
by an hour's rest. The author pointed out the differ-
ent effect of these baths and fresh-water baths. The
benefit did not come from absorption, for it had long
since been shown that there was practically no absorp-
tion in baths. The effect of the bath on the heart had
been shown by physical signs and by the .r-ray.
After the treatment had been started, a diminution in
the dilated heart cOuld be observed after the individ-
ual bath, and a progressive diminution was demon-
strable. In addition to the bath, resistance movements
were practised. These were made slowly and without
special exertion, each successive movement bringing
into exercise a different set of muscles. While these
were being carried out, the pulse, respirations, and alae
nasi should be watched. F'ive to ten minutes was long
enough for exercise at the commencement, but the time
should be e.\tended gradually to thirty minutes; and
when a second seance was held the same day it should
be only for twenty minutes. Always go slowly. The
reduction in the size of the dilated heart might be ob-
served in one or both ventricles, one or both auricles,
and diminution in different directions. The gain was
lost in a degree by the following day, but gradually
one succeeded in attaining that size of the heart which
gave the most perfect muscular accommodation. While
he was at Bad Nauheim the majority of patients re-
ceived only the bath and exercises, yet in general
practice one should omit no means by which the pa-
tient might be benefited. Diet should be regulated.
In explaining the benefit derived from the bath. Dr.
Heineman laid most stress on the surface influence.
There were a few cases of cardiac disease in which the
treatment was contraindicated. Among them were
complications by pulmonary infarction, excessive de-
bility, advanced arterial sclerosis, aneurism of the
aorta, acute and chronic Eright's. Some of these only
required special precautions. The treatment was of
most benefit in cases of irritable heart independent of
changes; cases of relative inefficiency; in that large
group, cardiac valvular lesions; and in angina pecto-
ris. During the past year he had followed one hun-
dred and twenty cases at Bad Nauheim. Of these,
considerably more than half had come the second
year, and many had returned yearly for three or more
years. By such cases the permanency of the improve-
ment had been established beyond doubt.
Gymnastics and Fatty Heart Dr. A. J.acobi
thought it worth while to mention the fact that neither
the author nor the doctors at Bad Nauheim regarded
the baths as a cure for all heart diseases. Regarding
gvmnastics, he thought they would be of special bene-
fit when the muscle of the heart was defective. The
exercise should be frequently repeated and not too vi-
olent. There were cases of fatty degeneration of the
heart and of over-fat. It was in the latter that gvm-
nastics were specially beneficial. But there was noth-
ing more dangerous than to try to reduce the overgrown
heart too rapidly.
Dr. Willi.\.m H. Thomson said his experience had
been limited entirely to gymnastic e.xercises in this
treatment, but he now proposed to extend it to the
baths. From exercises he had seen striking results.
He would attach a good deal of importance to the re-
flex dilatation of the small arteries, which were con-
tracted reflexly as well as narrowed by arterial change,
especially in Bright's. This opening of the small
blood-vessels by the bath went far tow'ard relieving
the heart.
Dk. Jacob Teschner read the histories of three
cases, in which there was marked improvement of the
pulse and diminution in the size of the dilated heart
dependent upon valvular lesion, following gymnastic
exercises, prescribed more particularly for rotary lat-
eral spinal curvature, in the manner which he had de-
scribed on former occasions. These exercises were
MEDICAL RECORD.
[November 14, 1896
pushed more rapidly than those recommended by the
author, but they were not violent.
Dr. F. W. Jackson e.xpressed surprise that more at-
tention had not been directed to the method in Amer-
ica. He asked Dr. Heineman whether the elTect upon
the heart could be accepted as permanent, or whether
it was only temporary compensation, which was likely
to be lost, at least if the patient did not continue his
visits to the bath. He thought the method could be
adopted with advantage at bath springs in this coun-
try.
Dr. Heinemax said the patients came back to the
baths to retain, not to regain. After practising the
treatment a while, cardiac tonics which had lost their
power could again be used with effect. He agreed
with Dr. Thomson that the influence upon the capil-
lary circulation was an enormous factor in relieving
the heart. He again impressed the necessity for not
hurrying; otherwise, harm would be done in nine cases
out of ten.
Semicentennial of the Academy. — The Presi-
nENT, in accordance with a resolution recommended
from the council, appointed several committees on the
approaching semicentennial of the academy.
SECTION OX NEUROLOGY.
Stated Meeting, October jo, i8g6.
Pearce Bailey, M.D., Chairman.
The Relation of Toxic Agents in the Production
of Nervous and Mental Diseases. — Dr. Ira \'an
GiESON read parts of several papers on this subject
which he had prepared for another audience but had
not presented. The following were the subjects of the
several chapters: i. The homology of the structure of
the nervous system with that of the general viscera and
tissues of the body. 2. The homology of the diseases
of the nervous system with those of the simpler organs
of the body, as the kidney or liver. 3. The significance,
reasons, and explanation of the fundamental patholog-
ical processes, such as degeneration, necrosis, and
inflammation. 4. Separation of the toxic diseases.
5. Acute degeneration of the nervous system. 6. Res-
titution or destruction of ganglion cells after acute
degeneration. 7. Acute degeneration of the nervous
system from auto-intoxication. 8. From extrinsic
poisons. 9. Acute exudative inflammation of the
nervous sy.stem. 10. Sequela; of acute exudative in-
flammation of the nervous system. 11. The occur-
rence of acute bacterial toxa*mias of the nervous system
apparently independently of somatic disease, and on
the distribution and selective action of poisons on the
several departments of the nervous system. 12. Acute
parenchymatous degeneration and exudative inflam-
mation of the spinal cord. 13. Acute toxic lesions
of the pia mater and the relations of the pia mater
to the central nervous system in the toxic diseases.
14. Chronic degeneration of the nervous system.
15. Several examples of that, mainly the systemic dis-
eases of the spinal cord, such as locomotor ataxia and
others of the so-called system diseases of the cord.
Our knowledge of the effects of toxic agents upon
the nervous system, he said, was much more limited
than with relation to other parts of the body. The
nervous system had been looked upon as something
apart from the rest of the body, as if it were not sub-
jected to similar pathological processes. During the
past fifty years it had been studied in a topographic
sense. Furthermore, formerly it was thought that as
long as the ganglion cell was not blotted out changes
were likely to be overlooked, whereas now it was
known that the ganglion cell itself might remain and
yet show change more or less destructive.
The laws of pathological processes were few, were
uniform and unavoidable. Nor did the brain escape
them. They were not modified greatly in the nervous
system, although the clinical results were much more
complex on account of the varied functions of the
nervous system and the intricacy of its anatomv.
Neurologists had plunged into the study of the ner-
vous system without the preparation which came from
studying similar processes as they occurred in simjiler
organs in which they could be understood more readilv
and their significance interpreted. All sorts of clini-
cal names had bgen given to nervous symptoms which
were in reality due to but a few basic changes in the
nervous tissue, similar to what was often seen in other
structures of the body. The majority, if not nearly
all, of the diseases of the nenous system were depend-
ent upon or secondary to diseases of the general body,
and these were usually due to or associated with poi-
soning from intrinsic or extrinsic toxic agents — bac-
teria and their poisons, auto-intoxication, alcohol, etc.
After pointing out the homology of the structure of
the kidney and nervous system, each containing pa-
renchyma and stroma, the author mentioned the several
lesions of the kidney and their analogous conditions
in the nervous system. For instance, acute parenchy-
matous nephritis, so often present in connection with
infectious and contagious diseases, had exactly its
counterpart in the brain — a fact of great importance
but very little recognized. When the poison produc-
ing the lesion was not too voluminous or intense, the
cerebral as well as the renal tissue returned to its
normal state and the symptoms disappeared. Acute
and chronic diffuse nephritis, in which both the paren-
chyma and stroma of the kidney were involved, were
exemplified in the nenous system b)' some form of
general paresis. Fven the pia could be stripped off,
carrying with it .some of the cortex in some cases of
general paresis, just as the capsule of the kidney could
be stripped off in the similar condition in that organ.
Chronic interstitial inflammation in the kidney also
had its analogy in the brain. The early stages were
difficult to identify. It was seen in certain epilepsies.
Lesions corresponding to all of these were seen in the
brain, and were caused largely by the same things
which produced the lesions in the kidneys.
The author then passed to the etiology, and referred
as a most valuable article upon the subject to one en-
titled ■■ Immunity and Cure," by Dr. F. Stanley Abbot.
As already suggested, the chief cause was poisons, and
among these were bacteria, and especially their secre-
tions. At this point Dr. Van Gieson dwelt upon the
manner in which the bacteria gained entrance to the
body and the way in which the latter tried to cast
them out or to counteract their injurious influences.
There was an effort to limit them to the point
of entrance and also to neutralize their toxic agents.
The degenerative processes themselves were conserva-
tive, but of course at great cost to the tissues. In
disease, therefore, there were two factors, one pertain-
ing to the invader or the bacteria, the other to the
host. The bacteria varied in virulence and kind;
number was important; and there was the question of
mixed infection. Therefore this side of the equation
was a very variable one. The same was true of the
other side, the bodily resisting forces. In some per-
sons they were generally powerful, in others slight; in
some organs strong, in others w<ak: and varied at
difl^erent times as well as in different individuals of
the same and different races and according to the kind
of bacteria which were the invaders, etc. In tubercu-
losis and pneumonia the variation of these factors was
not so great but that they produced a pretty constant
result, whereas in typhoid it might vary greatly. In
typhoid with brain symptoms we might assume that
the bacterial forces were powerful or the bodily forces
weak. The lesions themselves varied to a certain
November 14, 1896]
MEDICAL RECORD.
extent both in degree and locality, but of tlie symp-
toms it could be said that they were kaleidoscopic, so
great might be the variations.
Acute degeneration of the ner\ous system had its
homologue in acute parenchymatous nephritis, acute
degeneration of the liver or of other organs, and was
seen in a great variety of acute infectious diseases, the
eruptive fevers, sunstroke, auto-intoxications, cachexia
from removal of the thyroid, eclampsia, poisoning by
alcohol and phosphorus or other drugs. All of these
things, if the poison were not too intense, acted in the
same way, causing acute degeneration of the nervous
system. The chromophyllic plaque within the cell
disintegrated in greater or less degree, and the cell
might even be destroyed. This disintegration of the
plaques might be in itself conservative, having an
antagonistic effect upon the poison or uniting with
it and producing an inert compound. U'hen the
dividing line existed between destruction of the cell
and the stage at which it could be restored, he had
considered in a separate chapter on the restitution of
the cell after degeneration. In one case of autopsy
after typhoid fever he had found nearly universal
breaking up of the chromophyllic plaques, yet the
woman had had no more delirium nor cerebral symp-
toms than the ordinary case of typhoid fever, which
would seem to show that such an amount of change in
the nerve cells was not uncommon in this disease and
restoration might still be possible. In fact, it seemed
remarkable to what an extent the brain cells could
recover after acute degeneration, just as happened
with the kidney cells. In -alcoholism this was also
seen, but it was evident that alcoholic poisoning could
not continue indefinitely without irremediable destruc-
tion of the brain cells.
Acute exudative inflammation of the nervous system
was generally misunderstood. It had been thought to
be an individual disease of the nervous system called
multiple sclerosis, the basic change and its cause hav-
ing been overlooked. It was a question of intensity
or amount of the poison, for the greater the intensity or
volume the greater was the effort of nature to protect
herself. This was accomplished by throwing out an
exudate, and this in multiple sclerosis resulted in
patches of sclerotic tissue. Landry's paralysis was
explained in a similar way.
Dr. \'an Gieson thought the freedom of the terminal
circulation of the given portion of the ner\'ous system
had much to do with its power to resist bacteria and
poisons. The pia mater was a network of blood-ves-
sels, and in that portion of the cortex w here the circula-
tion was freest the power of resistance and restitution
was greatest. Tuberculosis affected the base more
than the vertex.
Dr. Frederic Peterson opened the discussion.
He thought there was, besides pathological evidence,
also much clinical evidence in favor of the facts pre-
sented. Regarding insanity, the more we studied it
clinically the more circumscribed became the class of
cases which we had heretofore looked upon as with-
out special cause. He mentioned some cases in
which the evident cause was either intrinsic or
extrinsic poison. In one of them autopsy showed
renal disease as the source of the poisoning: in
another there was poisoning from bisulphide of car-
bon. Both patients were maniacal; one became
comatose.
Dr. p. yi. Wise, state commissioner in lunacy,
thought no one who had observed psychoses in hos-
pitals for the insane and the effect of treatment could
have reached any other conclusion than that a large
proportion of cases of insanity were of toxic origin.
He thought disease of the kidneys was the source of
the poisoning in a large number. There were insom-
nia and mental depression, which might go farther.
One of his assistants had found in some cases of peri-
odic insanity a relation between the attacks and the
quantity and quality of the urine. Acting on this
information he had sometimes been able to abort a
threatened outbreak of the mental symptoms by stimu-
lating kidney elimination.
Dr. George Bicgs emphasized the importance of a
knowledge of general pathology in studying the dis-
eases of the nervous system. The theory of the toxic
origin of most nervous diseases impressed him as a
very plausible one. It was certainly sufficient to ex-
plain a large number of them.
Dr. E. D. Fisher remarked that the author had
mapped out an immense scheme, one which would, as
suggested, permit of a great deal of amplification.
He regarded the paper as the most suggestive one that
had been read on any similar topic for a long time.
Regarding the etiology of nervous diseases or symp-
toms, Dr. Fisher thought the infectious diseases pro-
duced only very slight nervous symptoms usually, and
the toxic influence on the nervous structures could not
be great. He thought the cerebral symptoms corrt-
sponded more closely to the rise of temperature. As
to extrinsic poisons, alcohol produced immediate
effects, it was true, but these passed off, and then we
could observe no change in the cell. In chronic alco-
holism there was another factor to be considered. It
was the change in the arteries, not the direct effect
upon the nerve cells, which was the striking feature.
Cell degeneration here was not due directly to the
alcohol, but to diminished circulation through arterial
degeneration. While the paper was a most interesting
one, he thought it laid too much stress upon toxic
agents in the etiology of diseases of the nervous
system.
Dr. Granger said that fifteen years ago the alienist
considered scarcely anything but brain diseases and
what he could find in the brain itself. Pathology from
a broader view had then hardly been considered. We
w'ere now largely engaged in unlearning what we had
learned fifteen years ago. The study of the diseases
of the nervous system had been much broadened. Dr.
Granger referred to several cases of acute mania in
certain fevers, particularly typhoid, and attributed it
to poison acting on the nervous structures, as suggested
in the paper.
Dr. Bernard Sachs remarked that Dr. Van Gie-
son had given a great deal for one evening, yet he
had, no doubt, withheld more than he had had time
to read. Dr. Sachs had no criticisms to offer, but
thought there was a possibility of going to an extreme
in generalizing. Regarding toxic agents, it seemed
the author did not believe so much in differentiating
between the bacteria. It was possible to go too far
in this direction and cast aside valuable work done by
bacteriological investigators.
Dr. Ewini; was surprised to hear the author state
so definitely the changes which took place in the nerve
cells in toxic conditions. In the course of his study
he had been unable to make positive statements. The
subject was still a very complex one.
Dr. M. Putnam Jacobi mentioned some attempts
which had been made to show the association of cer-
tain forms of mental disturbance with given kinds of
bacterial or toxic poisoning, or certain diseases or
disturbances of the general system. In this connec-
tion influenza was mentioned, and dilatation of the
stomach, in which stomach irrigation relieved attacks
of mental depression. She also mentioned a case of
muttering delirium in typhoid succeeded by system-
atized delirium, and was unable to draw the line be-
tween the influence of the typhoid poison and of prior
alcoholism in producing the mental symptoms. Fere
had claimed to obser\-e a diminution of urine preced-
ing epileptic attacks, pointing to an accumulation of
MEDICAL RECORD.
[November 14, 1896
toxic principles in the tissues before the attack and
elimination afterward.
Dr. Herter thought progress was going to be along
the line mapped out by Dr. Van Gieson. In his opin-
ion the author had been sufficiently cautious in his
statements. He could not agree with Dr. Fisher in
his exceptions. In studying the influence of the
urine, too much attention had been given its clinical
aspect and its influence on lower animals.
Dr. Bailey said the presumptive clinical evidence
of intoxication as the causative factor in nervous and
mental diseases was very strong, yet absolute micro-
scopic and chemical proof was far from being com-
plete.
Dr. Van Gieson made some concluding remarks,
and was requested by the section to present the rest of
his paper at some early meeting.
'J'HE NEW VORK PATHOLOGICAL SOCTETV.
Stated Meeting, October 14, iHg6.
John Slade Ely, M.D., President.
Malformation of the Genital Organs ; Probably a
Case of True Hermaphrodism. — Dk. Carl Peck,
present by invitation, presented specimens taken from
an individual, twenty-one years of age, upon whom he
had performed laparotomy last June. The patient
died of pneumonia sixteen days later. One specimen
showed a well-developed penis, with the e.xception of
the urethra, in the place of which was a slight depres-
sion. There was an infundibulum, very closely re-
sembling the introitus vaginae. The membrane cov-
ering this was easily broken through, and disclosed a
vagina and an infantile uterus. The patient stated
that he had been regarded as a girl up to his seven-
teenth year, and that he had had sexual connection
from the fifteenth year. He then assumed the male
attire. There had been no menstruation, according to
the history. At the time of the operation, which was
done for the removal of two pelvic tumors, it was
found that the removal of the larger growth was very
difficult on account of extensive adhesions. The two
tumors tilled up the small jsclvis, the larger one reach-
ing up as high as the umbilicus. The pedicle of each
tumor was rather thick, and was attaciied to the peri-
toneum about half an inch laterally from the symphy-
sis and about one-fourth of an inch below the os pubis.
Dr. Beck said that he had a distinct impression that
on the right side an ovary could be felt, but, just as he
was endeavoring to examine into this point more care-
fully, the patient's respiration suddenly ceased, and
this abruptly terminated the examination and also the
operation. Unfortunately, the autopsy had been per-
formed in his absence, and many interesting points
had been consequently overlooked. The pathologist,
Dr. Brooks, reported that the tumor consisted of mixed
elements, making it impossible to classify it. The
bulk of the growth was composed of eiTibr)-onic tissue,
and the tumor apparently belonged to the teratomata.
He had shown these tumors to several eminent medi-
cal gentlemen, and none of these had cared to express
any distinct opinion on the question of whether these
growths were testicles or ovaries. Xo seminal vesi-
cles had been found. Dr. Torek had informed him
that this patient had been admitted to the Skin and
Cancer Hospital last year, and had been treated by
Dr. Fox for syphilis.
Discussion. — The President said that the decision
as to the actual sex in this case depended upon
whether these tumors were ovaries or testicles, or
whether one was an ovary and the other a testicle.
Such cases had been reported. An examination of the
specimen seemed to him to indicate that the case was
one of pseudo-hermaphrodism of the male type, with
failure of union of the lateral halves of the body at
the time of the completion of the external genitals,
and with the persistence of the remnants of the Miil-
lerian duct, which ordinarily becomes atrophied in
man, but which in the female is developed into the
uterus and Fallopian tubes. In a number of cases of
masculine pseudo-hermaphrodism, uteri of about this
size had been described as a result of the persistence
of a portion of the Miillerian ducts. In a case like
this, in which positive evidence was lacking, the fact
that the definite function of the male had been per-
formed should have considerable weight in reaching
a decision. Certainly, the penis in this case bore a
much closer resemblance to the true penis than to a
hypertrophied clitoris, although Ziegler pictures a hy-
pertrophied clitoris which very closely resembles the
organ found in this specimen.
Dr. H. J. GARku;i'Es, present by invitation, said
that in order to understand these cases of hermaphro-
dism, whether true or false, we must go back to the
history of development. Before the tenth week we
could not distinguish the sex at all. It should be re-
membered that the development takes place from three
different localities, viz.: (1) For the outer part the
starting-point is the genital tubercle and genital fold.
(2) Inside of that are the Miillerian and Wolffian
ducts. The former develops into the Fallopian tube
and uterus in the female; tJie other duct becomes the
vas deferens in the male,, and is often found as a rem-
nant in women. (?) The sexual glands are devel-
oped from the epithelium covering the Wolffian body.
Bearing these facts in mind, he said, it was evident
that anyone of these three parts could assume the type
of the opposite sex. In spurious hermaphrodism,
there is only one sex, and there is an opposition be-
tween the outer part and the inner part. In true herm-
aphrodism, there must be at least one testicle and
one ovar)-. A microscopical examination was neces-
sary to prove a case one of true hennaphrodism. So
far as he knew, there was only one reported case of
true hermaphrodism — i.e., one in which there had been
a microscopical examination to confirm the diagnosis.
This was the case of a little child, who lived only
one month. In this case there were two testicles and
two ovaries, and the nature of all of these organs was
demonstrated by microscopical examination. There
was no difficulty, he said, in understanding how one
sexual gland might take the male type, and the other
the female type; nor in understanding how the glands
might both belong to one sex, and the external geni-
tals to the other. But how could there be both ovaries
and testicles? The explanation probably was to be
found in the different origin of the stroma of the testi-
cle and the ovary. According to Waldeyer, the semi-
nal canals of the testicle were formed by invagination
from the Wolffian ducts, while the follicles in tlie ova-
ries were formed from the germ epithelium.
Dr. Garrigues said that he had seen the two tumors
in the case under di.scussion, just after their removal
from the patient, and hence while in the fresh state.
They had appeared to him to be sarcomata. He had
also had the opportunity of examining the patient
while alive, and had in this way been able to diagnos-
ticate an entirely normal virginal uterus. A certain
journal had made the statement that these cases were
quite common, but this seemed to him a gross exag-
geration. During twenty-five years he had made a
considerable number of examinations, and he had
never seen a specimen as well developed as this one.
He had measured the uterus in this case, and had
found it two and one-fourth inches deep. On the left
side was an entirely normal ovarian ligament, one
November 14, 1896]
MEDICAL RECORD.
and one-fourth inches long, which hid been abruptly
cut off. The same was true of the broad ligament
on that side. On the other side the post-mortem
knife had left only short tabs to indicate the site of
these parts. In his own mind he felt sure that this
was a case of true hermaphrodism, and hence he re-
gretted exceedingly that a minute examination had not
been made. He knew of an individual, now alive,
who not only menstruated, but possessed semen. The
left side of this individual looked like a male, and the
other side like a female.
Dr.. J. F. ERDM.A.NN, present by invitation, said that
he bad also seen the specimen. He could not add
materially to the report of this case, but desired to re-
fer to an interesting clinical history recently sent to
him, which bore on the subject under discussion.
The patient was about twenty-five years of age, aud
had all the appearance of a female as regards the
mammary development, and all the appearance of a
true hermaphrodite as regards the development of the
genitals. In the labia majora on both sides were what
appeared to be testicles, and there was also a vagina.
The patient would not submit to an examination with
the finger or with a sound. He stated that he had
had sexual connection after the manner of the male
sex. Recently a specimen had been shown in the
genito-urinary .section of the academy which was really
an example of the false type of hermaphrodism.
Dr. Beck, in closing, said that he personally had
very little doubt that this case was one of true hermaph-
rodism. It was not certain that there had not been
menstruation in this case, for the patient might have
had it and denied the fact. The fact that this patient
had had a chancre — the initial lesion of syphilis — on
the male organ would also be in favor of the opinion
that this organ was a true penis.
Congenital Occlusion of the Bowel. — Dr. Tho.m.as
S. Sot THWORTH presented a specimen. The child was
one of twins, and died when five days old. The other
twin died after two hours and a quarter, and the au-
topsy showed congenital pulmonarv- atalectasis. In the
child about to be presented there had been no asphyxia
at birth. On the first day a little mucus had been
passed from the bowel, and the infant also vomited.
On the third day, there ha\ing been no further dis-
charge from the bowel, castor oil was given, without
effect. On the fourth day there was a little vomiting,
but there was no ftecal odor to it. The little finger
was passed a short distance into the rectum and a
catheter was also introduced in the same way. The
only result of this examination was the discharge of a
long string of mucus. Just before death, on the fifth
day, there was fffical vomiting. Post-mortem examina-
tion showed the lungs fairly well aerated and the heart
normal. The stomach was distended with gas, and
Its greater curvature was turned upward by the dis-
tended intestine. The peritoneum contained from
four to six drachms of bloody fluid and a few stringy
clots. The small intestine protruded from the abdo-
men on making the first incision. The small intestine
and the vessels of the mesentery were injected. The
intestine was distended with a yellow ish fecal matter.
The lower part of the ileum was green and contained
meconium. The diameter of the gut at the point of
greatest distention was about three-fourths of an inch.
In the ileum, and about two inches above the C£ECum,
the bowel was filled with a rather firm mass of fa;cal
matter and mucus. Below- this, the ileum was con-
tracted and nearly empty. A probe could be easily
passed through the ileo-cacal valve. The caicum was
exceedingly small and the appendix was normal. The
colon varied from one-eighth to three-eighths of an
inch in diameter. The rectum was a little larger and
admitted the little finger up to the first joint. It was
connected to the sacrum, and appeared to have been
torn from its attachments. This probablj' accounted
for the bloody fluid found in the abdomen.
The speaker said that cases of congenital occlusion
were rare. It had been stated that only two cases had
been found in the Vienna Hospital in over one hun-
dred thousand children. There might be: (1) An ab-
normally short or double bowel: (2) a double C£ecum
and appendix; (3; abnormal positions, due to unusual
length of mesentery, to hernia through the diaphragm,
orto transposition of the viscera; (4) congenital absence
of portions of the gut, a condition generally met with
in poorly-developed and acephalic monsters; (5) the
stenosis might exist in the form of one or more rings.
Atresia was only a more advanced condition. The most
frequent sites were the beginning of the rectum, the end
of the rectum, at the duodenum, and at the lower end
of the ileum. Occlusion might also occur from anom-
alies connected with the omphalo-mesenteric duct.
The persistence at the umbilicus of a portion of this
duct might give rise to "mucous polyp of the umbili-
cus,'' or it might result in a blind pouch, extending
out of the ilemn. Sometimes there was only a cord,
extending from the ileum to the umbilicus.
The etiology was briefly summarized as follows:
(i) The duct may be occluded by a fold or diaphragm
of mucous membrane, a condition which is most com-
mon in the duodenum or jejunum; (2) such malfor-
mations are ascribed to arrested foetal development,
or to accidents in development; (3) the occlusion may
be due to fcetal peritonitis; (4) it may arise from
changes in the peritoneum in early foetal life, resulting
in adhesions or constricting bands; (5) there may be
obstruction at the junction of the ileum and omphalo-
mesenteric duct, due to an excessive twisting of the
umbilical cord — an increase of the normal condition
at this point. If the twist extends to the intestine
itself, atresia occurs. In the case just presented, the
stenosis was about two inches above the ileo-c£ecal
valve, and there was very imperfect development of the
entire large intestine.
A New Morphological Element in the Cones of
the Retina -" The Kuttarasome Body."— Dr. Ira
Van Giesox said that the cones of the retina had
been studied only as regards their shape and form.
Max Schultze, in 1869, had so well described the
cones, not only in the retina of the human subject, but
in some of the lower animals, that ver)' little had been
added to our knowledge for about twenty years after-
ward. Then the connection of these cones with the
central organs and with the ganglion cells of the retina
was perfected. The cytologj' of the cone up to the
present time had been almost entirely neglected. It
had been his fortune to secure the retinae from crimi-
nals executed at Sing Sing, and hence it had been pos-
sible to obtain them in a very fresh condition. They
had then been stained by Nissl's method, and exam-
ined according to the most recent and approved meth-
ods. Unless done in this way, the object to be de-
scribed could not be seen. A striking body had been
found just at the neck of the cone. It was composed
of a series of parallel bars, and presented a gridiron
appearance. These bars had lateral anastomoses, and
at the top joined in a semicircular manner. For this
reason he had given this body the name of the "kut-
tarasome body." This body was to be taken as the
analogue of the chromophyllic granules in the ganglion
cells. He would also call attention to the fact that
the material composing this body extended up into the
cone itself in the form of lines.
A Case of Fissure of the Abdomen, Pubic Re-
gion, and Genitalia was described by Dr. J. S. Ely,
by means of diagrams and photographs. The appear-
ance of the child was that of one in good health. It
was the third child, two previous children being
healthy. There was an indefinite history of an at-
726
MEDICAL RECORD.
[November 14, 1S96
tempt at early abortion, followed by slight hemor-
rhage. The labor occurred on June 26, 1892, and the
presentation was R. O. A. 'Ihe umbilical cord was
so short as to cause some delay in the labor. 1'he
child died about twelve hours after birth. At the
autopsy the development was noted to be that of a
child at full term. There was talipes varus of both
feet, and the abdominal wall and genitals were mal-
formed. From about three centimetres below the
xyphoid cartilage down to the usual situation of the
symphysis pubis was a large gash, measuring eight
centimetres from above downward and se\'en centi-
metres laterally, and having an elliptical shape. In
the edge of this defect in the abdominal parietes a
membranous pouch protruded forward. In this pouch
a large part of the liver and small intestine could be
seen and felt. From about the centre the umbilical
cord originated and was of normal diameter. The
development of the genitals was exceedingly abnormal.
A small wart-like prominence was seen in the median
line, about live millimetres in both diameters, and of
a bluish-red color. Just external to this was a slit-
like opening, about six millimetres in length, from
which meconium could be forced by pressure on the
gut through the thin- walled omphalocele. At the same
time meconium passed in small quantity from a small
opening just above the wart-like mass. In each groin
was a reddish mass, about two centimetres long and
one centimetre at the broadest part. The lower part
of this mass was composed chiefly of a thin reddish
membrane. Toward its inner border was a small
round opening, through which a probe passed into a
larger cavity. Above and externally this mass in the
groin was made up of denser tissue. Below this mass
was a slender protrusion, one centimetre long, and
somewhat resembling in appearance the labium minus.
Below this was a rounded prominence, covered with
tissue-like skin, and resembling slightly the labium
majus. Below this was a small depression. On
opening the abdomen by a median incision, the upper
and anterior portion of the liver was found loosely
adherent to the sac of the omphalocele. There was
no evidence of a urachus. The liver was rather large,
somewhat irregularly lobulated, and situated on the
right side of the abdomen. The spleen was somewhat
enlarged; it was situated normally, and its structure
was also normal. The stomach iiad the usual situa-
tion, size, and shape. The small intestine was nor-
mal in size and attaciiments, but at tiie lower extremity
of the ileum it was adherent to the anterior abdominal
wall at a point corresponding to the small median
opening already described. A probe passed from
this opening into the lower portion of the ileum. 'I"he
ileum also communicated by an opening in its right
wall with the caput coli. This last was of normal
size, and to it was attached the vermiform appendix.
It was, however, almost spherical, and formed a sac
about two centimetres in diameter. It represented all
that there was of a large intestine. This cloaca-like
pouch was closely attached to the posterior abdominal
wall by a very slight mesentery. The ureter passed
almost straight downward and communicated with the
pyriform bodies extending upward from the promi-
nences in the groin. These pyriform bodies were
alike on the two sides. Each was about four centi-
metres long, broad below, and circular throughout in
cross-section. The lower portion was soft and hol-
low, and was lined by a somewhat wrinkled mucous
membrane. The upper three-fourths of the body were
hard, but contained a very small cavity and resembled
the uterus. It communicated below with the vagina
by a well-marked cervix. From the upper and outer
side of this uterine mass a tortuous Fallopian tube ran
upward to the vertebral column. It had a distinct
fimbriated extremity. Each pyriform body represented
a hymen, uterus, tube, and ovary, and the ureter on
each side opened into the vagina on the corresponding
side. The pelvis was rudimentary and defective in
form. The ischium was represented only by a small
knob. The ilium was well formed.
Dr. Ely then presented three specimens showing
deficiency of the anterior abdominal wall. He said
that when there was absence of bladder and of the
pubic bones there was apt to be complete fissure of
the genitalia, the ducts developing on their respective
sides but never fusing.
Discussion. — Dr. C. N. Dowd said that it was no-
ticeable that almost all of these deformities were due
to a failure of one of the ordinary processes. In one
of the specimens there were various amniotic bands
and adhesions. It would seem quite possible that
many of these deformities w-ere due to such bands.
We could not but grant their existence: and, having
done this, many malformations could be explained by
such mechanical obstruction to growth. He had
found that there were very few cloven feet on record
— one such had been shown in the specimens just ex-
hibited. In all the reported cases there had been a
failure of development in the middle of the feet. It
was easy to understand how such a cleft might result
from amniotic bands. In all the cases he had been
able to study there had been an absence of one or
more of the bones of the tarsus.
Dr. \V. B. Novks said that, in contradistinction to
a purely local cause, such as amniotic bands, he
would call attention to a series of cases in which the
monstrosities occurred in families showing a distinctly
hereditary element. For instance, certain families
were known to have cretins, associated with deaf-
mutism, or with supernumerary digits, or something
of the kind. Unless this could be explained as a
coincidence, it was difficult to understand its occur-
rence on the theory of a jwrely local cause.
Dr. Down said that it could not be denied that
there was a hereditary element, jiarticularly in regard
to the occurrence of supernumerary parts. The me-
chanical explanation, however, applied to a certain
number of the cases of failure of development.
Dr. George P. Biggs thought that a band of suffi-
cient size to produce such marked disturbances of de-
velopment ought to be represented by some remnant.
This would indicate that there must be something
more than the bands to explain the condition.
Dk. Down replied that if the arrest of development
occurred at a very early period of development, it
would not be necessary to suppose the existence of
very large amniotic bands.
Dr. F'i.v said that there could be no question that
amniotic bands had much to do with the occurrence of
certain very marked malformations; nevertheless, the
theory did not seem necessary to explain the failure of
union of the two lateral hahcs of the body, or such
phenomena as cleft hands or cleft feet. It was well
known that the respective halves of the hands de-
pended for their development upon the respective
sides of the forearm. If, for example, the thumb
were absent, the radius would be frequently found to
be absent. It seemed quite possible to suppose that
some maldevelopment — such as an interference with
the nutrition of the cells which u.sually united the two
lateral portions in the median line — might result in
this class of malformations. It was now known that
certain malformations could be produced by irritation
of the embryo. 'I'he cytologists were able to state,
very early in the development, the exact part which
would result in the formation of the respective systems
or divisions of the body. It was evident, therefore,
that certain cells were set apart for the formation of
certain definite parts of the body.
The society then went into executive session.
November 14, 1896]
MEDICAL RECORD.
727
^euicins and
glottccs.
Minor Surgery and Baxdaging: Including the Treat-
ment of Fractures, Dislocations, the Ligation of Arteries,
Amputations, Excisions and Resections. Operations upon
Nerves and Tendons, Tracheotomy, Intubation of tlie
Larj-nx, etc. By Henry R. Wharton, M.D., Dem-
onstrator of Surgery in the University of Pennsylvania,
Surgeon to the Presbyterian Hospital, etc. Third Edition,
thoroughly Revised and Enlarged, with 475 Illustrations.
Philadelphia and New York : Lea Brothers & Co. 1 896.
The title page tells what the book contains, or almost all.
The ground of minor surgerj- is well covered, and as there
are five hundred and seventy-nine text pages it will be seen
that they are quite well covered, too — with pictures. Most of
them are very good, especially those illustrating bandaging,
which are reproductions of photographs, several somewhat
suggestive of the "living pictures." The chapters on an-
tiseptic and aseptic wound treatment have been thoroughly
revised, and some additions have elsewhere been made.
We bespeak for the work a continuance of the favor with
which it was originally received.
A Manual of Obstetrics. By W. A. Newman Dor-
land, A.M., ALD., Assistant Demonstrator of Obstet-
rics, University of Pennsylvania, Instructor in Gynecology
in the Philadelphia Polyclinic, etc. With 163 Illustrations
in the Text and 6 Full- Page Plates. Philadelphia : W. B.
Saunders, 925 Walnut Street. 1896.
This work is constructed upon a combined clinical, physio-
Jogic, and pathologic basis. A normal labor in a normal
woman is taken as the representative of physiologic obstet-
rics. In the second part the pathological deviations from
this natural state are taken up and discussed in the same
order, beginning with ovular development and ending with
the pathology of the puerperium. Following this is a chap-
ter upon the pathology- of the new-born, covering the acci-
dents from asphyxia neonatorum to umbilical hernia.
The manual is illustrated in a practical and instructive way.
The general style of the publisher's part is that of the " .Saun-
ders' New Aid Series."
It is a work worth having by all engaged in learning,
teaching, or practising obstetrics. A system of paragraph-
ing, numbering, and cross-reference makes the efficiency of
the work more pronounced.
A Manual of Pharmacology and Therapeutics.
By William Murrell, M.D., F.R.C.P., Physician to
and Lecturer on Pharmacology and Therapeutics at the
Westminster Hospital, Late Examiner in Materia Medica
and Pharmacy to the Conjoint Board of the Royal Col-
lege of -Surgeons of England and the Royal College
of Physicians of London. Revised by FREDERICK A.
C.\STLE, M.D., Member of the Committee for Revision
and Publication of the Pharmacopoeia of the L'nited States
of .-\merica. Late Lecturer on Pharmacology at Bellevue
Hospital Medical College, Physician to the Presbyterian
Hospital; Editor of "New Remedies, " etc. New York:
William Wood and Company. 1896.
This is an abstract of the lectures on pharmacology delivered
by the author before the students at the Westminster Hospital,
and especially designed for the purposes of students prepar-
ing for examination. Still, the therapeutic part has been writ-
ten in such a way as to make the work most available for
the requirements of practitioners of medicine, and with this
view a large number of modern prescriptions has been in-
corporated in the text, and in a separate appendix the intro-
duction covers one hundred and forty-three pages and em-
braces a large variety of subjects, including climate, baths,
serums, alkaloids, ptomains, the art of prescribing, etc.
An excellent feature, in connection with the index, is the ad-
dition of the customary maximum single dose for adults,
placed opposite each drug intended for internal use. The
work of the reviser has been carried out with a full realiza-
tion of the requirements of the American student and reader,
and all points interesting the English purchaser of the work
alone have been omitted. In compensation much of interest
and importance has been added, and this matter is enclosed
in brackets to indicate its source. The work upon both sides
appears to have been done with the utmost painstaking care.
and the experience and reputation of the .American reviser in
such matters are a warrant that accuracy may be depended
upon.
There would seem to exist a field of usefulness for just
such a work, since pharmacology is attaining from year to
year greater importance in the college course, and the branch
is keeping well up with advances in other lines.
A Text-B(_)Ok. of Diseases of the Nose and Throat.
By Francke Huntington Bosworth, A.M., M.D.
Profusely Illustrated with nearly 200 Engravings and 7
Full-Page Chromolithographic Plates. New York : Wil-
liam Wood and Company. 1 896.
This work, unlike the rather voluminous one recently issued
by the same author, is better adapted for the practical use of
both practitioner and student. It is in reality a condensa-
tion of the two volumes into one, leaving out such portions
as were mainly intended for reference. Only a few imma-
terial changes appear to have been made in the condensing
process, which was accomplished, as the author states, mainly
through the efforts of Dr. A. R. Schroeder. The number
of chapters escaped by one reaching the hundred mark,
making eight hundred and twenty-one pages, including
seven colored plates inserted after the index. The chap-
ters are divided into six sections: (i) "Diseases of the
Nasal Passages." (2) "Diseases of the Naso- Pharynx. "
(3) " E.xternal Surgerj' of the Nose." (4) "Diseases
of the Fauces." (5) "Diseases of the Larj'nx." (6)
External Surgery of the Throat." The list of illustrations
covers a wide range of subjects, whose description is
thus rendered much clearer. 'The wide experience of the
author as practitioner in this department and as teacher of
this special branch has well qualified him for the task which
has been accomplished. Not only have the usual affections
which are so common in this climate been almost exhaust-
ively dwelt upon, but all the serious operations which the
surgeon is called upon to perform in this region of the body
have been described and depicted. The original work hav-
ing been reviewed at some length, it need now only be said
that the reducer of those two volumes has acquitted himself
in a most satisfactory manner and presented a book well
worthy of the extensive and important subject.
A iVlANU.AL of Clinical Diagnosis by Means of Mi-
croscopic and Chemical Methods. For Students. Hospital
Physicians, and Practitioners. By Charles E. Simon,
M.D., Late Assistant Resident Physician, Johns Hopkins
Hospital, Baltimore. With 132 Illustrations on Wood
and 10 Colored Plates. Philadelphia and New York : Lea
Brothers & Co. 1S96.
This is a work which enters into a comparatively new field,
and one which we must admit has been too much neglected
both m .America and in Europe. To be sure, the schools are
taking up laboratory methods of examination more and more
each year, but the older generation of physicians has not
realized the importance of securing competent assistants
to do such work for it when too busy to devote the requis-
ite time to it. The student and the diagnostician will alike
find here pointed out the way through clinical chemis-
try and clinical microscopy to the attainment of definite re-
sults. The arrangement is such that one who has had no
special training in these branches can follow out the scheme
of work in examinations of blood, secretions of the mouth,
the stomach contents, faeces, nasal secretions, sputum, vaginal
discharges, milk, etc. The normal secretions of the part are
described and afterward the pathological, and finally the tech-
nique of examination. Naturally the chapter on the urine
is the most important, in point of number of pages devoted to
it, which extend from page 239 to page 460. There are a
number of in.structive colored plates, some of which, as well
as many of the wood cuts, are taken from von Jaksch's work.
Malakine has been found by Merkel to possess
marked influence over rheumatism in those cases in
which salicylate of sodium remained without effect. In
three cases Korotky and Oussofif secured, by its employ-
ment in doses of from two to three grains daily, a low-
ering of temperature and suppression of pains without
any of the discomforts which the salicylate may oc-
casion.— Meditz. Oboz, No. 2, 1896.
728
MEDICAL RECORD.
[November 14, 1896
©orrcspouclcncc.
OUR LONDON LETTER.
(From our Special Correspondent.)
JUBILEE OF THE PATHOLOGICAL SOCIETY — A GLASGOW
INSTITUTE FOR PATHOLOGY THE HARVEIAX ORA-
TION— GUILD OF ST. LUKE — DOCTORS AT ST. PAUL'S
CATHEDRAL THE ARMY DEADLOCK — SIR W. MAC-
CORMACK — WATER SUPPLY — ENTRIES AT THE SCHOOLS.
London, October 23, 1896.
The Pathological Society, on Tuesday, celebrated its
jubilee by an address from the president, Mr. Butlin,
and an exhibition of a series of specimens which
have no little historical interest. Mr. Butlin spoke of
the great influence the society has e.xerted in promot-
ing the study of morbid anatomy and pathology. The
society held its first meeting on October 20, 1846,
when a number of specimens were contributed by the
members. Indeed, the exhibition of specimens, draw-
ings, casts, or models of morbid parts was the first ob-
ject of the society, and has held a foremost place
through the half-century of its existence. The forty-
six volumes of Transactions are a kind of record of
the progress of pathology, and of immense use in the
study; but I doubt not the influence of the meetings
has been far more widespread. Mr. Butlin anticipates
that the records of the society are likely to be of value
for the next fifty years, and he spoke from his expe-
rience as to their use in collecting cases of morbid
growths for analysis — an experience common to all
searchers and writers for the last thirty years. Still,
I think, as I have said, that the influence of the meet-
ings has been more useful in promoting a wider inter-
est in the subject.
Nevertheless, Mr. Butlin was constrained to express
apprehension that the society may have passed its ze-
nith and is in the stage of decadence, although there
are some seven hundred members on its list. From
some points of view this is undoubtedly the case,
and to assist in its rejuvenescence I would suggest
that an effort should be made to make the meetings
more interesting to those who cannot attend regularly.
In this view it is doubtful whether set discussions, in
which a few experts are engaged to state their views,
are really attractive. Such debates can be read in the
journals. That which can only be obtained at the
meetings is a sight of the specimens and the remarks,
which often shed fresh light on them from different
points of views.
.After reviewing the history of the society for the
last fifty years, the president expressed a hope that the
work should go on for an equal period, and he sug-
gested that departments of applied pathology, estab-
lished at our hospitals, would be a good plan for main-
taining the proper relations between purely scientific
work and the practice of medicine and surgery.
Sir R. Quain, one of the five surviving original
members, moved the vote of thanks to the president,
which was seconded by Dr. Wilks, who mentioned that
the idea of the society was due to Dr. Bentley, of
Guys, at whose house the first meeting was held.
The exhibits were confined to specimens of morbid
anatomy, which illustrated subjects of general patho-
logical interest — the restriction being due to want of
space. A catalogue was ready. Among them were
Paget's specimens of osteitis deformans; Wilks' speci-
mens demonstrating the fact of visceral syphilis; Ad-
dison's specimens of suprarenal capsules, from which
he made his discovery; and others of similar histori-
cal interest.
While pathology has been to the front in London, it
has also attracted attention in Glasgow, where a Path-
ological Institute, in a suitable building erected at a
cost of ^"15,000, has just been opened. Professor
Gairdner gave an inaugural address on the occasion.
No one is more capable of showing the place of pa-
thology in the science of medicine, and this, of course,
he did in the felicitous manner that charms his hear-
ers whenever he is the speaker.
On Monday the Harveian oration was delivered by
Dr. J. F. Payne, before the College of Physicians.
The chief point in his discourse was the relation of
Harvey to his predecessors, and especially to Galen,
the final representative of the great Greek school.
Dr. Payne argued that it was that school which put
into shape, but could not solve, the problem which re-
mained insoluble until the appearance of Harvey.
His genius was able to solve it. But it may be said
that he was influenced in no small degree by his two
preceding generations. In fact, Linacre and Caius
may be said to represent two successive stages in the
movement whicli was preliminary and essential to the
work of Harvey, and of which his discovery was the
culmination. The jjeriod of the renaissance was that
of the revival of Greek learning, and Linacre's object
was to make the works of Aristotle and Galen accessi-
ble to all by translation and the earnest study of all.
Modern science, the orator argued, grew out of Greek
learning, and it was only a speculation as to how oth-
erwise it could have arisen. The student of to-day,
who goes to his anatomical work with his text-book
and dissecting-case in his hand, should be thankful
that in the fifteenth century they began to read Greek
manuscripts. The moral drawn by the orator was that
we cannot ignore the instruments of the past, and that
is a growing truth of which the lovers of Greek learn-
ing scarcely need a reminder.
On Thursday St. Paul's Cathedral was the scene of
an interesting ceremony, promoted by the guild of St.
Luke. This guild is an association of doctors who
are churchmen — and one may' say high churchmen, for
it is in that party tlie guild originates and on its lines it
is carried on. But all practitioners and even students
were invited to the service at St. Paul's, and doubtless
many of the throng who attended neither knew nor
cared what party organized the ceremony. It was the
thirty-second anniversary of the Guild of St. Luke
(patron saint of doctors, as "the beloved physician"),
and that association initiated the ceremony, which was
announced to be analogous to that among lawyers
when Her Majesty's judges annually attend St. Paul's
in state, though I fail to see how a private association
is analogous to Her Majesty's judges, or can give
state to a ceremony of the kind named. However
this may be, the guild satisfied the lord mayor and
sheriffs, who attended in state and so gave civic pomp
to the occasion. It had been requested that graduates
should appear in the gowns and hoods of their aca-
demical degrees, and, as many complied with the re-
quest, the scene under the great dome was unusually
brilliant, and must have given great satisfaction to the
organizers and all who take delight in robes and or-
naments. The Bishop of Stepney preached the ser-
mon, in the place which was to have been occupied by
the late archbishop. He referred to the training of
young medical men, which he had ob.served at ("am-
bridge, and did not wonder that some for a time be-
came materialists, as they found no part of nature that
might not fully occupy the highest intellects. But
that phase must not continue, and, though he was quite
certain that religion could not do without science, he
also was profoundly convinced that science could not
do without religion. In the harmony of the two and
the perfection of each is the healing of this world and
the building up of the next. After praising the work
the guild is doing in this direction, the bishop spoke
of the deceased archbishop, whose vacant pulpit re-
November 14, 1S96]
MEDICAL RECORD.
729
•minded them of that " marvellous voice — once heard,
never forgotten — which would have said things that
not all the anxieties of professional life would be able
to remove from your minds." He asked if they need-
ed a more speaking message of the poor, feeble thing
materialism is, when they met such a blow as his
■death. In such cases consolation, strength, hope, has
to be sought outside any particle of matter. It is in
the world of spirit you are plunged. Then he dwelt
on how the late prelate would have rejoiced to see the
enormous and brilliant assembly that thronged the
great cathedral — "" such a gathering as I have never
seen in this place, under circumstances that make the
occasion absolutely and entirely unique."
The deadlock in the army medical service seems, at
length, likely to rouse public attention. The Court
Circular protests against the attempt now being made
to conceal the dearth of officers by overworking those
who remain, to an extent likely to lead to an igno-
minious breakdown. The Circular says that " rather
than admit a deficiency in the medical staff, the de-
partment, where possible, is doubling the duties of
medical officers." This new departure, adds the jour-
nal quoted, '' at best can only serve a temporary pur-
pose, and sooner or later the weakness of the staff w ill
have to be officially acknowledged." The sooner the
better, for the public is determined to maintain the
army and navy in an efficient state, and should these
forces have to be employed and the wounded lack
medical aid a stern retribution would overtake those
responsible.
The service papers cannot ignore the state of affairs.
In one of them a correspondent, over the signature
■" Common-Sense," makes suggestions which should,
perhaps, have been sent to a comic paper. However,
whether intended as a joke or not, their appearance in
a service paper shows the folly of the officials and the
prejudices of the so-called combatants. " Common-
Sense" says he would abolish the director-general and
his staff of doctors, and put the medical staff under
the adjutant-general, vho could have a civilian doctor
on his staff" to advise him on professional matters.
Exactly ! Give your pretentious " combatants" ever\-
possible post, and for the sake of doing so make the
mere doctors civil servants. Then, when army sur-
geons were wanted for the grasping combatants, who
had driven them from the service, what an outcry
would be raised on behalf of the wounded, who could
send for " civilian doctors" only.
I am glad to report that Sir William MacCormack
is much better, and it is hoped he will soon enter the
con\'alescent stage.
The London water supply is now impugned on the
ground of quality, and recent analyses are far from re-
assuring.
The entries at the London schools are much below
the number exjjected, and the lamentations of the
teachers are loud. The provincial schools have kept
up their average.
Nymphomania. — Search carefully for local causes,
such as may occasion pruritus vulvas — vaginitis, vege-
tations, vulvitis, eczema, syphilis, herpes. Investi-
gate, especially, as to diabetes. Where ner\'ous dis-
orders are suspected, bromides in medium dose are
indicated. When associated with opium, they combat
in an effective manner the exaltation of the venereal
appetite. Camphor may be added, and when insom-
nia coexists chloral is to be given at night. Local
applications are useful. Cocaine in lotion or oint-
ment has the preference. Hydrotherapy is indicated
in all cases. When scientific douchings are not pos-
sible, applications of cold water to the vertebral col-
umn at bedtime are beneficial. — Lutaud.
"THE APPENDICITIS CONTROVERSY "—AN
UNFAIR CRITICISM.
To THE Editor of the Medic.\l Record.
Sir: Having read with no little astonishment Dr.
Halton's communication and severe arraignment of
some gentlemen who treated a case according to mod-
ern methods, I shall feel grateful for space in your
valuable journal for a few remarks in reference to cer-
tain statements it contains.
Usually those opinions concerning this very impor-
tant and dangerous disease which have the greatest
weight come from men who are able to substantiate
their statements w-ith an experience in a fair number
of cases. Still greater weight should be accorded the
opinion of the physician or surgeon who has treated a
number of cases by both plans, thereby enabling him
to speak intelligently, drawing his conclusions from
clinical experience and actual observation. I regret
that I am not personally acquainted with Dr. Halton,
and that I am unable to find his name in the green
book as being a member of any of the scientific bodies
formed for the purpose of discussing just such ques-
tions. While operation has saved a large proportion
of patients in appendicitis, he says it has also killed
not a few of them, a very bold statement, which no
attempt is made to substantiate by recorded experi-
ence. Bad judgment in the selection of cases to be
operated upon is mentioned, but he does not tell us
what cases we should operate upon and those which
should be treated otherwise. He does not tell us who
it is that belittles the physician and elevates the sur-
geon. Dr. Halton criticises the work of thousands of
students of surgery and medicine throughout the civi-
lized world who advocate in the strongest possible
terms operative procedure in appendicitis. He also
deems himself competent to criticise the judgment of
these same men in their selection of cases to be oper-
ated upon, when he must know, even if he has had
but a limited experience, that no living man can fore-
tell the final result of any given (well-marked) case of
appendicitis. Physicians and surgeons, in the early
operative days, receded from position to position in
their honest endeavors to stay the ravages of this de-
structive disease and to lessen its mortality, until they
betook themselves to storming the citadel by early
operation, which is at the present day advocated by
the majority of both physicians and surgeons.
In reference to the case related by Dr. Halton, ac-
cording to his own statement, we find a boy sick with
appendicitis for at least three days and perhaps longer,
without medical attendance of any kind whatever, not-
withstanding the fact that he himself was the family
phvsician. .A. neighboring physician was called and
recognized the disease at once; but just what the con-
ditions were that this physician found, whether the
boy wore the facial expression which at all times be-
speaks very great suffering, whether he had a glazed
and dry tongue, a rapid pulse, a high temperature, a
swollen and tvmpanitic abdomen, whether he had a
well-marked tumor in his right iliac fossa. Dr. Hal-
ton fails to tell us. Perhaps he is to be excused for
not informing us of these points, not having been
there. We understand from the criticism that the boy
had pain, vomited, went to bed; got up and walked
around (a very dangerous thing, by the way, to do in
appendicitis I. The patient's condition, it is stated,
finally became alarming and the neighboring physician
was sent for. The latter seems to have been prompt
in applying the best possible remedy in a very much
neglected case, namely, operation.
We are not told whether catarrhal appendicitis is
more or less fatal than other forms of the disease, but
the simple statement is made that he was told the boy
had a catarrhal condition.
730
MEDICAL RECORD.
[November 14, 1896
Dr. Halton states that when he saw the boy the lat-
ter was dyuig (by the way he lived for several days after
this), but he learned that the attending physician ex-
pressed a hopeful opinion; he does not state whether
the attending physician or surgeon qualified this state-
ment. He concludes that here was a healthy boy suffer-
ing with appendicitis (I presume he means that here
was a boy sick with appendicitis whose previous health
was good) starting slowly for the grave from the mo-
ment of operation. Being entirely unacquainted with
the facts in the case, how could he say that the patient
did not start in this direction from the beginning of
his attack? He does not explain what the pathologi-
cal conditions were in this case. He thinks it would
be reasonable to infer that the wrong time was chosen
for operation. Here is the only point on which I can
possibly agree with the writer. The proper time was
within the first twelve to sixteen hours of the attack.
He further thinks that by waiting twenty-four hours
longer the tendency to general peritonitis might have
been reduced by warm applications and the administra-
tion of opium. If the appendix was necrotic and its
mucous lining had sloughed, warm applications would
do no good, and as for opium, this drug has long since
been condemned in the treatment of appendicitis be-
cause it masks the symptoms. Dr. Halton thinks that
the physician's powers of obser\-ation are very differ-
ent from those of the surgeon, forgetting that many
surgeons have spent years in the practice of medicine
before devoting themselves to the practice of surgery.
To make it clear that Dr. Halton does not voice the
sentiments of physicians generall)-, at least in the city
of Brooklyn, I will relate two cases now under my care :
Case I. — Immediate operation advised by two emi-
nent physicians after seeing the patient for the first
time. Mr. G , native, aged forty-five years ; mar-
ried; residence, Vanderbilt Avenue, Brooklyn. Octo-
ber 3, 1896, complained of pain in the stomach; the
following day of pain lower down on right side. Oc-
tober 5 th and 6th somewhat better. October 7 th,
compelled to take to his bed. October 8th, went to
business. October 9th, was again compelled to go to
bed. October loth, morning, called his family phy-
sician, who is visiting physician to St. Mary's General
Hospital, Dr. George R. Kuhn, who diagnosticated
appendicitis and suggested operation as being the
proper remedy. Dr. Kuhn asked me to see the patient
with him in order to settle this question. I saw the
patient at ii 130 a.m. of the same day and had but to
confirm Dr. Kuhn's diagnosis and proposed plan of
treatment at 3 p.m. Dr. Kuhn and Professor Mc-
Corkle of the Long Island College Hospital saw the
patient together, both concurring in the diagnosis and
advising immediate operation. At no time was the
temperature by the mouth above 99° F. or by the rec-
tum above 100.6' F. per rectum.
The patient was sent into my service at St. Mary's
Hospital the same evening, and at 10 P.m. was ope-
rated upon. The appendix was found curled upon it-
self and partially embedded in a firm coating of in-
flammatory tissue, with its lower end adherent to the
omentum. This was separated from the appendix and
about two inches of it cut away after being firmly tied
with catgut. The serous covering was stripped down
to the base of the ap|5endix, which was then cut off
and the stump inverted. The serous covering was
drawn over it by Lembert sutures. Tlie appendix was
perforated about half an inch from its apex, its mucous
membrane having entirely sloughed ; its muscular wall
was necrotic for about three-fourths of its length, its
mesoccEcum partially gangrenous. At the point of ]3er-
foration there was a small abscess cavity containing
perhaps two ounces of foul-smelling pus. The part
of this abscess wall which pointed toward the base of
the appendix was very thin. Internally to this the
general peritoneal cavity was unprotected, so that in
time this thin wall must have given way, flooding the
general peritoneal cavity with pus. October 21st the
patient is still in the hospital but practically well.
What would have been his fate had Dr. Halton's
methods been carried out, I leave the reader to sur-
mise.
Case II. — Dr. I. Fuchs after early consultation ad-
vises early operation. Miss G. S , native, aged
fourteen years; residence, Madison Street, Brooklyn.
October 5, 1896, in the evening, patient complained
of pain in the abdomen. October 6th, used some
home remedies. October 7th, sent for Dr. I. Fuchs,
visiting physician to St. Catherine's Hospital. Dr.
Fuchs took almost immediate steps to have his patient
operated upon, thereby saving her life, as the follow-
ing pathological conditions will show: She was sent
into my service at St. Catherine's Hospital on Mon-
day, October 8th, and operated upon at once (2 a.m.).
The enlarged and inflamed appendix was removed and
found to contain four large fecal concretions, some
little distance apart, filling almost the entire canal.
The meso-appendix and the base of the appendix were
partially gangrenous, necrosis extending well upon the
C£ecal wall. The general peritoneal cavity was not
protected. There are other interesting and instructive
points in connection with this case which I will not
bring out here.
I quote these cases to show that the eminent phv-
sicians interested in them are at variance with Dr.
Halton in his plan of treatment, namely, warm appli-
cations, opium, and waiting, and in each case they
followed the course pursued by the physician whom
Dr. Halton criticises.
That some patients get comparatively well without
operation no one denies, but usually improvement
commences in such cases within from twelve to sixteen
hours from the onset. On the contrary, if the symp-
toms become aggravated after this time or if the dis-
ease persists in spite of palliative measines (opium
excluded), it becomes an operative case, and the phv-
sician or surgeon who hesitates to advise operation
robs his patient of one of the best means known to
science at the present day of saving life in this
dreaded disease. James C. Kennedy, M.D.,
Visiting Siirgt'on to St. Mary's and St. Cat/u-rinc's Hos-
pitals, Brooklyu, N. Y.
The Absence of Gonococci in Gleet. — Dr. Tay-
lor, in his recent work on " \'enereal Disease," be-
lieves that after gleet has lasted for some months the
gonococci are in all probability absent. Dr. Pilcher,
in reviewing the work, remarks that this is a comfort-
ing doctrine, but if true the exception must be very
frequent, as is shown by the experience of numerous
unfortunate young women, who, upon marriage, find
that the mucous membrane of the vagina and uterus is
a most favorable culture ground for the gonococci that
still persist in the urethras of the husbands.
Dislocations of the Hips. — Dr. Oscar H. .\ilis, irv
a monograph relating to the difficulties encountered in
the reduction of dislocations of the hip, discusses the
following points: i. The capsule is the mo.st important
agent against traumatic dislocations of the femur.
2. For the laceration of the capsule and dislodgment
of the head of the femur, the femur is emjiloyed as a
lever. 3. Every lever has a fulcrum: the fulcra re-
quired in dislocations of the femur are bony and
ligamentous. 4. Dislocation by thrust, if possible, is
infrequent. 5. Reduction by circumduction is the sim-
plest, the most brilliant, and the most hazardous of all
modes of replacement. 6. Method suggested for re-
duction of dislocation of the head of the femur when
associated with fracture of the shaft.
November 14, 1896]
MEDICAL RECORD.
731
Suvoical J>ui3ocstions.
Pyelitis in Infancy. —Dr. V\'olfstein {Archives of
FeUiatriis, .\iii., No. 5) names the following causes:
I. The lithaeniic state, especially any irritation of the
kidney by uric acid, in form of crystals or calculi, or
strong acidity. 2. Tuberculosis. 3. Retention of
urine with ammoniacal decomposition, causing an
ascending pyelitis. 4. Irritation by such drugs as tur-
pentine, carbolic acid, and salicylic acid. 5. V'ulvo-
vaginitis, cystitis. 6. Infectious diseases. 7. Septic
catheterization. 8. Idiopathic p\elitis from chilling
or wetting.
Menorrhagia in Virgins. — Dr. Laroyenne (Lyon
Alaiicale) distinguishes the majority of cases of profuse
menstruation in young girls which require no local
treatment from a minority in which the use of the cu-
rette is advisable. If, after long attention to hygiene
and a course of suitable tonics, menorrhagia persists,
interrupted by occasional amenorrhoea, granular or
fungous endometritis probably exists. This disease is
yet more safely diagnosticated when the patient has
been perfectly healthy and quite free from ana-mia be-
fore profuse menorrhagia appeared, and equally free
from evidence of diseased appendages after the local
symptoms became marked. It is right after dilatation
to use the curette when the e.xcessive menstruation
causes debility. A single application of cotton wool,
soaked in equal parts of water and chloride of zinc,
made immediately after the scraping, is sufficient. Re-
peated cauterizations may readily cause atresia.
Surgical Treatment of Focal Epilepsy Drs.
Sachs and Gerster {Amci-ican Joui-iial of the Medical
Sciences, QcXahex, 1896), after a discussion of this sub-
ject, summarize as follows : I. Surgical interference is
advisable in those case of partial epilepsy in which not
more than one year, or at the utmost two years, have
elapsed since the traumatic injury or the beginning of
the disease which has given rise to the convulsive seiz-
ures. 2. In cases of depression or other injury of the
skull, surgical interference is warranted, even though a
number of years have elapsed; but the prospect of re-
covery is brighter the shorter the period of time since
the injury. 3. Simple trephining may prove sufficient
in a number of cases, and particularly in those in which
there is an injury to the skull, or in which a cystic
condition is the main cause of the epilepsy. 4. Ex-
cision of cortical tissue is advisable if the epilepsy
has lasted but a short time, and if the symptoms point
to a strictly circumscribed focus of disease. 5. Since
such cortical lesions are often of a microscopical char-
acter, e.xcision should be practised even if the tissue
appears to be perfectly normal at the time of opera-
tion; but the greatest caution should be exercised in
order to make sure that the proper area is removed.
6. Surgical interference for the cure of epilepsy asso-
ciated with infantile cerebral palsies may be at-
tempted, particularly if too long an interval has not
elapsed since the beginning of the palsy. 7. In cases
of epilepsy of long standing, in which there is in all
probability a widespread degeneration of the associa-
tion fibres, every surgical procedure is useless.
Transperitoneal Treatment of Artificial Anus
Dr. Gangolphe [Re-iue de Chinirgie) advises opening
the peritoneum at once in operating for artificial anus,
instead of having recourse to the enterctome of Du-
puytren. He claims that it has the following advan-
tages: I. It is rapid; the surgeon is not delayed by
fear of wounding any important organs or tissues. 2.
It is sure; the finger introduced into the abdominal
cavity explores the parts in the neighborhood of the
opening; it also guides the scissors in loosening the
intestines at a distance from it. 3. It permits the
withdrawal of the infected intestines outside the ab-
domen, where they can be protected with gauze while
being operated upon; the chances of infection are di-
minished, while manipulations are facilitated. 4. It
is possible in all cases, while operation by other
methods is not always possible.
A New Traumaticine — Treat an aqueous solution
of soap with a solution of alum. A magma forms
which can be pressed out and which is a fatty-acid salt
of alumen. This magma is dissolved in ether while
it is still moist. The solution thus obtained can be
medicated with chrv'sarobin, etc., for the treatment of
psoriasis. — Ducommun.
Foreign Bodies Swallowed by Children The
American Aledical and Surgical Bulletin in an article
on this subject says that pins, safety pins, pebbles,
jackstones, etc., swallowed by children need occasion
no alarm, as they will all pass through without harm-
ing the child. The greatest danger is from the castor
oil with which the child is usually dosed in such
cases; it is better to leave the bowels at rest and give
gruel, crackers, baked potatoes, milk, anything which
will constipate the child and make a pultaceous mass
in which the foreign bodies will be embedded and car-
ried through. When foreign bodies stick in the throat
and the child is unable to swallow, it should receive
an emetic, or the coin catcher should be introduced.
This is a basket-like affair easily used. In one case
both a one-cent and a two-cent piece were removed at
the same time by this instniment.
Surgery of the Kidney. — Dr. Holmes {Journal of
the American J/cilical Association, September 5, 1896)
makes the following summary : i. Tuberculosis of the
kidney is a relatively common disease. 2. It usually
begins in the kidney itself, descends through the ureter
to the bladder, and ascends to the opposite kidney.
3. It is, therefore, for a long time a unilateral disease.
4. It is a progressive and destructive disease, not sub-
ject to improvement through medication, offering an
unfavorable prognosis as to life and comfort, and sub-
ject to extension downward by the urinar}' tract and
outward through the perirenal lymphatics. 5. Diag-
nosis can be made through the symptoms of cystitis
with low temperature, rapid pulse, and dilatation of the
heart; the detection of tubercle bacilli in the urine:
tuberculosis of the bladder about the orifice of the
ureter of the diseased kidney ; pus or blood with tuber-
cle bacilli and diminished normal constituents in the
urine from the diseased kidney : normal urine in in-
creased quantity from the opposite kidney; sometimes
tenderness, pain, and tumor /« situ of diseased kidney
and ureter. 6. The indications in case of an absolute
diagnosis of tuberculosis of one kidney and healthy
opposite kidney are immediate removal of the diseased
kidney and its ureter; in case of disease in both kid-
neys, no operation should be performed. 7. The com-
petency of the healthy kidney should be proved by
repeated catheterization of the ureters before nephrec-
tomy and the removal of all toxic elements from the
blood should be secured by a liquid diet, irrigation of
the colon, and hydration of the whole system for some
days before the removal of the kidney. 8. Lumbar
extraperitoneal nephrectomy is the safer operation.
g. In women tiie removal of the ureter should be com-
pleted through the vagina. 10. .Any remaining tuber-
culosis of the bladder should be treated locally by
curretting or cauterization. 11. Catheterization of
the ureter is not a dangerous procedure, and it may
easily be accomplished in women with the simple cys-
toscope of Simon, Pawlik, or Kelley, and in men with
the more complicated instrument of Casper.
"32
MEDICAL RECORD.
[November 14, 1896
l3tlc(Ucal Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending November 7, 1896:
Cases. I Deaths.
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-po.x
102
97
21
4
77
I
0
0
57
2
210
24
0
0
The Diagnosis of Typhoid Fever Facilities for
the new diagnosis of typhoid fever are now offered to
the phvsicians of New York, as will be seen by the
following:
"New Vokk, Noveml^er 6, 1896.
''Hon. Charles G. Wilson, President, Health Depart-
ment, City 0/ New York.
" De.\r Sir: I desire to direct the attention of tlie
board to a new laboratory method for the diagnosis of
typhoid fever, which, judging from the data available
at the present time, promises to be of very considera-
ble practical value in the diagnosis of early or ill-de-
fined cases of this disease.
" The investigations of Pfeiffer and W'idal have
shown that the blood of persons suffering from typhoid
fever, when mi.xed with active cultures of the typhoid
bacillus, has the power of arresting the active move-
ment of these organisms, and of producing peculiar
and characteristic clumping of the bacilli. It has
been shown that this reaction occurs frequently very
early in the course of the disease; that it is found
throughout its course, during convalescence, and often
for a considerable period after complete recovery. It
does not occur with other organisms than the typhoid
bacillus, and it does not occur with cultures of the ty-
phoid bacillus when the blood of persons suffering
with other diseases is employed. As has been shown
by VVidal and Johnson, this reaction occurs as well
with specimens of dried blood as with fresh blood, and
thus can be employed practically in municipal labora-
tories for the diagnosis of this disease. Observations
on this matter, which liave been in progress in the lab-
oratories of this department for some time past, have
thus far confirmed the conclusions of pre\ious in\es-
tigators.
" In order that more numerous data shall be at the
command of this department, and that physicians of
New York may at the earliest moment have facilities
for testing the reliability of the observations thus far
made, I would respectfully recommend that arrange-
ments be made to place facilities for such examination
at the command of all physicians in this city — it being
distinctly understood that this actirin of the department
is for the purpose of gaining information on this im-
portant subject, and at the same time of placing at the
command of physicians opportunities for observing the
results. If the data already obtained are entirely con-
firmed by subsequent observations, this method will
undoubtedly prove of great service in the diagnosis of
early and obscure cases of typhoid fever.
" Should this action be determined upon, circulars
of information as to the method of collecting blood
and slides for this purpose may be left at the depots
already established for the collection of diphtheria
culture tubes and the distribution of diphtheria anti-
toxin.
'■ Respectfully submitted,
•■ Hermann M. Biggs,
" Pathologist anil Director of the Bacteriological Lab-
oratory."
The following resolution was adopted by the board
of health of the health department, at a meeting iield
on November 6, 1896:
" liesolval. That the recommendations of the direc-
tor of the bacteriological laboratories of this depart-
ment, contained in the communication dated Novem-
ber 6th, be and are hereby approved, and that lie is
hereby authorized to place facilities at the command
of physicians of this city for the diagnosis of cases of
typhoid fever, in accordance witli liie method pre-
scribed in said communication."'
Circulars of information regarding the method em-
ployed, and slides for collection of blood, may now be
obtained at the various pharmacies where diphtheria
culture tubes are kept. Physicians desiring to make
use of this method in the diagnosis of early or obscure
cases of typhoid fever can secure these, and, after col-
lection of blood as described, may leave the slides,
with the data relating to the case, at the various de-
pots. They will Ise collected each day, examined the
following day, and the report of the result forwarded
to the physician.
Boiled Milk requires much more digestive effort
than does the unboiled material, as in the latter case
the serum albumin and nucleated cells, it is said, are
absorbed directly by osmosis without any chemical
change. Milk may be pasteurized (warmed to 160^
F.) without interfering with its digestibility by coagu-
lation of the cell and serum ali)umin. — Atlantic Aledi-
cal Weekly.
Grape Growers in the neighborhood of the lakes
ha\e allowed their crops to be fed to hogs and to rot
on the vines this season, because the appendicitis
craze has injured the business. We therefore see the
luscious but inoffensive grape, that graces the table
and brings to pass so many delights, banished to the
domain of the pigsty. Could tliere be a sadder com-
mentary on ignorance in these panic days of dislocated
wit and judgment, when so many people are suffering
for the want of wholesome food.' — Dk. Rosse, Mary-
laud Medical Journal, October.
gaofes ^ecjeitJcd.
While the Medical Recoku is pleased to receive all new publi-
ealioiis which may lie sent to it, anj an acknowledgment will he
promptly made of their receipt under this heading, it must he -with
the distinct understanding l/iat its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it -.uhich in l/ie judgment of its editor luilt not be
of interest to its readers.
rhird edition, i2mo, 436
It-i8l2. By James
Illustrated. .Swan,
Prescribers" I'h.vrmacopceia
pages. Kemp & Co., Bombay.
The Diakv of a Resirrectionist, 1
Blake liailcy, B..\. l2mo, 184 pages.
Sonnenschcin & Co., London.
Transactions of thf, American Climatological Asso-
ciation for the year 1896. Vol. .\1I. 8vo. 293 pages.
The Practice of Medicine. By Horatio C. Wood, M.D.,
and Reginald H. Fitz, M.D. Royal 8vo, 1.088 pages. J. B.
Lippincott Company, Philadelphia, I'a.
System of Diseases of the Eve. By various authors.
Edited by W. F. Norris. M.D., and C. A. Oliver, M.D. Vol.
I. Royal 8vo. 670 pages. Illustrated. J. B. Lippincott Com-
pany, Philadelphia, Pa.
A Text-Book of Materia Medica, TiiEKArEUTics, and
Pharmacoi.oc;y. By G. F. Butler, M.D. 8vo, 858 pages. \V.
B. .Saunders. Philadelphia, Pa.
Medical Record
A Weekly youmal of Medicine and Surgery
Vol. 50, No. 21.
Whole No. 1359.
New York, November 21, 1896.
$5.00 Per Annum.
Single Copies, loc.
©viginal Jivticlcs.
THE SPHERE OF THE PHYSICIAN AND
THE HOSPITAL.'
By henry DWIGHT CHAPIN, M.D.,
NEW YORK.
Mr. President, Gentlemen of the Board ok
Trustees, Ladies, and Gentlemen : When Professor
Chandler asked me to give the annual address before
St. Luke's Hospital, I was much at a loss to select a
proper theme for such an occasion. The distinguished
gentlemen who have been with you in previous years
have ably treated the topics that would naturally sug-
gest themselves at such a time. Hence, much that I
can say will doubtless be but a repetition of what has
been already well said. The fact, however, that the
medical profession is beginning to assert itself not
only in questions relating to its own interests, but in
the larger problems of the day, tempts me to offer a
few random thoughts upon the calling of the physician
and the work of the hospital in their relation to the
community at large. I can heartily agree with Dr.
Andrew Smith's address before you last year, in
which he deprecated the extreme tendency toward spe-
cialism that has manifested itself in the profession in
recent years. That this tendency, unless checked in
some proper degree, will work an injury to the profes-
sion itself, as well as to the public at large, is equally
clear to my mind. Upon the physician himself the
exclusive working upon single lines cannot but have
a narrowing effect, unless offset by a large general ex-
perience previously^ spent in the practice of medicine
in all its branches. It is too much the fashion for
young graduates in medicine to start at once upon
the e.\clusive practice of a specialty, in the operation
of which they soon gain great manual dexterity. But
this skill, as just suggested, is of the hand rather than
of the head. As we inspect the ingenious and too
often complicated contrivances for repairing and re-
moving the organs of the body, we are reminded more
of the mechanic than of the physician. In direct ra-
tio to the celerity with which the parts of our economy
can be removed, there seems to be a weakening of the
judgment that will tell us not only when they should
be removed, but whether it is necessary to remove
them at all. This extreme specialism cannot but be in-
jurious to the public at large, which is now beginning
to trust the various organs of their body to as many
different healers, and this again suggests the idea of
the machine and the mechanical repairer. The com-
mon argument that the field of medicine is now so
broad as to prevent any one from attempting to occupy
it all is only a half-truth. While much advanced
work is being done by special investigators, any posi-
tive results that they may gain can usually be absorbed
by the mass of the profession for the benefit of their
patients. It is well to bear in mind that the margin
between what is known and necessary for the good of
the patient, and needless theorizing and differentia-
tion, is often a pretty wide one. The post-graduate
' Annual address delivered at .St. Lute's Hospital, South
Bethlehem, Pa., on St. Luke's Day.
schools of medicine that in the last decade have
sprung up all over the country cannot but have a bene-
ficial effect in acquainting the every-day practitioner
with the advances in all lines that can directly bene-
fit his patients. It has often seemed to me that, as
far as our patients are concerned, we need in medi-
cine less science and more philosophy. A man who
has an average development on all lines will often-
give safer advice than the extreme specialist, even in
his own department. It is not here contended that
every physician should not pursue some special line
of research. Indeed, this is highly desirable; but
both the science and art of medicine will be benefited
if such researches can be made by men of broad equip-
Kient and experience, who will see facts in their
proper relations, and who will thus be less liable to be
carried away by undue theorizing. The general prac-
titioner is not yet in his decadence. He has a future
of more importance than acting as a sort of intelli-
gence office, to dole out his patients to the proper
specialist. The specialists themselves will become
more important as they grow less differential, less ver-
bose, and develop out of a solid foundation of knowl-
edge and experience with the whole art of medicine.
A hopeful sign in the physician's sphere of work is
the lessening tendency of detaching himself from par-
ticipation in the broad movements of modern life. .
To many of the questionings of the day he can throw'
as nnich if not more help than most classes in thej
comniunity. The medical profession affords oppor-
tunity for broad and candid judgment upon many
problems of life, as it touches humanity in close and
many-sided relations, dealing with all classes, drawing
experience from tlie poorest in swarming dispensaries
and hopilals., as well as from the better favored iii
homes of ease The pure philanthropist is often apt
to consider a subject in an unreal, hypothetical sort of
way, that may be out of touch with the actual life of
the world. The physician, if any one, sees the world
as it is — -not as it should be, nor as many suppose it
to be. Of tlie many panaceas that are offered for so-
cial as well as individtial ills, very few are based upon
a correct appreciation and knowledge of the operation
of natural hiw.
It may be that physiology will be able to afford the
best preliminary solution of some of the problems of
sociology. Attempted social relief that is not based
upon essential causes cannot be permanently success-
ful. Social reformation that is not in harmony with,
the underlying laws of nature will always be a failure.
It must follow in the lines indicated by a logical study
of the sciences of biology, of physiology, and even of
pathology. Social law must conform to natural law.
All artificial adjustments only complicate existing-
troubles, in leaving untouched the underlying causes
of these troubles. Economic laws are often, at bot-
tom, the outcome of physiological laws and conditions.
Assuredly, laws of nature are fundamental, and must
largely underlie even economic laws; tlie latter may
be modified but are not necessarily altered by artifi-
cial social relations. Here, then, is briefly traced the
line in which the physician's knowledge and experi-
ence can throw some helpful side-light upon many of
the questions of the day. By recognizing and enter-
734
MEDICAL RECORD.
[November 21, 1896
ing into this larger sphere the profession can take its
true commanding position in the community at large.
In like manner should the work of the hospital be
planned to meet the widest requirements of the com-
munity and the profession. A hospital may be rightly
considered as a place to study the nature and course
of disease and the most approved methods of cure.
Many other interesting questions, however, confront
one in such a service. What have been the life con-
ditions of the patients before entrance that have led
them to need hospital care, and what becomes of them
when they leave the institution? How are they to be
handicapped in the struggle for subsistence as a result
of disease or injur}'? How far are preventable social
or hygienic influences responsible for their illness?
What part does ignorance, or poverty, or evil habits,
or simple misfortune play in causing their condition?
These and similar questions may well be thought of
in studying the collection of sick and unfortunate that
are housed together in a hospital. An attempt was
made by me a few years ago to study a group of cases
that came in my service at the babies' wards of the
New York Post-Graduate Hospital, somewhat after
this manner. Endeavor was made to find out as
nearly as possible the environment and life condi-
tions of these little children on entrance. The study
of children is simplified by being divested of many
confusing factors which enter into the investigation of
adult misfortune.
Of the 600 cases considered, 322 were males and
278 females. The ages ranged from one week to four
years, the large majority being under two years. In-
quiries were made in regard to certain social facts
about the parents, as throwing light upon the past
and future lives of the children. Twenty-two different
races and nationalities were represented in the fami-
lies, the three highest being the Irish, 70; tiie Ger-
man, no; and the American, 250, most of the latter,
however, being of Irish descent. Of the fathers, 490
were living and 1 10 dead. Among the li\ing fathers,
245 were healthy and 113 were unhealtliy, while the
physical condition of 132 was unknown. Of the moth-
ers, 556 were living and 44 dead; 298 were healthy,
75 were diseased, and no satisfactory information could
be procured about the health of 227. The parents
were unmarried in 25 cases, unknown in 5:, and in
the remaining 524 cases claimed to be married. In
114 cases the wives had been deserted by their hus-
bands, leaving them with families of little children
and without means of support. The common history
appeared to be that the man, unable to get steady
work, either through fault or misfortune, after spending
much of his time at a saloon, would suddenly leave
for parts unknown. In such cases drinking habits are
both a cause and an effect of misfortune. Among 200
cases in which direct inquiry was made, 14 were
drunkards, 140 claimed to drink in moderation, 31
were abstainers, and the habits of 15 were unknown.
In a few cases, husbands had been deserted by their
wives. In many the poverty was e.xtreme, as might be
expected from the disinclination of even the poorest
classes to leave an infant or very young child in a
hospital. Endeavor was made to find out the earning
capacity and resources of the families. In 88 cases
the fathers were out of work, in 176 cases the mothers
as well as the fathers were obliged to work, while in
107 cases the mothers were the sole bread-winners.
The combined earning capacities of the families were,
in 150 cases, between five and ten dollars per week;
and in 117 cases five dollars or less per week. In
many of the latter cases a father and mother with sev-
eral children were obliged to subsist on a weekly in-
come of from three to four dollars. In 248 cases the
weekly earnings were reported to be very small, the
exact amount being variable or unknown. In only 85
cases was the earning capacity of the family more than
ten dollars per week. These statistics were collected
during 1891 and 1892, and hence do not represent the
present hard times. They show the usual and chronic
condition of many people in average times.
The number of other children in the families from
which these little ones came was as follows: No other
children in 125 families; one in 148; twoin92; three
in 63; four in 38; five in 31; six in 10; seven or
more in 14; number unknown in 79. This is not so
large a showing as one would expect. Of 200 fami-
lies, 82 were Roman Catholics, 76 Protestants, 17
Jewish, and 25 were of no religion.
Coming now to the children themselves, the condi-
tion at birth was reported to be good in 508 cases,
bad in 20 cases, only fair in 12 cases, in 60 unknown.
This brings out an exceedingly important point,
namely, that the troubles of a large proportion of
these infants were acquired and not hereditary. A\'hile
a tendency to constitutional disease may be inherited,
it is the bad surroundings and faulty conditions of life
that powerfully predispose to illness. Environment
is often stronger than heredity in this, as in many
other factors in early life. Poverty and ignorance kill
and cripple more than disease germs, or, rather, these
malign conditions furnish a fruitful soil for the attrac-
tion and development of all kinds of specific poisons.
One of the greatest evils of charitable and philan-
thropic work is what may be called its segmental
character. Results are too often temporary, rather than
permanent, from a lack of proper conception and co-op-
eration in the factors aiming at relief. One cannot
help noticing how this humanitarian age is abun-
dantly equipped with asylums, almshouses, reformato-
ries, and hospitals of all kinds. If the good accom-
plished by such agencies could be measured solely
by relief of suffering and cure of disease, the results
would be nothing but gratifying. A collateral danger
consists in the simple temporarj' alleviation which
keeps ali\e sickly and defective classes, who are
often as prolific as they are inefficient. What is ur-
gently needed are homes or retreats, where poor con-
valescent patients can recuperate after their discharge
from the hospital. As it is, such people, in a weak-
ened condition, have no place to seek the needed rest,
and either fall victims again to a former disease or
become chronic invalids. Here would seem to be a
more fruitful field for philanthropy than the building
of additional hospitals, liy aiming to counteract the
evil effects of illness, as well as preventing the causes,
we are in the line of permanent results. Municipal
governments annually devote large sums of money for
the care of the sick, the criminal, and the insane, but
devote no energy to investigating and striving to prevent
the factors that are constantly at work in producing
these classes. Here, if ever, an ounce of prevention
is equal to many pounds of cure. In making such an
appeal for a broadening of the sphere of hospital
effort, it is not intended that there shall be any lessen-
ing of the zeal for scientific medical research. As
any work tends to compass life in all its relations,
each department will be stimulated to do its best, in
order to contribute to the common result.
There is a feeling in some quarters that there is a
tendency to an unnecessary multiplication of hospitals,
as of colleges. Perhaps, if there were fewer, they
would be better equipped for their work. Reference
is here made more especially to populous communi-
ties, where there is little danger of any one suffering
for want of hospital care. In such communities, how-
ever, most of the hospitals suffer for want of complete
equipment for their work. For instance, no splendid
architecture or imposing dimensions will make up for
the lack of a complete and well-manned laboratory.
Most of the advanced scientific work of the hospital
November 21, 1896]
MEDICAL RECORD.
735
must be done in the latter place. The mere collection
of statistics of cases from clinical observation has
about served its uses in medical advance. The com-
bination of careful clinical study with accurate bacte-
riological and pathological observations in the labora-
tory is now necessary to obtain substantial results.
Where this method is pursued more generally, we shall
have less "hearsay" in medicine and advance will be
in more rapid strides. If all the great hospitals would
utilize their vast clinical resources in this way, scien-
tific medicine would be a great gainer. Unfortunately,
a laboratory does not appeal to the wealthy governors
and patrons of hospitals in the same way as an en-
dowed bed, a gorgeously decorated ward, or even an
imposing tower. A laboratory, to do good service,
should have a sufficient endowment to attract and kee])
the best men in its service. They need to be men of
special aptitude and training, who should be paid liv-
ing salaries for giving up their time to this important
and exhausting, but not lucrative, work.
In further reference to hospital equipment, there is
a deplorable lack, in large as well as small communi-
ties, of suitable places to attend contagious diseases
of all kinds. These cases are refused admittance to
children's as well as general hospitals, and epidemics
spread through communities that could often be pre-
vented if there were facilities for collecting the first
few cases in one place, and thus stamping out the in-
fection. The nature of these diseases is now pretty
well understood, and if there were suitably equipped
places for taking patients who cannot be properly iso-
lated and treated at home, widespread suffering would
be avoided. The Empress Frederic Children's Hos-
pital, at Berlin, besides the usual medical and surgical
services, has separate pavilions for the treatment of
scarlatina, diphtheria, measles, and even for whooping-
cough. No harm ever comes from the comparative
continuity of these pavilions, as all needful precau-
tions are taken. The large class of people living in
hotels, boarding-houses, or small apartments is often
in sore straits when visited by contagious disease.
Such are fortunate if they escape with great inconve-
nience and possibly pecuniary extortion, but the inno-
cent people following them may likewise suffer. One
form of grave contagion is singularly neglected. I re-
fer to ophthalmia neonatorum. These patients require
constant and skilful treatment from the first, failing in
which the eyesight is hopelessly lost in a large pro-
portion of cases. There is no place to send these chil-
dren if the parents lack the intelligence or means to
command the proper treatment. Children's hospitals,
and even most eye hospitals, will not or cannot take
them. According to the last census, there are over
fifty thousand blind persons in the United States. A
conservative estimate places twenty per cent, of this
blindness as due to ophthalmia neonatorum. In other
words, ten thousand people are blind from shortly
after birth, a large proportion of whom could have es-
caped this awful infliction if proper nursing and treat-
ment had been available.
While the work of the hospital should be broadened
out as much as possible to meet all the needs of the
community, it must not be forgotten that the profession
has peculiar claims for consideration. There can cer-
tainly be a more thorough utilization of the work of
the hospital for the good of the profession. This may
include not only a systematic and scientific study of
disease, as hinted previously, but enlarged facilities
for teaching and demonstrating any facts or conclu-
sions that maybe reached as a result of such research.
The hospital should be a sort of Mecca for physicians,
where public clinics and free discussion will be offered
to all who come. A hospital that does not include
teaching in its routine falls very far short of its duty
and opportunities, not only to the profession, but in-
directly to the public as well. Again, why cannot
some, at least, of the wards of a hospital be utilized
by the general profession in the treatment of their
cases? It would be a great help if a hospital, in any
community, would set aside a special ward for anv
reputable physician to attend a case specially needing
hospital care. Certain facilities for operations might
also be afforded, under proper conditions and safe-
guards.
Finally, a more thorough co-operation between the
hospital and the profession at large, in the advance of
humanitarian work, cannot but have good results. As
the conception of professional opportunity widens, it
will be beneficially reflected upon the hospital. The
fact that a broadening of professional ideals and op-
portunity is in the air has already been touched upon
in this address. It should be encouraged by all well-
wishers of humanity. There are great possibilities
for good in this direction. As body and mind and
spirit are so closely blended, the two latter depending
much for their best activity upon material health, the
mere physician may become as well a mental and
moral healer. The old Eg}-ptian idea of combining
priest and physician was not without its advantages.
ACUTE CATARRHAL SALPINGITIS; ITS
RESEMBLANCE TO APPENDICITIS; DIF-
FERENTIAL DIAGNOSIS; TREATMENT.'
By HIRAM N. VINEBERG, M.D.,
ATTENDING GYNECOLOGIST TO ST. MARK's HOSPITAL, MOUNT SINAI HOSPITAL
DISPENSARY, AND MONTEFIORE HOME FOR CHRONIC INVALIDS.
My object in selecting this subject is based on the
circumstance that there is very little relating to it to be
found in the books, and what there is is so meagre as
to be of little value to the one seeking information.
My own knowledge was gained by hard-wrought ex-
perience, particularly in one case that puzzled me very
much, as it did also an eminent surgeon and diagnos-
tician, who saw the case with me several times in con-
sultation.
I can think of no better way of painting a clinical
picture of the disease and of demonstrating the diffi-
culties met with in diagnosis than by narrating the
histories of some of the cases that have come under
my observation within the past few years.
Case I. — Miss J had partaken of a hearty
meal, composed of herring and other articles of food
difficult of digestion, at 8 p.m., on November 27, 1892.
During that night she had colicky pains, radiating
from the epigastrium. In the morning she took a
tumblerful of Hunyadi water, which produced sev-
eral watery stools during the day. Still the pain in
the abdomen continued with the same severity.
I saw her November 28th, at 6 p.m. She was in
bed, complaining very much of pain all over the ab-
domen. The abdomen was rigid, rather tender, but
not distended. No special point of greater tenderness
could be elicited. Pulse was 102, small and wiry;
temperature, 103° F. I ordered turpentine stupes to
the abdomen, and small doses of opium and spirits of
chloroform internally.
November 29th, pain no better. Temperature,
101° F. ; pulse, 104. I ordered castor oil, half an
ounce.
November 30th, she had a large copious stool after
taking the oil, and felt considerably relieved. She had
much pain all of this day. Temperature, 100' F. ;
pulse, 116; abdomen slightly distended. A bimanual
examination per vaginam and rectum was rather unsat-
isfactory, owing to the rigidity and tenderness of the
abdomen. No mass could be felt at either side of
' Read before the Manhattan Medical and .Surgical Society,
September itj, 1896.
736
MEDICAL RECORD.
[November 21, 1896
the uterus, nor any mass or marked tenderness in the
area of McBurney's point.
December ist, temperature, 102° F. ; pulse, 120.
Pain was most severe in right lower quadrant of the
abdomen. This area of the abdomen was more tender
than the remaining parts, but no one point showed
greater sensitiveness than the other. Certainly Mc-
Burney's point was no more tender than numerous other
areas. A bimanual e.xamination showed a torn cervix
(patient had a premature delivery at the sixth month,
some months before) and the uterus in forward posi-
tion and freely movable. There was moderate sensi-
tiveness over the right tube and ovary, and the tube
seemed slightly thickened. But the elongated mass,
about the size of one's finger, might just as well have
been regarded as a prolapsed and adherent vermiform
appendix. She was seen now in consultation by Dr.
F. Lange. The diagnosis was considered to lie be-
tween appendicitis and salpingitis of the right tube.
There being no urgent symptoms and the diagnosis
being uncertain, it was decided to continue with the
palliative treatment and rest in bed.
December 3d, temperature had ranged from 99.3'
to 100.5° ^- T^^ menses set in in the morning and
were unattended by pain.
December 8th, temperature, 99' to 100.3° F- She
had been having more or less pain, which, however,
was kept in abeyance by small doses of opium regularly
administered. She was flowing, the flow being more
profuse than was usual with her. On bimanual exam-
ination some fulness in Douglas' space was made out.
This fulness extended somewhat to the right of the
uterus.
December 22d, temperature had ranged from 99°
to 100'^ F. Patient was still in bed, and was not free
from pain when the opium was discontinued. She
was seen again by Dr. Lange in consultation. A diag-
nosis could not be made with any greater degree of
certainty. Dr. Lange was more inclined to the diag-
nosis of appendicitis, while I was more in favor of
right-sided salpingitis.
[anuary 8, 1893, the patient was allowed out of bed
for the first time. Temperature had ranged from 99^
to 99.8° F". She could not stand up erect, on account
of pain in the right side of the abdomen. Xo mass
was to be felt through the abdominal wall. On bi-
manual examination an elongated mass, resembling a
thickened tube, could be felt pretty high in the pelvis,
and apparently running from the right horn of the
uterus.
January 14th, latterly the patient had been having
higher temperature, 100° to 101° F. (rectum). She
had been flowing aboot ten days and rather profusely.
She was not entirely free from pain. It was decided
by Dr. Lange and myself to make a thorough ex-
amination under narcosis. Accordingly, the patient
was narcotized and an examination made. We made
out the same mass on the right side of the uterus, but
thought it rather high up in the abdomen for a thick-
ened tube. Still, we could not be certain whether it
was a thickened appendix or an exudation about the
ca;cum. F'rom this on, the patient gradually im-
proved, and on Februarv 13th was allowed to take a
walk.
May 23d, she had had slight pain at times on ex-
ertion ; otherwise she was in good health. The right
tube could be distinctly felt, the size of a lead pencil.
The uterus was in good position. The patient was
under my obser\'ation until a year ago. She had re-
mained perfectly well, entirely free from pain and
menstrual disorders.
Case II. — This patient, a relative, was living in
the same house as the writer, and consequently was
ver)- closely observed. She was twenty-eight years
of age, had been married five years, and had had two
children. Four years ago she had a premature deliv-
ery, and after this some fever lasting about ten days,
the cause of which was doubtful. There were no exu-
dations in the pelvis and no fetid lochia, and, as
the patient was in excellent general condition, it was
assumed that she had a slight attack of puerperal sa-
pramia. She had to be catheterized for some days
after deliver)', and, as a result of carelessness on the
part of the nurse, she developed a moderately severe
cystitis, and several weeks elapsed before it disap-
peared entirely. She made a good recover)', however,
and was in the enjoyment of good health until De-
cember 17, 1893, when she was suddenly seized with
pain in the left hypochondrium and vomiting. I saw
her at 8 p..m. The abdomen was then flaccid. No
points of tenderness could be felt at any point. Tem-
perature, 99" F.; pulse, 90.
December i8th, she had pain all night and several
chills. The abdomen was moderately distended and
universally tender. On bimanual examination per
rectum and vaginam, I thought that I could feel an ill-
defined mass near the left horn of the uterus: but the
abdomen was so tender and rigid that a satisfactory
examination was impossible. Temperature, 103° F. ;
pulse, 130. 9 r.M., temperature, 103.3 F- ' pulse, 132,
small and wir}'. Midnight, temperature, 103° F. ;
pulse, 144. The patient was very restless. If the
pain were on the right side instead of on the left, the
suspicion of appendicitis would be very strong. The
diagnosis of left salpingitis with general peritonitis
was made.
December 19th, 8 a.m., temperature, 100° P.;
pulse, 108. II A.M., temperature, 103° F. ; pulse, 132.
5 P.M., temperature, 104' F. ; pulse, 132. She was seen
by Dr. Lange in consultation, who, after a careful
and thorough examination, could not make a definite
diagnosis. The pain being situated in the left hypo-
chondrium, and thinking he could make out some en-
largement of the left kidney. Dr. Lange suspected sup-
puration in the pelvis of the left kidney. Though
recognizing the obscurity of the case, the writer still
adhered to the diagnosis of salpingitis. The abdomen
was greatly distended, and a bimanual examination
was unreliable in the extreme. Opium in small doses
was ordered, and cold water compresses were applied
to the abdomen.
December 2 1 St, temperature had ranged from 100.4°
to 104° F". ; pulse, 108 to 132. During the last twelve
hours the pain had moderated and the distention of
the abdomen liadgone down considerably. From this
on, the patient gradually convalesced, and in the course
of three weeks was able to leave her bed. When the
abdomen again became quite flaccid, on bimanual
examination the left tube was found to be of the thick-
ness of one's little finger. A prolonged course of treat-
ment with ichthyol, hot baths, pelvic massage, and
bipolar vaginal faradization has cured the patient to
the extent that she is free from pain, except after some
unusual exertion. The tube now is about the thick-
ness of a lead pencil and is but very slightly sensi-
tive. The right tube and ovary are normal. The pa-
tient has since gone through a gestation, which was
normal in every respect, and has been well since, a
period of seven months.
The next case, though strictly not belonging to the
disease under consideration, affords another striking
example of how a general peritonitis, in some obscure
way depending upon the generative organs, can be
mistaken for an acute appendicitis. I will give the
case in briefest outlines, as it is my intention to write
of it more fully on another occasion.
Cask III. — Mrs. G , about twenty-four years
old, married eight months, and pregnant .seven and
one-half calendar months, had been in the enjoyment
of the best of health until the night of August 19th of
November 21, i8g6]
MEDICAL RECORD.
/o/
this year, when she awoke about midnight, with a
slight chill and general pains all over the body. I
saw her on the next morning, when she had a temper-
ature of 100.4° !*"•• and pulse of 90. Her tongue was
clean and general condition good. A thorough e.\-
amination of all the organs was attended with negative
results. There were indefinite and vague pains in the
lower part of the left chest and left side of abdomen,
which were called forth only on movement ; there were
also superficial tenderness over various parts of the
chest, back, and abdomen. The bowels had been mov-
ing regularly every day. The general impression gained
was that the patient had a slight rheumatic attack,
affecting the muscles of the chest, back, and abdomen.
August 20th, condition about the same. Tem-
perature, 101° -F.; pulse, 116.
August 2ist, temperature, 100^ to 101° F. ; pulse,
120. She vomited once or twice, which she attributed
to medicine taken. There was slight distention of the
abdomen ; she complained more of pain in the right
side of the abdomen and in the right hypochondriac
and umbilical regions. I was beginning to feel uneasy
about her condition, particularly on account of the
disproportion between the pulse and the temperature.
Abdominal and vaginal examinations resulted nega-
tively; I could not make a diagnosis. The probabili-
ties that occurred to me were :
1. Fsecal impaction. Still, she had been having
daily stools, and for the past two. days had had ene-
mata, with good results.
2. An abnormal incipient typhoid; but there was
no splenic enlargement, and the pulse is usually com-
paratively slow in that disease.
3. Peritonitis from an unknown cause.
The urine had been frequently examined during
her gestation, and had been found normal. The
same result was now obtained.
August 22d, 10 A.M., temperature, 101° F. ; pulse.
120. The tongue was beginning to show slight coat-
ing. She had another chill during the night; the ab-
domen was moderately distended and universally ten-
der on pressure. I asked for a consultation. An able
general diagnostician was called in at i 130 p.m. He
diagnosed acute appendicitis, and urged operative in-
terference in the event of the symptoms growing mor-^
severe. Though I iiadnot thought of this condition, I
must confess that the diagnosis grew upon me, particu-
larly as the symptoms for the next seven or eight hours
seemed to point in that direction, the pain now being
chiefly located in the right side of the abdomen, be-
tween the border of the ribs and the crest of the ilium,
over which area the tenderness was the greatest.
Temperature went up to 102.4° F- : pulse, 130. The
patient was very fidgety and restless when not under
the influence of morphine. She was seen at g p.m. by
a prominent surgeon, who thought he could feel a mass
in the right flank and was certain of the presence of
pus. He advised immediate operation. At 10 p.m. I
performed lateral laparotomy, the patient lying on her
left side. The ascending colon was found very much
distended; the peritoneal covering was deeply injected
and of a dark bluish color. Some thin membranous
adhesions of the peritoneum were found. The colon
was carefully followed down until the appendix was
reached, and it was drawn into the incision. It was
found to be quite normal, and was consequently left
intact. I passed my two fingers into the incision, and
palpated in every direction as far as I could reach.
Nothing abnormal was detected. Of course, with the
enormous uterus in the way, the exploration with the
fingers was limited and imperfect. The abdomen was
then closed. The patient rallied nicely from the
operation, and excepting for a few hours during the
next twenty-four her condition was fairly good, liut
from then on, the abdominal distention grew more and
more intense, and regurgitation of the liquids taken
(so ominous a sign in peritonitis) set in.
On the morning of .\ugust 25th, sixty hours after
the laparotomy, I began to induce labor by passing a
bougie into the uterus. 1 waited for thirty-six hours,
during which time I made use of means, such as hot
douches, etc., to hasten dilatation. Slight labor pains
set in, and the os dilated to the size of a fifty-cent
piece. The patient's condition was now very critical;
the abdominal distention was enormous, the uterus was
crowded over to the left side by the distended bowels,
and the breathing was perceptibly interfered with.
Though keenly alive to the risks of employing manual
dilatation and extraction, further delay could not be
entertained.
.Accordingly, on August 26th, at 9 p.m., I rapidly
dilated the uterus and extracted a female child, first
doing a version. The patient came near dying on the
table from the narcosis, though the chloroform was
administered by a skilful and experienced anaesthe-
tizer. The whole operation did not consume more
than twenty-five minutes. The uterus was irrigated,
and there was but a very slight loss of blood. During
the following twenty-four hours, though the distention
was decidedly less immediately after empt}"ing the
uterus, her general condition was worse ; pulse and
temperature were going up, and the distention was
increasing.
At 6 P.M., August 27th, twenty-one hours after the
delivery, I gave up all hopes of the patient's recovery.
The temperature was 104.8° F. ; pulse, 170 to 180,
small and weak; and abdomen very much distended.
Having observed the marked beneficial effect of opi-
ates all through the illness and the futility of other
medication, I decided, as a dernier ressort, to bring her
fully under their influence. She was accordingly
given larger doses of morphine hypodermically and
opium by the rectum. At midnight she feel into a
deep sleep, and when roused up at 2 a.m. her temper-
ature had fallen to 102.4° F- and pulse to 140. She
was at this time seen by a consultant, a well-known
surgeon, who still thought the case hopeless. From
this on, however, her improvement under the treatment
of opiates and enemata was gradual but certain, and
she has now been sitting up out of bed for a few days.
I might cite several other cases, but those narrated
will sufficiently serve the aim in view. I fully recog-
nize that the crucial test — a laparotomy — in the
diagnosis of Case I. is absent. Be that as it may, the
case loses nothing in value through that circumstance
in accentuating the point I wish to bring out promi-
nently in this paper. Here was a patient who, after
an indiscretion in diet, was suddenly seized with pain
in the right side of the abdomen. This was followed
by fever and symptoms of general peritonitis. Re-
peated examinations by the writer and by a surgeon
known for his skill as a diagnostician and for his
vast experience do not determine satisfactorily
whether it be appendicitis or salpingitis. Even an
examination under narcosis, after the patient had
been under close and careful observation for weeks,
does not remove the uncertainty in diagnosis.
There can be no reasonable doubt in the diagnosis
in Case II. Had it been the right instead of the left
tube that was affected, I fear the patient would have
been subjected to an operation for appendicitis.
The events in Case III. speak for themselves.
Three facts are fully sub.stantiated : i. The insidious
and misleading onset of the affection. 2. The pres-
ence of general peritonitis. 3. The absence of ap-
pendicitis as a cause of the peritonitis.
We have seen, in the cases reported, that the onset
may be sudden and without any apparent cause. But
on close scrutiny it was learned that the first two pa-
tients had suffered from a uterine discharge — in other
738
MEDICAL RECORD.
[November 21, 1896
words, from a uterine catarrh— and which, whether
it be specific or non-specific, is liable at any time to
cause a salpingitis or oophoritis by extension. An-
other very common cause of salpingitis is the intro-
duction of instruments within the uterine cavity in the
absence of the strictest antiseptic and aseptic precau-
tions. And here it may not be amiss to sound a note
of warning against the dangerous procedure recently
recommended, of following a curettage for the treat-
ment of an endometritis by daily intra-uterine
douches for a week or longer. Intra-uterine douches
without very thorough dilatation of the uterus are
fraught with great risk, even when every precaution
has been taken in regard to cleanliness. But to rec-
ommend such a procedure to the general profession,
without laying great stress upon the details for carry-
ing out the most thorough surgical cleanliness, is
culpable neglect, and shows a lack of sense of the
responsibility a writer assumes when he recommends
to the profession at large intra-uterine therapeutics.
Many a woman has been rendered an invalid for life
by the heretofore frequent resort to the sound to ascer-
tain the position of the uterus or the depth of its cav-
ity; and should the advice be generally followed of
giving intra-uterine douches for the treatment of an
endometritis, many a woman will have grafted upon
her a serious pelvic lesion in the effort to cure her of
her uterine catarrh. Numerous other causes capable
of giving rise to an acute salpingitis might be men-
tioned, such as exposure to cold during menstruation
(a very doubtful cause in my mind, unless there be
some pre-existing lesion), extension of infection
through the lymphatics, traumatism, and so on. But
the first two mentioned are the most important.
We have also seen that an acute salpingitis may
be attended with a diffuse peritonitis, differing in no
respect from that accompanying an acute appendicitis;
and should the tubal lesion be situated on the right
side, the solution of the problem of differential diag-
nosis is difficult in the extreme.
Of course, on paper the solution can be made to ap-
pear easy. In the one case, you have tenderness over
a certain well-defined area, known now the civilized
world over as McBurney's point; in the other, all
you have to do is to make a bimanual examination,
and you find a thickened and sensitive tube passing
from one horn of the uterus. But at the bedside
things are not cut and dried for us in this simple man-
ner. It is no easy matter to determine always which
is the most sensitive spot in an abdomen that is uni-
versally distended and tender, and it is next to an im-
possibility to palpate a sl'ghtly thickened tube when
you have a rigid and an extremely sensitive abdomen.
The following points the writer has been able to glean
from his experience and observation. In ap]>endicitis,
the pain is frequently more excruciating than in sal-
pingitis, and is more likely to be limited to the abdo-
men. It does not usually radiate to such an extent as
the pain arising from salpingo-oophoritis. When the
ovary is involved with the tube, as it frequently is,
the pain commonly descends the corresponding thigh.
Gastric disturbances are common to both. In salpin-
gitis, the very alarming symptoms usually subside to
some extent in the course of three or four days; in ap-
pendicitis, they may continue or grow more severe.
Certainly, it must be our aim to make a diagnosis be-
fore the lapse of three or four days; but, if the case
be a doubtful one, and no very urgent symptoms are
pressing, we can afford to wait that period of lime in
a suspected case of catarrhal appendicitis. In other
cases, when the symptoms are severe, an examination
should be made under full narcosis. Even this may
not always be decisive, as we have learned in our first
case. Still, in the majority of cases, such an exami-
nation w'ould be attended with positive results.
The question may be pertinently asked. What good
is there to be gained from making a positive diagno-
sis? If the symptoms are severe, would you not oper-
ate in either case.' But the answer is that it is just
in the matter of treatment wherein lies the importance
and value of differential diagnosis. Without entering
into any discussion as to the question of operative
interference in acute appendicitis, I think the state-
ment may be safely made that the consensus of opinion
is in favor of such interference in a large percentage
of the cases. But, on the other hand, operative inter-
ference is contraindicated, at least in mv opinion, in
catarrhal salpingitis in the acute stage during the first
attack. Further still, it may never be called foi, as we
have seen that, for all intents and purposes, the pa-
tient may be cured afttr such an attack.
I desire to reaffirm that it is only the non-purulent
variety of salpingitis that engages my attention in
this article. Whether it be always possible to differ-
entiate clinically between catarrhal salpingitis and
pyosalpinx, is a question I do not care to raise here.
Suffice it to say that in the vast majority of the cases
such a differential diagnosis is possible through an
analysis of the subjective and objective signs. Kven
in pyosalpinx it is certainly wise and feasible, in a
large percentage of the cases, to wait until the acute
symptoms have subsided before resorting to surgical
intervention.
Having reached a diagnosis of acute catarrhal sal-
pingitis, the treatment should consist of absolute rest
in bed, opium per rectum to alleviate the pain and
subdue the peritonitis, daily enemata to remove con-
tents of rectum and mildly to excite the peristalsis of
the upper bowel, light nutritious diet, and ice applica-
tions to the abdomen if they be well borne; if not, the
ice to be replaced by a Priessnitz compress. In the
majority of cases, after the very acute symptoms have
subsided, it is advisable to do a thorough curettage
under narcosis. This should be performed under the
strictest anti.septic and aseptic precautions and with the
greatest gentleness. The curettage may be followed
by packing the uterus with iodoform gauze, in the
event of that organ being large and succulent. Oth-
erwise, the packing may be dispensed with. When
the curettage is of benefit, it is so, in my opinion,
from its destroying the/o/is et origo of the disease,
and not froin the much-talked-of drainage. It is so
seldom that the contents of an acutely intlanied tube
can drain into the uterus that such a contingency may
be entirely ignored in the therapeutics of that condi-
tion. If you can destroy the source from which fur-
ther infection may come, the tendency of the natural
powers is toward a cure, if certain favorable conditions
be maintained. And these are, as already stated,
absolute rest in bed, comparative rest of the tissues
immediately in contact with the inflamed structures in-
duced by the free administration of opium, and the
avoidance of sexual excitement. Even at the risk of re-
peating myself, I wish to lay great stress upon the im-
portanceof prolonged rest in bed — and it is well to tell
the patient at the outset, that if she desires to gi\ e her-
self the best chancts of a permanent cure she must be
willing to remain in bed four, five, or six weeks, and
longer if the condition demands it. She ought to re-
main in the horizontal position as long as there is the
slightest elevation of temperature, and as long as there
is marked sensitiveness on pressure over the affected
tube. Then, for a period of some weeks, she ought
to remain comparatively quiet, walking about in the
room, but not going up or down stairs, and lying down
for an hour in the forenoon and a couple of hours in
the afternoon.
By following such a course, one may expect, in a
fair number of cases, a permanent cure, if this term
may be applied to a condition of freedom from symp-
November 21, 1896]
MEDICAL RECORD.
739
toms for a period extending over tliree or four years
(my own experience). Tlie tube remains somewhat
thickened, and in many cases, no doubt, is sealed at
the abdominal end; but it is net sensitive, and is no
cause of discomfort to the patient. In other cases,
when this course of prolonged rest has not been fol-
lowed, and in some cases in spite of it, the patient
gets apparently well, but only for a short time. Every
now and then, after some unusual exertion or exposure
to cold, or without any apparent cause, she suffers
from pain on the affected side, and may or may not
have some elevation of temperature. These seizures
\re evidences of fresh attacks of inflammation, consti-
tuting recurrent salpingitis — another point of resem-
Ijlance to appendicitis. If these attacks are allowed
to recur, it will not be long before the patient will be-
gin to suffer from pain on the opposite side and the
disease become bilateral. Of course, it may be bi-
lateral at the very beginning; but, in the majority of
■ny cases, the disease at the commencement was lini-
■ted to the one side. In my opinion, recurrent attacks
after the patient had been subjected to proper treat-
ment call for surgical interference; and now the
sooner the diseased tube is removed the better. Just
as emphatic as I was before in non-interference, I
am equally emphatic now in active inter\-ention, and
to my mind the latter course under the changed con-
dition is as strongly conservative as the former one.
Nowadays one hears a great deal about conservatism
in gynecological affections. This conser\-atism means
different things to different men. With some it means
a dallying course until both appendages are hope-
lessly involved, then doing an operation for their re-
moval and leaving the useless uterus behind. These
men are inclined to designate that operator as radical
and extremist who, on finding the same conditions,
removes the uterus also. The one plan of procedure
has just as little genuine conservatism in it as the
other.
To my way of thinking, however, true conservatism
consists in actively attacking diseased structures as
soon as it has been learned that proper palliative
treatment has no influence in checking the progress
or the recurrence of the pathological lesion. In
adopting such a course of action, we are frequently
enabled to conser\-e to the woman at least the tube
and ovary on the one side, which will carry on the
function of generation just as well as both appendages
would.
I can cite many pregnant examples of this within
my own experience — one typical of many others will,
perhaps, sutfice. A young married woman came to me
about three years ago, with a gonorrhaal endometritis,
which she had shortly before contracted from her hus-
band. She had given birth to her first child some
months before. The affection in a short time involved
the right tube and ovary. She was curetted and kept
in bed for several weeks, under the course of treat-
ment outlined in this paper. There was an apparent
cure; the pain had disappeared; the tube and ovary,
which formerly had formed a mass about the size of a
hen's egg, had gone down to almost normal dimen-
sions. In about three months she had a recurrence of
the pain in the right iliac region, and on examination
the tube and ovary were found again to be about the
size of a hen's egg. Rest in bed for a time was fol-
lowed by the disappearance of the mass and the pain.
During the following fifteen months she had several
similar attacks, during the last of which she began to
suffer with pain in the left side also. The left tube
was now for the first time found to be sensitive on
pressure, though not appreciably thickened. I de-
cided not to wait any longer. " Accordingly, on June
6, tSg:;, at St. Elizabeth Hospital, I performed vagi-
nal section, first delivering the left appendage. The
ovary contained a couple of cysts, which were punc-
tured. The peritoneal covering of the tube was con-
siderably injected, but the fimbria were apparently
normal. Both tube and ovary were then returned into
the peritoneal cavity. The right appendage was de-
livered with considerable difficulty, owing to the pres-
ence of dense and rather extensive adhesions. Tube
and ovary were ablated in the usual way. On exami-
nation afterward, the tube was found to be the thick-
ness of my thumb, club-shaped, and filled with thick
pus, the ovary being completely disorganized bv cystic
degeneration. The patient made an uneventful re-
covery and left the hospital on June 23d, seventeen
days after the operation. She has remained perfectly
well ever since.' There is no doubt in my mind that
had I waited much longer in the foregoing case, the
left appendage would also have become irretrievably
damaged." '
The reason that conservative surgical work in fe-
male pelvic affections is so often unsatisfactory is
that frequently- when the woman comes to the operat-
ing-table the time has long been past for such a plan
of action. My own experience with conservative sur-
gery during the past four years, in patients whom I had
under obser\-ation during the early stages of the pelvic
lesion, has been gratifying in the extreme, and there
is no class of cases in my recollection that gives me
greater satisfaction than just those in which I feel
morally certain that by timely intenention I was en-
abled to conserve to the woman the tube and ovary
on the one side, and in many cases part of the tube
and ovary on the affected side. These women have
remained free not only from their former pains and at-
tacks of fever, but have been freed from a menace to
their remaining generative organs, and in some in-
stances to life itself.
I will briefly cite one more case, in support of the
assertion that what at first was evidently a simple
salpingitis may prove a menace to life, and I have
done. The wife of a physician had some trouble with
the left tube and ovary, giving her frequent attacks of
pain. She consulted some authorities here and in
Germany, all of whom advised her not to have any-
thing done, and not even to allow herself to be exam-
ined. She followed this advice for three years, during
which time she had several slight attacks, laying her
up from a few hours to part of a day. Some months
ago she had a more severe attack than usual, and when
I saw her she had been in bed for four days, with fe-
ver and pain in the lower part of the abdomen. A
superficial bimanual examination revealed to the left
of the uterus a hard mass of the size of a closed fist.
For the next few days her symptoms improved. Then
suddenly, after a slight chill, her temperature began
to go up, and reached 105.2° F. ; pulse, 150, small and
thready; and her condition for several hours was one
of partial collapse. She rallied from this, and was
operated upon the day following by a vaginal inci-
sion, which gave exit to a large quantity of pus. Since
then, I am informed, she has been operated upon sev-
eral times to give exit to other collections of pus on
the right side, and that she is still an invalid. Com-
ment is unnecessary.
While penning this article, a prominent gynecolo-
gist told me of a very unfortunate experience he had
recently had, bearing on this question. It occurred,
also, in the case of a physician's wife. He had exam-
ined her and found a slightly thickened tube and
ovary, and advised non-interference. Some hours
afterward she was seized with symptoms of collapse.
He was sent for, but was not at home. Another gyne-
cologist was called, who opened the abdomen and
found free pus in the peritoneal cavity, coming from
' September, 1S95.
'American Medico-Surgical Bulletin, May 7, 1896.
740
MEDICAL RECORD.
[November 21, 1896
a ruptured pyosalpinx. The patient died of septic
peritonitis.
It would appear that these untoward events are
prone to occur in physicians' families. This is, no
doubt, from the circumstance that, the subjects being
the relatives of physicians, the operator displays more
timidity and so-called conservatism than he otherwise
would. It might be wise for a physician, in case of
illness in his family, to repeat Napoleon's famous an-
swer to the attending physician, who consulted him as
to the advisability of following a certain course of
treatment. Napoleon replied : " Follow the same line
of treatment in the case of the empress as you would
in the case of a cobbler's wife.'"
GONORRHCEA IN WOMEN."
By BERNARD GORDON, M.D.,
VISITING GYNECOLOGIST TO BETH ISRAEL HOSPITAL AND DISPENSARY, NEW
YORK, ETC.
GoNORRHCEA is such a frequent disease in v.omen that
it comes not only to the hands of the specialist of ve-
nereal diseases and to the gynecologist, but comes also
abundantly to the hands of the general practitioner.
Nevertheless, gonorrhceal infection in women finds
very little space in our gynecological works. Neither
Hart and Barbour, Lawson Tait, Fritsch, Schroeder,
Chrobak, Hegar, Kaltenbach and Olshausen give any
place to it; nor Zweifel, Winkel, IJreisky, Thomas and
Munde' ("An American Te.xt-book of Gynecology),''
Garrigues, Keating and Coe, Pozzi give any impor-
tance to this, one of the most frequent diseases. The
following statistics will give you an idea of the wide
spread of this infection in women. Noeggerath, for
instance, mentioned once with enthusiasm that 80 per
cent. (?) of all women treated by him had gonorrhcea.
Oppenheimer found (in 1884), out of 108 pregnant
women, 30 with gonorrhoea, i.e., 27.7 per cent.
Schwarz (in 1886) proved that out of 617 women, 112
had suspicious symptoms of gonorrhcea, of which 77
had the gonococcus of Neisser, /.<■., positively 12.4
percent. Saenger considers that 12 per cent, of all
our female patients are suffering from gonorrhceal in-
fection; but, in my opinion, Schwarz's statistics of
12.4 per cent, should be considered the very minimum
frequency of the disease, because, if he would have
employed the present methods of e.vamination for the
gonococcus, he would have undoubtedly found the
disease in a great many more of his suspicious cases.
Our gynecologists have devoted separate chapters to
dysmenorrhiea, amenorrhoea, sterility, and many other
symptoms, which are not diseases, but symptoms, and
have neglected to give the proper place to this, one
of the most common diseases; therefore, I selected
this subject in order to give to the profession the miss-
ing chapter in the te.\t-books on gynecology.
Etiology. — Neisser discovered tiie micrococcus
whicii is the e.xciting cause of gonorrhcea in 1879,
and proved that not only the gonorrhceal catarrhs of
the mucous membranes were caused by gonococci, but
also the intiamniations coincident with gonorrhoea;
also the suppuration of lymphatic glands, the parame
tritic infiltrations, the perimetritic inflammations, the
parenchymatous thickening of the tubes, the suppura-
tion of the ovaries may deix-Mid entirely upon the ac-
tivity of Neisser's gonococci. Tiiey are comparatively
large, somewhat oval micrococci, which seldom appear
singly, usually in twos, closely adjacent to each other,
easily separable, constantly forming groups, but never
chains; found in the free fluid or oftener found upon
the pus cells and epithelia. By this description they
' Read before the New York Academy of Medicine, section on
obstetrics and gynecology. October 22. i3g6.
can be difterentiated from many other micrococci.
According to Bumm, the most positive sign for recog-
nizing the gonococci is in the fact that they penetrate
into the epithelial and pus cells, and multiply until
the cells fall to pieces and the gonococci remain in
round-shaped groups. The virulence of gonorrhcea
depends upon the number and vitality of the gono-
cocci.
Gonorrhoea is always contracted in the acute form ;
even the infection from a chronic case produces acute
gonorrhtta, and when the infection is retransmitted to
the chronic case it also will become acute.' Neisser
and Wertheim made experiments by transferring gon-
ococci from chronic cases upon patients, and produced
acute gonorrhcea. IJelicate and thin epithelium is
predisposed to the infection. That is the reason for
the more frequent and more serious affection of blondes
and generally delicate women, pregnant women, girls,
etc. The disease is usually transmitted through sex-
ual intercourse, but can also be transmitted by cloths,
linen, baths, and, according to Suchard,' even through
bathing in a stream. He describes an epidemic of
twelve cases, caused by bathing together in one place
of a river. Weil and Barjou (Lyon) reported' an epi-
demic of gonorrhcea in a hospital where the transmit-
ting medium was the thermometer.
Bacteriology. — Since Neisser and Wertheim have
proven that the gonococcus is the only cause of gon-
orrhcea in any part of the genitals and even perito-
neum, the most positive diagnostic proof of gonorrhoea
is the demonstration of the presence of the gonococ-
cus. Althougii in a great many cases we are able to
diagnosticate gonorrhcea clinically, still there remains
a large share of them, especially those of a chronic
nature, which can be recognized as gonorrhceal only
by the aid of the microscope. Just as diphtheria of a
seemingly malignant appearance, with very few Loeffler
bacilli or none at all, will be considered a mild case
of diphtheria or a simple local inflammation, so will a
seemingly severe case of gonorrhcea change in our
opinion to a mild one or a simple local inflammation,
if the microscojx; should reveal very few gonococci or
none at all. Microscopic examinations during the
course of treatment are usually of great value, because
the effect as to better or worse can be definitely deter-
mined during the course of the disease. Examination
for tiie gonococcus is generally made microscopically.
Culture nietiiods, because of the difficulties attending
their employment, are only used in exceptional cases.
Although the demonstration of the gonococcus under
the microscope means positive gonorrhcia, still the
failure to find it is not absolutely negative, as gono-
cocci may be so concealed in the depth of tissues, la-
cuna;, and folds, that the superficial secretion of a
mucous membrane which is to be examined is free of
gonococci. The value ' of the microscopical examina-
tion is especially great in cities, where hundreds of
prostitutes are yearly withdrawn from their vagabond
life and subjected to hospital treatment, who, without
microscopical examination, would be pronounced
healthy, and permitted to become from day to day the
source of furtiier infection.
Staining the Gonococcus.' — In cover-glass prepa-
rations made from the susjxicted secretions, the coccus
is easily stained by watery solutions of the aniline
dyes, preferably methyl blue. It is decolorized by
Gram's method. Schwarz recommends staining cover-
glass preparations for five to ten minutes in a saturated
solution of methyl blue in five-per-cent. carbolic-acid
' S. Wertheim: Wiener klinische Wochenschrift, 1894, No. 24.
^ Centralblatt fiir Gynakologie, 1S94, p. 1,105.
' Weil and Barjou : Centralblatt fUr Gynakologie, 1895, p. 774.
■* II. T. Brooks: The Post-Graduate, October, 1893.
' T. M. Cheesman: " Reference Handbook of the Medical
Sciences," vol. 9. p. 78.
November 21, 1896]
MEDICAL RECORD.
741
water; then immersing for three seconds in dilute
hydric acetate five parts, water, twenty parts, and
washing thoroughly in water; contrast stain in a very
dilute solution of safifranin. V. Kahlden recommends
staining two to three minutes in an alcoholic solution
of eosin, and warming. The excess of eosin is ab-
sorbed with paper, and the film is then stained for half
a minute in an alcoholic solution of methyl blue. Wash
in water, dry, and mount in balsam. Sections should
be stained in Ziehl's solution and washed in alcohol.
Biology of the Gonococcus. — After a number of
e.xperiments for determining the best culture media,
the powers of resisting temperature, and the pyogenic
properties of the gonococcus, Drs. Steinschneider and
Schaefer ' conclude that:
1. The best medium is blood serum or serous fluid
of man, but the serum of the ox, sheep, dog, and rab-
bit may be substituted, and these media cannot be
dispensed with.
2. Urine agar has not proved to be a reliable me-
dium.
3. In Wertheim's plate method, a sterile camel's-
hair brush may be profitably substituted for the plati-
num loop, in spreading the pus over the surface of the
serum-agar plates.
4. Exposure to a temperature of 40° C. for twelve
hours or more not only inhibits the growth but de-
stroys the vitality of the organism.
5. When exposed to room temperature for not too
long a period, proliferation is inhibited but not de-
stroyed.
6. When gonorrhoeal pus is mixed with water or
urine, gonococci may retain their vitality for one to
two hours; under favorable conditions even longer.
7. When introduced into the subcutaneous connec-
tive tissue, the gonococci do not produce suppuration.
Medico-Legal Remarks. — Dr. A. Haberda (Vien-
na) ■"' allowed a few drops of gonorrhctal discharge to
dry upon pieces of linen, and by making thorough ex-
aminations came to the following conclusions: i.
The gonococcus could be well recognized microscopi-
cally by its form, size, and staining after many weeks,
and in thickly dried drops even after eight months.
2. Culture tests were successful only twice from thick-
discharge stains, which dried in from three-quarters
to one and one-quarter hours. Later the plates be-
came sterile. This experiment shows that perfectly
dry discharge loses its infectious character. 3. Inoc-
ulations upon the urethra by the dry gonorrhceal dis-
charge (after one to four hours) constantly failed.
Latent Gonorrhoea Noeggerath (in 1872) was the
first man to describe a certain stage of gonorrhoeal in-
fection and call it latent gonorrhoea. The wife of
many a man, who at any time before marriage con-
tracted gonorrhcea, becomes affected with latent gon-
orrhoea, which sooner or later makes itself known
through some one of the diseases I am about to de-
scribe. Wertheim only recently was enabled to give a
thoroughly scientific explanation of latent gonorrhoea.
He says that only young gonococci " are recognizable,
as they are stained by aniline solutions, while old
gonococci lose their typical forms by becoming granu-
lar spheres, variable in size and indefinite in outline.
This change occurs whenever the culture medium is
exhausted and no longer nutritious. He proves this
by transplanting the afore-mentioned altered forms
into fresh culture media and raising typical gonococci.
The logical consequence is that patients proclaimed
cured when the microscope revealed no gonococci
may possess them in their latent form, which can be
detected only when transferred to a better soil or cul-
ture medium, when the typical gonococci are raised.
' Berliner klinische Woclienschrift, iSg?, No. 45.
'■' Centralblatt fiir Clynakologie, iSq5, p. 145.
' American Journal of Obstetrics, .September, 1896, p. 3S3.
The Organs that Become Affected. — Gonorrhoea
in women manifests itself by one or a few of the fol-
lowing aft'ections: Vulvitis, bartholinitis, urethritis,
vaginitis,' metritis," perimetritis,^ parametritis, salpin-
gitis,' oophoritis,' and peritonitis." Sometimes the
disease ' extends from the urethra, causing gonor-
rhceal cystitis, ureteritis," and nephritis. Also gonor-
rhoeal proctitis," arthritis,'" phlebitis," endocarditis,'''
pleuritis," meningo-myelitis," and conjunctivitis'*
are met with, although located at a great distance
from the original seat of disease. Albuminuria"' is
reported to be observed very frequently in the acute
stage of gonorrhoea.
Vulvitis. — Vulvitis comes usually in the acute form,
and passes very rapidly. It manifests itself by red-
ness and swelling of the labia majora and minora.
The parts are covered with a thick, offensive, greenish-
yellow discharge." Itching and burning in the exter-
nal genitals, especially after urination, when the urine
passes over the inflamed and sensitive parts, are almost
constant symptoms, although the diagnosis can become
positive only when the gonococcus is found in the se-
cretion under the microscope. Prognosis is good, if
not extended to the other genital parts, as it invariably
tends to spread to the adjacent mucosa, resulting in
vaginitis, urethritis, cervicitis, etc.'"
Treatment: Since the reports of Dr. Neisser, of
Breslau,'" of the experiments in his clinic, and Dr.
Friedheim '"'" (of the same clinic), in 1890, about the
great value of nitrate of silver in gonorrhcea, in solu-
tions of I to 4,000 to I to 2,000, this drug has become
the ideal and most popular remedy abroad and here.
The plan described by Dr. Pryor, of New York,'" is
much in vogue in the United States. Nitrate of sil-
ver, a solution of twenty grains to the ounce, should
be painted and allowed to dry upon the vulva, meatus
urinarius, clitoris, and nympha;. The vagina should
be packed with twenty-per-cent. iodoform gauze,
wrung out of a i to 5,000 solution of bichloride of
mercury. The woman should bathe the vulva every
four hours with a one-half-per-cent. solution of lysol.
I have been in the habit of using permanganate of
potassium in solution, i to 5,000 to i to 2,000, and it is
especially recommended by Klein." Columbini'"" rec-
ommends five to ten per cent, of ichthyol in glycerin.
Abstinence from all kinds of stimulants should be in-
sisted upon. Frequent hip baths with sea-salt dis-
solved in the water, and frequent sea bathing in the
summer, are very beneficial. Nitrate of silver, al-
though very popular at present in the treatment of
gonorrhcea, will probably be soon displaced by either
' Pozzi : " Medical and Surgical Gynecologj'."
' Ibid.
^ Noeggerath : Annals of Gyn., vol. i., p. 582.
■•Pozzi: " Medical and Surgical Gynecology." Noeggerath:
Annals of Gyn., 1894 p. 775,
' Challan de Belval: Centralblatt fiir Gyn . 1894, p. 775.
' E. Gluender: Centralblatt fur Gyn., 1894, p. 775.
'' B. Brown: Medic.vl Record, vol. xl., p. 640.
* Mendelsohn: Vratch, 1895, p. 1,328.
' Neisser (Breslau): Medicai, Record, vol. xliii., p. 147.
'" Brodhurst (London): Med. Rec, vol. xl., p. 365. Stark:
Med. Record, vol. xlii., p. 208. O. Resnikow: Annals of
Gyn., vol. viii., p. 69. Northrup, Welch, Shattuck, etc. : Med.
Rec, vol. xlvii., p. 756.
" La Presse Medicate, December 7, 1895.
'■' The Med. Bulletin, vol. xvi., p. 106. W. Winterberg:
Centralblatt fiir Gyn., 1S95, p. 927.
" P. Faitout: Vratch, 1S95, p. 1,272.
'■* .Mf.d. Rec, vol. xl., p. 741.
'* Haga: Med. Rec, vol. xlii., p. 565.
'* P. Balser and Souplet: Med. Bulletin, vol. xv., p. 105.
" B. H. Wells: The International Journal of Surgery, vol. iii.,
p. 207.
'* More Madden: The Lancet, January, 1896, p. 39.
" Neisser: Medical Record, vol. xliii., p. 147.
'" Friedheim: Medical Record, vol. xxxvii., p. 708.
■■' W. R. Pryor: Medical Record, vol xlviii., p. 390.
" G. Klein: The Lancet, October, 189?, p. 328.
" Columbini (Siena) : Centralblatt fUr Gyn., 1894, p. 776.
742
MEDICAL RECORD.
[November 21, 1896
one of the two new remedies — argentamin and ar-
gonin. They answer more to the requirements of an
ideal remedy for gonorrhcea; namely, while they de-
stroy the gonococcus and penetrate deeply into the
tissues, still they do no harm to them.
Argentamin ' (ethylendiamin-silver-phosphate so-
lution) : A colorless, alkaline liquid, turning yellow
on exposure. Antiseptic and astringent, like corrosive
sublimate, but not coagulating proteids. It is highly
recommended by Ashner, of Budapest,' Schaeffer, of
Breslau,^ and Albertazzi, of Rome,' in solutions of i
to 4,000 to I to 2,000. It is very similar in its effects
to nitrate of silver, with a special advantage, that it
does not coagulate albumin. It does not affect, there-
fore, the epithelium of the mucous membrane, and can
permeate into the tissue and attack there the deeply
seated gonococci. The following are the conclusions
arrived at in experimenting with argentamin:
1. Solutions of argentamin give no precipitate in
the presence of albumin and sodium chloride.
2. They penetrate deeply into the tissues without
altering them.
3. A solution of argentamin, i to 4,000, unfertilizes
a pure culture of gonococci in from five to seven min-
utes of contact, i.e., sooner than a solution of nitrate
of silver, i to 4,000.
4. Injections of a solution of argentamin into the
urethra, even as strong as 1 to 1,000, are well toler-
ated. The quantity of gonorrhctal discharge increases
after a few injections, but afterward gradually and
rapidly disapjjears.
5. Usually on the sixth or seventh day the discharge
is already quite thin, and you can hardly find any cells
with gonococci in them. If you stop the injections
when the gonococci are not found, the discharge will
disappear anyhow very rapidly.
6. The treatment with argentamin can be com-
menced at any stage of the disease.
7. The cases are usually cured within six to fifteen
days, the length of the sickness depending also upon
general dietary and h\gienic conditions.
Argonin: .A, soluble silver-casein salt. It is a fine,
white powder, soluble in hot water; ammonia in-
creases its solubility. It is a non-coagulating antisep-
tic, like argentamin. .Argonin is strongly recom-
mended by Jadassohn, of Breslau," R. Meyer," and
Schaeffer,' in 1.5 to 2 per cent, solutions. This
remedy, combining the good properties of argentamin
with its additional advantage of being non-irritating
in character, will probably become in time the most
popular antigonorrhcuicum.
Bartholinitis.' — Bartholinitis gonorrhojica takes
one of the following three courses : ''
First, the entire gland may rapidly suppurate.
Within three or four days a tumor forms in the labium
majus, which may attain the size of a child's fist or
even greater dimensions. The labium becomes hard
and red. Treat it like a phlegmon, by incision and
antiseptics.
Second, the process runs a slower course, and the
inner surface of the labium becomes more prominent.
In this case the secretion of the vulvitis seals the
efferent channel. The secretion of the gland cannot
escape from the duct, expands it, and lies at the inner
surface of the posterior third of the labium majus in
the shape of a cyst, the size of a hazelnut or larger.
' Manufactured by E. Schering, Berlin, Germany.
* Ashner: Wiener med. Wochenschrift, Maerz u. April, 1895.
'Schaeffer: Centralblatt f. Gyn.. No. 50, 18S5, p. 1,333.
* Albertazzi: Vratch, iSg?, p. S74.
' .\rchiv f. Dermatol, und Syphilologie, vol. xxxii.
' Rudolph Meyer: Zeitschrift f. Hygiene u. Infectionskrank. ,
1895, vol. xl.
' Schaeffer: Centralblatt f. Gyn., No. 50, 1895, p. 1,333.
* C. Herbert: Centralblatt f. Gyn., 1S95, p. 926.
' H. Fritsch; " The Diseases of Women."
The secretion can often be forcibly expressed. In
this latter case cysts also form which persist for years
without incommoding the patients. These cysts con-
tain yellow or dark brownish fluid, and do not refill if
freely opened.
Third, the chronic kind of gonorrhcEic bartholinitis
is the most pernicious in its consequences, the form
probably leading most frequently to the infection of the
male. .\ moderate quantity of pus continually flows
from the efferent duct. This pus covers the vulva in
a thin layer. It is very probable that precisely the
act of coition, owing to compression of the gland by
the sphincter cunni or to accidental pressure of the
tip of the penis upon the gland, leads to a more co-
pious production of the infectious secretion of the dis-
eased gland.
Treatment depends upon circumstances. Either di-
late the canal by a sound and apply antiseptics, such
as argonin, argentamin, nitrate of silver, etc.; or in-
cise, if there is an abscess. Should the glandular
body be affected, extirpation becomes the most ra-
tional treatment.
Urethritis, Cystitis, and Ureteritis. — Urethritis
is almost always an accompaniment of gonorrhoeal
vulvitis. Bunuii ' and Luczny," for instance, find it as
frequently as in ninety per cent, of all their cases of
gonorrhcea. Sometimes a periurethritis is developed,
and usually in such cases the Skene's glands " become
affected. The glands surround the urethra, and their
canals open on either side and behind the meatus
urinarius. l*he gonococci are peculiarly prone to
linger in these openings, and often long after all trace
of the disease is supposed to have disappeared one or
more drops of thick, yellow pus can be squeezed out
of them. The gonorrhceal process can also extend
from the urethra to the bladder, ureters, and even into
the pelves of the kidneys, causing death through pye-
litis and pyelo-nephritis. When the patient com-
plains of a burning sensation during and after urina-
tion, your suspicion of a gonorrha;al infection should
be aroused. Introduce a finger into the vagina against
the neck of the bladder and withdraw it while press-
ing it agai ,st the urethra, and if a purulent discharge
comes out of the meatus urinarius the diagnosis of
gonorrhceal urethritis is positive, as there is no other
urethritis that will produce a purulent discharge.
The urethroscope or endoscope, which is easily
used in the female urethra, shows that the whole canal
is inflamed, and in some instances discloses the pres-
ence of small ulcers. In order that an affected urethra
may be better distinguished, I will give here a de-
scription of a healthy urethra as seen in the urethro-
scope :* I, The mucous membrane of the canal is trav-
ersed with radial folds; 2, the urethral orifice appears
in the shape of a darkish spot; 3, with regard to col-
or, the urethral mucous membrane closely resembles
the oral; 4, muciparous glands are invisible. As the
scope of this paper does not permit me to give more
space to urethroscopy, I take the liberty of referring
you to an excellent article on " Practical Urethros-
copy," by Dr. Wossildo, of Berlin, Germany, pub-
lished in the Medical Record, September 7, 1895.
Treatment: The best plan of treating the urethra is
by local applications daily, either of nitrate of silver,
two to five per cent, solution; argentamin, i to 2,000
solution; or argonin, one-per-cent. solution.
Cystitis.' — When a patient who is suffering from a
urethral gonorrhcea complains of severe suprapubic
pain, with disturbances in urination, and when on a
bimanual examination you exclude the affection of
' Centralblatt f. Gyn., 1892, p. 729.
* Ibid., p. 572.
* " An American Text-Book of Gynecology," p. 616.
' Eberman: Medical Record, January 6, 1894.
' Centralblatt f. Chirurgie, March 14, 1896.
November 21, 1896]
MEDICAL RECORD.
743
the uterus, you can make your diagnosis cystitis gon-
orrhceica, and your diagnosis will in all probability
be correct; but you cannot be positive unless you re-
sort to the use of the cystoscope.
A cystoscopic examination reveals pale red, irregu-
lar patches upon a healthy mucous membrane, mostly
around the os urethras. If one of the ureters is
affected, an inflammatory patch can be seen surround-
ing its opening; the flow of urine from that opening is
at much shorter intervals than from the healthy ureter.
Treatment: Wash out the bladder once daily. Pour
one quart of a solution of permanganate of potassium,
I to 2,000, into a fountain syringe; then introduce a
disinfected catheter (not double current) into the blad-
der. After the urine has flowed out, connect the cathe-
ter with the rubber tube of the syringe and let the
solution fill the bladder, until the patient states that
she cannot stand it any longer. The catheter is then
withdrawn, and the patient has to retain the fluid from
one to three minutes. She then passes the muddy
and discolored solution; or, if she is unable to pass
it, she is catheterized. I have seldom seen a patient
not cured within a week or twelve days by this plan.
Should I meet an obstinate case of gonorrhceal cysti-
tis, I would try argonin or argentamin.
Ureteritis, when detected cystoscopically, must not
be neglected, or it may ost the patient's life. Check
it immediately by a local application, by Kelly's
method, of either nitrate of silver, two per cent.; ar-
gentamin, I to 2,000; or argonin, one per cent. The
last may be the safest and most reliable gonococcicide.
Vaginitis. — Pathology: Although the pavement
epithelium lining the vagina is not so easily penetra-
ble for the gonococci, which is an established fact,
and although, according to Doederlein, the acidity of
the vaginal secretion depresses their vitality, still we
meet a great number of cases of gonorrhceal vaginitis.
These cases usually come together with vulvitis, and
are called gonorrhceal vulvo-vaginitis; but we meet
the affection of the vagina alone very often, espe-
cially of the posterior vaginal pouch, and also of the
vaginal portion of the uterus, while no other genital
part is affected. In the a ute stage we find redness,
swelling, cedema, erosions, swelling of the papillae, and
secretion of a serous, rapidly developing into a puru-
lent, discharge.
Symptoms: Vaginitis is characterized by the sense
of fulness and heat about the genitals, muco-purulent
secretions, and slight febrile variations. Duration of
the disease is from one to three weeks, and it seldom
becomes chronic.
Diagnosis: The diagnosis of vaginitis is easily ar-
rived at by the above symptoms, but the question as
to its being of a gonorrhoeal nature can be solved only
by the microscope.
The speculum shows that the mucous membrane is
inflamed and covered with a muco-purulent discharge;
the redness is usually in the form of patches, but may
be diffuse.
Treatment: My plan is as follows: I prescribe to
the patient potassium permanganate in papers, four to
seven grains in each, and order her to dissolve the
crystals out of one pajDer in a quart of lukewarm w-ater ;
then to pour the solution into a fountain syringe and
make a vaginal irrigation, while lying on her back with
a bed pan under her. If the patient is not ordered to
be e.xact in this, she will very frequently make an in-
jection in the sitting posture, which is certainly much
inferior for a thorough washing of the vagina. About
eight irrigations within forty-eight hours are made, and
then I apply a solution of silver nitrate, thirty grains
to the ounce of water, to all the inflamed surfaces
through a bivalve speculum and tampon with either
boro-glycerin or ichthyol-glycerin, ten per cent.,' on
' Columbini; Centralblatt f. Gyn., August ii, 1894.
absorbent cotton, or iodoform gauze, ten per cent. The
patient removes the packing after twenty-four hours
and continues to make injections of permanganate of
potassium every six hours for two days. Then a second
local application of silver nitrate is made as before.
Treatment is continued on this plan until the patient
needs no local applications but vaginal injections.
Those are gradually diminished in frequency and
strength until entirely dispensed with. For a short
time I have been using a solution of argonin, two per
cent., instead of the nitrate of silver, in my cases of
vulvo-vaginitis.
Argentamin in solution of 1 to 1,000 as a local ap-
plication will also be found more efficient than the
nitrate-of-silver solution. Dr. R. T. O'Brien reports '
a number of cases of gonorrhoea treated by means of
injections of sea water. He had the injections given
seven or eight times in twenty-four hours. The aver-
age duration of the disease under treatment was 8.87
days. Alumnol is recommended by Chotzen, of Bres-
lau," as a good astringent and gonococcicide. Vaginal
irrigations are made with a solution of one to two per
cent.
Methyl blue, five-per-cent. solution, to moisten tam-
pons, is said to act directly upon the bacteria in vagi-
nitis, causing discharge and pain to cease. ^
Pyoktanin and boric acid, in proportion of ten per
cent, of the former, are found by Hulbert * to be the
most ideal and ettective germicidal antiseptic yet pre-
sented for the cure of primary gonorrhceal vaginitis.
After being cleansed with hot water, the cavity is freely
and liberally dusted and packed with any mild anti-
septic gauze to the hymen.
Uterine Gonorrhoea. — Pathology: Gonorrhceal en-
docervicitis is usually mild in its manifestations; the
patient ne\er suffers any pelvic lesions, because the
cer\'ical mucous membrane is dense, with few lym-
phatics, and drainage is readily obtained.* The only
and the most important danger is the tendency of the
infection to spread to the endometrium. Gonorrhoeal
endometritis " presents the pathological appearance of
an interstitial inflammatory process of the mucous
membrane of a purulent nature. In quite a number
of cases there is an increase in the glandular supplv of
the mucosa, especially during a chronic course. This
may be called endometritis glandularis gonorrhceica.
Gonorrhoeal Metritis. — Dr. Max Madlener,' of Mu-
nich, gives the following resume of his investigations:
Neisser's gonococcus is capable of passing from the
endometrium into the muscular apparatus of the entire
uterus and there setting up an inflammatory process.
This inflammation may reach even to the point of
abscess production. This result appears especially to
occur in the puerperium. Usually the inflammation
remains of moderate intensity. The gonococcus dis-
appears quickly from the myometrium, in that it either
perishes or wanders farther. By the introduction of
germs into the uterine wall, even as far as the serosa,
infection of the peritoneum from the endometrium
with evasion of the tubes is a possibility, and in this
way perimetritis in gonorrhoea without implication of
the adne.xa is explained. The uterus is next to the
urethra in frequency of affection. Steinschneider
found uterine gonorrha;a in fifty per cent, of his
gonorrhoeal cases, Neisser in sixty-one per cent., and
Bumm in seventy-four per cent. It happens often
that the uterus directly and alone becomes infected.
Symptoms: Uterine gonorrhoea usually sets in
acutely. You can see through the speculum that the
' liritish Med. Journal, November 30, 18S9.
* Centralblatt f. Gyn., October 26, 1895.
^ Medical Record, March 17, 1894.
■* Medical Record, .\pril i, 1S93.
^ " An .American Text-Hook of Gynecology," p. 235,
* Wertheim: Centralblatt f. Gyn., June 29, 1895.
' Centralblatt £. Gyn., December 14, 1895.
744
MEDICAL RECORD.
[November 21, 1896
vaginal portion is swollen, the mucous membrane
tense, glistening, and red. In the e.vternal orifice of
the cervix you can see the dark red congested mucous
membrane. A green-yellowish, purulent discharge is
flowing out of it, presenting a picture similar to the
urethral gonorrhoea in man. In this discharge you
will find gonococci as usual near and upon epi-
thelial and pus cells. Uterine gonorrhaa may last
from a few weeks to many months. During the sec-
ond stage or subacute condition the pain, redness,
and swelling gradually disappear, the discharge be-
comes thinner, translucent, and the disease gradually
abates, leaving the usual healthy cervical secretion.
In many cases the subacute stage gradually turns into
the chronic, when gonorrhcea may become latent, dis-
appear, and reappear when certain conditions influ-
ence it. E.xcessive sexual intercourse, alcoholic
stimulants, etc., may produce exacerbations of an
acute condition.
In gonorrhoeal endometritis the muscular wall usu-
ally becomes affected before the gonorrhcea extends
to the tubes and this is usually a cause for chronic
metritis. On a bimanual examination you will notice
pain, swelling, and hard consistency due to hyperaemia
and infiltration.
There is no doubt that conception can take place
after an attack of uterine gonorrhcea, but usually in
these cases either an abortion or an abnormal devel-
opment of the ovum is the consequence. When
gonorrhoeal infection and conception take place at the
same time, there is less chance for the infection to
spread to the tube, ovaries, and peritoneum, because
by the agglutination of the decidua reflexa with the
vera the uterine cavity becomes closed and protected
from the spread of the infection. In this way the dis-
ease is limited to the lower part of the genitals and
can be easily checked, but in case the disease is not
cured in time there is extreme danger of its spread
during the puerperal state, as the tubal openings are
widely dilated and can freely admit the infection.
Puerperal gonorrhceal endometritis is a grave febrile
affection, with a temperature often reaching 105° F.,
but it is not so fatal as the puerperal septic endome-
tritis and therefore should be carefully differentiated.
Diagnosis: Endometritis gonorrhceica is usually a
complication of gonorrhceal vulvo-vaginitis or ure-
thritis, and is therefore diagnosticated as gonorrhceal
by its mere presence, but when there is any doubt the
uterine secretions can be examined microscopically
for Neisser's gonococcus.
Treatment : Local applications of silver nitrate, ten
per cent., zinc chloride, twenty per cent., argentamin,
five per cent., argonin, five per cent., or ichthyol-glyc-
erin, ten per cent., are useful. Recently alumnol ' was
introduced and considered as very efficient; either
alumnol gauze, five per cent., or an alumnol antrophore,
five per cent., is introduced into the uterus. My
method is more radical and I claim for it positive
success. When there is no complicating salpingitis
present, I dilate the cervix, irrigate the uterine cavity
with bichloride of mercury, i to 4,000, then curette
thoroughly with a sharp curette, touch up the endome-
trium with ninety-five-per-cent. carbolic acid, pa' k the
uterus with iodoform gauze, ten per cent., and tampon-
ade the vagina with ichthyol-glycerin tampons, ten per
cent. After forty-eight hours the tampons and packing
are removed, and a few fresh ichthyol-glycerin tampons
are placed in the vagina. One week later I examine
the patient, especially her uterine secretions, and if the
disease is still persisting I repeat the above procedure.
Salpingitis and Oophoritis. — Pathology: (a) Sal-
pingitis occurs according to Bumm in 3.7 per cent, of
the gynecological practice, while Schauta finds it in
17.8 per cent, of his own carefully investigated cases.
' Dr. Chotzen (Breslau): Cencralblatt f. Gyn., October 26, 1895.
The gonorrhceal affection of the tube is therefore less
frequent than gonorrhoea of the uterus, probably due
to the narrowness of the lumen in the tube. The mu-
cous membrane becomes thickened and the ciliated epi-
thelia are destroyed. In some places the destruction
goes so far as to uncover the underlying connective
tissue; infiltration then takes place in the intermuscu-
lar and submucous connective tissue, and thickening
of the wall is the consequence. At times atresia or
stenosis of the tube occurs. On account of stenosis
in both ends of tlie tube a fluid accumulates. This is
either purulent or serou.s, but very seldom bloody.
We have therefore the pyosalpinx, hydrosalpinx, and
rarely the haematosalpinx.' \Vertheim succeeded in
proving the presence of gonococci in the tubal wall
and in its contents. The gonococci reach only the
superficial layers of the connective tissue, which be-
comes exceedingly infiltrated with pus cells. No
other pyogenic bacteria have been found as yet in these
gonorrhceal inflammations of tubes, ovaries, and even
peritoneum. (/') Oophoritis: Gonorrhceal oophoritis
may be produced in two ways : either by route of the
tubal lumen the gonorrhoeal pus flows into an open
Graafian follicle,' or the infection spreads from the
tube to the peritoneum and then afterward to the
ovary. Wertfieim found gonococci not only in the
pus of the ovarian abscess, but also in the solid tissue
of the ovary.
Symptoms: Pain is complained of in the lower part
of the abdomen and sacral region, extending down to
the lower extremities. There is also pain at times in
the chest and upper extremities. It may be either
continuous or interrupted, simulating labor pains.
Metrorrhagias are very frequent in these cases, also
irregular and profuse menses. Painful urination and
purulent vaginal discharge are seldom absent. Fre-
quent peritonitic attacks, loss of appetite, emaciation,
nervousness, constipation, painful defecation, and a
general impaired nutrition can be observed. Hamo-
globin falls to twenty or thirty per cent. Sterility is
most frequently the consequence. In case pregnancy
is coincident with this affection, it becomes then a
source of torture and danger to the patient. Either
abortion is produced by the interference of the tumor
with the rise of the uterus, or if pregnancy is carried
to the full term a pelvic peritonitis is a probable
complication in the puerpurium.
Diagnosis: Salpingitis or oophoritis is made out
by the usual bimanual examination, like the simple
inflammatory aflections of the tubes and ovaries, and
the question as to gonorrhoeal infection is solved by
the history of the case. Be guarded against mistak-
ing the tumor for an ectopic gestation.
Treatment: First or acute stage: When a hard
tumor is felt bimanually, but no fluctuation is present,
when the heat and pain in the pelvis are severe, then
an ice-bag full of ice kept on the afTected side will
subdue to a great extent the acute inflammatory proc-
ess; morphine (one -eighth of a grain every two
hours) will quiet the pain and comfort the patient;
quinine or antipyrin will relieve the fever. Perfect
rest in bed, ichthyol-glycerin, ten per cent, (a few
ounces injected into the vagina t.i.d.), and fluid diet are
indicated in this stage. If this plan does not improve
the condition of the patient, several leeches or a blis-
ter may be applied to the affected side, and vaginal
injections of permanganate of potassium, two grains to
the pint, should be used. Second or subacute stage:
Dilate the cervical canal and introduce an Outer-
bridge's wire dilator to allow the free exit of secre-
tions from the uterus. Order warm linseed poultices
to the abdomen and warm vaginal injections of bi-
chloride of mercur)', i to 4,000, twice or three times
' " Lehrbuch der Gynakologie," Schauta, Wien, 1896.
^ Menge; Centralblatt i. Gyn., July 20, 1895.
November 21, 1896]
MEDICAL RFXORD.
745
daily. Third or chronic stage : This may terminate in
two conditions — one, the purulent affection, in which
fluctuation is distinct; either a pyosalpinx or an ova-
rian abscess, or both, can be diagnosticated on one or on
both sides. Then the best plan is extirpation of one
or of both appendages. Professor Schauta, of Vienna,
practises simultaneous extirpation of the uterus, when
both appendages are to be removed.' On the other
hand the chronic stage may show a tendency toward
improvement, especially in cases in which there is no
fluctuation to be detected. In these cases mild saline
laxatives, iodides, massage, glycerin tampons, sea-
salt baths, or sea bathing will produce a decided effect.
Peritonitis and Parametritis. — Pathology: As
long as the view of Bumm was in vogue, that the
gonococcus could penetrate into cylindrical epithe-
lium only, it was thought impossible that Neisser's
gonococcus alone would be sufficient to cause peri-
tonitis, but that streptococci and staphylococci would
have to appear in tiie field of infection in order to
produce a peritonitis. Wertheim by experiments upon
white mice and guinea-pigs proved that within twenty-
four hours after inoculation of gonorrhoea upon the
peritoneum a sero-purulent secretion on the infected
spot could be distinctly seen.
Peritonitis usually leaves behind many adhesions,
which tie up the pelvic organs in different ways.
Very often there are among the adhesions ensacculated
accumulations of pus, blood, or serous fluid. Para-
metritis is one of the rarest gonorrhceal affections, and
all that is known of it through operations is that it
occurs usually as a sequela to long-standing or recur-
rent peritonitis.
Symptoms: There is a slight rise of temperature
during the first few days, seldom above 10 1.5" F.
Pain and tenderness are distinct, as in simple pelvic
peritonitis, but the gonorrhceal peritonitis seldom lasts
longer than four days. Cases of peritonitis produced
by the sudden rupture of a gonorrhceal pyosalpinx
are usually very grave and in most cases fatal. The
symptoms of chronic pelveo-peritonitis are usually
confused with those of the adnexa, and it is hard to
say w'hether they belong to salpingitis, oophoritis, or
peritonitis. The symptoms of parametritis are also
obscured by the affection of the adnexa.
Treatment: It should be the same as in all cases of
circumscribed or pelvic peritonitis, namely, rest, ice,
and morphine.
Prophylaxis (i) Early marriage. This would cer-
tainly strike the severest blow against prostitution, the
agency of gonorrhceal distribution. I say "early''
marriage from a social point of view; still, I mean
"timely" from a physiological point — namely, if boys
and girls whose sexual organs have completed their
development should marry, they would have the least
possible chance of falling into the paths of prostitu-
tion and be the least exposed to gortorrhceal infection.
The pediatrist is frequently asked by the anxious
mothers when they shall wean their babies and he
wisely answers, as soon as they have teeth and can
eat; but the gynecologist is never asked by the anx-
ious mother when shall her daughter marry and what
can he advise her? Shall he advise the girl to marry
as soon as she menstruates, as nature designed, or
shall he advise her to attend college, etc., and wait
till she is a thoroughly accomplished woman? Cer-
tainly, with the present stage of civilization the latter
advice, which is a transgression against nature's laws,
is the most proper one. Nature though, as a rule, pun-
ishes her transgressors. She gives a tobacco heart to
the smoker; provides the drinker with Bright's dis-
ease; surprises the mother who neglects the nursing
of her infant with mastitis; turns the onanist into a
weak and nervous imbecile; she curses the prostitute
' The Lancet, p. 302.
with gonorrhoea, syphilis, etc. So also does nature
punish society for its late marriages by hard child-
births and by prostitution.
2. Isolation: As long as society will recognize the
necessity of late marriages, so long will it have to
recognize prostitution as an inevitable evil. Never-
theless, a great many people are not decided yet as to
the propriety of permitting the establishment of "pub-
lic" houses and the registration of prostitutes. They
think that by such formal allowances they would give
prostitution a recognition by which it would become
a legalized profession. Nobody though can deny that
prostitution does exist and does disseminate venereal
diseases; why not have it in isolated quarters and
under the supervision of the police and health de-
partments, in order to prevent the spread of gonorrhoea
and syphilis? Would this not be the most radical
prophylactic? For instance, if all prostitutes should
be examined by health inspectors as frequently as
practicable and the sufferers from venereal diseases
should be sent to a hospital, which they could not
leave until positively cured, gonorrhoea and other
venereal diseases would certainly become scarce.
3. Warning: The patients must be strictly warned
against sexual intercourse or marriage as long as
gonorrhoea is present. Many a man is base and care-
less enough to bring the disease home to his wife and
even children. I treated quite a number of families
in which all the members were infected. Some men
have a superstitious idea that gonorrhoea can be got-
ten rid of by transferring it to a pregnant woman and
they get their unfortunate victims. Lawson Tait ' re-
lates the cases of several girls who were infected at
their first connection. They were \ictims of the brutal
superstition that a man can get rid of his disease by
conferring it on a virgin. The prostitutes, as a rule,
do not restrain themselves from connection while in-
fected with gonorrhcea, except when they are suffering
pain. They are either glad to revenge themselves
upon men for their wrongs, or they are compelled to
earn their living whether sick or well.
4. Rational and thorough treatment of men by spe-
cialists is of utmost importance, bearing in mind the
obstinacy of this disease, especially in the chronic
and latent stages.
5. Instruments: Thorough cleanliness of instru-
ments and antiseptic precautions should not be for-
gotten in the physician's office, as well as in the clinic
or dispensary.
132 Henry Street.
The Blood in Pernicious Anaemia Dr. Cabot has
published in the Boston Mii/iral and Stiij^ical Journal
a study of fifty cases of pernicious anemia. He con-
cludes that the points most typical in the blood of this
disease are : i. A reduction of the number of red cells
to about 1,000,000. 2. The absence of leucocytosis.
3. Possibly a relatively high percentage of hemo-
globin in some cases. 4. Increase in average diame-
ter of the red cells. 5. The presence of large numbers
of polychromatophilic red cells. 6. The presence of
nucleated red cells, a minority being normoblasts. 7.
The presence of myelocytes. 8. A relatively high
percentage of small lymphocytes at the expense of the
polymorphonuclear cells. Post-mortem examination
in eight cases brought out nothing not already well
known. Fatty degeneration and pallor of all or-
gans were noted in all; the "tiger-lily" heart in
six; pericardial and peritoneal ecchymoses in four.
The spleen was slightly enlarged in two"; no enlarge-
ment of lymphatic glands was observed. The marrow
was examined in five cases, showing in all a notably
red color in the shaft of the long bones.
' I.awson Tait: " Diseases of Women."
746
MEDICAL RECORD.
[November 21, 1896
REPORT OF A CASE OF MALIGNANT UTER-
INE TUMOR TREATED BY THE TOXINS
OF ERYSIPELAS AND BACILLUS PRO-
DIGIOSUS.'
By R. M. stone, A.M., M.D.,
0,\IAHA, NEB.
I WISH to present to the readers of your valuable jour-
nal a report of the only case of malignant uterine dis-
ease, so far as I can learn, treated by the erysipelas
and prodigiosus toxins.
It is particularly appropriate just now, after the un-
favorable editorial upon the subject in the Medic.-\l
Record of October 19, 1896.
The writer has endeavored to be perfectly scientific
in his methods. He had the judgment of four phy-
sicians who, upon inspection, pronounced the case as
malignant and inoperable. They agreed that the pa-
tient was apparently near to death. The opinion of
three or more competent microscopists agreed that the
specimens were malignant. He may be excused for a
slight degree of enthusiasm when, after such con-
ditions, he has seen the patient restored to apparent
perfect health, to entire freedom from all symptoms,
and to restoration of normal weight. He is not igno-
rant of the fact that but one year has elapsed and
knows that permanent conclusions cannot yet be
drawn.
He recognizes the danger of the injections, because
an overdose nearly killed his patient.
He thoroughly agrees with the conclusion of the
committee that as yet the use of the toxins should be
confined to inoperable cases, but it should be noted
that Dr. Coley himself has advocated the method only
in inoperable cases, and practically only in inoperable
sarcoma.
History. — Mrs. L. B , aged forty-two, a vigor-
ous woman of excellent family history, the mother of
five children, the youngest three years old, called upon
me in May, 1895, stating that she was flowing and
had been for two or three weeks. I asked her to call
again, when not embarrassed by the flow, and let me
investigate. In July she met me in a store and re-
marked that she had flowed very much since May and
would surely come and see me soon. Early in No-
vember, 1895, six months after the first symptoms
appeared, she finally came for examination. She
reported that she was still flowing a little and had lost
blood every day in October. Her normal weight was
about one hundred and twenty pounds ; she was now
reduced to about one hundred and five. Her color
was bad and she was very ansemic. Examination
showed the cerv'ix very large, its inner surface eroded,
bleeding easily, and open sufiiciently to admit the tip
of the index finger. Malignancy was quite evident.
The uterus was large and heavy, and there was infil-
tration of the right broad ligament. I called in my
friend, Dr. Charles C. Allison, professor of rectal and
genito-urinary surgery, Omaha Medical College, for
consultation. He confirmed the diagnosis. We ad-
vised the curettage of the uterus and the amputation
of the cervix. On November 12th Dr. Allison ope-
rated. When he took hold of the posterior lip with
the volsellum it tore away. Curettage was done thor-
oughly and a large portion of the uterine tissue, which
was found soft and friable, was removed. The ante-
rior lip of the cervix was removed with the scissors.
The cautery and the chloride of zinc were thoroughly
used, as the hemorrhage from the cervix was profuse.
Dr. W. R. Lavender, professor of pathology, Omaha
Medical College, ver}' kindly made microscopical ex-
amination of the cervix. He made about one hundred
sections and found a "decidedly abnormal amount of
fibrous connective tissue, in addition to the normal
' Read before the Omaha .Medical .Society, June. 1896.
tissue found in the cervix uteri. There were distinct
groups of round cells with very large nuclei without
connective tissue between the cells. There were
small spaces in which were found red blood corpus-
cles, the walls of these spaces being formed by cells.
A careful search for epithelioma proved negative.
There was a hyperplasia of the uterine follicles at the
junction of the cervix and the body of the uterus, but
a decided absence of the characteristic invasion of
normal tissues usually found in epithelioma.'" His
diagnosis was '" spindle-celled sarcoma." Unfortu-
nately we were able to send but two sections to Dr.
Coley for examination. Mr. B. H. Buxton, assistant
pathologist to the New York Cancer Hospital and
bacteriologist of the Loomis Laboratory, New York,
pronounced the growth, to be of epithelial origin.
Whether it was epithelioma from stratified epithelium
or carcinoma from the glands of the cervix was uncer-
tain. It was probably the former. It certainly was
malignant. Dr. E. K. Dunham, pathologist to the
New York Cancer Hospital, director of the Carnegie
Laboratory, and professor of pathology in Bellevue
Medical College, confirmed Mr. Buxton's diagnosis.
To resume our history. Recovery from the opera-
tion was uneventful up to November 24th. During
this period of twelve days the temperature was be-
tween 98 '3° and looyy"^ F. The pulse was of good
quality and was between 80 and 96. She rested well,
had little pain, ate well, and sat up in bed on the
22d, 23d, and 24th. She was cheerful, bright, and
happy, with a prospect of rapid recovery.
Hemorrhages. — There followed a period of sixteen
days, during which there were five almost fatal hemor-
rhages. The first occurred on the evening of the
24th, without warning, after a good day. Dr. Van
Gieson, living nearer than I, first reached her bedside,
and had the horrible hemorrhage under control before
my arrival, having packed the vagina thoroughly with
ropes of absorbent cotton. On November 28th and
29th and again on December ist there were equally
severe hemorrhages. The last one, somewhat less
severe, occurred on December 9th. With reference to
the packing I wish to say that the hemorrhages were
so violent that they ran right through any ordinary
packing. We found that ropes of cotton pushed with
great force, completely filling the vagina, were the
best. Gauze was too harsh. Packing daily to this
positive occlusion of the vagina was continued for
twenty-five days. The hemorrhages usually came on
in the evening after the packing had settled some-
what. Packing to a moderate degree was carried on
daily up to January 15th, both to prevent possible
hemorrhage and to allay the nerv'ous tension due to a
dread of hemorrhage. During most of the sixteen
days during which the five hemorrhages took place
life was despaired of and exhaustion was profound.
The temperature was within three-fifths of a degree of
100^ F. all the time, except before the hemorrhage of
November 29th, when it ran up to 102 !.'° F., and before
that of December 1st, when it ran up to 101^ F. The
respiration was from 20 to 30 and the pulse from 90
to 108, usually above 100. Bovinine was the sole
dependence for food during this period. Strychnine
and tonics were freely used. On November 30th we
called Dr. A. F. Jonas, professor of surgery, Omaha
Medical College, in consultation. Examination by
us all then showed decided infiltration and nodulation
of both broad ligaments. Dr. Jonas concurred in the
diagnosis of malignancy and our prognosis was most
grave. Death in the near future seemed imminent.
There was no possibility of the removal of the uterus,
even if it were at all likely to be of value. The case
was without question that of an " inoperable malig-
nant tumor."
Use of the Toxins. — Under these most unfavorable
November 21, 1896]
MEDICAL RECORD.
747
conditions we began on December 4tii the use of the
unfiltered toxins of erysipelas and bacillus prodigio-
sus, received from the Loomis Laboratory, prepared by
Mr. Buxton. I began with three minims injected be-
tween the shoulder blades. No reaction followed.
On the 5th I used seven minims; on the 6th, ten;
on the 7th, fourteen; and on the 8th, twenty minims,
with no reaction whatever, unless that perspiration,
not before present, was a shadow of reaction, and ex-
cept also that at once sleep was much improved.
Communication was had with Dr. Coley, who was
greatly interested and very kind with his suggestions.
On the 14th I used in the morning two minims, in the
evening four; on tiie 15th, seven minims; i6th, ten;
17th, twelve; 19th, fourteen; 20th, seventeen; all
without reaction. During this period, December 4th
to 20th, the temperature was between gg' and 100°
F. on seventy-two observations; seven times in the
morning it was 98)2° F. The patient's condition
was improving, appetite was increasing, sleep was
better. The elimination from the uterus was very free
and of most offensive odor. Having failed to secure
the sought-for reaction from the use of two to seven-
teen minims in the muscles of the shoulders, we de-
cided to go closer to the seat of the disease. We had
found no directions as to any change in dosage if we
approached nearer to the tumor and so decided to keep
on increasing our dose. On the morning of December
2ist I injected nineteen minims in the vagina near
the outlet. I had hardly driven out of sight of the
house before trouble began. Rigor and chill were
present in twenty minutes. By 10:30 the temperature
was 101 " F. The face became dark purple, the patient
delirious, restless, and pulseless. A most e.xtraordi-
narily anxious expression of countenance was present.
Breathing became labored and exhaustion was pro-
found. Total deafness was soon present. The urine
was suppressed and by noon the temperature was
ioj\.l4° F., and death seemed very near. Dr. Allison
and I were both away on surgical cases, and these most
dangerous symptoms were met by the nurse, Miss
Elmer, from Blockley Hospital, Philadelphia, who
gave our patient most skilful and assiduous care for
nine weeks and deserves very great credit. She used
stimulants, hypodermic injections of morphine and
strychnine, and bovinine freely. By 12 .-30 the temper-
ature was down to io3_;'2^ F. By i :3o it was loi J^'
F. By 6:30 it was 100° F. At i p..m., when Dr. Alli-
son and I reached her, the pulse had become percepti-
ble, but barely so, and 120 beats to the minute. The
deafness lasted si.x hours only. Seven ounces of urine
were secreted in the following eighteen hours. Per-
spiration was slight. Nausea and vomiting were
present all the afternoon. Intense redness of the face
followed, accompanied by vertigo and headache. On
the 23d, the third day, there appeared a violent herpes
of the lips and tongue, which absolutely prevented the
taking of any food for two days and caused very great
distress for a week. Sleep was of course very restless
and fitful. Vertigo from involvement of the semi-
circular canals was present to an annoying degree
from December 21st to January 3d. Our patient ral-
lied very slowly from the terrible depression of the
t jxins injected in the vagina, and was not able to re-
ceive another injection until January 2d, when I used
three minims in the vagina, in which locality all sub-
sequent injections were made. On the 4th I used
three minims; on the 5th, six. This produced a
reaction fever of 102 '2^ F. with a pulse of 120. She
was not able to bear an injection again until the loth,
when two minims caused a reaction of loo'"' F., and a
pulse of 124. On the 13th two minims, on the 14th
three minims produced no reaction. On the 15th four
minims caused a chill, a tempierature of 101° F., and a
pulse of 120. At Dr. Coley's suggestion we now be-
gan the use of the filtered toxins. From January 21st
to March 6th 1 used the toxins twenty-seven times on
forty-seven days. The dose used was from three to
twenty-three minims. There was a chill after nine of
the injections. The temperature rose above gg,'2° F.
and as high as 103^ F. on seven occasions. The
pulse during the chill was from n6 to 138. On
March 15th I began again the use of the filtered tox-
ins injected in the gluteal region, using between this
date and the 24th eight injections ranging from five
to thirty minims, all without reaction, the only
symptom apparently produced being malaise. On
April 8th I began the toxins again, now using the un-
filtered in the gluteal region. I used five injections,
reaching ten minims without reaction except blueness
of the finger nails. On May nth the patient insisted
on the injections being made at the vaginal outlet. I
used two minims of the unfiltered and on the 22d five
minims; neither caused reaction. On the 25th I used
seven minims at 10 a.m. By noon she was suffering;
at two o'clock there was intense headache with delir-
ium ; also pronounced cyanosis, with a very severe pain
in the thighs and in a small spot under each breast;
there were diarrhoea and vomiting. At three I saw
her; she was again, as on December 21st, pulseless,
anxious, but clear mentally. The skin was less cya-
notic than at two, but was dusky red all over the body.
The temperature was 103° F. Herpes labialis ap-
peared the next day. This was the second reaction in
point of severity, and the patient, as usual forgetful to
a degree of the more alarming symptoms of the former
reaction, pronounced this one even more severe.
General Conditions. — Our patient had passed
through two critical periods. The first was that of
hemorrhages lasting from November 24th to Decem-
ber gth. Emaciation was extreme, ansemia was pro-
found, the heart's action was very feeble and rapid.
Vitality was almost e.xhausted. Under the use of the
toxins elimination through uterine discharge was pro-
nounced and copious. All conditions gradually im-
proved, without reaction fever and chill, until the
collapse due to the overdose of the toxins injected
December 2 ist in too close proximity to the uterus.
This most violent reaction came near being fatal, and
vet most happy results were inaugurated by this over-
dose.
Menses. — The atrophy of the uterus had caused
both Dr. Allison and myself to feel that there prob-
ably would be no further menstruation ; but on March
5th to the gth and March 28th to the 31st there was a
show of blood. From April 17th to the 22d there
was normal menstruation; from May i6th to the i8th
there was menstruation, free on the 16th only.
Going back in her history to January 21st, elimina-
tion from the uterus had almost ceased and at this
early period, only one month from the terrible reaction,
neither Dr. Allison nor myself could find any nodula-
tion in either of the broad ligaments and granulation
tissue was fast disappearing from the site of the ampu-
tated cervix. On January 23d the patient sat up in bed
for the first time; on the 26th she sat in a reclining-
chair ; on January 2gth Dr. Jonas could find no nodula-
tion in the broad ligaments. On February 2d bhe
walked while supported. On February 20th she walked
unsupported all over the house up and down stairs. On
February 24th she rode out and dined. On May 4th
Dr. Allison and I made a careful examination and
were still unable to discover any infiltration in either
broad ligament and the uterus was very much atro-
phied. The site of the cervical amputation was clean
and entirely healed over.
Status prjEsens, October 31, 1896; The patient
now weighs ten pounds more than her normal weight,
is rosy, vigorous, eats and sleeps well, has neither
pelvic pain, tenderness, nor dyspareunia. She has
748
MEDICAL RECORD.
[November 21, 1896
resumed all. her duties in the household. Her mus-
cles are hard and her spirits are high. The malig-
nancy of the tumor in this case cannot be questioned.
It was apparent to both Dr. Allison and myself upon
inspection. Dr. Lavender, Mr. Buxton, and Dr. Dun-
ham all confirmed it with a microscope. Dr. Van
Gieson and Dr. Jonas confirmed it upon their exami-
nations. We may never know absolutely whether it
was a sarcoma, as Dr. Lavender pronounced it, or an
epithelioma, as Mr. Buxton and Dr. Dunham pro-
nounced it. The fact that Dr. Lavender examined
one hundred sections and Mr. Buxton and Dr. Dun-
ham only two, would lead us to think the diagnosis of
sarcoma more probably correct. The favorable re-
sults even so far obtained are mar\'ellous, if it was a
sarcoma. If it was an epithelioma or sarcoma, it
makes our success, as Dr. Coley writes, "all the more
remarkable." As far as the present literature upon
the treatment of these malignant inoperable tumors
by these toxins is recorded the case is unique, in that
no other case of a uterine tumor is reported followed
by such favorable results. Nearly all the favorable
cases so far reported have been of sarcomata in visible
regions.
^tjogresa of '^cdicul J^cicncc.
The Causation of Dropsy. — Dr. Ernest H. Starling
in tiie Arris and Gale lectures on the physiological
factors involved in the causation of dropsy classifies
them as follows: I. — ^ Factors causing increased transu-
dation : A. Increased intracapillary pressure: (<?)
Venous obstruction. (/') Vasodilatation, (c) Pleth-
ora. B. Increased permeability of vessel wall: (a)
Local injury by mechanical irritants. Local injury
by thermal irritants. Local injury by chemical irri-
tants. (/') Malnutrition, (r) General injury by circu-
lating poisons (?). C. Watery condition of blood
(hydrajmia). II. — Factors causingdiminished absorp-
tion: A. By lymphatics: (a) Paralysis of limbs. (/')
Obstruction of lymphatic trunks. B. By veins: (</)
Venous obstruction. (/>) Watery condition of blood,
(f) Concentrated transudations.
Pleurisy with Effusion. — Dr. C. H. Goodrich
reports ten cases in the Ajnerican Medico-Surgical
Biillelin in only one of which was there a tuberculous
family history. The treatment followed was rest in
bed and a restricted diet. Potassium citrate and
sodium salicylate were the only drugs used. Seven pa-
tients were aspirated. Nine of the ten patients were
discharged cured. One died. Convalescence was
slow. The conclusions were that hard and fast
inferences cannot be drawn w ith the aid of points from
only ten cases of pleurisy with el'tusion, but some evi-
dence may be presented: i. Delafield, Osier, Pepper
Peabody, and others are decisive in commending the
timely removal of fluid from the pleural cavity. The
outcome of these cases bears witness to the wisdom of
the procedure. Weeks or months, " perhaps years,"
some one has said, might elapse before sixty-four
ounces of serum or even one-third that quantity could
be absorbed by a serous membrane whose surface is
coated by a thick layer of fibrin and whose meshes are
choked and distorted by sero-fibrinous exudate and
perhaps by the growth of some new connective tissue.
2. It seems reasonable to use sodium salicylate and
like drugs in cases of pleuritic inflammation, because
of the intimacy of the relations between acute articu-
lar rheumatism and inflammations of serous mem-
branes, and because it surely relieves pleuritic pain.
Further observations may teach us more on this line.
3. .-Vlthough careful to include all the recognized
methods in our examination, we failed to find anv evi-
dence of tuberculosis in these cases. 4. The decid-
edly slow recovery of general health seems to indicate
that there is room for improvement in the methods
of treatment of cases of pleurisy with effusion after
the removal of serous accumulations. 5. Empyema
seems to be an unnecessary consequence of aspira-
tion of the pleural cavity for pleurisy with effusion.
The Palliative Treatment of Cancer of the Cer-
vix Uteri. — 'Dr. Marocco at a meeting of the Lan-
cibian Society for the Hospitals of Rome ( Wiener
klinische Ruiiclscluiu, August 9, 1896) reports good
results from tamponing with gauze impregnated with
tannin, iodoform (ten percent), and powdered quinine.
Heredity and Crime. — The following, taken from
the Mcdual J'nss, compiled by Professor Belman, of
the University of Bonn, relates the career of a notori-
ous drunkard who was born in 1740 and died in 1800.
Her descendants numbered 834, of whom 709 have
been traced from their youth. Of these 7 were con-
victed of murder, 76 of other crimes, 142 were profes-
sional beggars, 64 lived on charily, and 181 women
of the family led disreputable lives. The family cost
the German government for maintenance and costs in
the courts, almshouses, and prisons no less a sum
than $1,250,000; in other words, just a fraction under
$1,500 each. It would probably be difficult to find a
more remarkable example than this of the evil effects
of the transmission of hereditary defects.
Transfusion, Infusion, and Auto-Transfusion. —
Dr. Schachner Utmnial of the American Medical Asso-
ciation, September 12, 1896) compares their merits and
indications and summarizes as follows: i. In enor-
mous hemorrhages the resulting dangers are more fre-
quently due to the reduced intravascular pressure than
to the actual loss of blood. 2. In view of this the
indications point more decidedly toward infusion than
transfusion. 3. That transfusion has not received the
attention which its merits justify. 4. In transfusion
we possess a measure which in the severest hemor-
rhages is the only agent capable of restoring the vital
functions. 5. The indication for transfusion includes
any condition which reduces the total quantity of blood
to a fatal degree or which alters the character of the
blood to such an extent as to render it incapable of
sustaining life. 6. When the transfusion is performed
for the relief of a poisoned condition of the blood it
should be preceded by venesection. 7. Centripetal is
to be preferred to centrifugal transfusion. 8. In cen-
tripetal transfusion the injection should be made with
a slow steady stream, undue force being carefully
avoided. 9. In withdrawing the blood from the donor
the veins afford an easier, safer, and better source than
the arteries. 10. Indirect transfusion with defibrin-
ated blood is safer than direct transfusion with non-
defibrinated blood. 11. In alarming hemorrhages in-
fusion should be performed before transfusion ; should,
however, the improvement be transient in its nature,
the infusion must be supplemented with transfusion.
12. In addition to hemorrhages the indications for
infusion include any pathologic state attended with a
feeble pulse wiiicli is dependent upon a relaxed con-
dition and a diminished intravascular blood pressure,
namely, shock. 13. Restoring the tone of the circu-
lation by infusion is not wholly dependent upon the
increase of the intravascular pressure, but is in part
due to the stimulating influence which the salt solu-
tion has upon the heart. 14. In performing transfu-
sion or infusion after an enormous hemorrhage, the
use of an anasthetic is not only unnecessary but abso-
lutely dangerous. 15. In the auto-transfusion we
have a \aluable measure for combating shock and
preventing accidents in anfemic subjects during chlo-
roform narcosis.
November 21, 1896]
MEDICAL RECORD.
749
Medical Record:
A Weekly Jour?ial of Medicine ayid Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, November 21, 1896.
INTRA-UTERINE INFECTION OF SYPHILIS.
To workers in fields of science wliere knowledge is
exact and definite, where laws are made which become
true and unalterable for all time, where calculations
can be made with that accuracy of mathematical preci-
sion which admits of no question or cavil, it must ap-
pear strange that there are so many questions in medi-
cal science which are still unsettled, though seemingly
simple of solution. One of these problenis about
which opposing views prevail has been brought up li)'
Dr. Abner Post, in a recent issue of tlie Boston Medi-
cal and Surgical Journal. The question is one \er\-
simply stated, but not, it would seem, so readily and
satisfactorily answered: Can a woman wiio acquires
syphilis during her pregnancy transmit it to the fcetus
in utero I
The elements which have lent confusion in obser-
vations bearing upon the question are: The possibili-
ties of hereditary syphilis from the father; of the
mother being herself affected prior to the period of
supposed infection or at the time of conception ; and
of the infant becoming inoculated at birtii.
In analyzing the views advanced by most American
authors, the writer of the essay gains the impression
that " no one of them e.xpresses an opinion based on
his own ex[3erience," and that " all appear to speak
from authority or to reason from anatomical facts."
And here lies, we believe, the chief reason for sci
much difference of opinion concerning a matter which
should be definitely settled. It is the old story of
negative evidence and the citation of instances adT
mitting of doubt, which are allowed to weigh against
the fewer carefully observed cases of a positive nature.
The number of observations in which all the require-
ments for scientific accuracy are fulfilled must, of ne-
cessity, be limited. The few coming from observers
of recognized ability and accuracy of statement must
outbalance any theoretical considerations or laboratory
investigations. We must, too, recognize the value of
analogy as bearing upon the matter. Thus, it has been
demonstrated that, while in the rule variola is not
transmitted from the mother to her enwombed off-
spring, it occasionally is so transmitted. The writer
also believes we are safe in saying, at the present day,
that the microbes of anthrax, glanders, pneumonia, ty-
phoid, tuberculosis, and the bacterium coli commune
pass the placenta to attack the fcetus /// utero.
The analogy is thus further strengthened for those
who believe in the bacillary origin of syphilis. An
acceptance of this theory by the writer is implied in
the sentence : " Hence, we may infer that intra-uterine
infection is not impossible in syphilis."
Three cases are reported in illustration of the possi-
bility of such transmission, and, while they are not ab-
solutely convincing, they add to the cumulative testi-
mony which is of great value in strengthening the
proof. The conclusions which are drawn are as fol-
lows:
1. It is universally admitted that there is normally
no direct communication Isetween the maternal and
fcetal blood.
2. There is proof, however, that certain contagious
diseases are conveyed to the foetus in utero.
3. In some of these cases it is shown that hemor-
rhages have destroyed the original structure of the
placenta and opened a path of communication.
4. It is, then, no longer possible to say that intra-
uterine infection is impossible in syphilis.
5. Clinical observation shows that intra-uterine in-
fection does take place in syphilis.
6. Whether such infection is invariable, or what its
limitations are, we do not know.
How much better such a statement of the case would
appear in the present state of knowledge than that
made in a recent work by ('ulver and Hayden : " Tlie
syphilis of the mother acquired during pregnancv can-
not be conveyed to the fcetus tlirough the utero-placen-
tal circulation."
In 1883 Dr. Taylor wrote almost in the same words,
in his revision of Dr. Bumstead's work. In his own
treatise, recently published, it is admitted, however,
that "full infection may in rare cases occur when the
filtrative power of the placenta has been impaired by
morbid changes."
Hayden, plus royalist que le roi. nov.' says in his
"Venereal Disea.ses," 1896: "Syphilis of the mother
acquired during pregnancy may be conveyed to the
fcetus through the utero-placental circulation."
When authors are in accord upon the greater ques-
tion, let them take up the lesser one of the periods
during which the offspring is liable to escape infection
or to come into the world alive. In the mean time,
statistical data from our readers are in order and will
be gladlv received.
THE DOCTOR'S WIFE IN A NEW ROLE.
The doctor's wife is the very essential part of himself.
No one questions this who has any knowledge of her
varied functions as the efficient and ever-ready help-
mate. In season and out of season she is ever willing
to fill in vacant spaces in his recollection, to regulate
his unthrifty habits, and in various other ways to even
out those little irregularities in his living which, being
approvingly done, make him the acceptable, jovial,
and contented inort:-il for outside exhibition and gen-
eral adulation. If in the long run she finds herself
with an elastic conscience, she rightly blames the
peculiar environment which so necessarily fits the
situation. Tlie night bell, if it could speak on its
750
MEDICAL RECORD.
[November 21, 1896
own account, would as often bring tears to the record-
ing angel's eye as smiles to the father of lies — white
lies, translucent fibs, we mean, that balance their im-
perative utility against the inexorable expediency of
protecting the weary doctor on the one hand and pun-
ishing the thoughtless and improvident patient on the
other. It is she who has settled with her own con-
science the difference between in and out as applied
to the patient who really needs the doctor and is will-
ing to pay for an ugly night trip, as compared with the
other caller who always waits for dark nights, bad
roads, and believes in long-standing accounts.
It is reasonable to suppose that she is not solely
responsible for these conventionally pardonable and
innocent frauds. Oftentimes the man who is making
up his mind to go or stay is at her side as the hidden,
hesitating, and interested prompter, whose voice is not
heard but whose influence is felt. In the darkness of
the bed chamber at the proximal end of the night tube
there is generally a consultation not accounted for in
the bill, which results either in the expectant patient
trotting for another doctor or gladly taking the one
who is so conveniently found at home. The good
creature, hardened to the pressing necessities of this
common sin, becomes immune to all ordinary- entice-
ments for deception, and because we can so easily for-
give her we gladly and heartily respect her.
Being a recognized silent partner in the business
she necessarily claims certain privileges without cor-
responding restrictions. Under given conditions she
often says what she thinks and oftener does as she
pleases. Bound by no code of ethics, accountable to
no committee on credentials, she gradually in her
pleasantly assertive femininity becomes a law unto
herself and generally equally so to her accessory part.
Fortunately she is more discreet, more circumspect,
and more diplomatic than most wives of other profes-
sional men. Thus there is peace in the family and
.society is generally safe.
She may in a limited and friendly circle joke of
the incapacites of her husband, his social short-com-
ings, his irregular engagements, his waiting meals,
his settled and stubborn indifference to her ailments,
his opposition to medication in his own family, and
to his careless and shiftless habits, all of which we
would gladly forget in writing his obituary, but to the
outsiders, cunning and lovable hypocrite as she is, she
always pretends to a smiling confidence in the head of
the firm and has an assuring word for every doubting
Thomas. No one can blame her for this, as the proper
motive is always present with the proper feminine
discretion to balance it. While all this is true, judge
of our surprise in hearing from a distant correspond-
ent the following startling account of a novel way of
representing the purely business interests of her iuis-
band:
" I want to request you, as a reader of your journal
for many years, to devote a little space in the Medi-
cal Record to the practice of the wifes of some med-
ical men, who with their husband's consent act as
' watchers ' at the bedside of the sick — the patients of
other practitioners.
" I would my.self address a communication on the
subject, but I believe an impersonal review of the
abuse would be more effective, if it be possible by any
means to get beneath the pacchydermoid consciences
of those who practise this pettifoggery. The reason
of my notice of the abuse at this time is the presence
this very morning of two women — the wives of other
doctors, watching each other and the patient of a third
physician, with whom I was called in consultation.
Charitably disposed women of this class are never
found in the homes of poverty, but always at the bed-
side of some influential neighbor who does not employ
her husband as family physician. A notice of this
abuse is not likely to have widespread influence, be-
cause the criticism is of those who lack the delicate
instincts of ladies and gentleinen, but we are told that
there is great joy in heaven over even one sinner doing
penance, and maybe some one mind may be broadened
enough to appreciate his or her own littleness."
If this information did not come from a trustworthy
source we should indignantly deny on the behalf of
thousands of doctors' wives throughout the country
the possibilities of such meanness. Fortunately we
have only heard of two of these Sairey Gamps. They
are merely veritable curiosities rather than dangerous
examples. It is only in such a light that they deserve
any notice whatever.
THE P.\N-.-\MERICAN MEDICAL CONGRESS.
The second Pan-American Congress, which was held
during the past week in the City of Mexico, was a suc-
cess, not only in point of attendance from distant
countries of the continent, but from a scientific stand-
point in the great number and variety of topics pre-
sented for discussion. The addresses treated on
subjects of broad aspect, in which the philosophy of
disease and the science of pathology were consistently
applied not only to the needs of the individual but to
the necessities of the public, in large and represent-
ative gatherings of scientific men expressions of opin-
ion on matters concerning public health are always
expected and are becomingly respected. It is in dis-
cussions on such topics that science shows its higher
achievements and commands for itself its rightful
dues of respect and authority. In this regard more
particularly the congress has vindicated its right to be
and has shown a proper appreciation of its high mis-
sion. Too much praise cannot be given our Mexican
brethren for the earnest manner in which they system-
atized the work and made available the vast amount
of material at their command. V\'e take pleasure in
presenting in this issue the first instalment of the pro-
ceedings, furnished by our special correspondent, who
has been sent to Mexico for the purpose of obtaining
an accurate report. In a future issue, when the work
of the congress is given in full, the readers can be the
judge of the variety and quantity of scientific work
that has been done, and can form their own estimate
of its value.
Colored Nurses. — .A. training school for colored
nurses is to be established in connection with the New
Orleans University Medical College.
November 21, 1896]
MEDICAL RECORD.
751
THE "INS"' AND THE "OUTS."
The circumstances attending the relative positions of
the men who are inside and those who are outside of
a given privilege always give rise to radical diflfer-
ences of opinion. This is exemplified in every walk
of life. Generally, in order to change the respective
ways of thinking, it is only necessary to change places.
In a newspaper item it is stated that an architect op-
posed to the construction of tall buildings was placed
upon a committee whose function was to oppose such
innovations. While his associates, with his active
help, had prepared a suitable protest, the member in
question, for some reason not at the time understood,
voted to delay the report. This action on his part
was afterward explained by the fact that he was not
only an active competitor for the building of a so-
called "sky scraper," but had actually secured the
contract. The human nature of the action has an ap-
plication to the doings of many a struggling practi-
tioner, who is radically opposed to hospital extension
and free dispensary practice, until a coveted position
is within his grasp. The illustrations are too numer-
ous to mention. We have known of many such, whose
guns were turned by fortune in exactly an opposite
direction. This time-honored method of silencing
opposition to existing evils changes what would other-
wise be defeat on the part of hospital and dispensary
managers into a glorious victory for indiscriminate
abuse of charity. Hence the independence of men
who are in the position to do as they please with the
profession. No sooner does a staff of any of these
institutions resign, or a particular member drop out by
death, than hundreds of aspirants run to their friends
for recommendations for the vacant places and, with
hat in hand, beg of the self-important managers for
the eagerly sought preferment. If successful, the man
alters with his change of position, and the evil goes
on with one less opponent.
^eaus jof the '82JccU.
Diplomas for Sale The Wisconsin Eclectic Med-
ical College is still offering diplomas to practising
physicians at "much reduced rates, $35, all inclu-
sive." The prospectus states that they come " as a
boon and a blessing" to those who have hitherto prac-
tised medicine illegally.
Revolutionary Doctors Of the nineteen men who
constitute the officers and board of directors of the
"Oscar Primelles Club," whose object is to collect
and distribute medical and surgical supplies destined
for the revolutionary armies of Cuba and Porto Rico,
all but three have the title of " doctor" and the great
majority that of " M.D." They solicit contributions
of drugs, instruments, appliances, and money, which
may be sent to Dr. Gaston, the president, at 56 New
Street. The club's name is taken from the physician
who was the first in this war to seal his devotion to
the cause with his life blood.
Deborah Nursery has been ordered by the board
of health to vacate the premises occupied in One
Hundred and Sixty-First Street. It is reported that the
cause of this action was the lack of care in isolating
infectious ophthalmia at the institution, those affected,
to the number of twenty-seven, being permited to
mingle freely with the other children. If this is the
case, the radical measures employed are not too severe.
Indian Territory Medical Association. — The semi-
annual meeting of this society will take place at Vi-
nita, Ind. Ter., December i and 2, 1896.
Camden County (N. J.) Medical Society. — At
the regular monthly meeting of the Camden County
(N. J.; Medical Society, at Camden, on November
4th, Dr. H. A. Hare, of Philadelphia, read a paper on
" Unusual Eruptions in Fevers."
Street Dogs. — The board of health has under con-
templation the banishing of dogs from public thor-
oughfares. The lack of regard many dog owners
show for the decency of our sidewalks, to say nothing
of the public-health side of the matter, would seem to
make some action justifiable.
Department of Charities. — On Friday, November
13th, a civil-service competitive examination was held
for the position of general inspector, department of
public charities. The number applying was neces-
sarily small on account of the fact that candidates
for the position must have had executive experience
in hospital management and organization. Salar}-,
$3,000 per annum. Mr. Knowles, ex-superintendent
of the City Hospital, Blackwell's Island, was appointed
some time ago, his appointment being contingent upon
civil-service rules.
The Late Dr. J. Murdoch. — At a special meeting
of the Allegheny County Medical Society, held Octo-
ber 5, 1896, the following resolutions were adopted:
IV/it'reas, Dr. J. B. Murdoch, a member of the Alle-
gheny County, Pa., Medical Society, has been called
by death from the scenes of his beneficent professional
labors; and
IVhercds, We realize that in him was typified the
skilful physician and surgeon, the genial companion,
the upright and honorable man, the good citizen and
the Christian gentleman; and
Whereas, The loss to this society is deeply felt,
being that of a member always devoted to its advance-
ment in science, one invariably the supporter of the
cause of right, of a friend to every colleague, and of a
charitable and noble-hearted man: therefore, be it
Resolved, That the Allegheny County Medical Soci-
ety place upon public record this expression of its
sincere grief at the death of Dr. Murdoch, one of its
most valuable and highly cherished members: and
Resolved, That these resolutions be spread upon the
minutes of the society and copies be transmitted to
the family of the deceased, to the medical press, and
the daily p.apers of Pittsburg for publication.
W. S. HUSELTON,
W. S. Foster,
W. H. Daly,
J. W. McF.-vrlane,
J. J. Buchanan, See.,
CommitUe.
752
MEDICAL RECORD.
[November 21, 1896
Philadelphia Polyclinic. — Dr. W. Oakley Hermance
has been appointed instructor in the administration
of anaesthetics in the Philadelphia Polyclinic and
anxsthetizer to the Polyclinic Hospital.
Roosevelt Hospital, New York. — In response to
an invitation of the trustees of the Roosevelt Hos-
pital, a large number of friends of the institution in-
spected on Wednesday afternoon, November i8th, the
private patients' pavilion, located west of the main
building.
Black Diphtheria in Pennsylvania. — In Carlisle,
Pa., four children in one family have died from hem-
orrhagic diphtheria, and the father, two other chil-
dren, and an aged woman have been attacked with the
disease.
Contagious-Fever Van. — The Chicago board of
health has had presented to it, by the Columbian am-
bulance association, a mahogany, rubber-tired ambu-
lance, provided with basket stretcher and suspended
swinging stretcher, for conveying contagious diseases
to the hospital.
Vital Statistics of Philadelphia. — During the
week ending November 7th, there occurred in the city
of Philadelphia 374 deaths, 14 more than during the
preceding week, and 5 1 more than during the corre-
sponding week of the previous year. Of this number,
113 were in children under five years of age. Pneu-
monia and pulmonary tuberculosis were again the two
largest individual causes of death, the former being
responsible for 48 deaths and the latter for 36.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
November 14, 1896: November nth. — Assistant
Surgeon H. La Motte detached from the naval hospi-
tal, Norfolk, Va., and ordered to treatment at naval
hospital, Philadelphia. November 13th. — Surgeon E.
H. Marsteller detached from the S/. Mary's, ordered
home, and placed on waiting orders; Surgeon R.
Whiting ordered to the St. Mary's.
Bellevue Hospital. — Last week plans were filed at
the office of the department of buildings for a two-
story brick boiler and laundry house on the grounds of
Bellevue Hospital, the estimated cost of which is S85,-
000 ; also on the same grounds a two-story brick iso-
lating hospital at a cost of $45,000. Bellevue is to
be congratulated upon obtaining these much needed
improvements. On Blackwell's Island, just west of
the City Hospital, the city will erect a four and one-
half-story brick and stone water tower at an estimated
cost of $15,000.
The New York State Association of Railway
Surgeons, which is now holding its si,xth annual
meeting in this city, yesterday elected the following
officers for the ensuing year: President, Dr. J. F. Val-
entine, of Brooklyn : First Vice-PresiJent, Dr. George
Graves, of Herkimer; Second Vice-President, Dr. F.
H. Peck, of Utica; Secretary, Dr. C. B. Herrick, of
Troy; Treasurer, Dr. T. D. Mills, of Middletown;
Chairman of the Executive Committee, Dr. George Chaf-
fee, of Brooklyn.
Johns Hopkins. — Dr. W. S. Thayer has just re-
ceived the appointment of associate professor of med-
icine.
Low Mortality.— In the week ending November 7th
the smallest death rate ever recorded in Boston was
reached, the number being si.x hundred and eighteen.
A Young. Ovum — In removing a uterus for car-
cinoma Professor Leopold, of Frankfurt, Germany,
found an ovum the size of a lentil, which from facts
elicited was pretty clearly eight days old. It will be
examined and reported upon.
Rush Monument Fund. — The subscriptions to this
fund have reached $3,886.39.
Dr. Alice Bennett, who for sixteen years has held
the position of superintendent of the woman's depart-
ment of the Pennsylvania State Insane Asylum, has
just resigned this office.
Bicycle Exercise for the Insane.— According to
La M('decine Moderne of October 28th, the wheel has
been introduced as a therapeutic measure, with marked
success, in an institution for the insane at " Kahlma-
zov," Mich.
Tetanus Antitoxin has been placed under State
control in Germany, and Professor Behring has an-
nounced that the Hoechst factory, which ))roduces
diphtheria antitoxin, is authorized to dispense it from
the laboratory, under direction of Professor Ehrlich.
Obituary Notes Thom.^s H. Burchakd, M.D., of
New Vork, died suddenly, aged forty-eight years, of
cardiac disease, November 15th, at his home 7 East
Forty-eighth Street. He had just returned from a trip
abroad for the benefit of his failing health, and was re-
suming his practice when his fatal illness overtook him.
He graduated from Bellevue Hospital Medical College
in 1872 and soon after commenced practice in this city,
spending his summer months in Saratoga, where he
also became a leading practitioner. His genial dis-
position and kindly manner won for him hosts of
friends, who mourn their untimely loss. Always active
in professional pursuits, he was a ready writer, a fluent
speaker, and an able teacher. His numerous contri-
butions to .surgical literature won for him an enviable
reputation as an original thinker and necessarily kept
him in advance of the less ardent workers of his class.
He was a member of all the leading medical societies
of this city and was also a surgeon to the Charity
Hospital. — Dr. Henry Hollenback died at his
home at Burlington, N. J., on November 6th, at
the age of eighty-four years. He had at one time
been mayor of the city of Burlington. — Dr. William
Havward died at Cambridge, Md., on November 7th,
at the age of sev^enty-eight years. — Dr. F. H. Rankin,
formerly of this city, and of recent years one of the
best-known practitioners in Newport, R. I., died in
that city on the morning of November 9th. He was
a graduate of the New York University, class of 1862,
beginning practice in New York City in 1871, after
serving as assistant surgeon in the German army dur-
ing the Franco-Prussian war. He leaves a widow, but
no children.
November 21, 1896]
MEDICAL RECORD.
753
SECOND
Society Reports.
PAN-AMERICAN
CONGRESS.
MEDICAL
HELD IN THE CITV OF MEXICO, NOVEMBER
1(1, 17, i3, AND 19, 1S96.
(Special Telegkai'Hic Report to the Medical Record.)
First Genera! Session — Moiiiiay, November j6fh.
The section work of the Second Pan-American Med-
ical Congress began informally on the morning of
Monday, November i6th, in different parts of the city,
the formal opening being reserved for the general ses-
sion. This was held in the evening in the National
Theatre. The building was crowded to its utmost
capacity by the native and visiting physicians, most
of the former and many of the latter being accom-
panied by ladies, by the officials of the federal and
municipal governments, and by many residents of tlie
capital.
The first business after the opening of the session
was the
Report of the Secretary. — Dr. Eduardo Liceaga,
secretaiy-general of the congress, then read his report.
He recalled the fact that the first congress of phy-
sicians of the western hemisphere was held in Wash-
ington in 1893. Its inception was due to the labors
of Dr. William Pepper, who honors us this evening
with his presence, to the tireless activity of Dr. C. A.
L. Reed, and to the action of the United States Con-
gress, which authorized the President of that republic
to invite all the other nations of the American conti-
nent to send delegates to the medical congress. At
one of the sessions of this congress the honor of hold-
ing the second meeting was granted to Mexico.
The Mexican Medical Society, which met in San
Luis Potosi, in 1894, named an organization committee
for this reunion. This committee found a ready as-
sistant in the President of Mexico, General Diaz,
and thanks are due to him for the readiness with
which he assented to invite the other nations to par-
ticipate in this congress.
All the ministers have also lent their valuable co-
operation to make the meeting a success, and the vari-
ous scientific societies have cordially accepted the
invitation extended to them. Special mention should,
however, be made of the international committee hav-
ing its seat in the United States, for arousing and
maintaining an interest in the congress in the United
States and Canada, and for inducing so many to come
from those countries to assist at this meeting. Thanks
were also extended to the municipal and district au-
thorities, for their part in receiving the delegates to
the congress.
The invitation to attend the congress has been ac-
cepted by the United States, Canada, Guatemala,
Nicaragua, San Salvador, Honduras, Costa Rica, Ar-
gentina, Venezuela, Equador, Uruguay, Cuba, Hayti,
and the French and Danish West Indies. Special
delegates have been sent by most of the countries
named, by several of the States of the United States,
and also by a number of the medical societies in vari-
ous countries of the western hemisphere. Five hun-
dred and fifty physicians, ninety-six of whom are to
be accompanied by their wives, have signified their
intention to be present. Titles have been announced
of two hundred and ninety-four papers to be read.
We may hope that the scientific results of this con-
gress will redound to the good of humanity. Meet-
ings such as this offer a consoling spectacle to those
who have the good of the profession at heart, for they
advance civilization and they make one feel the bene-
fits of association and give us a practical proof of the
universal fraternity of science. All who come here,
those from the distant north and those from the torrid
equatorial regions, will meet to discuss medicine
alone, and will leave behind all race prejudice and
all questions of religion or politics. Those who come
here at the expense of separation from family, making
long, fatiguing, and dangerous journeys, abandoning
for the time their lucrative practice — all for the sake
of science, pure and simple — present a pleasing con-
trast to the picture drawn by Lord Byron of the mer-
chants and traders who run like risks and suffer similar
inconveniences, not for the good of their fellows but
in the unquenchable greed of gain.
In closing, Dr. Liceaga extended a most cordial
welcome to the delegates, in behalf of the medical
profession of Mexico.
The Presidential Address. — Dk. Manuel Car-
MONA Y Valle, the president of the congress, then de-
livered his address. At the end of the fourth century
after the discovery of America by Columbus, the happy
idea of calling together the physicians of the western
hemisphere originated and was carried into effect in
the United States. This first Pan-American medical
congress was a perfect success, whether from the point
of view of members, of importance of papers read, or
of the welcome accorded the visiting physicians.
None who took part in that first meeting can ever for-
get the warmth of their reception, and in behalf of the
other nations of America he would say gracias / mil
gracias I and he hoped those present would find that
the Mexicans knew how to reciprocate, if not with
such opulence, at least with a sincerity of affe> tion.
It was the speaker's privilege and pleasure (solely, he
feared, on account of his age) to have been selected to
preside over this second congress and to welcome the
visitors.
Medical Education in Mexico. — Dr. Carmona
took for his subject the history of medicine and of
medical education in Mexico. It had been said that
Spain repressed education in her colonies, in order to
keep them in subjection; but that was a calumny, as
far as Mexico was concerned, at least. Eight years
after Mexico fell into the hands of Cortes, the college
of San Juan de Letran was founded. The first viceroy
of New Spain, Don Antonio de Mendoza, in 1534 —
thirteen years after the conquest — petitioned the king
to permit the establishment of a university, and this
was obtained in 1553. The first faculties were of the-
ology and law, since at that time the science of medi-
cine was but little esteemed. In 1578, however, a
chair of medicine was established, there being but one
professor, who taught all the branches of medicine in
a course of four years. Candidates for this course
were required to study previously Latin, and to make
the courses of arts and astrology or mathematics.
In 1599 a second chair of medicine was established,
and, later still, others were added. The first profes-
sors were appointed by the viceroy, but later the
chairs were given after a competitive examination.
The chairs were retained for life, and if any professor
became too old for his duties, an examination was held,
and a temporary professor appointed to serve for four
years; but no full professor was appointed until the
old one died.
In 1768 a decree was issued for the creation of a
Royal College of Surgeons, with four chairs. This
school graduated phlebotomists, dentists, bone setters,
midwives, etc. The surgeons graduated from this
school were called Romancist surgeons, in contradis-
tinction to the Latin surgeons or graduates of the
university.
In 182 I Mexico obtained her independence, and for
some years the university continued as before, the
Royal College of Surgeons changing its name to the
754
MEDICAL RECORD.
[November 21, 1896
National School of Surgery. In 1830 it was ordered
that no one should be admitted to the surgical school
who had not previously obtained the degree of bache-
lor of philosophy. In 1831 an end was put to the dis-
tinction between physicians and surgeons, but one di-
ploma— that of Ijoth medicine and surgery — being
henceforth granted. In 1833 the university was
closed and a general board of education was estab-
lished, a number of schools being created, among them
that of medical science. Then came a series of polit-
ical changes, during which the medical school suffered
many vicissitudes, owing to changes in locality, to
changes in the government, and to pecuniary difficul-
ties.
In 1842 the name of the medical school was changed
from " Institution of Medical Science" to " The Na-
tional School of Medicine," a name which it now
bears. The speaker entered the school in 1849, ^^hich
then occupied a part of the College of San Juan de
Letran. In 1850 the professors of the school were
informed that by yielding $50,000 of their already
overdue salaries they could obtain a permanent habi-
tation. Tliis was agreed to, and for two years all was
peaceful; but in 1853 the building was seized by the
government for use as a barracks. Lectures were then
resumed in the College of San Ildefonso, where the
school was entertained as a guest; but a )'ear later
the director of the college imposed such conditions
that the medical professors felt themselves obliged to
leave. At that time it was ascertained that the old in-
quisition building could be purchased, and the pro-
fessors again gave up S50.000 of their unpaid salaries.
The perigrinations of the school now came to an end.
The salaries of the professors were very irregularly
paid, and they had to depend in great part upon fees
for examinations and the like; but since 1857 the sal-
aries of the professors have been regularly paid, and
the number of chairs has been gradually increased,
five new ones having been added during the decade
ending in 1877.
Dr. Carmona then spoke of the great prosperity
which had come upon the country under the wise and
beneficent administration of President Diaz, who was
a ruler as great in peace as in war. Under him Mex-
ico was rapidly advancing in material prosperity, but
not alone in that, for, under the favorable conditions
offered by the present era of peace, education was ad-
vancing with equally rapid strides. The School of
Medicine has progressed along with other schools.
At the time it was founded it had eleven chairs, from
1833 to 1877 five chairs were added, but from that date
to the present the number of professors has been in-
creased by ten, and very many assistants have been
appointed.
The speaker then referred to the requirements of
medical study in Mexico. No one is admitted to the
study of medicine who has not passed a successful ex-
amination in the preparatory studies of five years' du-
ration. These studies include mathematics, French,
English, Latin, Spanish, figure and landscape drawing,
physics, geography, chemistry, (ireek roots, botany,
zoology, logic, morality, history, and national and
general literature. The medical course is one of five
years, and embraces the following subjects: Descrip-
tive anatomy and dissection, normal histology, ele-
ments of pharmacy, physiology, surgical pathology
(two years), medical pathology (two years), operative
and minor surgery, materia medica and therapeutics,
clinical medicine and surger)', hygiene and medical
jurisprudence, medical meteorology, obstetrics, patho-
logical histology, bacteriology, ophthalmology, gyne-
cology, and diseases of children.
Nosological Reforms. — The President then re-
ferred to some of the questions which might profitably
be considered at the present congress. In the first
place, the recent advances in bacteriological science
had brought confusion into nosology, and a new clas-
sification was needed. We ought either to suppress
the idea of infiammation as a distinct symptom, or, if
that is admitted, we must agree that it may be caused
by a number of micro-organisms. Again, we must
not lose sight of the fact that in some diseases the
microbe appears to be the fundamental part, as in lep-
rosy and tuberculosis; while in others the microbe
takes a secondary place, its ptomain being the active
injurious agent, as in diphtheria and tetanus. Then,
again, there are other diseases which resemble those
of microbial origin, and possibly or probably are such,
yet until we discover the germ we cannot assert that
they are due to the action of micro-organisms. Such
diseases are rabies, syphilis, small-pox, measles, and
scarlet fever.
Unjustifiable Surgery. — The second subject to
which he would gladly call the attention of the con-
gress, he would put in the form of a simple question:
" In the present condition of science, can surgeons be
so certain in their diagnosis and so certain as to per-
fect asepsis and antisepsis, that they are justified in
undertaking operations for the sake of satisfying the
patient, when the operations may be of such character
that the slightest accident or carelessness will jeopard-
ize the life of the patient?"
Proprietary Remedies — The third question was
that of tlie enormous increase in the use of patent
medicines. Little by little the drug stores are being
transformed into simple warehouses for already pre-
pared medicines, and in many places the druggist has
seldom to compound a prescription, all the drugs or-
dered being already put up in bottles or boxes. \\'hen
a formula is thought out by an educated physician
and compounded by a competent druggi.st, we have
some guarantee that the product will be what it claims
to be ; but when we use drugs already put up by some
foreign manufacturer, there is no guarantee of their gen-
uineness, and the physician can never be certain what
his patient is taking. But even with the best guaran-
tee, we cannot make an already prepared remedv fit
every case; patients have idiosyncrasies which must
be met intelligently, and no drug nor any set combi-
nation of drugs will benefit every case of anamia, of
tuberculosis, or of dyspepsia. Patent medicines and
proprietary articles should be left to the vulgar crowd,
to those opinionated individuals who think they can
dispense with the .services of a physician and treat
their own maladies.
In closing. Dr. Carmona expressed the hope that all
his hearers would have an agreeable stay in Mexico,
that their scientific labors would be crowned with suc-
cess, and that this would be but the second in a long
series of congresses, which would enrich the science
of medicine and increase its repute in all the
Americas.
Aims of the Congress.^DR. William Pepper, of
Philadelphia, president of the first Pan-American
medical congress, then delivered an address. It was
regarded as especially appropriate, he said, that the
second congress should meet in Mexico, since the first
had received such cordial support from the govern-
ment and medical profession of this countrj-. He re-
ferred in complimentary terms to the great activity
now displayed in Mexico in all scientific and educa-
tional matters. The Pan-.\merican Medical ('ongress
w'as established with definite objects, the most obvious
of which was to secure reunion at a stated interval of
the medical men of America, in order that a spirit of
fraternal relationship might be promoted and that the
great current medical questions might be discussed in
a broad continental spirit. Of late it had been the
habit of the ignorant to decry medicines as uncertain
in their action. Some had drawn invidious compari-
November 21, 1896]
MEDICAL RECORD.
755
sons between the rapid expansion of surgery and the
less rapid progress of medicine, but physicians could
turn with pride to the advances made in bacteriology,
in the study of the infections, of the morphology of
the blood and the properties of the leucocytes, and to
application of these studies in the prevention and
treatment of disease. When we contemplated the dis-
coveries of Pasteur, of Behring and Kitasato, and of
Metschnikoff, we had passed before us a dazzling
vista of the probabilities as to the power of fortifying
the system against infection already acquired and even
of overcoming constitutional tendencies, as shown by
the action of thyroid extract in myxoedema ; but at
least equal gain had been made in the direction of
accurate diagnoses. The speaker then related some
experiments in w^hich he was able to see distinctly the
heart pulsations by means of Roentgen rays emanat-
ing from a specially constructed tube. Another no
less important work of these congresses was the pro-
motion of public health, and it was the duty of the
members to urge the recognition of public medicine
by the appointment in the cabinet of every government
on this continent of a secretary of public health. Dr.
Pepper then spoke of the superior board of health of
Mexico and predicted brilliant residts from its labors.
He referred to the settlement of the Venezuelan mat-
ter as being of great promise for the future of the
nations of America, and also spoke in approval of the
proposed establishment of a Pan-American archaeo-
logical society, making effective tlie resolutions of the
association.
International Sanitary Legislation — Senor Don
Josfi M. Gambo.a. then delivered an address with this
title. He passed in review, first, the discovery and
colonization of America by the Spaniards and later by
the English and spoke of the conquest of liberty, first
by the English and later by the Spanish. These
historical points led up to the question which formed
the title of his address. The existence of legislative
authority in the different countries of America was
guaranteed by their independence, but the problem
was how to excite the necessary exercise of this au-
thority. The legislatures should deal with all matters
of quarantine and hygiene, and the speaker proposed
the following as adapted to secure the desired result:
First, the Pan-American Medical Congress should
establish a permanent committee in each of the capi-
tals of the American nations and should maintain
also a committee of initiative in one capital, prefer-
ably Washington. Second, whatever measure seemed,
in the judgment of one of these committees, to de-
serve legislative action should be referred to the com-
mittee of initiative. Third, the latter should have all
these projects read at the next medical congress.
Fourth, the congress should discuss and vote on these
suggestions, and if the latter were approved they
should be referred to all the permanent committees, in '
order that each of these might urge upon its respective
government the enactment of the project into a law.
The speaker believed that by a plan such as this it
would be possible to bring about the adoption of nec-
essary and uniform sanitary laws, by all the Ameri-
can republics.
The session was then closed by the president of
Mexico, Gen. Porfirio Diaz, who delivered a brief ad-
dress of welcome to the visiting physicians and their
wives, and expressed the hope that the labors of the
congress would redound to the benefit of all the in-
habitants of the new world.
Second General Session — Tuesday, November ijth.
Yellow Fever an Obstacle to Civilization. — Dr.
Juan Santos Fernandf.z, of Havan.i, delivered the
opening address. The discovery of America, he said.
was the greatest event recorded in history, but it had
not borne its legitimate fruit in the warmer parts of
the western hemisphere, owing to the menace which
yellow fever offered to European immigration. The
material prosperity and advancement of North Amer-
ica was not attributable to any superiority of the
Anglo-Saxon race over the Spanish, but solely to the
fact that North America was free from yellow fever.
Except for this scourge, Spanish America would be
as populous and as prosperous as the United States.
The lack of a population of European origin was the
cause of the backward condition of Latin America,
and the only obstacle to European immigration was
the existence of yellow fever in epidemic form. It
lay in the power of his hearers, Dr. Fernandez said,
to provide a remedy for this evil, and Latin-American
physicians should form a league for the extermination
of the disease. It had been said that the infection
came from the soil, and that we were powerless to
prevent it; but this was a grave error. Isolation was
the sole means of preventing the spread of yellow fe-
ver. Although we were, it might be hoped, on the
eve of discovering a means of conferring immunity
against the disease, we ought, nevertheless, to insist
upon strict isolation. In this way yellow fever could
certainly be stamped out, and then the tropics would
offer an immense field for European immigration and
enterprise.
Bacteriology, Hygiene, and Medicine. — Dr. E. P.
Lachapelle, of Montreal, Can., was the next orator,
taking the above title for his address. After a brief
introduction, he spoke of the influence upon hygiene of
Pasteur's discoveries. This investigator, in showing
that water, air, food, and all our surroundings may
contain pathogenic germs, had thrown a new light
upon the etiology of an entire class of diseases form-
ing one of the chief causes of mortality; and since
by the same discovery he had demonstrated the
importance and efficacy of prophylactic measures, he
placed hygiene in the front rank of the medical sci-
ences, hygiene being but prophylaxis in action.
The speaker then showed that the studies of Pasteur
had never had any other aim than protection, and that
it was only secondarily that they had rendered such
immense service to practical medicine. It was worthy
of remark that Pasteur's early studies, those which,
perhaps, helped most to turn medicine into new paths,
were also those which had contributed most to the ad-
vance of hygiene. His studies on anthrax had proved
the virulence and the inoculability of its germ, and,
at the same time, the possibility of attenuation of its
virus. Indeed, in all his labors he seemed to be
guided primarily by the idea of prophylaxis, and it is
this which has made Pasteur one of the gr^at benefac-
tors of the human race. He it was who made of hy-
giene an exact science.
Dr. Lachapelle then showed hygiene utilizing the
facts presented by Pasteur and basing all its action
upon the foundation of isolation and disinfection.
Hygiene, having become an exact science, was now
greatly extending its field of action. The preserva-
tion of food stuffs, whch had become such an enor-
mous industry, was but one of tiie many useful appli-
cations of Pasteur's discover}\ After this rapid study
of the progress which hygiene had made in utilizing
bacteriology, Dr. Lachapelle then reviewed the ad-
vances which hygiene had imposed upon the theory
and practice of medicine. Infant mortality had been
greatly reduced by alimentary hygiene. Antisepsis
was merely prophylaxis applied to surgery. Other
points touched upon were the dysenteric origin of
purulent hepatitis, the conveyance of cholera and ty-
phoid fever in water, the cure of scorbutus by vegeta-
ble alimentation, industrial and food poisoning — in
all of which medicine was indebted to hygiene. But
756
MEDICAL RECORD.
[November 21, 1896
the field of hygiene was still widening. Its laboratories
were now in the service of the physicians. It showed
him the nature of the disease which he treated, and en-
abled him to prevent its spread. The importance and
the strength of hygiene rested upon the fact that it had
but one aim, namely, the preservation of individual
and public health. Modern nations understood this,
and everv'where hygiene was receiving greater public
recognition and was being taught in all the universities.
When we should have accomplished the diffusion of the
precepts of modern hygiene, and should have popular-
ized a knowledge of the conditions of the spread of
infectious disease, we might then hope that the people
themselves would second our efforts to preserve public
health, and then the execution of sanitary laws would
give results which would be the pride of ci\ ilized na-
tions.
Orrhotherapy. — Dr. Rafael Lavista, of Mexico
City, then delivered an address, taking for his subject
the treatment of disease by the injection of toxins and
antitoxins. The question was of intense interest to
all physicians, since it seemed to point a finger toward
the goal to which all aimed and which was the ulti-
mate object of e\ery branch of medical study, namely,
the cure of disease. The researches of Pasteur, Koch,
Roux, Behring, and many others had paved the way
for this new science, which was as yet in its infancy
but which offered hopes of a wonderful future. It
was as yet too early to speak with any positiveness of
the results of orrhotherapy, but it was only by collect-
ing and recording the experiences of many observers
in many lands that we could obtain the necessary facts
upon which to establish the indications for this
method of cure.
Dr. Lavista said that he wished to record his own
experience and that of his Mexican colleagues, and
would not dwell upon the results obtained by observ-
ers in other countries, with which his hearers were
already familiar. He therefore reviewed very briefly
the principles upon which orrhotherapy was estab-
lished, and proceeded to give the results obtained
by him in the treatment of a number of infectious dis-
eases, referring also to the methods employed when
these differed from tho.se in use elsewhere.
In tuberculosis a number of exjjeriments had been
made, but the results obtained were not of a satisfac-
tory or encouraging nature. In leprosy also no dis-
tinct benefit had followed the injection of serum; in
some cases there seemed to be a slight improvement,
but it was usually very evanescent and the patients
soon relapsed into their former condition. A number
of injections of toxins had been made in cases of can-
cer with varying results. Like other observers he had
obtained the best results in cases of sarcoma, but he
had never seen any benefit follow when the neoplasm
was an epithelioma. He had at times been pleased
with the effect of double toxin injections in sarcoma.
In syphilis quite marked temporarj' benefit had been
observed as regarded an amelioration of the more dis-
tressing symptoms, such as the headaches, the pains
in the bones, the skin eruptions, and the like, but a
cure of the disease had not been obtained in a single
instance. The fact, however, that the accidents of the
disease could be controlled by orrhotherapy was one
of great importance, and this would be a decided gain
in the therapy of the disease, even if we never suc-
ceeded in eradicating it entirely from the system by
this means.
Diphtheria was a very uncommon disease in Mexico;
consequently the speaker's experience in its treatment
had been slight; what he had seen of orrhotherapy
was good, but he had seen so little of it that he would
not venture to formulate an opinion concerning it, in
the presence of those of so much wider experience.
Typhoid fever was also rare. The results of serum
injections in typhus had hitherto been nil ; in mild
cases the patients recovered, in severe ones they died,
and as yet no specific treatment had been discovered.
Experiments with serum were being continued, how-
ever, and it was possible that with a greater approach
to perfection in the methods of preparing and using
the serum more satisfactory results might be obtained.
In septicarmia no great benefit had been obtained
thus far, and of his personal experience the speaker
could say nothing, for he had had none. In tetanus
he had employed antitoxic serum to some extent, but
his best results had been obtained by the use of cor-
rosive sublimate in fairly large doses.'
Dr. Lavista then spoke of the use of injections of
normal salt solution after extensive hemorrhage, and
as a preventative of shock after surgical operations.
His results had been almost uniformly excellent. He
had employed the intravenous method chiefly, but had
occasionally jjassed the fluid into the subcutaneous
connective tissue of the abdomen. The latter method
was more troublesome, and the results obtained were
no better; the injection directly into a vein was easy
and perfectly safe if the proper precautions were
employed.
Leprosy in America. — Dr. Ricardo Cutirrez Lee,
delegate from Colombia, took "The Prophylaxis of
Leprosy " as the subject of his address. He spoke first
of the danger for the future that there was in the con-
tinual spread of leprosy unless prophylactic measures
were speedily adopted. In Colombia, especially, the
situation was grave by reason of the increase of this
disease, but there was no occasion to despair. He
compared the condition of that country to that of Eng-
land, France, and Germany in the fourteenth, fifteenth,
and sixteenth centuries, when leprosy prevailed to an
enormous extent. He believed the spread of the dis-
ease could be checked by the adoption of certain
economic and social measures; first, obligatory public
education ; second, the opening of ways of communi-
cation so as to facilitate communication between
difterent countries and different parts of the same
country; third, immigration of people of the white
race from Spain or elsewhere, this immigration being
encouraged by government bounties. In this way
new blood would be introduced and the habits and
customs of the natives would be changed. Leprosy
would no longer find a soil favorable to its growth and
it would die out, as it had done under similar influ-
ences in European countries.
i'l'o be Continued.')
NEW YORK ACADEMY OF MEDICINE.
-SECTION ON OBSTETRICS AND GYNECOLOGY.
Stated Meeting, October 22, i8g6.
.Simon Marx, M.D., Chairman pro tem.
An Alloy for Instruments Dr. Griswolu pre-
sented some gynecological instruments, including a
vaginal speculum, cast from what he said was an alloy
of silver, but which had about the weight of alumin-
ium. Its elasticity was represented to be about that
of brass. It did not tarnish. The cost was about one
dollar and a half per pound.
Residual Water in Cystoscopic Work — Dr. P. A.
Harris presented an instrument with which to with-
draw the residual water when doing cystoscopic work.
He said the method which Dr. Kelly employed, it
seemed with entire satisfaction, had resulted in his
hands causing a little injury to the bladder surface,
attended by slight hemorrhage. That method con-
sisted in withdrawing the small amount of residual
water or urine by suction. Others had absorbed the
water by a piece of cotton held in forceps: but there
November 21, 1896]
MEDICAL RECORD.
757
was danger of losing the cotton in the bladder, and
difficulty in causing it to absorb the water when com-
pressed in the blades of the instrument. The instru-
ment presented by Dr. Harris to replace the other
methods, some of which have been mentioned, con-
sisted of a glass tube with a conical distal end. Into
this tube a pledget of cotton was inserted down to and
projecting beyond the end. The somewhat narrowed
opening of the tube would prevent the cotton from es-
caping into the bladder. It readily absorbed the
water. Tubes of two or more sizes were made.
Dr. Polak said he used, as a means of taking up
the residual urine, an ordinary applicator carrying
cotton.
Dr. Valentine used uncut match sticks, ten inches
long, in the male urethra. Cotton could be wound on
both ends, each end being used in succession in dry-
ing out the posterior urethra. He thought it might
be a desirable method in cystoscopy of the female
bladder.
Dr. Vineberg performed cystoscopy on the female
with the patient in the knee-chest position. In this
position any residual water in the bladder flowed
toward the fundus, and there was no necessity for us-
ing any of the instruments spoken of this evening.
Infantile Uterus ; Sterility. — Dr. Bernard Gor-
don presented a woman, twenty-seven years of age,
in illustration of a condition which was seen every
day in clinics for the diseases of women — infantile
uterus. She had been married si.x years, had had no
children, no miscarriages; had first menstruated when
fifteen years of age, a year later had her second men-
strual period, after which she was regular until her
marriage. She menstruated a few weeks after her
wedding, then ceased altogether. When he examined
her and found the cervix measured an inch, the body
but half an inch, he was surprised that with the uterus
in such an infantile state she had menstruated regu-
larly five years.
Gonorrhoea in Women. — Dr. Gordon then read a
paper on " Gonorrhcea in Women" (see page 740).
The Birth of a New Remedy Gives Him Pain.
— Dr. F. C. Valentine said he must confess that the
birth of a new remedy for gonorrhcea gave him pain —
not because he believed there was but one remedy for
the disease, but because of the scores of disappoint-
ments which we had had in the employment of new
drugs. His experience with argentamin had been as
short as it was not sweet. The patients did not im-
prove. A friend of his in Berlin wanted him to try
argon in, and he did so religiously; but his patients
damned him irreligiously. In fact, he failed to see
what was to be gained by using a drug which was di-
rected toward killing the gonococcus. His belief,
founded on experience, was that there was only one
method of destroying the gonococcus, namely, to re-
move its pabulum — destroy its culture medium. To
direct remedies against the gonococcus itself would
fail. He did not propose to dwell again upon hydro-
static irrigation, nor would he assert that hot water
and permanganate of potassium would cure all cases ;
but those who tested them would not waste time on
other methods. In some cases it was necessary to
use nitrate of silver, i to 5,000 or i to 2,000, and it
was necessary at times to add to the permanganate of
potassium corrosive sublimate. Regarding pre\en-
tion of gonorrhoea, if early marriage would do it, what
would become of specialists in this line of work?
Marriage did nothing of the kind. The author had
spoken of regulating prostitution. There was no place
where it was better regulated than in Berlin, yet in
that city there were only two thousand regulated,
while there were twenty-five thousand who were not
regulated. One of his assistants had asked each of
his patients where he had contracted gonorrhoea, and
the answer was almost exactly in accord with statistics
published by a European author: venereal disease,
especially gonorrhoea, was oftenest contracted from,
in the order named, factory girls, house servants,
seamstresses and milliners, married women, kept
women, lastly, prostitutes. It was the prostitute's
business to keep herself clean, and she was more likely
to do it than the other unfortunates named. If it was
intended to regulate the female disseminators of gon-
orrhoea, let it be directed toward those who did the
largest amount of harm. He would rather the author
would permit the general practitioner to treat gonor-
rhcea, but would teach him to do it properly. If the
work were thrown entirely upon the specialists, they
would have to labor forty-eight hours a day. Regard-
ing marriage and contamination of the wife, Dr. Valen-
tine thought that any man who loved a woman enough
to give up his liberty, his life, for her, ought to be
willing to spare half an hour for several days before
the wedding, to be cured of all signs of urethritis.
Gonorrhoea in Children — Dr. Louis Fischer said
said he had not seen in children more than five cases
of true gonorrhceal discharge, such as was seen in the
adult, in seven years. They had, however, in the last
two years treated at a large city dispensary not fewer
than forty-two cases of true vulvo-vaginitis in children,
and in twenty-four of these the gonococcus was found.
In the majority of the cases the disease was a sequel of
other diseases, especially diphtheria. The most obsti-
nate of the cases came after diphtheria. In ten per cent,
there was ophthalmia as well as vulvo-vaginitis. Dr.
Valentine's statement that treatment should not be di-
rected to removal of the germ was in accord with the
views held for years by the speaker, that one should
rather seek to bring the system up to as near the nor-
mal point as possible in all germ diseases, in order
that the germs might have no culture medium suitable
for their propagation. His treatment had been, in
addition to constitutional treatment, thorough irriga-
tion of the vagina twice a day with warm salt solution,
a teaspoonful of table salt to a pint of water, and
wearing a pad of sterilized gauze during the intervals.
Sometimes he used a solution of pyoktanin, i to 10,-
000; sometimes of bichloride solution, i to 10,000.
Dr. Vineberg said surgical treatment should not
be employed in the first attack of acute gonorrhceal
salpingitis. Surgery should be reserved for recurring
attacks, and then the sooner the diseased tube and
ovary were removed the better; otherwise, the other
side would be likely to become involved.
Dr. R. a. Murray did not believe that gonorrhoea
was the cause of so much salpingitis as some persons
had claimed. He thought gonorrhoea was usually
cured ; otherwise, instead of there being few women
sick with salpingitis, there would be few who were not
so affected. The working classes were more exempt
than the upper classes. It was the people at the top
of the social ladder who had kept the disease going,
and it was mostly in that class that we saw the effects
of gonorrhcea. The first thing to insist upon when
one saw a case was to earn,' out the treatment to the
end. The physician should have his own medicine
and require the patient to come for his treatment. If
he were given a prescription, it would pass from one
patient to another, and would be applied in stages of
the disease when it ought not to be used. He be-
lieved thoroughly in the antiseptic method. Clean-
liness could be secured only when aided by antisepsis.
The uterus should be entered only when it was infected;
otherwise, the doctor would be the cause of infecting
it. He again mentioned six cases of gonorrhceal
salpingitis reported by him, in which the tubes emptied
pus into the uterus, were cured, and the women subse-
quently bore children. In all of them certain g>'ne-
cologists had said the tubes would have to come out.
^58
MEDICAL RECORD.
[November 21, 1896
Dr. Murray used permanganate-of-zinc solution in
gonorrhcta in preference to permanganate of potas-
sium, believing that it not only cleansed the parts, but
was beneficial in contracting the mucous membrane
and preventing penetration of the gonococci. He had
seen four deaths from acute endocarditis, occurring
less than two months after contraction of gonorrhoea.
For cleansing, he first required the patient to irrigate
with quarts of borax solution, then employ perman-
ganate of zinc, one grain to the pint to begin with,
increasing up to one grain to the ounce. For the
urethra he made the applications himself.
Dr. Sp;i,l reported a case of gonorrhcea in a woman
from the South, who went on to have all the " itis's"
one could think of, and who, after having been abused
by certain advertising specialists, came to New York
and, under long and painstaking treatment, mostly
constitutional, finally quite recovered.
A Disease Principally of Filth. — Dr. H. L.
CoLLYER regarded gonorrhoea as a disease principally
of filth, and it thrived on a filthy soil. But not all
filthy women had it. He did not believe it was pres-
ent in so many as eighty per cent, of gynecological
cases. One writer had divided the cases into three
classes, according to the depth into the tissues that
the gonococci had penetrated. In the first stage,
when only the epithelium was affected, the disease
could be easily eradicated in women. He had not
seen gonorrhceal salpingitis relieved short of removal
of the tubes. He did not believe in early marriage as
a prevention, nor in establishing assignation houses,
for prostitution was not a necessity.
Dr. Gordon said, in some concluding remarks,
that gonorrhoea was a local disease and required local
treatment. A treatment, such as he had mentioned,
might be appropriate in women when not in men.
He had not recommended early marriage, but simply
had stated that it would be more physiological. The
general practitioner had a right to his livelihood, but
he thought the specialist could treat gonorrho;a more
successfully.
Bladder Tuberculosis Successfully Treated by
Kelly's Method of Direct Medication. — Dr. John
O. PoLAK read the history of the case. It was that
of a girl, about eighteen years of age, who had been
treated eight years in early life for hip-joint disease,
which healed with limited motion and shortening.
She menstruated at fourteen. About three years later,
when in an an.X'mic state, she began to suffer from
frequent and painful micturition and ha;maturia. She
was seen by several specialists, who diagnosed ure-
thral fissure and chronic cy.stitis. Dr. Polak was
called in in an attack of ha;maturia, when more than the
usual quantity of blood was lost. He gradually di-
lated the urethra, introduced Kelly's speculum, but
the source of the hemorrhage could not then be de-
termined by direct ins])ection. The finger was intro-
duced, and an ulcer the size of a silver dollar was
detected at the base of the bladder, including part of
the trigone. It was raised, and ragged, and studded
with tubercles. They were removed w ith the finger.
The treatment until cure was effected consisted of
washing out with boric-acid solution and applications
to the ulcer of iodoform in linseed oil or glycerin;
later, of strong nitrate-of-silver solution, and irriga-
tion with salicylic-acid solution. Tubercle bacilli,
which had been present in the urine, entirely dis-
appeared, the ulcer healed, and urination became
normal.
Dr. Vineberg related two cases with bladder symp-
toms, which had been attributed to disease of the kid-
ney, etc. ; but cystoscopic e.xamination showed fissure
near the ureteral orifice, which he proceeded to cure
by direct applications of nitrate of silver. In ninety-
five per cent, of cases of supposed bladder trouble, he
had found the difficulty located near the base of the
bladder, which showed how useless it was to make
general injections when the disease could be much
more satisfactorily treated by direct applications.
Dr. p. a. Harris related a case of tuberculosis, in
which he thought bladder trouble was secondary to
tuberculous degeneration of the kidney.
Dr. Valentine asked a question, and Dr. Polak
closed the discussion.
SECTION ON GENERAL SURGERY.
Stated Meeting, November g, j8g6.
B. Farquhar Curtis, M.D., Chairman.
Plastic Operation on the Ear. — Dr. W. W. Van
Arsdale presented a child, si.\ months old, which w^as
brought to him four weeks ago with congenital de-
formity of the left ear. The left face was also small.
The ear was drawn down; the tip and back were ad-
herent in front of the meatus, so that the child could
not hear on that side. He freed the attachment in
front, but the ear then drooped, and in order to over-
come this he took out a piece here and there until it
had come to stand up fairly well and was of good
shape. He asked for suggestions how best to main-
tain the lobe so that it would not droop. There
was also tendency to contraction, as usual after such
operations. The external auditory canal and meatus
were now free, and tlie child could hear on that
side.
Tuberculosis of Axilla following Tuberculosis of
the Hand. — Dr. R. A. Sands presented a boy who
last spring cut his hand with some object in a back
yard where a tuberculous patient was in the habit of
expectorating. The boy was brought to Dr. Sands in
July, witii a sluggish sore of the hand and a swelling in
the axilla. He let out pus from the axillary abscess
and scraped the sore on the hand, but was surprised in
September to find that the wounds were not healed.
Tuberculosis being suspected at this time, microscopic
examination w-as made and this diagnosis was con-
firmed. He then cleaned out the parts more thorough-
ly and the wounds healed. The case was of interest
as being probably one of tuberculous infection from
wounds of the hand by a contaminated instrument and
spread of infection tiirougli the lymphatics to the axilla.
There was no family history of tuberculosis.
Result of Bassini Operation. — Dr. W. B. Coley
presented a man in illustration of permanent good re-
sult from a double liassini operation for hernia after
failure by another method practised previously. The
cure had existed three years and seven months.
Irreducible Hernia Complicated by Inflamed Ap-
pendix in the Sac — Dr. John V>. Walker presented
a hoy of seventeen years, who was said to have had a
rupture since a baby. He wore a truss from time to
time. In 1895 the hernia became irreducible, and at
times would be larger and cause pain. Dr. Walker
operated in October of this year, found a large mass
of omentum and another mass, the size of his thumb,
which proved to be the appendix, inflamed and club-
shaped at the lower end, adherent to the testicle, and
containing over a drachm of sero-purulent fluid. The
adhesions to the sac and omentum were firm, and the
probability was that the pain from which the boy had
suffered had been caused by pressure of the truss upon
the appendix. Dr. Walker excised the appendix and
performed Bassini's operation for closure of the ingui-
nal canal with complete success.
Hydatids of the Back Dr. Samuel Llcjyd pre-
sented a man on whom some weeks ago he had ope-
November 2 1, 1896]
MEDICAL RECORD.
759
rated, removing a large and many smaller hydatid
cysts from the back. Among the points of interest in
the case was the fact that the patient had letters from
many surgeons, stating that they regarded the tumor
as inoperable sarcoma. The man was paraplegic,
both as to motion and sensation, caused, as the neu-
rologists informed him, by pressure on the cord in tlie
region of the seventh or eighth dorsal vertebra. The
tumors extended from the sacrum to the right scapula.
Dr. Lloyd said he was at first misled by the letters to
think it was sarcoma, but on reflection it seemed
hardly likely there would be multiple sarcomatous
tumors up the back and not elsewhere. Hydronephro-
sis was thought of, but was not suflicient to explain
the chain of tumors. Some fluid being withdrawn,
it was shown to be hydatids. An extensive incision,
reaching from over the right scapula dqwn to the sa-
crum, was made and the hydatid cysts were removed.
The man recovered both from the operation and the
cord symptoms. The active symptoms had dated
from 1889.
Discussion on the several cases being in order. Dr.
Curtis said he then had a case of deformity of the ear
similar to that in Dr. Van Arsdale's case, except that
there was no bony canal, and all that could be done
was to straighten the ear for the cosmetic effect.
Dr. Wveth suggested anchoring the ear to the scalp
to prevent drooping. He also thought a strip of plat-
inum might be inserted between the outer and inner
skin near the edge of the ear, whereby it could be
made to assume the desired form. Platinum did not
corrode, and would remain indefinitely if introduced
with all aseptic precautions, so that primary union
would result. Such had been his experience in opera-
tions on the nose.
Dr. Lloyd, referring to Dr. Sands' case, said that
in New York tuberculosis had been found limited
chiefly to certain houses occupied at a prior time by
consumptives. The case related pointed to the dan-
ger of local infection.
The chairman. Dr. Curtis, mentioned the case of
a woman whose husband died of tuberculosis. She
had nursed him and broke the spit cup, which infected
a wound of the hand and caused tuberculous inflam-
mation of the tendinous sheaths. The parts healed
after he removed the diseased structures. She had
been in good health in other respects, and was well
when last seen after the operation.
Dr. Tuttle mentioned the thinness of the hernial
sac in the uninflamed area in Dr. Walker's case.
Dr. Coley spoke of the indication for removal of
the appendix vermiformis when in the hernial sac.
He had seen about eight cases, but had removed the
appendix in only two, and then only for gangrene or
strong adhesions. Ordinarily he would leave it.
Dr. Walker concurred in this view.
The Ch.\ir.man remarked that it was rather contrary
to the practice of some who always removed the ap-
pendix on sight, whether it were diseased or not. In
one case the chairman had found the appendix in a
left inguinal hernia and returned it, and Dr. Erdman
had yesterday made an autopsy in such a case.
D. Coley had seen the appendix in a left inguinal
hernia in a child.
Dr. Coley had seen Dr. Lloyd's case of hydatids
of the back, had considered it inoperable sarcoma,
and congratulated Dr. Lloyd on his correct diagnosis
and very successful operation.
Formalin in the Treatment of Septic Wounds.
— Dr. Kdw.ard M. Foote read a paper relating expe-
rience with formalin, dried in gelatin and powdered, in
the treatment of wounds, more especially suppurating
wounds. Schleik had reported two hundred wounds
treated by filling them with this preparation, and
claimed tiiat in every case he had obtained aseptic
union — blood clot formed with the gelatin in the
wound and union took place without any suppuration.
Dr. Foote had had no such results, yet they had been
very satisfactory. He had chosen suppurative wounds,
forty-five cases, because if the powder would destroy
sepsis and cause healing in these, it was more than
probable it would prevent formation of pus in clean
wounds. He had been able to follow thirty-five of
the cases. In three of these it was a failure; in the
remainder the gelatin dried the wound up, checking
suppuration, and led to healing in a comparatively
sliort time by granulation. .As was well known, for-
malin was antiseptic, and when dried in gelatin it
remained a longer time in the wound. The powder
disappeared as the wound healed, perhaps partly by
absorption, partly by drying up. It caused a little
pain. Acetanilid was tried in a few cases, was pain-
less, but did not prevent suppuration. The author
concluded that formalin in gelatin powder was a
marked advance in the management of suppuration,
and was of special benefit when there was moderate
cellulitis in the case.
Dr. Foote presented a man with glanders infection
of a wound on the chin, to which this powder had been
applied. There was now no suppuration, but swelling
and induration had increased rather than decreased.
Constitutional symptoms were absent.
Dressing of Balsam of Peru in Castor Oil Dr.
Gallant called attention to a dressing which Dr. W.
W. Van Arsdale had used for wounds over ten years,
consisting of about fi^•e per cent, of balsam of Peru in
castor oil. Gauze was soaked in this and introduced
into suppurative wounds or abscesses. Many ab-
scesses when simply emptied and filled with this
dressing became entirely free from pus within three
days and healed. Cellulitis nearly always subsided
in twenty-four hours and pain disappeared at once.
Of twenty-eight thousand cases so treated, ten thou-
sand six hundred and thirty-three were of abscess.
Drainage was not necessary with this dressing.
Dr. Cole thought the formalin dressing did more
than simply permit drainage; it seemed to act by
antisepsis and removal of the suppurative process,
after which healing took place as when a scraping
operation had been performed.
Dr. DeGarmo said he had had occasion to use
fomialin gelatin in a case at the hospital last spring,
and the result seemed to be so remarkable that he
spoke of it to the house surgeon, who had since em-
ployed it in a number of cases with, it seemed, equally
satisfactory results.
Dr. R. a. Sands had tried the formalin gelatin in
a few cases and had been very much disappointed.
In some cases the wounds healed rapidly, but in a
number there was scabbing, which he thought was not
desirable in suppurative wounds, and in some there
were more disagreeable results. It did not control
the cellulitis. He had used the dressing of Dr. Van
Arsdale, balsam of Peru in castor oil, with decided
benefit.
Dr. John Erdmann had used formalin solution on
a sinus following removal of the inferior maxilla, and
he thought it would kill his patient, for within two
hours it began to produce hardening and most dis-
agreeable results.
Rupture of the Bladder. — Dr. John Erdmann re-
lated a case of rupture of the bladder in a man, w-ith-
out known cause. The patient was brought to the
hospital drunk, and while in the hospital symptoms
pointing rather indefinitely to rupture of the bladder
manifested themselves. He made abdominal section
and after considerable search found an opening of
three-eighths of an inch in the iiladder, which had per-
mitted leakage into the peritoneal cavity. The man
recovered.
760
MEDICAL RECORD.
[November 21, 1896
SECTION ON GEXITO-URINARY SURGERY.
Stated Meeting, I^ovembcr 10, i8g6.
F. K. Otis, M.D., Chairman.
Initial Lesion of Syphilis on the Hand — Dr. G.
K. Swinburne presented a man with the initial lesion
of syphilis on the hand, followed by roseola and other
symptoms of syphilis. The epitrochlear gland was
enlarged. The source of infection was probably from
inocidation of a sore, present on the hand, by using a
towel which a fellow-workman who had syphilis used.
The Chairman remarked that when he first saw
this lesion there was some question of its being syphi-
litic, but at present it was perfectly typical of chancre.
Dr. J. Blake White had found on investigation
that when one or both epitrochlear glands were en-
larged in cases of suspected syphilitic lesion the diag-
nosis of syphilis could be made with safety nine times
in ten.
Healing of a Chronic Suprapubic Sinus without
Operation. — Dr. Bangs being absent, the case was
shown by Dr. Peterson. The patient had come to Dr.
Bangs in July, with a history of operation for stone in
December, 1895, and a second operation subsequently.
Both suprapubic and perineal cystotomy had been
performed. The sinus above the pubes refused to
heal, but the patient had had such disagreeable e.xpe-
rience with operations that he refused further operative
interference. By rendering the urine bland and mak-
ing patient use of simple measures the wounds had
quite or nearly healed.
Whalebone Filiform Urethral Dilator. — Dr. Gui-
TERAS presented Dr. E. .\. Banks' whalebone filiform
dilator. The instrument was of filiform size at the
distal end, and gradually enlarged. The small end,
which would pass through a narrow stricture, coiled
up in the bladder as the instrument was pushed far-
ther along to dilate the stricture.
Trocar and Cannula. — Dr. Guiteras presented a
trocar and cannula, the latter being a modification of
the grooved director, for use in perineal operations
for tight stricture. The knife could be passed along
the groove.
Stone Obstructing the Urethra in a Child. — Dr.
Samuel Alexander presented a stone which he had
removed by operation from the urethra of a child,
three years of age, after symptoms of urinary obstruc-
tion had existed for three months. The urinary symp-
toms had gradually increased until only one or two
drops would pass every few minutes. The stone was
phosphatic with an oxalate nucleus. The latter had
probably passed down from the kidney and lodged in
the urethra, where it increased by phosphatic deposit.
He removed it through an incision into the membra-
nous urethra, pushing it back to that point with a staff.
The chairman. Dr. Otis, thought stones could best
be removed from the urethra by pushing them back
into the bladder, there crushing them, and washing
them out.
Dr. Alexander would agree with the chairman
if the stone was in the first place in the membranous
urethra and the canal was large enough not to require
dilatation.
The Treatment of Strictures of the Male Ure-
thra.— Dr. John A. Wveth read the paper. He
would deal only with organic strictures due to fibril-
lation of the connective tissue which resulted from
cell proliferation under the stimulus of an infectious
inflammation, specific or non-specific. Clinically
strictures of the urethra might be divided into three
groups, according to their location: 1. Those in the
anterior half-inch of the urethra; 2, tho.se between
this point and the bulb; 3, those in the bulbo-mem-
branous portion.
A true organic stricture of the meatus was rare, but
narrowing out of proportion to the lumen of the ure-
thra was not infrequent. The majority of cases in
his experience had resulted from the abuse of urethral
syringes in the hands of the patient. Applications of
corrosive substances were also causes. As a rule, he
incised these strictures along the middle line of the
floor, but when there was considerable cicatrization
he did not hesitate to incise the roof or sides. Inter-
rupted dilatation was the after-treatment. He treated
stricture in the second division either by direct inci-
sion or by modified divulsion. When the stricture
would admit the Otis urethrotome, after carefully lo-
cating the anterior and posterior boundaries, he put
the stricture fairly well on the stretch and passed the
blade back and forth once or twice along the middle
of the roof. He then separated the bars of the instru-
ment still farther, and practised divulsion if the stric-
ture bands yielded readily, otherwise the still unyield-
ing fibres were divided. It was his aim not to wound
the urethra more than half an inch in front of and be-
hind the stricture. If the Otis urethrotome would not
pass, he made partial preliminary dilatation with the
dilating filiform bougie of Dr. E. A. Banks — one of
the most useful instruments ever invented.
Stricture of the bulbo-membranous portion was far
the most difficult to deal with satisfactorily. In the
rare cases in which the Banks dilating filiform bougie
would not pass, or in w'hich there was perineal abscess
or urinary fistula, he performed external urethrotomy
or perineal section.
A large proportion of strictures at the bulbo-mem-
branous junction could be relieved by a modification
of the internal cutting operation. For the last ten
years he had practised this method in a large number
of cases and in not a single instance had he met with
a result which contraindicated the procedure, and he
was firmly convinced that perineal urethrotomy was
done in many instances when a less formidable pro-
cedure would suffice. The method was as follows:
Presuming that the stricture would not admit the ure-
throtome, the an.fslhetized urethra was injected with
sterilized sweet oil, some pressure being used in order
to force a small quantity through the obstruction. As
w:as well known, the cut-off muscle readily yielded to
hyperdistention of the urethra. A Banks dilating fili-
form was introduced and the stricture partially di-
vulsed until it would admit the urethrotome, the
straight instrument being used, as for the anterior
portion. It usually required a little force for its pas-
sage. He then gave the compressor urethra; two or
three minutes to get tired of the grip with which it
seized the instrument, after which a better idea of the
density and tightness of the stricture could be ob-
tained. Without any separation of the bars of the
instrument, the knife was drawn from behind forward
along the roof of the membr^ous portion of the ure-
thra. The bars of the instrument should now be
separated, and, if the bands yielded readily under
ordinary pressure, divulsion was accomplished, the
fibres tearing in the line of the partial incision already
made. If the instrument blocked as the screw was
turned, the effort at divulsion should cease, the blades
be approximated, then separated ven.' slightly, and the
incision repeated. Divulsion could then be accom-
plished accurately and satisfactorily, without danger
of breaking the instrument.
This modified method of divulsion was to be pre-
ferred to the simple divulsing instruments which were
used without incision, because in the one the surgeon
intelligently selected the line of cleavage, while with the
other it was blind explosion in any direction. After
divulsion as described, interrupted dilatation was car-
ried out. For this purpose he preferred the straight
sound to the curved instrument. In broad dense
November 21, 1896]
MEDICAL RFXORD.
761
strictures it might be necessary subsequently to pass
a sound once or twice a month to prevent recurrence.
When early reconstriction took place, requiring so
much attention as to be annoying to the patient, a
perineal section should be advised.
Regarding sterilization of the urethra before oper-
ating, the author effected this by local cleansing and
rendering the urine sterile. For the latter purpose he
administered twenty drops of a mi.xture of two drachms
of oil of gaultheria and one drachm of salol three or
four times a day. This would sterilize the urine in
twenty-four hours. Locally he irrigated the urethra
with permanganate of potassium, 1-3,000, for five min-
utes before the operation, or by ballooning the canal
three or four times under sufficient pressure to overcome
the cut-off muscle and thus reach the whole canal.
Anesthesia could be secured from the meatus to the
compressor urethras by using from one to three drachms
of a two to four per cent, solution of cocaine according
to the susceptibilit}' of the patient. Anaesthesia of the
membranous portion could be obtained by carrying the
Keyes-Ultzmann syringe point down to the cut-oiT
muscle, pushing it slightly within, and injecting ten
to fifteen minims of a four-per-cent. solution. Anes-
thesia beyond the cut-off muscle was practically im-
possible, because the urine was in contact with the
cocaine, diluting it.
Hemorrhage was controlled by external pressure,
using a compress of cotton and bandage.
Dr. Wyeth had not used electrolysis. When it
could be proved that cicatricial tissue could be dis-
solved by an electrical current without of itself produc-
ing an eschar, he would be compelled to accept the
superiority of electrolysis over urethrotomy. Until
then he would believe in the operation just described.
Dr. R. W. Taylor opened the discussion. He had
never seen strictures of the meatus due to injections.
They were usually caused by venereal lesions. He
was unalterably opposed to overdistention or dilata-
tion of the urethra. He thought the large number of
cases of crooked penis seen of late years were due to
turning up of the urethrotome and cutting, and that
most of the mischief was done by the overdistention
rather than the cutting. The cut would heal up: the
injury from overdistention would remain. When dila-
tation alone was not sufficient, a cutting operation
might be resorted to, but it was only a prelude to
dilatation at best. Overdistention should never be
made. He had had considerable experience with
Fort's method of electrolysis, and had found it a very
valuable method in many cases.
Dr. Alexander agreed with Dr. Wyeth in the
treatment of stricture at the meatus and in the anterior
portion of the urethra. In stricture at the bulbo-mem-
branous junction he followed his teacher. Dr. Ke)'es,
and dilated. The results were as permanent as by
incision. But if the patient could not spare the time
he cut; also when the stricture was dense and broad
he used the knife, but in marked cases it was best to
make perineal section and dissect out the stricture
material. First he would treat the urethral discharge,
get the urethra in fairly aseptic condition, then over-
come the stricture, and then it would be possible to
cure entirely the existing inHammation.
Dr. Culvert no longer believed in using the very
large sounds, and had learned while in Vienna that
Ultzmann was satisfied to get the urethra up to No. 26.
Dr. Swinburne avoided instrumentation of the
urethra until the canal had been put in as healthy a
condition as possible without it. After cleansing
treatment and reduction of inflammation in the urethra
and bladder, strictures could be treated with much
greater safety.
Dr. F. C. Valentine had treated ten strictures by
Fort's method of electrolysis, with two absolute fail-
ures and eight successes. He thought those who fol-
lowed the method of treatment of Oberlander had no
reason to complain of their results.
Dr. Klotz agreed with Dr. Taylor that strictures
in the anterior portion or at the meatus were due to
chancres or chancroids. Overdilatation in the ante-
rior urethra resulted in leaving the urethra as a bag
without any elasticity, so that the patient was unable
to e.xpel his urine properly.
Dr. Eugene Fuller feared that those who should
read the paper would be led to cut too much, although
that might not be the author's practice. The last few
years there had been too much cutting of the urethra.
Vet there was a place for cutting, especially in the
deep urethra. He thought abundant diuresis would
be of more benefit than attempts to render the urine
sterile by administering drugs by the mouth.
Dr. Green said that at clinics he had observed
some of the unfavorable results of cutting operations :
I, cases in which the Otis urethrotome had been used
and was followed by deformity; 2, in which external
urethrotomy had been done, some nene cut, and the
patient left impotent; 3, in which nearly the whole
lower portion of the urethra had been a mass of cica-
tricial tissue and an operation (divulsion) had led to
destructive sloughing. Many strictures could be pre-
vented by attention to a urethritis accompanied by
small ulcers.
Dr. Wyeth thought there was not a great distance
between himself and Dr. Taylor or the other speakers.
He had for a long time practised simple dilatation,
but by the method described in the paper he got as
good a result in a mucii shorter time. He believed if
there had been deformities the patients would have
returned. He had seen no deformities. Organic
stricture was never absolutely cured, but there might
be no subsequent obstruction. Cicatricial tissue
always remained wherever present.
CCoi-vcspoiiclcnce.
OUR LONDON LETTER.
(From our Special Correspondent.)
GASTRIC VARIX RESECTION OF DILATED SIGMOID
FLEXURE — NEPHRECTOMY FOR RUPTURED KIDNEY
VAGINAL HYSTERECTOMY — THE MEDICO-CHIRURGICAL
DINNER — HOSPITAL REFOR.M BERIBERI AGAIN
LIBRARIES FOR HOSPITALS — DEATH OF DR. GEORGE
HARLEY.
London, October 30, 1896.
A RARE case was brought before the Clinical Society
of London on Friday by Dr. Cronier Lancaster, of
Swansea. It was gastric varix which ruptured, bring-
ing about fatal hamatemesis. He showed the part of
the stomach containing the varicose veins. The
bowels acted twice on the day of admission (July
28th), the stools being dark and tarry. From the his-
tory gastric ulcer was diagnosed. On August 7th the
patient, a married woman aged thirty-six years, be-
came unconscious and remained so until her death at
11:30 P.M. She had not vomited once while in the
hospital. The bowels acted on August 5th and 6th ; the
stools were pale and formed ; but on the day of her
death she passed one stool containing freshly poured-
out blood. At the autopsy, sixteen hours after death,
the principal points obser\-ed were as follows: 1.
Several branches of the gastro-epiploic veins in the
great omentum and gastric submucosa were typically
varicose. 2. The largest of the gastric varices pre-
sented on its upper surface a small circular smooth-
edged aperture about the size of a pin's head. 3.
Except for the varices the mucosa of the whole of the
digestive tract was healthy. 4. No cause for the
762
MEDICAL RFXORD.
[November 21, 1896
varicose state of the veins was discovered ; the thoracic
and abdominal viscera were healthy. 5. There were no
left kidney and no left adrenal. Dr. Lancaster said
that varix of the veins of the stomach was apparently
of extreme rarity, but suggested that a certain number
of cases supposed to be of gastric ulcer, cases in which
hcematemesis is the only prominent symptom, might
in reality be cases of varix.
Mr. G. H. Makins observed that if physicians could
diagnose this condition in the stomach the arrest of
the hemorrhage might be effected under far more
favorable conditions than in the case of ulceration,
and the operation would not be much more dangerous
than for the removal of a foreign body.
Ur. Kingston Fowler, referring to the cases of
pseudo-ha:matemesis in association with cirrhosis of
the liver, in which blood came from the veins of the
oesophagus and cardiac end of the stomach, mentioned
that in a recent post-mortem examination at Middle-
sex Hospital this condition was found to exist.
Mr. H. H. Clutton related a difficult case of resec-
tion of dilated sigmoid flexure for chronic obstruction.
The patient was a lady, aged fifty, who had suffered as
long as she could remember from chronic constipation
and occasionally from attacks of distention accom-
panied by pain. During the last five years she had
had frequent attacks of obstruction, lasting from five
to ten days, accompanied by great distention of abdo-
men and occasional vomiting. Her trouble increased
so much that in hope of obtaining relief she gladly
submitted to operation. On November 19, 1895, a
very large dilated sigmoid flexure was removed, and
the two ends of the divided bowel were united by a
Murphy button. The operation was perfectly suc-
cessful except for the fact that the button remained
/';/ situ. She has had no attacks of obstruction since
the operation, and has led an ordinary life. She has
been so comfortable, indeed, that she declined even to
submit to an examination under an anesthetic to de-
termine if the button was movable. Lately she devel-
oped gradually increasing symptoms of obstruction,
and last Sunday Mr. Clutton performed median lapar-
otomy; the small intestines were collapsed and empty,
but the large intestine was encrmously distended with
liquid fa;ces and practically filled the abdomen. He
could feel the button higji up in the splenic flexure.
He made an incision and evacuated two basinsful of
liquid faeces, and then Jie managed to move down the
button as far as the site of the original operation, but
no farther. He therefore cut down upon it and took
it away. At the line of junction left from the previous
operation there was a stricture admitting the finger,
so he made a longitudinal incision, which he sutured
transversely. The operation was done under great
difficulties, and took nearly three hours.
Mr. J. C. W'allis then related a case of abdominal
nephrectomy for ruptured right kidney in a groom,
aged twenty-two. On February 27, 1896, he fell
through a distance of twelve feet from a ladder on to
a spiked railing. On admission he was conscious, but
in evident pain and somewhat collapsed. One of the
spikes — three inches in length — had pierced the ab-
dominal wall, nearly an inch below tlie tenth costal
cartilage on the right side. On operation a lacerated
wound of the peritoneum was seen, through which
bruised intestines presented. The peritoneal wound
was enlarged and large masses of blood clot were
turned out of the abdomen. Sponges were inserted
and the sides of the abdomen held apart by two long
silk ligatures. The under surface of the liver and
gall bladder were exposed and found intact. The
intestines were then examined in the wound track and
were seen to be bruised; one piece of small intestine
had the external coats torn, and the mucous mem-
brane bulged through the opening. No faces could
be seen nor fscal odor detected. At the bottom of the
cavity the kidney could be felt torn almost in two;
blood welled up through the wound at a great rate.
The left kidney was next sought for and its presence
made out. The peritoneum was now divided along
the outer edge of the ascending colon and this portion
of the gut pushed in toward the middle line. The
left hand being passed in behind the colon, the kidney
was rapidlyfreed and brought out of the wound. Tiie
ureter was clamped, tied, and cut; the vessels were
treated in the same way, and the kidney was removed.
The deep muscles were considerably lacerated and
bled freely. Sponges were temporarily inserted, and
the abdominal cavity was washed out with saline solu-
tion. The wound was packed with iodoform gauze in
strips, dressed with cyanide gauze and blue wool, and
bandaged. The patient, being greatly collapsed after
the operation, was left on the table for an hour. He
rallied from the shock very rapidly during the next
twenty-four hours, and made an excellent recovery,
the wound being thoroughly aseptic throughout. The
gauze was removed on the fifth day after operation
and the stitches were removed on the tenth day. The
patient was discharged on April 13th quite well, and
has been seen three times since. He is now at work
as a groom.
A few years ago vaginal hysterectomy for cancer
was pronounced an unjustifiable operation. Now,
as stated by the president of the Gynecological Soci-
ety, it is a " recognized procedure and even in cases in
which the disease seems most advanced there is often
no recurrence." This statement was made after a
paper by Mr. Jessett, who from the results of seventy-
five cases offered the following conclusions: i. In all
cases of leucorrhiLal discharge a vaginal examination
should be insisted on. 2. If on examination dis-
charge is seen e.scaping from the os in a woman at 01
past the menopause, which discharge is occasionally
slightly colored or offensive, the canal should be di-
lated and the cavity of the uterus curetted for micro-
scopic examination. 3. If the report is unfavorable,
total extirpation should at once be urged. 4. Kven
in advanced cases, so long as the uterus is movable,
much relief can be afforded and life prolonged by
vaginal hysterectomy. Dr. Purcell presented a table
of sixty-three cases w ith twelve deaths. This was a
higher mortality tiian Mr. Jessett's, but it included
early operations before the technique had been per-
fected. Dr. R. T. Smith congratulated Mr. Jessett
and Dr. Purcell, and said they had fully justified their
position as surgeons to the cancer hospital — a senti-
ment generally accepted.
The Royal Medico-Ghirurgical Society met on
Tuesday and the next evening there was a dinner at
which about one hundred and fifty fellows and friends
were present. The president, Dr. Howsiiip Dicken-
son look the chair, and was supported by Sir R. Quain,
Dr. VVilks, and other leaders. The toast of the even-
ing was proposed by Mr. Hutchinson, who quoted from
the first volume of transactions. He coupled with
the toast the name of the president, who in reply re-
marked that fifty-nine volumes of transactions had
appeared in the ninety-one years of the society's ex-
istence, and gave examples of the exceeding importance
of some of the papers they contained.
A " Hospital Reform Association" has been started
in London on the initiation of Dr. Garrett Horder. of
Cardiff. It is not proposed to confine membership to
medical men, but to enlist all philanthropists who see
the evils of the out-patient system and are willing to
join in the effort to abate them. The subscription is
only five shillings. It is hoped to enlist the public
press in the cause and to circulate pamphlets, etc.
The managers of hospitals and the Sunday and Satur-
day funds are to be appealed to. I am sorrj- the new
November 21, 1896]
MEDICAL RECORD.
763
association will not keep clear of the Charity Orga-
nization Society, which so many regard as useless and
meddlesome, and which seems to exist chielly for the
benefit of its officers.
Heriberi has again broken out in the Richmond
Lunatic Asylum, Dublin. Some eighty cases have
appeared. Vou will remember I apprised you of the
epidemic of two years ago when it occurred, and men-
tioned that the asylum was overcrowded. This is still
the case, and the lesson of the last outbreak seems to
h.ive been lost. At an inquest lately held, Dr. Nor-
man had to give evidence and stated that there were
seventeen hundred patients in the asylum, the nominal
capacity of accommodation being ten hundred. Dr.
Norman has again and again called attention to the
overcrowding, but so far without effect. Both phtiiisis
and dysenterv have prevailed in this institution, and a
searching inquiry is called for.
The West Haven Public Library gives books and
papers which are vv'ithdrawn from circulation to the
hospital for infectious diseases. Simple rules have
been adopted and circulated. Both patients and staff
are said to highly appreciate the boon. The com-
mittee and librarian maj' be congratulated on having
organized this considerate scheme.
I have again to report the death of a distinguished
and honored member of the profession. Dr. George
Harley, F.R.S., aged sixty-seven years, died suddenly
on Tuesday from rupture of a coronary artery. His
remains are to be cremated this afternoon. I knew
him for many years, a genial and cheerful companion,
whose intense interest in the scientific aspect of medi-
cine never abated. You will remember his researches
on the urine and on the liver, and important as these
were he made many others of equal value. He was a
very highly trained scientist. After graduation at
Edinburgh he spent two years in Paris under Magen-
die and Claude Bernard. Then he took two years in
Germany, working under Scherer, Kolliker, Virchow,
and others. On returning he was appointed to the
chair of histology and practical physiology at Uni-
versity College and physician to the hospital. Soon
for his elaborate researches, among which those on
the chemistry of respiration had great influence, he
obtained the scientific blue ribbon, F.R.S. He natu-
rally became a fellow of both the Edinburgh and
London colleges of physicians. He had to fight
against ill health for a long time, and he did it with a
courage deserving of admiration and sympathy. I
remember his attack of glaucoma, for which, on ac-
count of the state of the other eye, extirpation was
advised; but he retired to a darkened room for several
months to try what rest would do and recovered sight
in both eyes. He recorded a number of observations
he made on his vision as he recovered. He was
always ready to experiment on himself, and on more
than one occasion he ran considerable risk from doing
so. .A careful, exact experimenter and fluent lecturer,
his pupils had the greatest respect for his work, and
many will mourn the loss of an ardent devotee of sci-
entific medicine and a cheerful, skilful, and learned
physician.
OUR PARIS LETTER.
(From our Special Corrcspoodent.)
ALCOHOLISM ON THE INCREASE IN FRANCE — ALCO-
HOLIC CHILDREN — GOVERNMENTAL ACTION THE
MILK EXHIBITION — THE GENERAL ASSOCIATION OF
PARIS .STUDENTS — SUICIDE OF PROFESSOR HANOT.
Paris, November i, 1S96.
Alcoholis.m threatens disaster to the French race.
The danger is greater than ever before, because the
distilleries and absinthe shops are more numerou.s, the
use of w ine is more general, and the habit of drinking
any of the numerous liqueurs or aperitifs, as they are
called, is more common. French doctors and writers
have accused the Americans of burning their stomachs
with alcohol in the form of whiskey, the eftects of
which upon the stomach and circulation are far less
deleterious than those of the sweetened mixtures used
by Frenchmen. These are nothing more nor less than
pure alcohol of very inferior quality, into which is put
a large quantity of a powerful essence, such as anise,
absinthe, mint, or coriander, all having convulsive
and stupefying properties, affecting less the stomach
and circulation than the brain and cerebro-spinal
nervous system.
The government has several times seriously dis-
cussed the question, and it is thought that by limiting
the number of licenses and, above all, guaranteeing
that the alcohol used in the manufacture of drinks,
cordials, and liqueurs shall be of the highest quality,
some check will thus be put upon this steadily in-
creasing evil.
The Chamber of Deputies did, it is true, express
quite recently, in an order of the day, the desire that
the minister of finance should study the subject. Ac-
cordingly, he appointed an extra-parliamentary com-
mittee— that is, a committee whose members are not
deputies. This is a very convenient way of shelving
an embarrassing problem, and it is thought to be the
end of the matter, notwithstanding the fact that the
minister assures the chamber, and the public as well,
that he is endeavoring to eradicate the fraud and pro-
tect the public health. This is the tenth attempt of
the kind that has been made, and it is destined to
prove, like the others, fruitless.
On October 25th, Mr. Algave held a conference at
Rouen, under the patronage of the Normandy Society
of Hygiene, presided over by Dr. Ceine', on the mo-
nopoly of alcohol and its importance from a hygienic
standpoint. Many doctors and men of science were
present. There was also a goodly showing of wine
merchants and liquor dealers at the meeting, and these
became so uproarious when it was proposed to take
really serious action in the matter, especially finan-
cially, that the meeting was adjourned. It seems as
if all eftorts in this direction are doomed to be alike
futile, and distillers are to be allowed to go on manu-
facturing their poisons and the public absorbing them
to its own detriment.
Another beverage, at times as dangerous if not more
so than alcohol, is just now attracting official atten-
tion. We refer to milk — that has not unfrequently
been the direct cause of typhoid fever, cholera, and
tuberculosis; and as several children, whose ages vary
from eight to thirteen years, are now under treatment
in the hospitals of Paris for confirmed alcoholism, it
would be interesting to know exactly how many began
to acquire the habit unconsciously at the breast of an
alcoholic mother or nurse. There have been so much
adulteration of milk and so much consequent falling
off from the standard, that it has become urgent for the
public to know where that nourishment, so indispensa-
ble to infants and children generally, to which also
many adults are obliged to resort, can be best obtained
fresh, pure, and unadulterated. Some of our most
distinguished physicians and professors have, there-
fore, decided to organize a competitive exposition of
milk — a concoiirs de laitcric Jran^aisc — to which milk
and dairy men and women near Paris, and those keep-
ing cow stables, also milk venders in the city, are in-
vited to send their wares. The jury will be composed
exclusively of physicians, pharmacists, and veterina-
rians. A committee of patrons is to be appointed, con-
sisting of deputies, municipal councilmen of the Seine,
and the presidents of the syndical chambers of ali-
mentation. Prizes, such as bronze works of art, pieces
of silver, etc., will be given to'those furnishing the
764
MEDICAL RECORD.
[November 21, 1896
best specimens of lacteal fluid. Manufacturers of
milk apparatus of all kinds are also invited to take
part in the concourse. No doubt the very best and
purest milk will be e.xhibited, but will it guarantee to
the consumer that the milk furnished every day
throughout the year is up to the exhibition standard
as an article of nutriment, leaving septic germs and
sterilization out of the question? At any rate, the
concours will undoubtedly be productive of much good
as regards the sale of adulterated milk, and not with-
out beneficial influence on public health and hygiene.
The Students' General Association of Paris has just
treated us to another one of those scholastic revolu-
tions so common in the Quartier Latin. The president
and all the other officers have just resigned in a body,
because the members of the association had blamed
them for expending, without having consulted their
comrades, certain sums necessary for participation in
the recent Franco-Russian festivities. It seems that
for some time past the direction of the affairs of the
association had been in the hands of an executive
committee, composed chiefly of students at the Sor-
bonne, whose rule the association at large found tyran-
nical. The new president, officers, and executive
committee are students in medicine, pharmacy, law,
etc., but not one of them is from the Sorbonne. The
new regime ratified at once, purely, simply, and with-
out discussion, the credits spent during the Franco-
Russian fetes, the whole movement having been only
a mancEuvre to get rid of the old management.
We have just lost by suicide one of our most promi-
nent (agrege) professors at the Faculty of Medicine
— Professor Hanot. He had returned to his apart-
ment in the Rue de Rivoli on Tuesday evening last,
after having lunched with one of his students, and
went directly to his study, where his servant saw him
open a work on medicine, and retired, leaving him, as
he supposed, at work, according to his custom. When
he went to call his master for dinner a few hours later,
he found Professor Hanot stretched upon the floor, his
body lying upon the right side, the head under an
armchair, the right hand holding a small vial. A con-
frere was called in at once, and stated tliat death was
due to poisoning by cyanide of potassium. Dr. Ha-
not's appointment to a full professorship in the chair
of external pathology had been decided upon for some
time, and to prepare for his new field of labor he had
given himself up to such excessive mental work as to
bring about a state of constant cerebral hyperemia,
accompanied by melancholia of long standing, and in
a moment of aberration he committed the regrettable
act. Professor Hanot was very highly esteemed by
the profession and friends, who mourn alike his loss
at the early age of forty-five.
THE
MOSCOW INTERNATIONAL MEDICAL
CONGRESS.
To THE Editor of thk Medical Recokd.
Sir : A propos of an editorial in this week's Medical
RiccoRD, entitled ''Politics and Medicine in Russia,"
I desire to ask for some space in your esteemed and
most widely circulated journal in order to express my
opinion upon the subject. My at first, perhaps, some-
what startling opinion and advice is that the members
of the medical profession throughout the world should,
collectively or individually, resolve to have nothing to
do with that congress, to ignore it completely. This
opinion is shared by quite a number of my col-
leagues, and the reasons upon which it is based are
as follows: A country in which the popular and
higher education is in the palm of the hand of
Constantin Pobyednoszeff, a narrow-minded, marble-
hearted bigot, as cruel as Torquemada, with the only
difference that he does not burn his victims at the
auto da fi — this being out of fashion now — but sends
them instead to pine their young lives away in the
Siberian mines and prisons: a country in which the
students are watched and spied upon like penitentiary
convicts; a country in which the most brilliant uni-
versity professors are treated like lackeys, discharged
and e.xiled at the caprice of the above-named autocrat;
a country in which the possession or reading of the
Declaration of Independence or of the constitution of
the United States is considered a heinous crime and
is punished by from three to five years' solitary confine-
ment in a prison or subterranean dungeon (this is
fact, not fancy) ; a country in which citizens of the
highest ability and integrity are debarred from uni-
versity education, from certain professions and posi-
tions, on account of professing a certain faith; a
countr)' which in the last quinquennium of the nine-
teenth century establishes a school of medicine for
women and inserts a clause rigidly excluding women
of Jewish faith from entering its portals — such a coun-
tr)', I say, should not be honored by the holding of an
international medical congress in one of its capitals.
And in this opinion I do not stand alone. When in
Berlin I spoke to many physicians upon the subject,
and several of them who ])articipated in previous con-
gresses expressed their resolution to have nothing to
do with the Moscow congress, neither as readers of
papers nor as visitors. And if the entire medical pro-
fession throughout the world decided to do likewise,
the rebuke would have a wholesome effect upon the
pitiless Northern despot.
The case of Erismann is not by any means unique.
Many a Russian professor has been forced to resign or
has been exiled, only to be received with open arms by
the universities of Switzerland, France, and Germany.
Wii.LiA.M J. Robinson, M.D.
112 East One Hcsdred and Twenty-Eighth Street.
THE LEPROSY COMMISSION.
To THE Editor of the Medical Record.
Sir: In an editorial of November 7th you say:
" Would it not be well to have a national leprosy
commission appointed to determine what is to be done
with the leper here at home before we send delegates
to an international leprosy congress in London to de-
cide upon w'hat to do with the lepers of the entire
world?"
You must permit me to observe that the question
what we shall do with the corporal's guard of lepers at
North Protlier Island is just one of those questions
wliich will be presented to the congress. It is to
frame laws suitable to this country and to every other
country that we wish such a congress to meet. If the
decision is left to each countrj' separately, one country
will set tlie lepers loose, as our health commissioner
here proposed to do; another will pen them up like
animals, in utter disregard of such human and relig-
ious rights as certainly ought to be left them; another
country will put its leper aslyum in a moist climate,
like Louisiana, for instance, which favors the multi-
plication and propagation of the bacilli, and also that
of innumerable species of insects, which all may con-
tribute to the spread of the disease, etc.
No State board of health (I have already put myself
on record with this statement) should have anything to
do with the disposition of a leper. The local author-
ities will, in many cases, wink at the escape of lepers,
or let themselves easily be persuaded that they are
not dangerous. Our national government should have
full authoritv to take from every State its lepers, and
put them in a national lazaretto or reservation. No
November 21, 1896]
MEDICAL RECORD.
765
better place could be found for this than some part of
the Yellowstone Park, where the climate is unfavorable
to the lepra bacillus and where there is plenty of
room for leper colonies, that is, for the lepers and
their families, if the latter chose to follow them.
According to Hansen, the tubercular leprosy is
found in moist climates, the maculo-anssthetic form
in dry climates, and the only difference between the
two forms is in the degree of virulence and multipli-
cation of the microbe. Wherever "cures" have been
reported, it was always in the niaculo-anssthetic type.
This type has a natural tendency spontaneously to
"cure" without any medication whatever. (By "cure"
is meant here only the cessation of the activity of the
disease, the ansesthesia and previous ravages, of
course, remaining.) Now, if we put all our lepers in
the dryest climate to be found in the country, away
from the seacoast, whose influence is baneful, we
must of necessity prevent the multiplication of the
lepra bacilli in the human body and diminish their
activity.
It is not likely that any government will formulate
laws in accord with this scientific statement, unless
urged to it by such an imposing body as would be
formed by the competent and official representatives
of all the countries of the world.
Let me add this: The opinion of a man in anything
pertaining to this question can have weight and au-
thority only if he has for a considerable time lived in
countries where lepers are ver\' numerous, where they
are counted by the thousands, ten thousands, the hun-
dred thousands, and where the population has for
many centuries been compelled to observe the dis-
ease, to fight against it, etc.; and the studies made
during a few days, on five or six lepers, entitle no
man to speak with authority on any such question.
All the competent men say that the disease is inocu-
lable and that isolation is indispensable.
Albert S. Ashmead, M.D.
A SIMPLE MEAXS OF THROAT EXAMINA-
TION.
To THE Editor of the Medical Record.
Sir: It is well known that many children have a
dread of the doctor's visit — especially should the visit
be made because of throat disease. The fears are in-
creased if a spoon or tongue depressor is thrust down
into the throat without ceremony. All of this may be
overcame by a method used by me for the past twenty
years, which can be successfully practised in nearly
every patient over three years of age. It consists in
simply teaching the child to use the index finger of
either hand, thrust back along the tongue as near the
base as possible, with the injunction to open the
mouth wide and press down the tongue. In this way
can be secured, after one or two attempts, a perfect
view of the tonsils and in many instances even of
the epiglottis and the adjacent folds.
The reason why this is preferred is based on, first, the
fact that a child, or even an adult, does not fear any
injury from his own finger; second, his own effort will
not provoke emesis or straining, as a trial w ill convince
the reader; third, there is no danger of contamination
by a dirty spoon or depressor, and no possibility of
auto-infection, and finally, the fingers are always at
hand. This plan of course is impracticable in the
moribund and in infants, but at least ninety-five per
cent, of all instances of acute and chronic disease of
throat or of foreign bodies can be more successfully
examined by it than by any other method. The pur-
port of this note is particularly directed to the busy
every-day doctor and not to the specialist.
J. D. MlI-MGAN, M.D.
PlTTSBL-RG, Pa.
^Txevapcutic Jlints.
Bites of Bedbugs, Fleas, and Mosquitoes —
If 01. oliva; 20
Ung. styrac 25
Bals. I'eru 5
Or,
If Naphthol ,3 5-10
Ether sufficient to dissolve.
Menthol 0.25-1
Vaseline 100
— Brocq and Jacquet.
Salicylate of Methyl locally applied in subacute
and chronic rheumatism, during painful paroxysms,
acts at times as well as when salicylates are given by
the mouth. — Lannois and Linossier.
Trional, in from one to two grain doses shortly be-
fore bedtime, gave favorable results in thirteen cases
of insomnia. It may be given in warm milk. No
bad effects upon the heart were noted. — Koster.
Carbonic Acid in its nascent state is a new agent
in the treatment of blennorrhagic vaginitis, proposed
by Piery (Aixri/k Medkalc, No. 23), for which much is
claimed.
Large Doses. — Do not enter into competition with
the object of seeing who can give the largest dose. A
small quantity will often do all that is required of a
drug, and a large dose may do harm.
Antitoxin. — Dr. Billings' observations upon the hae-
matic effects of antitoxin prove that the corpuscles and
haemoglobin are diminished less with the injections
than without them.
Asafoetida. — The tincture, combined with milk of
magnesia, furnishes the best remedy for colic due to
intestinal acidity. As a diffusible stimulant in ca-
tarrhal pneumonia and capillary bronchitis, it is ex-
ceedingly valuable. — Pediairks.
Inoperable Cancer. — Dr. Snow, surgeon of the Lon-
don Cancer Hospital, says that morphine, associated
with cocaine, given in large doses for a long time, ex-
ercises a favorable and curative action upon carcino-
matous neoplasms and retards recurrences.
Puerperal Eclampsia. — Norwood's tincture of vera-
trum viride in large dose (ten to twenty minims), pref-
erably by hypodermic injection, is said to be dis-
tinctly an American practice. The initial dose can be
safely followed, in from thirty minutes to an hour, if
necessar)-, by a dose of from five to eight minims. — -
Bauer.
Pertussis has been successfully treated for fifteen
years by Dr. Josset (La Med. mod., March 28th), with
the aid of hypersulphurous baths, seventy-five centi-
grams of polysulphate of potassium per litre being
employed. The temperature of the bath should be
36° C, and the duration twenty-five to forty-five min-
utes, according to the age. Fifteen baths are, at most,
required.
Unusual Effects of the Bromides — In certain epi-
leptics the prodromal signs of an attack and the sub-
sequent manifestations take on an intensity altogether
unusual when bromides are being employed in high
dose. In cardiac epileptics the bromides ace likewise
injurious, cardiac asthenia leading to a state of col-
lapse. In children paralytic piienomena with ptosis,
loss of memor)% etc., have been noted. Homicidal
tendencies and melancholia with attempts at suicide
may be observed. — S. Weir Mitchell.
766
MEDICAL RECORD.
[November 21, 1896
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending November 14, 1896:
Cases.
Tuberculosis
Typhoid fever
.Scarlet fever
Cerebro-spinal meningitis,
Measles
Diphtheria
Small-pox
Deaths.
161
83
22
7
85
8
I
2
66
4
173
27
0
0
Small-Pox in the German Army. — Only two sol-
diers in the immense German army have died from
small-po.x since 1873, owing to the strictness with
which vaccination is enforced. During the Franco-
German war the Germans lost only three hundred,
compared with a French loss of twenty-three thousand
four hundred men from small-po.x.
Curious Pharmacy. — Toward the end of the six-
teenth century. Sir Henry Unton was sent on a mis-
sion to the French king in Paris, and there became
ill, whereupon the court physician gave him a "iw/-
Jectio alcannas" — compounded of musk, amber, gold,
pearl, and unicorn's horn, "with pigeon's dung ap-
plied to his side, and all other means that art could
devise, sufficient to expel the strongest poison, and he
be not bewitcht withal." It is almost needless to add
that, after the administration of this extraordinary
medicine, the ambassador promptly expired. — British
and Colonial Drui^gist.
A Ring on Penis for Fourteen Years. — An extra-
ordinary case of a ring buried in the penis for four-
teen years has recently been reported. In September
last Dr. Lefiaive was called to a patient who com-
plained of not being able to urinate except by drops
and with exquisite suffering. On being questioned,
the patient confessed that when twelve years old, at
school, fie passed his penis through a brass curtain-
ring, when the organ swelled considerably, so that the
ring could not be withdrawn. In spite of his suffer-
ings the boy kept the matter quiet. By degrees the
ring ate its way through the skin into a circular
groove and in course of time the parts healed com-
pletely over it, so that it was lost to sight, his sufferings
being all the while almost intolerable. Twelve years
afterward the patient married, but at the first attempt
to fulfil his marital duties the penis became greatly
inflamed and contact very painful. He bore valiantly
with his infirmity for two years longer, but at last had
to appeal for medical aid. \\'hen examined, the pre-
puce and the glans were found to be enormously swol-
len and of a phlegmonous aspect. It was impossible
to find the meatus, and all attempts at catheterism in-
creased the agony. About the middle of the penis
could be seen a circular white band representing a
cicatrix, and at this point could be felt the ring, em-
bracing the cavernous bodies. After having chloro-
formed the patient, Leflaive made a longitudinal inci-
sion through the dense cicatricial tissue, which gave
issue to a certain amount of pus; at the bottom of the
w-ound could be seen the ring. A director was passed
under it, and the foreign body was cut through by
means of bone forceps and thus removed. The pa-
tient recovered quickly. Nowhere else in the annals
of medicine can be found a case of a metallic ring
thus buried for so long a period without calling for
surgical interference. — A/eilital Press anil Circular.
Epileptics recover in this country in one per cent,
only, while in Germany, under the village system, be-
tween five and six per cent, recover, and more than
half of those admitted are greatly benefited. — Phila-
delphia Polyclinic.
Anatomy an Explanatory Science. — The New
York Medical Neik's publishes an article by Dr.
Stiles, in which he writes as follows: "To the zoolo-
gist you owe the transformation of anatomy from a
descriptive into an explanatory science. He has
already solved the riddles of many of the rudimentary-
organs of the human body. You are no longer taught
that the pineal gland of the brain is an unexplained
organ, possibly the seat of the soul ; but you are told
that it represents a rudimentary third eye, which has
been traced through a long series of animals until
found developed to such an extent in certain reptiles
that it is probably capable of perception of lights and
shadows, while the paleontologist has here come to our
aid and shown that in certain fossil reptiles this organ
must have been a comparatively well-developed inter-
parietal eye. You no longer learn a minute descrip-
tion of the plica semilunaris and then wonder what it
is, for you are told that it is a third eyelid, very rudi-
mentary in most human races, slightly better developed
in the Malay, while it is well-developed and func-
tional in birds and frogs. "
The Prosecution of Quacks h quack of the name
of Tlionuiso, though fortified with the usual bogus
.American diploma, was fined ^20 last week at the
Southwark Police Court, under the apothecaries act,
for practising medicine. It is only by the byway of
this ancient enactment of 1815 that a quack can be
punished for practising in England. In Ireland no
such protective enactment exists, for which reason
quacks can do as they please in that country, as long
as they do not publicly represent themselves as regis-
tered practitioners. Fortunately there are, in Ireland,
practically no quacks. The good St. Patrick banished
them along with the toads and other venomous ani-
mals, and since then, though many of the tribe have
sought to effect a lodgment, they have always died of
inanition. — Medical Press and Circular.
Magical Remedies. — In former times many curious
remedies were used in the treatment of disease.
Thus, the magi or priests of the Persians, the wise
men of the Fast, knew of herbs which, wrought into
pills and swallowed in wine, would make th^ guilty
confess their secrets. They also had an herb for be-
getting good and handsome children, and a wort to
revive old love, even when it had turned to hate. .All
these had magic names. They thought highly of the
common mole, and taught that, if any one swallowed
its heart, palpitating and fresh, he would become an
expert in divination. The heart of a hen, they said,
placed upon a woman's left breast while she slept,
would make her tell her secrets, if only her memory
served her. The magi also taught to drink the ashes
of a pig's pizzle in sweet wine, and so to make water
into a dog's kennel, adding the words, "Lest he, like a
hound, should make urine in his own bed." If a man,
in the morning, they said, made water a little on his
own foot, it would be a preservative against mala tne-
dicamenla, or drugs intended to do him harm. Pliny
mentioned many curious remedies. Thus, speaking
of ague, he tells us how to cure it by amulets; by the
dust in which a hawk has rolled; by the longest tooth
of a black dog; by a solitary wasp caught in the left
hand; by the head of a viper cut off, and by its living
heart cut out and wrapped in a piece of cloth; by the
snout and tips of the ears of a mouse, and so on.
Marcellus recommended, in order to avoid inflamed
eyes, that when you see a star fall or cross the heavens
November 21, 1896]
MEDICAL RECORD.
/"/
you should count quickly, for you will be free from
inriamnuition for as many years as you count numbers.
If a man, he says, have a white spot or cataract in his
eve, let him catch a fox alive, cut his tongue out, let
him go, dr}' his tongue, and tie it up in a red rag,
finally hanging it round the neck. For toothache you
are requested to spit in a frog's mouth and tell him to
make off with it. Ettmiiller is conspicuous for recom-
mending disagreeable and even revolting remedies, a
prominent feature of his treatment being the employ-
ment of the excrement of various animals. Album
canis, or album graecum — in other words, the "whites
of dogs" — he recommended for bleeding, and also as
a gargle for sore throat. — William Murrell, in A
Manual of Pharmacology and Therapeutics, p. 2 .
Malaria. — The importance of careful microscopic
examination of the blood in obscure cases of illness
cannot be overestimated. It is futile in many in-
stances, but invaluable in others. We must not as-
sume, however, that antimalarial treatment will correct
grave functional derangements, even when these are
primarily due to the disease. — F. S. Johnson.
A Full Stomach. — A paragraph is now going the
rounds which states that a gastrotomy performed on a
woman in a hospital at Odessa disclosed the follow-
ing objects in a state of incomplete digestion : A
fork, a piece of iron, two teaspoons, a needle, a piece
of lace with the crochet needle, two two-and-one-
fourth-inch nails, four pieces of glass, eight buttons,
and a key. — Boston Medical and Surgical Journal.
Dispensary Abuse. — The following extract from a
London letter by Dr. Boyes to the Occidental Alcdical
Times is worth a moment's thought: "In America,
even more than here, there are many such issues that
are becoming burning questions in these days of ex-
cessive competition on all sides. There seems, and
with great good reason, to be a feeling abroad that
many things demand rectification in our profession,
which, by the way, has increased out of all proportion
to population in most localities. We need but turn
our attention for a moment toward our general envi-
ronment to obser\e that the majority of the institu-
tions founded so generously and conducted so zeal-
ously for the benefit of the sick poor, whether on
charitable or co-operative principles, are entering into
keen competition with us, and that, of course, greatly
by our help. The association instances Birmingham.
England, showing that the hospitals and dispensaries
treated last year a grand (?) total of about one hun-
dred and twenty -eight thousand patients, out of a pop-
ulation of five hundred thousand. Just think what it
means. Imagine what inroads must have been made
in the incomes of the rank and file of the profession.
And remember that such detriment is at the hands of
their brethren. Nor is this an isolated instance, but
rather the rule, with amazingly few exceptions, in the
towns and cities of Europe and America. It is a
spectacle for the gods to laugh at — a body of learned
men exerting their best efforts toward their own un-
doing. The worst of it all is that this philanthropy
gone mad, this misguided generosity, has gone a long
way toward pauperizing the public at the expense of
the profession. It simply destroys the prospects of
many medical men who otherwise could get along
nicely and with benefit to the community. Assuredly
it is a great injury to allow numbers of wage earners
to profess the need of charity and to demean them-
selves as paupers to avoid paying fairly and in accord
with their means."
Progress at Craig Colony During the Eight
Months Since the Opening. — This has been the cru-
cial year in the evolution of Craig Colony. All of
the buildings which were in the Shaker settlement at
the time of its purchase by the State for dependent
epileptics have been thoroughly remodelled and put
into complete order for the reception of patients. A
perfect system of water supply, sewerage, plumbing,
heating, and electric lighting has been installed, and
on February i, 1896, the colony was informally opened
for patients. One hundred and forty-nine patients
have been received thus far, and as soon as the hospi-
tal building now in course of construction is com-
pleted, and the west group of buildings heated, the
accommodations of the plant, as it now stands, will be
ready for a population of over two hundred epileptics.
In spite of the shortness of the time now elapsed since
the opening of the colony, two very important facts
have become evident: First, that remarkable improve-
ment has taken place in the condition of the patients
admitted; and secondly, that the economic success of
the scheme is assured. Nearly every subject has
gained in weight and in general health. In all cases
the epileptic seizures have diminished in frequency to
a marked degree, and in some instances this has been
even extraordinary. The expression of the inmates
has altered, so that, instead of the dull, hopeless look
of the almshouse epileptic, one sees on all sides happy
faces, in which intelligence and hope are being re-
awakened. The school has been successfully started
for fifteen or twenty of each sex. Much of the print-
ing of the colony is now done by two or three epilep-
tics in the colony's own printing-office. Carpentry,
sewing, painting, etc., are being carried on by the pa-
tients. They have their own epileptic blacksmith.
Naturally, the great work of the inmates of both sexes
is in the field and garden. Eighty-three per cent, of
the males and seventy-six per cent, of the females
have given us eight hours' daily work. This labor
has had a great effect upon the income of the colony,
demonstrating the economic value of the scheme.
From the report of the superintendent and steward for
the year ending September 30, i8g6, we learn that the
products of the farm and garden for the year 1896
amounted to §14,230.20. The cost of maintenance of
patients, from the date of opening, February i, 1896,
tp October 1, 1S96, a period of eight months, was
$28,258.24. The colony has, therefore, actually pro-
duced already one-half of the cost of maintenance.
.\ppropriations are asked for this year, to increase the
productivity of the agricultural department especially,
because upon this the economic success of the scheme
depends so largely. At the same time there is most
urgent need for accommodations for the hundreds of
patients seeking admission. There are nearly a thou-
sand patients still a public charge in the almshouses,
insane asylums, and various charitable institutions,
who need to be provided for at Craig Colony. The
managers will ask the legislature to provide, this com-
ing year, dormitory accommodations for at least three
hundred more patients.
The Physician's Relation to Society. — The trusted
physician sees intimately many classes of society,
whether he live in the countr)- or the city. In the
city he sees the well-to-do in their houses and the
poor at the hospitals and dispensaries. In the coun-
try he visits all the different kinds of people in the
town. The experienced physician is familiar with
the causes of poverty and misery, and he is equally
familiar with the ill-effects of wealth and ease un-
accompanied by mental and spiritual cultivation. He
can recognize the socially normal and the socially
abnormal, and distinguish unerringly between them.
In the city he knows the evils which result from
crowded tenements, and dark, ill-ventilated working-
places: in the country he knows all about the wet cel-
lars in which decaying fruits and vegetables are stored;
768
MEDICAL RECORD.
[November 21, 1896
the bad cooking; and the careless disposition of the
household sewage on the surface of the ground near
the dwelling. He should be the best adviser on all
social defences against the physical evils which the
greed, ignorance, or carelessness of individuals inflict
on the communit)-; on the building of hospitals, large
or small, in city or country; and on the training of
competent nurses, whether for hospital or family ser-
vice. The physician should be the chief defender of
society against the superstitions which still prevail
and the impostures which still thrive. His training
being essentially the training of the naturalist, he
should be the defender of the community against all
forms of unreason. If the physician have the needed
persuasive force, no one can defend society so effec-
tually as he against those unreasonable persons who
are constantly protesting against dissection, vaccina-
tion, and vivisection ; for no one can understand so
well as the physician the benefits which these proc-
esses have conferred upon the human race. The
medical profession has before it an entrancing pros-
pect of usefulness and honor. It offers to young men
the largest opportunities for disinterested, devoted,
and heroic service. The times are past when men
had to go to war to give evidence of endurance, or
courage, or capacity to think quickly and well under
pressure of responsibility and danger. The fields
open to the physician and surgeon now give ample
scope for these lofty qualities. The times are past
when the church alone asked men to devote themselves
patiently, disinterestedly, and bravely to the service
of their fellow-men. The medical profession now ex-
hibits in highest degree these virtues. Our nation
sometimes seems tempted to seek in war — that stupid
and horrible savagery ! — for other greatness than can
come from vast natural resources, prosperous indus-
tries, and expanding conmierce. The pursuits of
peace seem to pall for lack of risk and adventure.
Would it might turn its energies and its longing for
patriotic and heroic emotion into the immense fields
of beneficent activity which sanitation, preventive
medicine, and comparative medicine offer it! There
are spiritual and physical triumphs to be won in these
fields infinitely higher than any which war can offers
for they will be triumphs of construction and preser-
vation, not of destruction and ruin. They will be tri-
umphs of good over evil, and of happiness over
misery. — Dr. Eliot, in His Aildrcss before the Alcdical
Society of the State of Neiu York.
Anaesthetics. — 'I'he subsequent histor'y of the men
who introduced anaesthesia is instructive — and encour-
aging. Wells, after his failure at Boston, went home
disheartened, and was long ill and unable to practise
his profession. He gave up dentistry and went into
picture dealing. He tried to get some reward for the
priority of discovery, but was constantly disappointed,
and finally committed suicide. Twenty years after-
ward his statue was set up in Hartford; and five years
later, his widow being destitute, a subscription was
raised on her behalf. Dr. Long lived quietly and lit-
tle known till 1878, when he died. He received no
reward nor honor of any kind. Jack.son was equally
unsuccessful in his endeavors to obtain recognition,
and finally ended his days in a lunatic asylum. Simp-
son was made a baronet; had a statue erected to him
in Edinburgh, and a bust in Westminster Abbey. —
William Mirrkll, in Manual of Pliarmacology and
Therapeutics, p. 233.
The Tribulations of a Big Head. — Dr. Max Nor-
dau's name was originally Dudfield, and Nordau was
at first simply a pseudonym, which, with the consent of
his father, he afterward legally assumed. He lives in
Paris, above a wineshop, and here is his description
of his modes of work : " I spend my day in paying
visits to rny clients and receiving visitors. In the
intervals I attend to my journalistic duties, for I am
the Paris correspondent of the Vossische Zeitung, of
Berlin, and I also contribute to the frankfurter Zei-
tung, writing on all subjects. It is not till after din-
ner— that is to say, at about half-past eight — that I sit
down to my table to write books. I then write till
eleven o'clock, or midnight, as the inspiration goes.
When I set pen to paper, I am as sure of the last word
of what I am going to write as I am of the first. But
I find it hard sufficiently to concentrate my mind at
first, and the work of the first hour is about equal to
the work of a quarter of an hour later." — Literary Di-
gest.
Good Old Age.— On October 26th, died at Fitch-
burg, Mass., Mrs. Berube, at the ripe age of one hun-
dred and nine years. It is said that her grandfathers
lived to be respectively one hundred and fifteen and
one hundred and five years of age. Her eldest son
lives at Marlboro, Mass. He is eighty-seven years of
age.
CObituai-ij.
JAMES COOPER MARTIN, M.D.,
KANSAS CnV, MO.
Dr. James Cooper Martin, a leading practitioner
and prominent citizen of Kansas City, died November
7th, aged sixty-four years. He had been in failing
health since Eebruary, 1895, when he suffered a se-
vere attack of pneumonia, which developed into con-
sumption. A few months ago he went to San Antonio,
Tex., and, although he derived some benefit from the
change of climate, yet his advanced age precluded the
possibility of his recovery. He was born in Fayette
County, Pa., in 1832. When a young man he took up
the study of medicine. The first course of lectures he
attended was at the Ohio Medical College in Cincin-
nati, in 186 1. He then went to Long Island Medical
College, New York, and, upon graduating from that
institution in 1866, went to Madison County, 111., near
the city of .^Iton. There he was engaged in the prac-
tice of medicine a number of years, and it was there
he was married to .Miss Jennie W. (ladd, a sister of
Joseph H. (Jadd, of Kansas City, Mo.
Dr. Martin went to Kansas City in 1880, and began
practising in the city of Wyandotte. Although he
was not a politician in any sense, he took an active
part in municipal affairs. He was nominated for
mayor of Wyandotte by the Democrats in 1885, and
defeated Thomas C. Foster, the Republican candidate,
at the election held in April of that year. About that
time the cities of Wyandotte, Armourdale, and old
Kansas City, Mo., were growing rapidly, and during
Dr. Martin's administration the movement to consoli-
date them into one municipal government assumed
definite proportions, resulting in the issuance of a
proclamation by Gov. John A. Martin, on March 6,
1886, under which the three cities were merged into
one, to be known as Kansas City, Mo.
Dr. Martin occupied the mayor's chair until April,
1886, when Thomas F. Hannan was elected mayor at
the first election held in the new city. Dr. Martin
then served as a member of the common council three
years, when he retired from office. As a public offi-
cial his acts were free from criticism, and during his
administration there was not a shadow of suspicion of
corruption.
Dr. Martin was an elder of the First Cumberland
Presbyterian Church of Kansas City, Mo. He was
one of the founders of the Y. M. C. A. in Kansas Cit)-,
Mo., and was at one time its president.
Medical Record
A IVeekly youmal of Medicine and Surgery
Vol. 50, No. 22.
Whole No. 1360.
New York, November 28, 1896.
$5.00 Per Annum.
Single Copies, loc.
©Kioiunl |k.rtictcs.
MEDICAL ADDRESS AT THE TWENTY-
NINTH ANNIVERSARY OF THE WOMAN'S
HOSPITAL IN THE STATE OF NEW YORK,
NOVEMBER i8, 1896.
By T. GAILLARD THOMAS, M.D.,
PRESIDENT OF THB MEDICAL BOARD,
Mr. President and Ladies and Gentlemen, Gov-
ernors OF the Woman's Hospital: In these days
of national ambition and cupidity, our ears are from
every side saluted by the echoes of conventions called
for congratulation and rejoicing over the great victo-
ries accomplished by the terrible and bloody hands of
war. Of late England, Germany, Russia, and the
United States have rung with pteans of praise for the
success of their contending armies, ^^'e meet here to-
day to glory in a victory of peace ; to give thanks for
one of its triumphs, the growth, development, and fru-
ition of which we have watched with anxious eyes;
and with fervent sincerity to join hands over its cra-
dle and pledge ourselves to cherish, sustain, and hon-
or it.
Happy is the nation which can with complete sin-
cerity accept the grand truth which is beautifully ex-
pressed in the epigram : " Peace hath her victories no
less renown'd than war." For the reception and full
admission on the part of a community of this truth, so
charming in its setting of poetic diction, testifies to a
signal advance in civilization, refinement, and Chris-
tianity. "The normal state of man,"' says Hamilton,
in his great work upon "Military^ Surgery," "is war."
In the normal state of man peace hath no triumphs at
all comparable with those of war. For the hospitable
reception of the seed of such doctrine as this the land
must be prepared. Upon no rough and inclement soil
will it germinate; in the bosom of no cold, harsh
earth will it '" bourgeon and blossom." The minds of
men have been prepared for it by civilization and
Christianity. It was the Christian era which made
its real appreciation possible among men. In the
stirring ages which antedated this era, the eyes of all
were so intently fixed upon moving hosts of mailed
warriors, their ears so filled with the martial cries of
contending armies, and their senses so inflamed by the
lust after plunder and revenge, that he who had then
pronounced these words would have made himself an
object of ridicule and contempt. But now, two thou-
sand years of accumulated evidence have convinced
us of their truth, and caused us to imprint them in let-
ters of gold upon the banners of advancing civiliza-
tion. 'I'wo thousand years of trial of the doctrines
emanating from the Man of Nazareth have taught us
to turn with loathing from the grim and awful visage
of war, and to hail the fair and smiling face of peace
with the enthusiastic declaration, truly, truly, " Peace
hath her victories no less renown'd than war."
Of all the glorious triumphs of peace, so great in
their number as to baffle enumeration, not one out-
values the hospital, that outcome of the brotherhood
of man, which is of such recent development that no
evidence of its existence in pagan times rewards the
searcher of ancient literature.
We have met here to-day to honor the anniversary
of one small hospital out of the immense number
which are performing beneficent work in every city,
nay, even in thousands of small towns, throughout this
and every other civilized country in the world. And
yet, while I acknowledge in these words our apparent
insignificance, I shall be greatly disappointed if I do
not in the end make you feel proud of the institution
which you have fostered, satisfied with the service of
your medical colleagues, and astonished at the great
work which in this world and the next must be already
credited to your account.
It is not often that, in our self-seeking and aggres-
sive age, any body of men and women can be charged
with want of appreciation of the good which they have
accomplished; and yet I hope to show you, ladies and
gentlemen of the governing board of the Woman's
Hospital, that I shall to-day sustain myself in such r.
charge against you. Forty years ago that department
of medicine entitled gynecology, which is to-day sav-
ing millions of lives annually, assuaging pain and
sorrow for millions of women, and shedding the light
of happiness in millions of households throughout the
world, did not exist. Its benefits lay dormant in the
minds of medical men, even as the magnificent dia-
monds of South Africa have lain fallow and useless
for centuries in the bowels of that land. Let me tell
you as simply as I may, the story of the early begin-
nings of modern gynecology. All great things have
small beginnings. The lifting of a kettle's lid sug-
gested steam to Count Rumford ; tropical plants float-
ing upon the ocean gave to Cristobal Colon the idea
of a new continent; a Yankee printer's kite introduced
the world to electricity: and a Boston dentist, by a
kind of accident, stumbled upon anaesthesia. — ''^ tnag-
ntim Dei donuni.^^ So, forty years ago, a country doc-
tor from Alabama brought here to New York and
offered free to certain men and women living here,
some new views and new methods concerning the
practice of this department of surgery. These views
were appreciated, and for their carrying out this
Woman's Hospital was built, and here it stands to-day.
The man who came out of the far away South with a
gift in his hand was called Marion Sims; and the
men and women who have aided him in trying his
methods stand before me now as the authorities who
guide the destinies of this institution. Sims worked
out a great result for science and humanity; but it was
by your aid that he did so, by your generous assist-
ance that through the instrumentality of this hospital
he attained his ends. You were offered a glorious
opportunity, and you were wise enough to embrace it.
Come what may in the future, nothing can ever de-
prive you, or Sims, or this hospital in the wards of
which we now stand, of the glon,^ of having inaugu-
rated a beginning which has led up to grand results.
Great discoveries in medicine are not by any means
always recognized and appreciated, either by the med-
ical profession or by the public. Were you to ask me
to-day what I consider the greatest discovery which
has ever been made for clinical medicine, I would
answer, the us€ of the clinical thermometer; and were
770
MEDICAL RECORD.
[November 28, 1896
you then to ask what I regarded as the greatest ad-
vance in the treatment of that deadly atlection, ty-
phoid fever, I would tell you, the use of cold bathing
for the control of high temperature. Vou will be sur-
prised to learn that about a century ago, Dr. Curry, of
England, made both these discoveries, employed them
generally, and wrote a large volume for their dissemi-
nation; and tiiat both were utterly ignored until about
a quarter of a century ago, to be rediscovered then and
to be recognized as sheet anchors, one in diagnosis,
the other in treatment. You were better advised, and
the world reaped the benefit of your wisdom.
Many years ago a prophetic philosopher declared
that the evolution of medicine was becoming, after a
slumber of centuries, so rapid and promising, that the
day was not far distant when all that was old would
become effete, and what was new would be contained
in prophylactic or preventive medicine and surgery.
Truly, his prophecy seems advancing to fulfilment.
The remedies which have lived and flourished for
diphtheria, tetanus, small-pox, and a rapidly growing
list of other diseases are being thrown aside in conse-
quence of antitoxins, vaccine, and the like. So that
loathsome surgical affection, incurable until the times
of Sims, which more than anything else incited the
erection of this hospital, is now rarely seen within its
walls. Its prophylaxis, or prevention, has been ac-
complished by the improved teaching of obstetric
medicine, ignorance of which, in the olden time, be-
trayed the confidence of woman in the grandest mo-
ment of her existence. But this is a digression, and
I return from it to the line of my argument. When,
forty years ago, '" The Woman's Hospital in the State
of New York" was built and devoted to the surgical
treatment of the diseases peculiar to women, no similar
institution existed or had ever existed in any part of
the world — not in England, France, Germany, Scandi-
navia, nor in any country of Europe; not in America,
nor any of the Eastern lands. To-day there are, in New
York City alone, twenty-five public hospitals devoted
in whole or in part to this special work; while simi-
lar institutions exist in Brooklyn, Jersey City, Albany,
Buffalo, and almost all the cities of this State. The
same statement holds true as to the large cities of our
whole country: Boston, Philadelphia, Chicago, Cin-
cinnati, St. Louis, San Francisco, and others too nu-
merous to mention. Now, add to these the cities of
Europe: London, Paris, Berlin, Vienna, St. Peters-
burg, etc., and you will begin to appreciate that the
keynote which was struck here only forty years ago
has resounded throughout the realms of civilization.
If those who were so fortunate as to have been identi-
fied in so grand an enterprise as this do not feel their
hearts swelling with honest pride, they m\ist surely be
either more or less than human.
During these forty years, the medical men to whose
hands you have entrusted the fortunes of this hospital
have worked, with such capacity as has been accorded
them, to advance its interests and those of the depart-
ment of medicine which it represents. In simple jus-
tice to themselves, they declare that they stand before
you to-day, proud of the outcome of their labors, and
firm in the consciousness of honest effort and faithful
endeavor. That their tenure of office in connection
with this hospital has given them a vast deal of pleas-
ure and profit, they acknowledge with willingness and
gratitude; but, from the very nature of their position,
the very history of this institution, they have been ex-
posed to trials which up to this very moment they have
borne in silence. Would that their vindication had a
stronger advocate than I; but "truth is strong and
will prevail," without reference to its enunciator.
One of the most uniformly fulfilled laws of human
nature from the infancy of time has ever been this:
Every man, every society of men, and every institution
which has done for the world great w'ork and bestowed
upon it lasting obligation has sooner or later been
subjected to detraction and misrepresentation. Had
this hospital not been accorded this proof of its be-
stowal of benefits, I would not have dared to write
what I have just read to you; for I should have
felt doubtful as to the authenticity of my statements.
As it is, I feel that I stand upon strong ground
and need have no misgivings. You have heard
from various sources that the results obtained by the
Woman's Hospital in major operations are and have
been much worse than those of similar institutions
throughout our country; that the shortcomings of
its surgeons as to the matter of success have been by
comparison lamentable; and that it behooved those in
charge of its interests to examine and reform the ex-
isting state of affairs.
It is quite evident to you that these reports, kept up
for years, are calculated to prove injurious to the hos-
pital, unpleasant to your board, and not absolutely
agreeable to your surgical staff; and that it is high
time that the charges should be met. Anxious to in-
form you upon this momentous subject, and deter-
mined to report the facts in the case " w ilhout fear or
favor," I requested my friend, Dr. Freeborn, the pa-
thologist of this hospital, to make me a full and impar-
tial statement for presentation to you to-day. To the
uninitiated an appeal to statistics carries with it the
idea of mathematical accuracy, perfect certainty, and
an assurance against fraud or misrepresentation. But
the initiated know that statistics are either perfectly
reliable or absolutely misleading, in accordance with
the method of their preparation. So wonderful are
the effects which may be produced by juggling with
figures, so passing strange the deductions which may
be drawn from their manipulation, that the wittiest of
Englishmen, Sydney Smith, was induced to remark,
"There is only one thing more unreliable than figures
— that is facts." Sometimes the calculation of the
statistics of a hospital is made up by some youthful
and inexperienced subordinate who is deeply inter-
ested in a creditable display of success. In the Wo-
man's Hospital this work has always been allotted to
the pathologist of the institution, who takes no espe-
cial interest in the facts, except as they bear upon
pure science. For many years our statistician was
Dr. William Welch, whose name has been rendered
famous in connection with the Johns Hopkins Uni-
rersity of Baltimore; and for a long time, ever since
his resignation, the place has been filled by Dr.
George C. Freeborn, who is too well known in New
York to need introduction to you from me. The lat-
ter of these gentlemen, having carefully made out the
statistics of this hospital for the year 1894, compares
them for the same year w ith those of six equally large
institutions of this city and Boston, selected at ran-
dom, to the following effect.
The following table represents the statistics of ab-
dominal sections published by the seven hospitals, the
names of which appear, for the year 1894:
•
Number | Re-
of Cases, covered.
Died.
Percentage
of Deaths.
Boston City Hospital
24
66
67
104
55
114
153
18
50
52
86
46
96
130
6
l6
15
iS
9
18
23
25.
24.24
New York Hospital
22.37
New York Cancer Hospital
Mount Sinai Hospital. . . ....
17-3
16.36
Massachusetts General Hospital.
Woman's Hospital, New York..
15-79
15-03
In a note from Dr. Freeborn accompanying these
statistics he says : " The tables are made up from the
published reports of these hospitals." There are three
points connected with them to which I desire before
we proceed to draw special attention, ist. That all
November 28, 1896]
•MEDICAL RECORD.
771
the hospitals with which comparison is made are large
and highly respectable ones, having as surgeons the
ablest men in the medical profession in America.
2d. That of the seven hospitals the statistics of which
are quoted the Woman's Hospital has very much the
largest number of capital operations accredited to it,
one hundred and fifty-three being thus accredited,
while one hundred and fourteen represents the next
largest number; and 3d, that this institution has the
best statistics recorded by Dr. Freeborn. The only
reason for the choice of the year 1894, for taking the
statistics, was that the report for that year was the
latest publication from the seven hospitals which was
obtainable. To make the matter of statistics still
more certain, Dr. Freeborn has further put at my dis-
posal the statistics of the Woman's Hospital for the
last thirteen years, carrying the inquiry back to the
days when antisepsis, the sheet anchor of the surgeon
of to-day, was just being discovered, and when it was
of very little use. During these thirteen years 1,391
abdominal sections were performed, with a death rate
of 22.43. Remember that one of the si.x hospitals
with the statistics of which comparison was made for
the year 1894 reports a death rate of 25 per cent., an-
other of 24.24, and still another of 22.37; ^""^ then
decide whether you need feel ashamed of our statis-
tics, extending back thirteen years, which give a per-
centage of only 22.43 deaths.
The surgical staff of this hospital has absolutely
nothing to do with the making of its statistics. Dr.
Freeborn, the pathologist of the institution, and not a
member of its medical board, is entirely responsible
for them. The statistics of the hospitals with which
comparison is made are gotten from their own pub-
lished reports, and the books of the Woman's Hos-
pital are at the disposal of all for investigation.
Surely the truth can be ascertained with absolute cer-
tainty, under circumstances so favorable for investiga-
tion, and truth once being recognized should not fall
a victim to the attacks of falsehood.
It gives me great pleasure to state that Dr. Free-
born's report for 1895 has just been handed in by him
and that it is better than that for 1894, which Ihave
just read to you. During the year one hundred and
eighty-four capital operations (abdominal and intra-
pelvic sections for removal of diseased organs) have
been performed, with a mortality of twenty-six, mak-
ing the percentage of deaths 14.02.
Once upon a time a Jew who lived in Venice, by
name Shylock, turned to his hostile and biassed judge
and asked this question: "Are you answered?" I
imitate that outraged old Hebrew merchant to-day,
and ask of those who have traduced this hospital,
"Are you answered?"
But I am admonished that I have in the performance
of a labor of love, this effort to defend the Woman's
Hospital from misrepresentation and wrong, imposed
upon your patience. Let me hope that the justice of
my cause may plead my pardon.
May that happiness which is born of an approving
conscience reward your faithful labors, and may your
noble work which has accomplished so much good in
this world find favor for you in that solemn hour when
you cross the threshold of that which is to come.
Strangulated Hernia. — Many a case of strangulated
hernia has been overlooked and the patient has been
treated for colic, epididymitis, bubo, and even for
"idiopathic" peritonitis, until at last the almost fatal
symptom of faecal vomiting appeared. It is wise in all
cases of acute abdominal disease to examine for her-
nia, and, by the way, do not forget that this condition
is not limited to the inguinal regions. — Internationa/
Journal of Surgery.
SUPPLEMENTARY NOTES ON TENDON
GRAFTING AND MUSCLE TRANSPLAN-
TATION FOR DEFORMITIES FOLLOWING
INFANTILE PARALYSIS.'
By SAMUEL E. MILLIKEN, M.D.,
NEW VORK.
At the last annual meeting of this association I pre-
sented a successful case of tendon grafting for infan-
tile paralysis (see New York Medilal Record,
October 26, 1895). My other cases of a like char-
acter at that time were too recent to call for other than
a passing comment. However, at present it affords
me great pleasure to state that the past year's experi-
ence has brought forth results beyond the expectation
of the most ardent advocate of this comparatively new
treatment.
While the operative technique has not been changed,
the applicability for such surgical interference has
proven to be much wider than I had first expected.
In other words, the number of patients with the vari-
ous group or individual muscle paralyses due to
anterior poliomyelitis can in many instances be re-
lieved by tendon grafting or by muscle transplantation
when other measures, such as electricity, mechanical
appliances, and even tenotomy, have furnished only
temporary or partial restoration of the function of the
paralyzed member.
Since February 14, 1894, I have performed fourteen
operations upon nine patients afflicted with various
degrees of deformity due to infantile paralysis. Of
this number, five of the patients required one opera-
tion, three patients two operations each, and in only
one case were three distinct tendon graftings per-
formed.
Operations. — Class I. Partial or complete trans-
plantation of the sartorius muscle into the sheath of
the paralyzed quadriceps extensor of the thigh.
(Twice performed.)
Class II. Grafting of the extensor propius pollicis
to the paralyzed tibialis anticus. (Five times.)
Class III. The gastrocnemius was attached to the
paralyzed peroneus longus and brevis. (Twice.)
Class IV. Extensor longus digitorum was attached
to the paralyzed tibialis anticus. (Once.)
Class V. The tibialis anticus was attached to the
paralyzed extensor longus digitorum. (Once.)
Class VI. The e.xtensor proprius pollicis was at-
tached to the paralyzed extensor longus digitorum.
(Once.)
Class VII. The flexor longus pollicis was trans-
planted on to the anterior surface of the leg and at-
tached to the tendon of the paralyzed tibialis anticus.
(In one instance.)
Class VIII. A graft was taken from the deltoid and
attached to the tendon of the paralyzed triceps of the
upper extremity. (Once.)
It will be seen by the above that of the fourteen
operations upon nine patients eight distinct forms of
paralysis were encountered.
In my first paper I emphasized the importance of
asepsis and minute technique in dealing with the ten-
don grafts and also the preservation of their respective
sheaths, as it is essential that we should obtain pri-
mary union of the wound throughout, thus insuring
the greatest degree of u.sefulness for the grafted or
transplanted muscle upon which additional work has
been placed.
In but one of the fourteen operations did I fail to
obtain the union between the transplanted muscle and
its new attachment, and that was in my first attempt to
transplant the sartorius muscle on to the anterior sur-
' Read at the thirteenth annual meeting of the New York
State Medical Association, October 15, 1896.
772
MEDICAL RECORD.
[November 28, 1896
face of the thigh, with the hope of supplanting the
quadriceps extensor, which was paralyzed. This fail-
ure of obtaining union between the sartorius muscle
and its new attachment, the patellar sheath, might be
accounted for in part by the fact that the flexors of the
leg on the thigh were greatly contracted, thus making
too much tension at the site of union.
However, my second attempt at supplanting the
ptiralyzed quadriceps by transplanting two-thirds of
the sartorius into the sheath of the vastus internus and
attaching it to the patella is best shown by the patient
whom I present to-day (see Figs, i and 2).'
The operation just described was performed on De-
cember 19, 1895. A previous operation, that of taking
a graft from the extensor proprius pollicis and attach-
ing it to the tibialis anticus, had been done by me on
November 4, 1895.
This little patient was referred to me by Dr. W. A.
Goodall, of this city. The history of the patient was
that usually given in cases attacked with anterior polio-
myelitis, which is too well known to call for any
power in these two muscles rapidly increased, and
since June the faradic current has not been applied
and we are depending solely upon the natural use of
the limb, together with massage, which is carried on
by the mother.
The atrophy of the quadriceps extensor clearly
demonstrates that without the second operation, that
performed on the sartorius muscle, our patient would
otherwise be. compelled to wear a brace which would
stiffen the knee in order to walk. The fact that the
limb is somewhat abducted is due to the partial at-
tachment of the sartorius at its original site on the
inner side of the tibia, and in my future operations for
this deformity I shall transplant the whole muscle
instead of, as was done in this case, taking only two-
thirds of it.
Of the second series I have been able to follow all
five of the cases, and it has been clearly proven that
the extensor proprius pollicis can be sufficiently devel-
oped to carry on the work of the paralyzed tibialis
anticus.'
Fig. I.
description. The attack occurred August 2d, which
was about eight weeks before I first saw the patient,
and resulted in the loss of the use of the left lower
extremity so far as the ability of the child to walk was
concerned.
This very flattering result I consider can, in a cer-
tain measure, be attributed to the fact that the opera-
tion was performed while the patient was yet young,
only two and a half years of age, and before the usual
contractions and distortions had resulted.
In this case a long spring was worn until June ist,
a little more than five months after the second opera-
tion, which enabled the patient to walk by stiffening
the knee. During those five months the faradic current
was applied twice a week, together with the daily use
of massage to the sartorius and the extensor proprius
pollicis muscles.
As soon as it was found that the patient could walk
without the use of the brace, it was noticed that the
' For the accompanying illustrations I wish to thank my
friend, Dr. Sidney Yankaur, of New York.
Fic. I. Fic. 3.
Third series: In the two cases in which the gas-
trocnemius was made to supply the peronei both
patients were kept under observation for over twelve
months, and the apparatus in each instance was left off
and the walk was greatly improved (see Fig. 3).
Fourth series: In the one case in which the healthy
extensor longis digitorum was attached to the para-
lyzed tibialis anticus there was a decided improvement
in the position of the foot, when I saw the patient
some three months after the operation. This patient
was oi^erated upon by me before the members of the
Dutchess County .Medical Society, in Poughkeepsie,
on January 8, 1896, the patient having been referred
by Dr. John .S. Wilson, health officer of that city (see
Fig. 4)-
Fifth series: Just the reverse of the above, that of
taking a graft from the tibialis anticus and attaching
it to the paralyzed extensor longus digitorum, was per-
formed on one of the cases of Series III.
Sixth series: The extensor proprius pollicis (Fig.
' See Medical Record, October 26, 1895.
November 28, 1896]
MEDICAL RECORD.
773
5), which was once made to supply the paralyzed ex-
tensor longus digitorum, was the other case of Series
III. in which there was paralysis of the peroneal mus-
cles. This case, it will be seen, required three dis-
tinct graftings in order to re-establish the normal
symmetry.
Seventh series: In the one case in which the flexor
longis pollicis was transplanted on to the anterior
surface of the leg and attached to the tendon of the
paralyzed tibialis anticus the wound healed primarily,
but I question whether the result justified the opera-
tion, although I have not been able to follow the case
as the patient resides in Providence, R. I.
Eighth series: The little boy of two and a half
years whom I am happy to present to-day was referred
to me by Dr. W. A. Goodall, of this city, on March
30, 1896. The history was that of infantile paralysis
occurring one year previous, and affecting the triceps
of the right upper extremity. On April 28, 1896, a
graft was taken from the deltoid muscle and attached
to the tendon and sheath of the paralyzed triceps, al-
though not with the hope of obtaining such marked im-
provement as is shown. The atrophy of the triceps
remains, but the deltoid seems now to be carrying on
the work fairly well.
Conclusions. — ist. Infantile paralysis in the major-
ELD.
EPP
Fig.
Fig. 5.
ity of instances attacks groups of muscles or an indi-
vidual muscle of a group.
2d. Operative interference should be practised with
the hope of re-establishing the symmetry of the limb
and can be accomplished in one of two ways:
(a) When the whole group is paralyzed a healthy
muscle with the proper origin must be transplanted
and given the insertion of the paralyzed group.
(1^) When only part of the group is involved tendon
grafting should be performed; that is, making one or
more muscles do the work of those paralyzed.
3d. Animal suture material, preferably kangaroo
tendon, should be employed on the tendons and mus-
cles and in the closure of the sheath. As this mate-
rial requires twenty-one days for absorption, it will
usually be found that at the expiration of that time
perfect union will have been obtained.
4th. The skin wounds should be closed with inter-
rupted catgut and the sealed dressing of cotton collo-
dion applied.
5th. Perfect immobilization of the limb can best be
obtained by the plaster-of-Paris splint.
6th. The best results of such operative procedures
can be obtained only in young subjects, so as to take
advantage of the natural growth of an otherwise un-
developed muscle, upon which we place additional
work, as it would be unreasonable to expect a man
who has led a sedentary life up to the age of fifty- to
assume at that time the arduous labor of a mechanic.
640 Madiso.n Avenle.
THE TECHNIQUE OF INTUBATION OF THE
L.\RYNX IN CHILDREN, WITH SOME RE-
MARKS ON THE TIME FOR OPERATION
AND AFTER-TREATMENT.
By TH0M.\S J. HILLIS, M.D.,
NEW YORK.
It is not the object of this paper to treat on the his-
tory of intubation, nor to follow the progress of its
development, from its infancy to the present time.
That could not be crowded into a short paper like
this; indeed it would take a volume to do the subject
justice.
While, then, confining myself to the practical aspect
of the case, in passing it is impossible not to pay
tribute to O'Dwyer, whose energy and intelligence have
inspired this operation with a new life and whose
marvellous mechanical skill overcame obstacles to
others insurmountable. The brilliancy of his genius
has shed lustre on the profession to which we have
the honor to belong. He has bequeathed to posterity
a heritage rich in amelioration of human ills and
built for himself a monument imperishable in the
hearts and affections of a grateful profession, and now,
while he is still pointing the way to further progress
in the higher development of our art, it is our priv-
ilege to follow in his footsteps and profit by his ex-
ample.
To begin, the larynx of a child differs widely from
that of an adult. Speaking broadly, seen from above
down, the larynx of the adult has the appearance of a
mortar hod, the handle of the hod not inaptly repre-
senting the trachea. In the young child there is seen
a pealike slit behind the hyoid bone at the base of
the tongue. This is the larynx. Immediately above
and, as it were, looking down is an eminence, the
epiglottis. In a child from one week to two months old
the glottis and epiglottis are very apt to be over-
looked. It must be understood we are working in the
dark and only by the sense of touch, our objective
point the glottis, our guidepost the epiglottis.
The ability to do good and rapid work entirely de-
pends upon the recognition of those landmarks by the
operator. If he dilly-dallies, beats about the bush,
and chases after the larynx with the index finger of
the left hand, while the right, armed with the intro-
ducer, is prodding the adjacent tissues in a vain effort
to enter the glottis, he must surely fail by finally
slipping his tube over into the oesophagus, the grave-
yard that hides his incompetency. To avoid this
grave mistake, keep ever in mind the anatomical
difference between the larynx of the child and that of
the adult. Again, the larynx of the adult is much more
deeply set than that of the child. Before any attempt
to intubate is made, the physician should practise on
the cadaver and be able at a moment's notice to place
the tip of his finger on the spot where the larj'nx is
supposed to lie. In short, he must locate the glottis.
If he is not able to do tliis he has no business to try.
It will bring defeat and humiliation on himself, and
increase the sorrow of the family.
The instruments used in intubation from their
nature are frail. If ever the word " handle with care"
had any meaning, it is in this case; for either any jab-
bing or shoving is sure to be resented by the breaking
of the instrument, or else, if the operator is unlucky
enough by accident to get into the larynx, he will teai
774
MEDICAL RECORD.
[November 28, 1896
the ventricle, wound the cords, or punch a hole in the
wall of the trachea, probably the anterior wall.
It would be well for any one intending to practise
intubation to make himself acquainted with his in-
struments, to spread them on his office table, and take
note of each joint and hinge, and every weak and
strong point they may possess, and by various passes
and motions practise on some phantom subject.
In order to use his instruments well, he must know
them well, they must have an active place in his
mind. A good swordsman is acquainted with his
steel. A huntsman knows the points of his riHe.
The Arab is attached to his steed; he knows the horse
and the horse knows him. Between them there is a
mutual understanding and from this understanding
the best results are attained. Then, finally, the oper-
ator must know and understand the tools he is to
work with, more particularly when it is known that
any bungling on his part may mean death to a fellow-
being.
The operation is said to be most simple and easily
accomplished after a little experience. I cannot quite
agree with this opinion and regard it as hedged in
with difficulties and dangers. In fact there is no
branch of medicine or surgery in which the technique is
so easily forgotten as this one now under considera-
tion, and in order that it should not be forgotten the
operator must keep in touch with the cadaver as well
as with his instruments, and not lose sight of it unless
he has unusual opportunities of practising on the liv-
ing subject.
While the sense of touch is of the first importance,
it is not all. There is the faculty, as it were, of seeing
in the dark and being dexterous in manipulation.
The trained finger of the gynecologist loses its cun-
ning here, and the laryngologist, so well acquainted
as he is with the topography of this region, this land
of his adoption, the pillars of the fauces, the roof of
the mouth, the base of the tongue and the walls of the
pharynx, at his first attempt to introduce a tube into
the larynx of a child suffering from croupous laryn-
gitis is beaten on his own ground. His efforts end
in signal failure. He cannot locate the larynx, and
will not be able to do so until he studies the tech-
nique of intubation.
Preparing the Child — If the surrounding condi-
tions permit, the child should be stri])ped naked and
with neatness and dispatch rolled in a piece of strong
muslin or other cloth. It is much to be referred to
the bulky and clumsy blanket usually employed. It
should be arranged so as to have it pinned behind — -
the arms hanging by the sides, forearms and hands
crossed on the abdomen. This is done to keep them
off the chest, as any bulging or enlargement here is
apt to interfere with the movements of the operator,
who wants a clear field.
The child now recognizes that something is being
done and grows more fretful and uneasy, but will in
a short time be reconciled to the situation.
The child is now held by a nurse, a trained nurse if
possible, uprigiit in her lap. She grasps the child's
legs between her knees, facing the operator. The
assisting physician standing behind holds the child's
head firm and binds, as it were, nurse and child to the
chair. The position is now directly upright, and, as
the saying goes, the child is hanging as it were from
the top of his head.
Placing the Gag. — -The vast majority of children
develop croup lietween the eleventh month and fourth
year, so for this reason the gag must be brought into
requisition very frequently. It is a powerful instru-
ment and looks not unlike bulldog forceps, and is
provided with a groove above and below for the re-
ception of the teeth of the upper and lower jaws.
The physician is assumed to be right-handed. He
may have to force the mouth open with a spoon or
tongue depressor, but, as a rule, in croup and stenosis
of the larynx the mouth is involuntarily open, the nose
and mouth making strenuous efforts to drink in the
particles of air.
The operator places the gag quickly to the left, open-
ing it gradually and carefully and sliding its grooves
over the teeth far back between the jaws; in fact as far
as it can be got. By this method there is less liability
to dislocate or break the jaw, an accident that hap-
pens not infrequently, than by first carrying the instru-
ment to the angle of the jaw and suddenly and
abruptly opening it. If the gag is properly placed
the handles will not lie snugly on the side of the
cheek, but pointing a little outward.
Too mucli stress cannot be laid on the value of
placing the gag; in fact it is the first step toward
success.
Now we are ready to introduce the tube. The
physician should sit on a chair or stool, preferably
the latter, as in sitting there is more composure,
more self-possession, and the operator is more at
ease. The assisting physician holds the gag firmly
by the handles so that it cannot slip off the cheek.
The mouth is now open wide. Let us look for a
moment at this open mouth. We can see the gag
filling up a not inconsiderable space to the left.
Above, the teeth look angrily down, while the right
corner is reserved for the index finger. From this
it can be seen that there is little space left and that
the operator must utilize this space to the very best
possible advantage. There are now two ways of pro-
ceeding:
First Method.— First slip the index finger of the left
hand rapidly but gently along the fioor of the mouth.
Keep as much as possible to the angle of the jaw.
Draw the hyoid bone upward and forward, the so-called
hooking up of the epiglottis process. Then with dex-
terity push the finger to one side, of course the outside,
and with the right hand introduce the tube riding on
the obturator, travelling under the roof of the mouth
exactly in the median line to the chink of the glottis,
which it enters just behind and below the base of the
tongue. Elevate the handle of the introducer as the
tube enters the glottis until its perpendicular is at
a right angle to the plane of the floor of the mouth.
After the crycoid cartilage is reached, the direction is
downward parallel to the plane of the long axis of the
trachea. It is easy to observe these points when their
value is appreciated, as maintaining these planes and
perpendiculars will keep the tip of the tube off the walls
of the larnyx and greatly, wonderfully facilitate its in-
troduction. When the tip of the tube engages in the
glottis, push it gently but with a firm hand by the
trigger which plays in a groove running up the handle
of the director. When the collar is caught in the
grip of the larynx, hold it by the margin of the finger
and w ithdraw tlie obturator. The tube is now in place.
Second Method The operator, sitting or standing
as suits him best, tilts the child's head a little on the
shoulder of the nur.se and gently thrusts his left index
finger backward along the margin of the tongue until
its tip recognizes the slitlike aperture known as the
glottis. Then he slips the instrument transversely
across the tongue until its nose comes in contact with
the finger. After righting the director and elevating
the handle, he passes the instrument along the finger
as a guide, when it will become immediately engaged
in the larynx. Then he pushes off the tube with the
side of the finger and withdraws the obturator. Now,
as before, the tube is in place. If it require any con-
siderable force to press the tube down, stop at once;
there is something wrong. It is of the first impor-
tance to know when to stop, indeed second only to
knowing how to do the operation well.
November 28, 1896]
MEDICAL RECORD.
775
The peculiarities of the second method are, first, that
the tube lies fiat across the tongue, the convexity of
the instrument just touching the gag; second, the
median line need not be considered at all; third, the
instrument is made to right itself as it travels back-
ward toward the larynx; fourth, the tilting of the head,
while altering the anatomical lines and angles, will
put the tissues of the part on the stretch, thereby in-
creasing the facilities for recognizing the larvnx.
P'urther, by tilting the head we have the teeth a little
out of the way. These teeth are a formidable obstacle
in the path of the operator, hampering him from
above and often pinching the first phalanx of his in-
dex finger, causing annoyance if not actual danger
from blood poisoning. Then again, by the tilting
process the chin is lifted from the breast, which is an
advantage of supreme importance when accurate and
rapid work is the thing desired.
It may seem strange to depart from the median line
when the objective point is the terminus of that line;
but, however paradoxical the assertion may appear, a
straight line is not always the shortest distance between
two points, especially if a mountain intervene. In that
case it is easier to go around than to climb the moun-
tain; in the other it is easier to enter the mouth with
the instrument on the fiat, resting across the tongue,
tlian in the perpendicular and median line; in short,
the object of the second plan in passing from without
inward is to take advantage of and be accommodated
by the most favoring conditions.
How to Take Out the Tube.— To do this there
are four ways. The first is very simple; the string
being attached, pull in the direction of the median
line, when the tube slips out easily.
The second way is called expressing the tube. If
the child is under a year old, the cartilaginous rings of
the trachea are yet soft and yielding and respond to
manipulation. Place the child on his back, as in Sil-
vester's method for artificial respiration. Put a small
block or pillow under the neck and press the head
back. This will bring the trachea prominently into
view. Now manipulate the sides of the trachea, as in
delicate massaging. Direct your force upward and
backward, with the tip of the index finger of the right
hand on the larynx to steady the tube; then turn the
child on his side, elevating the buttocks, and slip the
index finger and thumb into the mouth, when the tube
can be easily and quicklv withdrawn.
Third, for this purpose there is an instrument
called an extractor. By placing the nose of this
extractor in the mouth of the tube and pressing with
the thumb on a spring, the nose or jaws open widely,
biting the calibre of the tube and holding it tightly
in its grip. Now withdraw the instrument and the
tube comes also. There is an old saying that the best
way of catching a bird is by first putting a little salt
on its tail. The same way with the extractor. First
put it into the tube, and as with the salt on the bird's
tail the catching is easy. Now, how are we going to
put salt on the bird's tail, or the nose of the extractor
into the mouth of the tube.' They are both very
difficult undertakings, and require agilit)' and tact.
M present we will confine ourselves to considering
the latter proposition.
The gag being in place, the tip of the index finger
tries to locate the collar of the tube, which may be
hidden or embedded in a mass of organized deposit
or adventitious membrane. That very often practi-
cally buries the tube. The metallic click of the
instrument when it touches the collar gives warning,
and by delicate play the finger may direct it into the
lumen of the hidden tube. Some clever operators and
writers have argued ingeniously that the arytenoid
cartilages may assist in locating the tube, but this is
very doubtful, for the reason that those cartilages are in
the child rudimentary and soft, and sometimes require
the most delicate and exquisite sense of touch to be
recognized.
Since it is so difficult to enter the mouth of the tube
with this instrument, and since while trying to do so
much injury may be done to the larynx and adjacent
tissues by opening and closing the blades of a mechan-
ism that has such tremendous leverage, it has been
considered wise to discard it altogether. To this end
a tireless and ceaseless worker in this field, Dillon
Brown, adjunct professor of diseases of children at
the New York Pol}xlinic, has invented an ingenious
little instrument in the shape of a ring open at the
centre with a small perpendicular bar having a hook
at its extremity. This little ring is placed on the
index finger of the left hand, so arranged that the
hook will look up from the palmar surface. The
tube is the same as before, only that a semicircular
thread of wire rises from the centre of the collar and
passes upward and backward, its convexity about two
lines above and parallel to its posterior wall.
Now slip the finger armed with this ring in the
median line to the root of the tongue, when it will at
once become engaged in tiie segment of the wire ris-
ing from the head of the tube; then the extraction is
easy.
The only disadvantage of this method is that the
tube, especially if too large, may rotate and bring the
loop parallel to the median line, thereby increasing
the difficulty of hitching on to the wire. Even with
this drawback, it is immeasurably superior to the
clumsy and dangerous old extractor. The wire loop,
so valuable in the fourth method, will not interfere
with the field of operation of the few who prefer the
third style of procedure.
The Time for Operation There is no duty con-
nected with his profession that weighs so heavily on the
mind and heart of the physician as this one — when to
interfere mechanically to save the child. He is con-
fronted by three problems, namely: Can the child get
well without interference? Is it too early to interfere?
Or is it too late ? He has ghostly memories of meddle-
someness on a previous occasion, when in his excite-
ment he mistook simple for croupous laryngitis and
laryngismus stridulus for stenosis of the larynx. These
memories haunt him. The spectre clings to him.
Now these grewsome recollections contribute not a
little to make him ner\'ous and unhappy. He wishes
this time to make no mistake, and will not by keep-
ing in mind the following suggestions:
He is called suddenly into a sick-room; there is a
child suffering from croup. He knows nothing of the
previous history or treatment. The child's skin may
be cold or hot. There is clammy perspiration with
cyanosis, often not marked. The face may or may not
be anxious and drawn ; the pulse is feeble and beats
irregularly, whether fast or slow. On percussion, over
the region of the back on both sides there may be
slight or marked dulness, according to whether air or
water or both are in the pulmonary cells.
To the ear the normal vesicular murmur is wanting.
The sounds are those transmitted from the trachea,
now the seat of riot and turmoil, and they are mixed,
coarse, irregular, without vibration or interval of re-
pose. Further, he sees the diaphragm, the great fly-
wheel of the respiratory system, slow down to a few
revolutions per minute, and he observes that the seat
of respiration has been transferred from the thorax or
chest to the trachea and larynx — the so-called shallow
breathing.
Then the efforts of this new respiratory system at
inspiration are long, vibrating, and labored, wlrije
expiration is short, shallow, and jerky. At every effort
at inspiration the auxiliar}' muscles of respiration at
the root of the neck contract violently, drawing th'e
776
MEDICAL RECORD.
[November 28, 1896
head downward and forward on the chest, making
great gaps and depressions in the supraclavicular and
suprasternal regions. The heaving of this region is
like the rolling of the billows, and as regular as a
clock. The alae nasi contract and e.xpand and flap
like sails in a cross-wind. The mouth may be in
repose, or the lips slowly move in unison with the
nose and muscles of the neck.
It takes some time to describe these symptoms, but
the physician will take in the situation at a glance
and recognize that the time to act is now or never.
Since it is a bloodless operation, he will have no
difficulty in gaining the consent of the family, and
even if his efforts are not crowned with success, he
may still be able to command their confidence and
gratitude, in that he at least lightened the labors of
their little one and that the last moments of their
darling were those of repose.
The After-Treatment. — How long should the tube
be left in the larynx.' Just as long as it is necessary
— until the danger of the development of false mem-
brane has passed. .\s a rule, more danger is encoun-
tered by taking it out too soon than by leaving it in
a little longer than required. The danger of the
tube exciting inflammation downward decreases the
longer it is in place. Following the general law,
the tissues soon become accustomed to the altered
conditions and the tube speedily usurps the functions
of the trachea.
If the child begins to look like himself again, take
notice of his playthings and surrounding objects, and
if the temperature is normal or nearly so, and the
child shows a disposition to eat well, the danger is in
all probability over and the tube can be removed,
whether it is in one day or seven.
'i"he physician would do well to remain on the
premises for half an hour and be within call for six
or eight hours, as the larynx may get blocked by
shreds of broken-down membrane, or, the pressure be-
ing removed, the parts may swell and fill the lumen
of the canal. However, the physician must not get
frightened and rush for his case the moment he de-
tects an obstruction, for there is always more or less
after the removal of the tube ; but if it becomes marked
and progressive he must act at once by replacing
his tube. After placing the tube there should be im-
mediate relief, all the urgent symptoms at once sub-
siding. The air will pass through if the tube is not
blocked by shreds of broken membrane that it
pushed down. A few drops of water in the child's
mouth will excite the act of coughing and probably
clear the air passage.
If no matter is coughed up and the breathing re-
mains bad, withdraw the tube by the string or thread
you placed in the eye at the collar when preparing for
the operation.
The tube withdrawn, further coughing may free the
trachea and there may be no further trouble, when
rapid convalescence will ensue.
When the tube in place fails to give relief and
when no relief comes upon its withdrawal, the false
membrane has extended down below its further ex-
tremity. Now tracheotomy holds out the only hope,
and in this instance is to be preferred to intuba-
tion.
Feeding the Child. — No matter what position a
child is placed in while feeding, there is danger of
particles of food passing into the larynx. However,
some advantage is claimed for feeding with the head
bent over, the child resting on its back on the lap of
the nurse. It is that the food that may not be carried
in the act of deglutition to the pharj-nx cannot block
or choke the tube by dropping into the larynx, since
it must gravitate into the mouth, when the body is
placed in this manner or on an inclined plane. The
anatomical position being altered, the glottis is poorly
if at all guarded by the epiglottis.
Now, with the head in this awkward position, the
food passing over the larynx is apt to act on the re-
flexes and excite increased coughing, which often leads
to death from exhaustion. Further, the diaphragm
itself, being more active, gives a suction-pump action
to the trachea, which may draw particles of food into
the larynx, even though counteracted by gravity.
A good way to feed a child is to let him lie on his
stomach with his face down. This method is not
so liable to excite coughing, and there is an inclined
plane, but of course not so marked as in the other
position.
It is certain (though the act is involuntary) that
he has more command of the constrictors, and that the
larynx is more fi.xed and the act of deglutition as a
whole is more complete, than with the body in the
dorsal position and with the head down and backward.
Some patients do very well in swallowing with the
body in the upright position, and will resent, and
make that resentment permanent, if any effort is made
to depart from the natural manner of feeding. Give
the child no food for half an hour; better still if feed-
ing could be postponed for an hour. That would give
the lame and crippled tissues of the constrictor group
an opportunity to recuperate, and by their increased
activity and watchfulness prevent the particles of
food in passing over into the pharynx from dropping
into the larynx and finding their way into the bronchi,
when speedy inflammation would follow.
The best food for a child wearing an intubation
tube is bread soaked in milk or beef juice, or oatmeal
porridge.
Feed the child at stated intervals, a small quantity
at a time, and about every two hours. Do not take him
at a disadvantage ; let him see you prepare for feeding.
By this method he will cough less, and it will decrease
the liability of some particles slipping into the larynx.
After the Operation.— .\ great deal toward its suc-
cessful termination rests with the family. If its mem-
bers are careless, forgetful, and indift'erent, notwith-
standing the warning of the physician that the danger
is only half over, the probabilities are the child will
die, though the operation itself was in every way suc-
cessful and a road to recovery opened.
Then intelligent nursing is a factor to be reckoned
with, and the want of this nursing in the tenement
districts is the secret of so many failures, not only in
intubation but in every form of disease.
If those ever eager to do good, always prating in
lecture rooms and on church platforms about the dear
neglected poor, who go about hawking their philan-
thropy like hucksters and fishmongers in a market-
place, always ready to plant the plague spot called free
dispensary, would only consult those best able to give
advice and inform themselves on the real needs of the
poor, it would be to wipe out the pestiferous dispen-
sary and plant on its ruins a school to train and
instruct the people in the value and importance of self-
reliance, temperance, fortitude, and hope. They would
recognize that these are the weapons with which to com-
bat disease and the ladder with which to climb to con-
valescence and health; and further, that while we have
the poor always with us, we have the physician too,
their tried, sincere, and abiding friend.
Then philanthropy would run in its proper chan-
nel, and the moral and material welfare of the poor be
advanced and elevated, and the mortality of the city
materially decreased.
51 Chaklton Strekt.
Cremation in England. — The third crematory in
England is now lieing built in Liverpool.
November 28, 1896]
MEDICAL RECORD.
m
THE EFFECT OF PERITONITIC ADHESIONS
ON THE DIGESTIVE TRACT.
By BYRON ROBINSON. B.S., M.D.,
CHICAGO,
PROFESSOR OF GVNECOLOGV IN fOST-GKADL'ATE SCHOOL.
During four hundred autopsies by myself on the hu-
man subject I have made careful observation of the
appearances of the peritonitic adhesions, in various
regions of the abdominal cavity. It may be stated
that scarcely a body above twenty-five years old could
be found without some form of local peritonitis. The
situation of local peritonitis and consequent adhesions
is quite constant, two factors being closely related,
viz., muscular action and bowel flexures. The effect
of the peritoneal adhesions might be considered in
two respects, viz. : {a) as to the pain, and (h) as to the
narrowing of the lumen of the bowel. In the history
of medicine few have considered the subject from the
point of anatomical pathology and still less from the
clinical standpoint. The old classical writers of Latin
gave the subject the exact title " Cotistrictio et adhesio
iiitestiiwlis et peritonitide. ' '
In the first place we may consider the common seats
of local peritonitis as actually found in the autopsies
of adults. So far as I have carefully observed and
recorded them in three hundred cases the following
is their order of frequence: i. Spleen, which includes
the flexura coli lienalis (over ninety per cent.). 2.
Meso-sigmoid (over eighty per Cent., left surface).
4. Coappendicular apparatus (over seventy per cent.).
5. Flexura coli hepatis (about sixty-five per cent.).
This might be called the gall-bladder region, but I am
convinced the chief causes lie in the colonic and
duodenal flexures. 3. The pelvic region (over sev-
enty-five per cent., /.e., the mouths of the Fallopian
tubes). 6. The point where the duodenum crosses
the right psoas and crus of the diaphragm (over forty-
five per cent.). 7. The point behind the stomach
which lies on the left diaphragmatic crus, i.e., at the
foramen omenti majoris, or at what I designate as
Huschke's foramen (over thirty-five per cent.). 8. At
the hernial orifices (this is accidental).
The five regions of local peritonitis in adults are
the meso-sigmoid, the pelvis, the cseco-appendicular
apparatus, the splenic and gall-bladder regions. Ob-
serve that four of them are over the long range of the
muscles, i.e., over the psoas and diaphragmatic mus-
cles. The three regions of dangerous peritonitis are
the pelvic, cfEco-appendicular, and gall-bladder re-
gions, in which abdominal surgery has shown its
brilliant successes and its dismal failures. Before
children walk the common local peritonitis does not
arise, as muscular action has not been sufficient to
irritate the gut. The etiology of the adult local peri-
tonitis is due to muscular action and microbic inva-
sion. In the pelvic region the peritonitis is chiefly
due to an infectious invasion from the ends of the
Fallopian tubes. In the other four common regions
it is due to muscular action irritating or acting on a
bowel at times when it contains virulent microbes.
The irritation of the bowel induces the microbes or
their products to pass through the mucosae and mus-
cularis of the gut wall to the serous coat, producing
plastic peritonitis. Now, the muscle itself is not the
cause of the peritonitis, but it is an essential feature.
When the bowel comes in contact with the long range
of action of the muscles of the peritoneum adhesions
are deposited in that region. One can find also local-
ities where infection has passed through the gut wall,
entirely away from muscular action, as marked by
white glistening peritoneal cicatrices: but such are
irregular, not frequent, and have no definite anatomi-
cal distribution.
Accidental local peritonitis plays an important
role in the life history of the peritoneum. I mean by
accidental local peritonitis that which occurs outside
of the common regions, due to muscular action or leak-
ing Fallopian tubes. We may have an accidental
local peritonitis, due to an ulcer of the mucosa allow-
ing infection to pass to the superadjacent peritoneum,
involving an area as large as the tips of the little fin-
ger to that of the palm of the hand or larger. I have
frequently found such points. A mesenteric gland
may ulcerate and break down, inducing adjacent peri-
tonitis. Strangulated and reduced hernia, a blow on
the abdomen, or perforation of the peritoneum by a
gall stone may induce an accidental local peritonitis.
We may find Meckel's diverticulum accidentally ad-
herent by its distal end to some point in the abdomen,
from a local peritonitis caused by infectious invasion
through its wall. Infection is more apt to pass out of
the distal end of Meckel's diverticulum than from any
other portion, on account of the liability of the mucosa
at the distal end to suffer injury, and because its in-
fection is more liable to tarry there and the facal cir-
culation is slower from physical reasons; and also we
often notice a short distance from the end of the di-
verticulum a constricted neck. This narrowing of the
diverticular lumen is very liable to obstruct the out-
let. It then produces a closed mucous cavit)% a con-
dition of distinct menace, as it is in appendicitis. The
omentum majus becomes fixed or adherent in differ-
ent localities of the abdomen by infectious invasions
through the gut wall or from the tubal ends. How-
ever, we note that local peritonitis is nearly always a
secondary disease. Tuberculous peritonitis perhaps
comes under the same category of infectious invasion
from the gut lumen, but it is more widely spread than
ordinary or common adult peritonitis. Again, the
origin of tuberculous peritonitis is very significant
when one notes that in most of the cases the tubercles
are most common on the peritoneum of the small intes-
tines, i.e., the business portion of the digestive tract.
The germs pass through the small bowel wall when
freed by the digestive process. The cause of typhoid
fever is the accidental perforation of the bowel, which,
however, frequently heals and leaves an irregular,
small, glistening peritoneal cicatrix. In the consider-
ation of the effect of peritonitic adhesions upon the
digestive tract we must take into account the subject
of mobility of organs. The digestive viscera have all
degrees of mobility, besides a more essential character-
istic expressed in the idea of rhythm. A widely mo-
bile viscus with a high peristalsis is compromised
when either mobility or peristalsis is checked by peri-
tonitic adhesions. If mobility or peristalsis is de-
stroyed the organ is dislocated. Any abdominal
viscus is dislocated when it is permanently fixed.
Rhythm is one of the means by which the digestive
tract accomplishes its end. It is the method of intro-
ducing new food on fresh mucosa and finally of dis-
posing of the de'bris. The vertical colons are fixed in
man ; normally there are no vertical meso-cola, so that
it matters little if many adhesions are .found about
them, unless the colonic lumen be compromised, since
at the time of the peritonitic deposit the colon gained
sufficient rhythm or motion while the peritonitic exu-
dates were soft and pliable to enable it to accomplish
its ends of slight digestion and essential expulsion.
The transverse colon and sigmoid flexure appear to
adapt themselves to considerable peritonitic adhesions,
for they are merely facal receptacles, to be emptied
periodically. But there is one feature that neither of
them, more especially the sigmoid, will agreeably ac-
commodate themselves to, and that is when the bowel
is drawn out to an acute angle by a peritonitic band.
I have proved by secondary laparotomy that, if the
highest point of the sigmoid flexure be fixed to the cut
778
MEDICAL RECORD.
[November 28, 1S96
ends of the Fallopian tubes, such a condition will
sometimes make a patient an invalid until released.
It then requires excessive peristalsis to force the faecal
current past the acute sigmoid bend. But probably
more than all else the peritonitic band creates irrita-
bility, excessive peristalsis at the seat of the adhesions.
The liver may be entirely surrounded by adhesions
without complaint from the patient. The mobility of
the liver is but little, within the range of respiration
only, and its rhythm is so limited, though definite, that
it adapts itself to the surrounding adhesions. While
the exudates are soft or fresh the liver by its rhythm
produces sufficient space to accomplish its necessary
functions, so that we can exclude the idea that merely
IKritonitic adhesions ever do much damage to the di-
gestive tract, either by producing pain or by compro-
mising digestive lumina. The spleen is capable of
considerable mobility, yet confining it by adhesions
does little damage, so far as is yet known. The rhythm
of the spleen is very limited, so that peritonitic ad-
hesions compromise the organ in a very small degree
either to impair digestion or to produce pain. Over
ninety per cent, of peritonitic adhesions are found
around the adult spleen, and if impairment of diges-
tion arose from parasplenic peritonitic adhesions it
would long ago have been demonstrated. The uterus
is so closely bound up in function with the tubes
and ovaries that one cannot be considered without the
other. Peritonitic adhesions dislocate the uterus be-
cause they permanently fix it. They produce pain
and unbalance the function of the uterus and disturb
its nutrition. Perhaps the chief pain in peritonitic
adhesions in the genitals are those which check the
rhythmical peristalsis of the Fallopian tubes. We
know this to be a fact, for with women possessing
considerable peritonitic adhesions about the tubes a
vaginal examination will frequently arouse tubal colic
lasting from one to three hours, of occasionally intense
degree. We know that peritonitic adhesions about
the pelvic organs induce pain both previous and sub-
sequent to laparotomies. It is such a patent daily
experience with a gynecologist to know that the peri-
tonitic adhesions create pain both before and after
vaginal hysterectomy, that it is amusing to see in a
journal article, as we do occasionally, that the writer
has' discovered that peritonitic adhesions create pain,
while no reasons are laid down as the cause of the
pain, nor is it stated which organs are especially com-
promised by the adhesions.
For ten years I have closely watched the subjects
of peritonitic adhesions, and my conclusions in re-
gard to what induces the disturbances are that if a
viscus with a long pedicle, />., a highly mobile viscus
with high peristalsis, becomes fixed at its most distal
point by peritonitic adhesions it will induce pain.
Dr. Lucy Waite and I have reoperated on ten or twelve
patients for peritonitic adhesions formed subsequent
to laparotomy. The patients who suffered the most
were two in whom the most distal point of the sig-
moid loop became fixed by peritonitic adhesions to
the cut end of the Fallopian tube. These patients
suffered very much from colic, indigestion, and neu-
rosis before we would again put them to the risk of
a second laparotomy. After the second operations
every patient improved, and some gained fifteen to
twenty-five pounds in weight within a few months.
In other cases a loop of small intestine with an elon-
gated piedicle, in other words a long mesenterium,
was found fixed to the cut ends of the tubes, the
uterus, bladder, or perhaps to a very mobile loop of
the sigmoid or transverse colon; i.e., some highly
mobile viscus with a high peristalsis was checked in
its natural movements. This is found in our abdom-
inal work to be the distinction between peritonitic
adhesions which disturb the patient and those which
do not. Sometimes one may do fifteen or twenty
autopsies and find in over half the cases some fixed
organ, i.e., one with a short mesentery, as the cacum,
liver, or even the spleen, immovably fixed in solid
peritonitic adhesions, but not the slightest complaint
was recorded from the patient during life. If we do
not make a definite distinction as to whom opera-
tions are applicable for peritonitic adhesions, many
young surgeons will be led into error. For, if a sur-
geon should operate in a case of supposed appendi-
citis and simply find the cacum and appendix buried
in peritonitic adhesions, he might think the operation
justifiable. But it is certainly not justifiable to ope-
rate for the peritonitic adhesions about the carcum, as
they occur there in over seventy per cent, of adults;
furthermore, the adhesions are no sign that appendi-
citis ever existed. No one denies that pain in the
right iliac fossa may demand an operation. If so, it
is more likely to be due to the fact that some in-
fiammation has fixed the appendix to a point at the
long or longest range of action of the psoas muscle,
and the motion of the muscle induces irritation in the
appendix and consequent appendicular colic. I have
operated on just such cases, in which if a patient was
quiet. I.e., did not walk, he was just as comfortable as
any one, but let him exercise the psoas and he was in
pain, an invalid. Now at the operation of such pa-
tients we find the appendix, having a small rupture or
perforation which is a year or more old, with a few
peritonitic adhesions, but it is fixed solidly to some
point on the anterior surface of the psoas muscle,
where walking or exercise will stir up the old point of
adhesions.
A short summary of conclusions may be drawn up
in regard to the effect of peritonitic adhesions on a
subject:
1. Peritonitic adhesions may induce pain, neurosis,
and indigestion, either before or after an abdominal
section.
2. Peritonitic adhesions seldom or never give pain
when surrounding fixed organs, i.e., those with short
mesenterial supports and limited peristalsis, as the
cacum and liver.
3. The pain in adhesions either previous or subse-
quent to operation is due to the fixation of mobile
viscera and to the checking of active peristalsis or
visceral rhythm.
4. The effect of peritonitic adhesions on viscera are
dislocations and compromises of their lumina.
5. The viscera of great mobility and high peristal-
sis are the loops of small intestine, the sigmoid flex-
ure, the Fallopian tubes, and the bladder.
6. The peritonitic adhesions have the most damag-
ing effect in cases in which a peritonitic band becomes
fixed to the point of the widest range of motion of any
organ, as about the middle of the sigmoid, inducing
an acute angle at the top of the bladder, or tlie cut
end or normal end of the Fallopian tube.
7. The peritonitic bands may be found at any point
where the peritonitis has existed, but is usually at a
point of peritoneal abrasion, at the cut ends of the
Fallopian tubes, or in the locality of an inabsorbable
ligature.
8. In laparotomies all adhesions around highly mo-
bile and highly peristaltic viscera, as the bladder,
sigmoid. Fallopian tubes, and the loops of small in-
testines should be broken up. So far as I have ob-
served, the transverse colon is less affected by peri-
tonitic adhesions than any other mobile viscus. I
have seen the extension of fourteen inches of the
transverse colon in an inguinal hernia and the two
limbs of the colon were absolutely adherent, like a
double-barrelled gun, yet no record of the patient's
complaints appeared. But the matter may be accounted
for by the fact that in the vast majority of cases the
November 28, 1896]
MEDICAL RECORD.
779
peritonitic adhesions of the transverse colon are lo-
cated about the hepatic and splenic Hexures, where
the colon is the most fixed, which is the very reason
that the peritonitic adhesions exist.
9. Patients with peritonitic adhesions before but
especially after laparotomy complain of periodic colic
and periodic dragging pain. It is exacerbated by
taking hot food or drinks. It is rarely made worse
by moderate exercise. In short, anything which in-
creases peristalsis makes colicky, dragging, bearing-
down pain. Just before or at stool the pain is annoy-
ing and occasionally continues some time after. In
the cases of peritonitic adhesions about the bladder,
the pain is exacerbated at the time of evacuations and
for some time later. Should a diarrhoea start, the pain
of peristalsis is severe.
10. Pain from peritonitic adhesions about the gall
bladder may arise from two causes: (a) the peritonitic
bands may drag the top or fundus of the gall bladder
so that it will produce a sharp bend or kink in the
neck or outlet ducts. Dr. Lucy Waite and I had just
such a case. The peritonitic bands had dragged on the
fundus of the gall bladder and added something over
four inches to its length. We released the gall blad-
der, elevating the fundus, relieving its bend or kink,
and curing the patient. (/;) As the gall bladder
empties, pain from dragging on the surrounding ad-
hesions may arise; also, as the adjacent colon may
rapidly distend and contract, this may produce drag-
ging pain from this effect on the peritonitic adhesions
adjacent to the gall bladder.
n. The viscera which come within the clinical
and surgical range of peritonitic bands are those of
wide mobility and high peristalsis.
12. The reason that so many patients recover from
peritonitic bands without requiring subsequent inter-
ference is because the active mobile peristaltic viscera
make room and space for their own function while the
exudate is still soft, pliable, and mouldable to the
environments.
About seventy-five per cent, of laparotomies are
followed by peritonitic adhesions or bands. Unless
there be some continued source of infection, like the
mouth of a Fallopian tube, normal or amputated,
ulceration of mucosa, stone in the urinary or gall
bladders, which sustains infectious invasion, peritoni-
tic adhesion will grow less; very slowly, however, until
the bands become organized with a steady blood or
nourishing supply, when they may persist forever.
13. The final persistent effect of peritonitic adhe-
sions on active mobile, peristaltic viscera are pain,
indigestion, and neurosis.
ACROMEGALY.
By H. H. DINKE, M.D.,
ST. CHARLES, MO.
Ten years have elapsed now since that careful and a
painstaking observer, Pierre Marie, first recognized in
strange complex of morbid symptoms a new clinical
entity and aptly termed it acromegaly. Since then
the clinical histories of quite a number of cases have
been accurately recorded, and exhaustive reports of
more than a dozen post-mortem findings in cases suc-
cumbing to this disease have been made, but they
have failed to throw much additional light on the sub-
ject, and our conceptions of the pathology and etiology
of this rare disease remain varied and indefinite. Dr.
William R. Parker, of Stricklandgate, Kendall, Eng-
land, who has given the subject of acromegaly, myxoe-
dema, cretinism, and kindred diseases much attention,
and who has had extraordinary opportunities for the
accurate study of these maladies, in a letter of recent
date writes as follows: "A few months ago I collected
all the information about acromegaly that had been
published in the British Medical Journal for the last
nine years or so, and found that it amounted to noth-
ing. Cases were described minutely, and a few illus-
trations were given and accounts of post-mortem
examinations, in which the pituitary gland was usually
found enlarged. Some few had imagined they could
observe some improvement by treatment with pituitary
extract, and one or two imagined thyroid extract had
done good. But no marked or obvious improvement
ever occurred. For the severe headache, trephining
sometimes worked wonders by relieving intracranial
pressure. I do not know of any recent information
about the subject of any value. I imagine we shall
be on its track before long, and find it curable, but
the goal is not attained yet." In spite of these dis-
couraging facts, or possibly on account of them, it
would seem important that all cases should be care-
fully recorded, the clinical histories as well as the
results of autopsies, as such reports will contribute to
a better understanding of the true nature of the dis-
ease. The recital of this case may gain additional
interest from the circumstance that our patient has
been treated uninterruptedly for the past five months
with animal extracts and that an effort has been made
accurately to note all changes in the physical as well
as mental condition resulting therefrom.
The family history of our patient is negative as to
any cachexia or faulty nervous inheritance. The
father died at the age of sixty-six years of "asthma;"
the mother died of rheumatism at the age of sixty-
tliree years. She has one brother and three sisters
living and perfectly well; none dead. No one in her
family was ever afflicted as she is. She is the mother
of one son, aged twenty-four years, in good health ;
and she has lost two children by diseases incident to
childhood. She is a woman of excellent habits, and
there is no history of any venereal disease. Up to
the time of the appearance of her present trouble she
had always enjoyed fairly good health and had never
been very sick. Her present illness commenced about
fifteen years ago, but the beginning was so gradual
and insiduous that neither she nor her relatives can
state accurately just when the trouble set in. Her
hands, feet, and face began to swell gradually, but her
attention at first was particularly drawn to her hands and
feet. The swelling of the extremities was accompanied
by lancinating pains suggestive of rheumatism. In
fact the disease was thought to be rheumatism and she
was treated for such until Dr. J. H. Stumberg, of this
city, recognized it as a case of acromegaly. The pa-
tient remains under the treatment of Dr. Stumberg,
and it is through his kindness that I am permitted to
place this case on record. Our patient is now fifty-
one years of age and was born in this country. She
is five feet five inches in height, and weighs one hun-
dred and sixty-seven pounds. She displays all the
classical symptoms of acromegaly; the hands and feet
are enormous, the head and face are large and broad,
the lower jaw is massive and projecting.
The head is large and covered by an abundant
growth of coarse hair. The forehead is retreating and
the superciliary ridges are very prominent. The nose
is much increased in size, in length as well as in width.
There is considerable exophthalmia, but she can move
her eyeballs readily in all directions, and the pupils
react well to light stimulus. The ears are very large,
slifT, and thick, and project from the head. The lips
are extraordinarily thick and everted, the lower one
more so than the upper one. The tongue is broad and
flat and so large that it completely fills the oral cav-
ity, and it is almost impossible to depress the tongue
sufficiently to see the condition of the throat. The
tongue and oral cavity are covered by a thick but pale
mucous membrane, having deep and irregular furrows.
78o
MEDICAL RECORD.
[November 28, 1896
The alveolar processes are broad and the teeth bad.
The lower jaw is massive and the teeth of the lower
jaw project in front of the upper jaw. The scalp and
the skin of the face are very fair and greasy in appear-
ance, and soft and spongy to the touch. It is evident
that the enlargement of the face and head is at the
expense of the soft parts as well as of the bones and
cartilages. The head is slightly bent forward, but
there is no marked cervico-dorsal kyphosis; the neck
is short and measures thirteen inches in circumfer-
ence. As far as we are enabled to determine by pal-
pation, the thyroid gland is absent. The clavicles,
scapulre, and ribs appear to be larger than usual.
The chest is normal in form. Palpation and percus-
sion reveal nothing abnormal ; no adventitious sounds
can be heard. The heart, too, is normal ; we are un-
able to detect any abnormal murmurs, but its pulsa-
tions are somewhat accelerated. The shoulder and
elbow joints are normal in size. The hands are
greatly enlarged, probably more so in width than in
length. The fingers are broad, thick, and stumpy; the
nails short, thick, and striated. This enormous in-
crease in size of the hands does not extend up very
Aged 28 Years.
high, for at the junction of the lower with the middle
third of the forearm the circumference is only seven
and a half inches, whereas at tlie wrists it is nine
inches. As far as we are able to determine, the ab-
dominal organs are healthy. There does not seem to
be an increase in the size of the thighs, but the knee-
joints are considerably enlarged. The legs also par-
take somewhat of this increase; the feet, however, are
simply enormous. Patient states that she used to
wear No. 4 shoes, but is now compelled to w^ear No.
7 V shoes. The feet are flat, broad, and thick, and
much increased in length. A thick cushion of soft
tissues surrounds the os calcis and the outer side of
both feet. The toes are very broad and stumpy, with
thick cushions on the plantar surface of the last pha-
langes, which press the tips of the toes up and cause
the nails to stand almost erect. It is evident that the
increase in size of the feet is more the result of an
hypertrophy of the soft parts than that of the bony
tissue. The skin is white, soft, and doughy, and
marked by deep furrows over the entire body, but
most markedly so about the face and e.xtremities.
The voice is coarse and speech thick. Patellar re-
flexes are lessened on both sides. The tactile sense
is not perceptibly impaired. The eyesight is bad; pa-
tient is unable to see objects distinctly at even short
distances. Tinnitus aurium is distressing, but the hear-
ing is good. Taste and smell are not affected. Her
mind is clear and she answers readily and intelli-
gently all questions addressed to her. Her memorv'
is very defective; there is no stupor, nor does she
suffer attacks of somnolence. She is inclined to be
depressed' in spirits, and keenly feels a sense of gen-
eral weakness. Headache, though present at times,
has never been a prominent symptom. Patient's ap-
petite is normal, but she has an extraordinary thirst.
She sweats freely upon the slightest exertion and
passes large quantities of urine, over half a gallon per
day. Examination of the urine does not show pres-
ence of albumin or sugar. There are no disturbances
of digestion. Temperature, 98° F. ; pulse, 85. The
hands and feet are usually cold to the touch. The
pains in her hands and feet, starting at the knee and
elbows and extending downward, continue to be the
most distressing symptoms and render it impossible
for the patient to sleep during the earlier hours of the
night.
The accompanying photographs show singularly
well the ravages of the strange disease. The first
photograph presents a rather attractive face with
pleasing features; the second photograph shows the
same face, but disease has cruelly and ruthlessly
effaced all traces of former beauty and impressed
upon it indelibly its own individuality. The accom-
panying measurements will serve to show accurately
the amount of deformity, and the extent of enlarge-
ment of the affected parts:
Measurements.
Length of hand, wrist to tip of middle
finger
Circumference of hand at knuckles.. . .
Circumference of metacarpus with
thumb
Circumference of thumb at first phalanx
Circumference of thumb at last phalanx
Circumference of wrist
Circumference of forearm at juncture
of lower and middle third
Length of foot, heel to great toe
Circumference of foot at ball of great
toe
Circumference of foot at instep
Circumference of foot across instep
and heel
Circumference of foot at ankle
Circumference of leg at knee
Length of nose (root to tip)
Distance between angle of jaw and
symphysis
Circumference of neck
Circumference of chest at nipples, ex-
piration
Circumference of chest at nipples, in
spiration
Circumference of abdomen
We decided to give our patient the benefit of treat-
ment with animal extracts. During the first two
months she took one-half grain of thyroid extract
three times a day. One grain of this extract repre-
sents ten grains of the fresh gland. During the third
and fourth month desiccated pituitary bodies were
given, about one and a half grains three times a day.
During the last month a combination of both extracts
was administered, four grains of desiccated pituitary
bodies and one-half grain of thyroid extract a day.
By comparing the measurements at the beginning of
treatment and five months later, it will at once be seen
that there is a decided decrease in size. The fingers
Be^nning of
Treatment.
Five Months
Later.
Right.
Inches.
Left.
Right.
Left.
Inches.
Inches.
Inches.
7^-
7>^
7^
TA
11^2
n
II
11
9X
9
4
3'A
3
3
9
9
7
7
TA
1%
1%
7X
10
934
10
9>4
9'X
It
9%
9 ,
loX
i3>^
16
'3 ,
lo'A
13
10
15X
3
SX
13
35
3S
-;
November 28, 1896]
MEDICAL RECORD.
and the wrists in particular are much thinner than
they were, and the shoes that fitted snugly at the be-
ginning of treatment are much too large now and feel
like loose slippers. Her general condition, too, has
improved. Her memory seems to be better, and she
is not so much at a loss for words as she was. She
can walk much better, and for greater distances.
She notices, however, that the extremities temporarily
swell whenever she exercises too much. The pains
in her extremities have left her almost altogether, and
there is an increased freedom of movement of the
hands and feet. The hair is softer, the skin a little
firmer, less wrinkled, and more natural. The lips
and tongue are perhaps a little thinner, but speech
remains thick. The mucous lining of the mouth is
less furrowed and more healthy in color. The thirst
is not extraordinary now ; she does not sweat nearly
so readily, and she voids less urine. Her bowels are
no longer constipated, but have become regular. (I
have noticed this to occur in patients to whom I have
given thyroid extract to reduce fat. These patients
not infrequently are suffering from chronic constipa-
tion, and thyroid extract not only effects a loss of
weight but also relieves the chronic constipation.)
Our patient has lost about fifteen pounds in weight
during these five months. The feeling of general
languor is not nearly so annoying, and she can sleep
now the entire night. The general condition of our
patient, therefore, is unquestionably improved, but the
unmistakable marks of acromegaly are nearly as plain
now as they were at the beginning of treatment. Pa-
tient believes that the thyroids benefit her most.
It might not be without interest to inquire what led
to the employment of animal extracts in acromegaly.
The experimental researches of Schiff, Horsley, and
Afurray resulted in establishing the function of the
thyroid body and demonstrated how important that
organ is to the growth and development of the organ-
ism. .Stimulated by these brilliant results, the func-
tion of other ductless glands and the internal secretion
of the glands having efferent ducts have been carefully
studied, and enough is already know^n to justify the
belief that these glands secrete substances sui generis,
which are carried by the blood to the most distant
parts and which are indispensable to the proper nu-
trition of all the tissues of the body. In other words,
that the glands of the body are practically the centres
governing normal metabolism would seem to have
been established. It is well known now that mxyce-
dema is a disease of the thyroid gland resulting from
an arrest of function of that organ. Anyone who has
had an opportunity of seeing and watching a case of
myxoedema and a case of acromegaly cannot help but
recognize the striking resemblance of many of the
symptoms of these strange affections. But the simi-
larity of many of the symptoms is evidently not the
only tie of relationship. There is every reason to
believe that in acromegaly the pituitary body is prin-
cipally involved, as it was first declared to be by
Marie; all the facts at hand go to show that acro-
megaly is either a disease of the pituitar)' body alone,
or of the pituitary body and other glandular structures
histologically and physiologically kindred.
In the twelve autopsies recorded ' this gland was
found enlarged and disorganized in eleven cases; in
one case, however,^ no particular changes were ob-
served. Then, too, it should be stated here that there
are two cases on record which militate against the
assumption that the pituitary body is the site of this
disease. In one case'' a large aneurism of the blood-
vessels at the base of the brain had entirely obliter-
' Hutchinson : .American Journal of the Medical Sciences,
Au^st, i8g5.
' V'irchow : Berlin, klin. Wochenschrift, i8Sq.
' Weir Mitchell : Journal of Xenous and Mental Disease.
ated this gland; in another case,' at autopsy the
pituitary body was found greatly enlarged. In nei-
ther case, however, were symptoms of acromegaly
present during life. It should be remembered, how-
ever, that symptoms of acromegaly develop very
slowly and very gradually, and it might be possible
that in these latter cases death occurred before the
symptom-complex of acromegaly could develop. The
post-mortem findings in the great majority of cases,
therefore, point unmistakably to the pituitary body as
the principal if not the sole site of the disease; then,
too, the symptoms of intracranial pressure, such as
headache, tinnitus aurium, defective vision, etc., though
differing in intensity and degree, are prominent in all
cases during life. Histologists have shown that the
structure of the pituitary body is almost analogous to
that of the thyroid gland, and experiments on lower
animals by Hofmeister, Vasalle, and Sacchi have
demonstrated that after the removal of the thyroid the
pituitary body enlarges, and after the ablation of the
pituitary body a compensatory enlargement of the thy-
roid gland takes place. Myxoedema and acromegaly,
therefore, are close ties, and there is every reason to
believe that leontiasis ossium, elephantiasis, and
giantism sustain a close relationship to both. All
Aged 51 Years.
these affections show evidence of grave nutritive dis-
orders, and the lesions of diseases resulting from
trophic disturbances are to be sought for in the glan-
dular tissues of the body. Up to within recent years
the treatment of acromegaly has been wholly symp-
tomatic and altogether unsatisfactory. In bad cases,
in which symptoms of intracranial pressure become
distressing and unbearable, trephining has been done
with satisfactory results, and this surgical treatment of
acromegaly deserves consideration. The treatment of
acromegaly by animal extracts is new. Dr. Richard
C. Cabot" has succeeded in collecting the details of
nine cases in which thyroid extract was exhibited, and
ten cases in which pituitary bodies were administered.
Quite a number of these cases were benefited by both
these animal extracts, which leads Dr. Cabot to advise
the simultaneous use of both. The results of the
' American Journal of the Medical Sciences, June, 1892.
' A paper on the clinical uses of the preparation from the thy-
roid gland, pituitarj- body, etc., read at the annual meeting of the
Massachusetts Medical Society, June g, 1S96.
782
MEDICAL RECORD.
[November 28, 1896
treatment .with these animal extracts, singly and com-
bined, have been recorded in the above. There is
probably no remedy which will completely efface the
ravages of the disease, and in our case the remedies
have been used for too short a time to permit us to
arrive at positive conclusions. In a general way, how-
ever, it may be asserted that a number of the most
distressing symptoms, such as pain, helplessness, etc.,
are either much relieved or entirely removed ; that
the patient's physical as well as mental condition is
greatly improved by this treatment, and that the re-
sults obtained by it are much more satisfactory than
those following the older remedies.
THE NEED OF ABDOMINAL SECTION IN
CERTAIN CASES TO AID THE GENERAL
PRACTITIONER TO DIAGNOSE OBSCURE
ABDOMINAL DISEASES.'
By J. H. CARSTENS, M.D.,
DETROIT, MICH.,
CHIEF OF STAFF AND GYNECOLOGIST TO HARPER HOSPITAL, PROFESSOR OF
OBSTETRICS AND CLINICAL GV.NECOLOGV IN THE DETROIT COLLEGE OF
MEDICINE, EX-PRESIDENT OF THE AMERICAN ASSOCIATION OF OBSTE-
TRICIANS AND GYNECOLOGISTS.
What surgical crimes have not been committed by the
reckless and ine.xperienced as the result of the state-
ment made by an eminent abdominal surgeon, " If you
don't know what is the trouble within the abdomen,
open it and find out," or words to that effect ! Such a
statement was made in an entirely difi'erent sense in
which it was accepted at the time by the reckless.
It seems to me that we often find growths and tu-
mors in the abdomen which we cannot diagnose with
certainty, but after we open the abdomen we can gen-
erally tell what they are. -Ml tumors and growths of
whatever kind require surgical interference and a posi-
tive diagnosis is not necessary. If it is a case of pus
tube or ovarian tumor, or if we mistake a cyst for a
fibroid, or make any other mistakes, as long as there
is palpable morbid condition, operation is the proper
thing. It does not make very much difference whether
it is the one kind of tumor or the other, as long as the
surgeon is prepared to meet all emergencies which
may arise.
The term exploratory cceliotomy is used a great deal
in the same sense. We generally mean that there is
some morbid condition within the abdomen which we
diagnose, but we are not positive whether it can be re-
moved, or if the removal is justifiable. We cannot
positively tell whether it is malignant, involving vital
organs, or whether it is a benign growth which can be
removed and which we know will not recur. We
make an exploratory abdominal section for the pur-
pose of diagnosing the exact condition and removing
the growth if possible, but if we find that the risk is
too great and that it would recur in a siiort time, even
if removed, we close up the abdomen and let the pa-
tient live as long as possible.
But there is another class of cases, not too common
and still frequent enough, in which it is utterly im-
possible for the general practitioner or any specialist
to make a proper diagnosis. There is no tumor, growth,
or other manifest condition. All our means of pre-
cision cannot help us; neither chemical analysis of
different fluids, nor in.struments of precision, nor the
latest fad, the Roentgen .r-rays, will help us to diag-
nose the trouble. The patient simply becomes grad-
ually weaker and weaker. All our medication, care-
ful diet, change of climate, and surroundings do not
help. Sometimes, even in acute cases, with the onset
sudden and rapidly fatal, the symptoms are so mixed
' A paper read at a meeting of the Northern Tri-.State Medical
Society at Angola, Indiana, July 21, 1896.
and obscured that the diagnosis is not made until
post-mortem investigation. In this kind of cases, it
seems to me, when the usual plan of treatment is of
no avail — the physician sees the patient gradually
slipping away from him — that abdominal section is
indicated, first, for diagnostic purposes, and, secondly,
also with a view to curing the patient. And when
I make this suggestion I do it with a tremble on my
lip, because it. will give any tyro an excuse to open
the abdomen for the most trivial things and refer
to me as his authority. If I say that such practice
should be limited to those who have had experience
and have facilities, I may be accused of being afraid
that some young man may become a rival. Therefore,
those of us who have made hundreds of abdominal
sections, and who start every new case with a certain
tremor and fear that it may be complicated and diffi-
cult and that the patient's life may be endangered, are
placed in a peculiar position.
If we say to the general practitioner that this is, as
a rule, without danger, that we can diagnose the case
and even submit the patient to an operation at the
same time, if necessarj', and thus save him, we spur
on the ambitions of the inexperienced and the con-
scienceless to reckless deeds. If we qualify the above
suggestion by saying that such operations should be
performed only in thoroughly equipped hospitals, sur-
rounded with every facility to meet every emergency,
and that the operation should be performed only by
those who have experience and manual dexterity, we
are accused of trying to have a monopoly and not giving
those who are to come after us a chance to get the
experience.
This is all wrong. Whoever wants to make this a
life work should prepare himself properly for it by
assisting at many operations, and should live in a
locality where he can expect to do a good many opera-
tions every year. An operation or two of this kind a
year will increase no one's reputation, nor would it
pay from the financial .standpoint; often it would not
pay even for the instruments and paraphernalia re-
quired.
All we claim, then, in advocating abdominal section
for diagnostic purposes, is that it should be done by
one of experience and in a place where every facility
is at hand. Then the danger will be so very little
that the family physician can conscientiously urge it
upon his patient, and the patient will gladly sulsmit
to it in order that a clear understanding of his case
may be arrived at, so that the proper treatment, be it
surgical or medical, can be instituted.
First, in reference to acute cases, everything in the
way of functional disorders of the bowels, excited by
indiscretion in eating, cholera morbus, cholera infan-
tum, etc., must be excluded; all these can be readily
diagnosed. But if the case presents itself with persis-
tent vomiting, there is grave suspicion that it is due to
obstruction and requires surgical interference. Also
cases with severe excruciating pain in the region of
the liver strongly point to gall stones, even if jaundice
does not exist; in fact, jaundice is so rarely found
with gall stones that the profession has been led
astray for years by the old text-books emphasizing
jaundice as a marked symptom. So renal calculi or
suppurating kidney may cause occlusion of the ureter
and can only be diagnosed inferentially, except by an
abdominal section. Of course, the marked symptoms
of appendicitis, I think, are so well known now that
every practitioner can diagnose the disease and also
knows that prompt surgical interference, as a rule, is
required.
Secondly, however, our principal aid can be given
to the general practitioner in chronic cases of trouble
of some kind within the abdomen. While no swelling
or growth can be detected, the patient is an invalid.
November 28, 1896]
MEDICAL RECORD.
783
even if not in danger; he does not enjoy life, and in
some cases it can be readily seen that he is gradually
becoming weaker and weaker.
In all cases of this kind an e.xploratory abdominal
section will clear up the diagnosis, and, if necessary,
can be made into an operation if something is found
requiring surgical interference. The technique of the
operation can be settled in each individual case only
according to the seat of trouble especially indicated.
In the large majority of cases the trouble is located on
the right side in the regions of the appendi.x, gall
bladder, or kidney. An incision made on the right
outer edge of the rectus about opposite the umbilicus
will allow exploration with the finger to be made
around the crecuni, the gall bladder, and the kidney,
and then the incision can be extended either upward
or downward. Sometimes the left outer edge of the
rectus is chosen; rarely, I think, the median line.
It is hardly necessary to mention that all the pelvic
diseases of women are excluded from this paper, be-
cause they can be readily diagnosed by conjoined
examination by anybody with even limited experience.
I do not report any cases, simply because I do not
want to take up your time, but I can mention any
number of obscure cases promptly explained and often
relieved by abdominal section.
The danger of abdominal section is very slight,
while the gain is immense. Accidents occasionally
occur, but the mortality should beiess than one per
cent. The vast majority of such patients can be saved,
either by prompt operation or by proper medication.
In conclusion I would say that abdominal section
for diagnostic purposes in a well-equipped hospital is
indicated :
(A) In acute cases with severe symptoms which
threaten life if not promptly removed.
(B) In chronic cases in which treatment has been of
no avail and the patient continues to be more or less
of an invalid, or steadily becomes worse.
progress of ftXcdicaX s,cience.
Contamination of Liquid Eye Medicines. — Dr.
Clough {Journal of Atedicine and Science, October,
1896) says: "A fruitful source of contamination of
liquid eye medicines is the common rubber-bulb
dropper. Many a solution over which much care has
been exercised to render it stable soon becomes worth-
less through these little miscreants. Their mischief
lies in the fact that many of them — the white variety
in particular — are coated with a flour-like film, which
becomes detached the instant any fluid touches it and
diffuses itself, in an insoluble state, throughout the
contents of the bottle in which it is used. Hence,
care should be taken that the pharmacist either dis-
pense droppers free from such objection, or else obvi-
ate the difficulty by careful cleaning before inserting
into the bottle.
A New Aseptic Method of Closing Wounds with-
out Sutures. — The great difficulty often experienced
in closing wounds where sutures are impracticable or
where they are liable to slough out from too great ten-
sion has been overcome in a great measure. The use
of adhesive plasters instead of sutures is not thor-
oughly aseptic, and to overcome this defect Dr. Schiir-
mayer uses pieces of fine platinum wire having hooked
ends. These wires span the wound, and can be ren-
dered aseptic by flaming. At either end they are
hooked into strips of adhesive plaster, that in case of
a limb encircle it, so that with the wire they entirely
surround it. The ends of the adhesive strips are
folded upon themselves to prevent their adhering, and
the hooked ends of the wire are passed through punc-
tures in this double thickness, .-^septic gauze is laid
on the skin beneath the ends of the wire to prevent
infection of the wound from the adhesive plaster.
The great advantages of this method are that the ten-
sion is applied at a distance from the margin of the
wound ; that the wires alone come in contact and may
be perfectly sterilized; they can be easily removed,
either singly or all together during the dressing and
then replaced; there is no strain upon the edges of
the wound during their removal, and coaptation of the
margins of the wound can be secured as easily and
perfectly as by the use of sutures. — Ceniralblatl fiir
Chirurgie,
Anterior Colpotomy. — At a late meeting of the Ob-
stetrical Society of London, as reported in the British
Medical Journal, Dr. John Phillips read a paper on
this subject. He considered that to Diihrssen be-
longed the credit of calling attention to this operation.
Any one who had performed either vaginal hysterec-
tomy or fixation could not but be struck by the ease
with which the pelvic organs could be examined
through the opening in the anterior vaginal cul-de-sac.
Full details of the operation as carried out by Diihrs-
sen, Mackenrodt, and the author were given, with his-
tories of four cases. In the first of these vaginal
fixation only was originally intended. The author
considered the advantages of this method to be: (i)
No hernia or cicatrix and less liability of the forma-
tion of adhesions with the omentum and intestines.
(2) Greater simplicity of operation, greater rapidity
of performance. (3) Post-operation sickness is much
less and the convalescence shorter. (4) No bleeding
of any consequence, except occasionally from the vag-
inal flaps. (5) No drainage tube required. The dis-
advantages, on the other hand, were : ( i ) Much greater
difficulty in making the vagina antiseptic, especially
if there be any fetid uterine discharge. (2) Greater
risk of wounding the bladder, ureters, and coils of in-
testine. (3) If the swelling is adherent in the left
and posterior quarter of the pelvis, the rectum may be
lacerated. A list of cases in which this operation
seemed indicated was given. With regard to recom-
mending the operation, the author wished it to be
borne in mind, first, that the peritoneal cavity was
opened, with its possibly grave after-results; and,
secondly, that removal of the ovaries and tubes, whe-
ther by vagina or abdomen, must always be looked
upon as a mutilation, and hence the same care and
anxious thought should be e.xercised as before resort-
ing to abdominal section.
Postoperative Intestinal Obstruction. — Dr. Ade-
not recognizes the following varieties of post-operative
intestinal obstruction : i. Occlusion caused by adher-
ence of the intestine to raw surfaces, intraperitoneal
drains, and inflamed organs. 2. Occlusions due to
bands. 3. Those due to anomalous position of the
intestines. 4. Those due to an exaggeration of the
normal left subcostal angle of the colon. 5. Spas-
modic occlusion. 6. Occlusions due to inefficient
operative procedures. According to him there are
three marked symptoms of post-operative intestinal
obstruction: i. Persistent absence of the passage of
flatus. 2. Nausea and vomiting. 3. Painful point
in abdomen. As regards treatment, one should not
delay too long. While it is legitimate to try mild
purgation, insertion of rectal tube, etc.. the amount of
such treatment should be abridged proportionally to
the severity of the symptoms and clearne.ss of diagno-
sis. The period of operation will be from three to
five days, according as the vomiting is urgent and
there is absence of stools or passage of flatus. The
abdomen should be opened largely. Work quickly
784
MEDICAL RECORD.
[November 28, 1896
and have good assistants. Examine tlie CiECum; if it
is not distended, the occlusion is located liigher up in
the small intestine. If it is distended, e-xplore the
sigmoid tiexure. One should always follow a definite
plan : first ascertain the extent of the occlusion, then
its location, and lastly the cause. Examine the
pedicles, raw surfaces, angles of the intestine, and
drainage apparatus. Examine the colic flexure of the
left side. If the obstacle cannot be found, evisceration
must be performed. Recourse should not be had to
tliis grave procedure too readily, notwithstanding that
it has succeeded in the hands of Jaboulay and PoUos-
son. Sometimes an artificial anus is necessary, but it
is not an operation of choice. — Revue tie Chirurgic.
Healed Wound of Heart At the London Clinical
Society, Mr. \V. G. Spencer recently showed a speci-
men of healed wound of the heart. The patient had
been stabbed in four places, and was admitted pulse-
less and unconscious. Infusion of saline fluid, etc.,
was employed, and he went on well for a week. Then
hemorrhage occurred, and Mr. Spencer passed his fin-
ger through the wound in the second left intercostal
space, and touched a large vessel with low tension and
a whirring current with each systole. The wound was
firmly plugged. The plugging had to be renewed again
and again, on account of fresh bleeding and the plug
becoming extruded. By the twenty-seventh day the
plug was all pushed out, and only a superficial wound
remained. This healed in six weeks from the acci-
dent, and nothing abnormal was heard in the chest,
except a faint murmur, as in anamia. The patient
continued weak and anamic, but attended a long trial,
and eventually sank exhausted seventy-nine days after
the injury. At the post-mortem, the scar in the left
intercostal space was seen to correspond with another
in the pericardium, and this again with a linear de-
pressed scar, five millimetres long, on the surface of
the right ventricle. Then opposite to this, on the en-
docardium, was a fine bluish line. This was thought
to be the scar of a firmly healed perforation of the
ventricle, and was just below the pulmonary valves.
There was no sign of any other vessel being wounded,
and no clot inside or outside the heart or great vessels.
The only question raised was whether the weapon had
actually penetrated the endocardium (the scar on which
was very fine) and the hemorrhage came from a branch
of the coronary. The question of suturing was men-
tioned, but Mr. Spencer said it was difficult to fix the
direction of the wound.
Pregnancy Diagnosticated by the Urine.— Dr.
William E. Parke, following Dr. William D. Gray, of
Richmond, states in the American Gyncccologicai and
Obstetrical Journal that he can make a positive diag-
nosis of pregnancy within twenty days after concep-
tion, by certain changes in the microscopical appear-
ance of the urinary phosphates. The normal triple
phosphate is stellate and markedly feathery. Soon
after conception the feathery parts begin to disinte-
grate, take on the crystals, approach to normal, and
at term are normal. In preparing the urine for exam-
ination Dr. Gray takes about one inch in a test tube
and adds about one-third as much of Tyson's magne-
sian fluid. This will throw down the triple phosphates
in fifteen or twenty minutes and furnish the necessary
material for examination. Tyson's fluid consists of
one part each of the muriate of ammonium, aqua ammo-
nia, and sulphate of magnesium, and eight parts of dis-
tilled water. When conception occurs the triple
phosphates lose their feathery appearance, the change
beginning at the tip and progressing toward the base.
One side only may be affected, or both, leaving only
the shaft and perhaps a few fragments adhering. The
shaft assumes a beaded or jointed appearance. These
changes are most marked in the early months of preg-
nancy. Dr. Gray draws the following conclusions: 1.
The change occurs in a very large percentage of preg-
nant women. 2. This change is not equally pro-
nounced in the urine at the same period of gestation
in different women nor at consecutive examinations of
the urine of the same woman. 3. When recognized
it forms strongly presumptive evidence of pregnancy.
This sign is recognizable very early. (Dr. Gray, in
a personal letter, states that he has made many diag-
nosis as early as ten days after conception.) It is
therefore of the greatest value when other signs are of
the least value, or not present at all. 4. A diag-
nosis of probable pregnancy can be made without a
physical examination or without exciting the suspicion
of the patient.
Treatment of Suppurating Buboes by the Injec-
tion of Iodoform Ointment. — Dr. Otis' method, given
in \\i^ Journal oj' Cutaneous and Genito- Urinary Dis-
eases, 1896, vol. xi., pp. 174-176, is as follows: "The
skin for some eight or ten inches about the affected
area was rendered thoroughly aseptic by scrubbing
with green soap, washed with sulphuric ether, and
then with bichloride (i to 1,000). A narrow bistoury
was then inserted into the abscess cavity, and the con-
tents were gently but thoroughly squeezed out, the cavity
was irrigated with bichloride (i to 1,000), and immedi-
ately filled to moderate distention with warm iodo-
form ointment (ten per cent, iodoform and vaseline),
care being taken not to use a sufficient degree of heat
to liberate free iodine. The syringe used for intro-
ducing the ointment was the ordinary cone-pointed,
glass clap syringe. The plunger being removed, the
barrel was warmed in the flame of an alcohol lamp,
filled with ointment by means of a spatula, and on fin-
ishing the injection, at the instant of withdrawing the
syringe from the wound, a compress wet with cold bi-
chloride solution was applied, which instantly solidi-
fied the ointment at the orifice, preventing the escape
of that in the abscess cavity. A large compress of
sterilized gauze was then applied by means of a firm
spica ; the patient was told to return in four days, when,
if all was well, the dressing was reapplied, but if any
evidence of inflammatory action was found the wound
was thoroughly irrigated and cleansed and the injec-
tion repeated." Out of sixteen cases. Dr. Otis reports
nine cured in six days, three in twelve days, one in
fourteen days, one in twenty-three days. He claims
the following advantages for this method: " i. That
it is simple and safe. 2. In suitable cases cure, as a
rule, seems more rapid than by any other method. 3.
The patient is not prevented from going about during
treatment. 4. The first gland being rendered thor-
oughly aseptic renders it less likely that other glands
in the chain will become infected (?). 5. It leaves
no telltale scar. 6. It in no way interferes with any
.subsequent surgical procedure, should such be
deemed advisable." Dr. Otis concludes by saying
that his experience has demonstrated that this method
is available only in those cases of infection by the
staphylococcus in which there is an appreciable pus
cavity, and thus a storage place for ointment until
absorption can take place. In difi'use phlegmons,
in which no pus cavity existed, the method was found to
be absolutely useless. He calls attention to the fact
that by this method patients are able to resume their
duties without any discomfort on the day following
the operation, and that, if secondary suppuration does
occur, the inconvenience is slight compared to that at
first. He says there is good chance of failure unless
two cardinal points are observed : i st, Absolute cleans-
ing of the cavity of all traces of pus; and 2d, the in-
jection of ointment into it in quantity barely sufficient
to produce moderate distention.
I
November 28, 1896]
MEDICAL RECORD.
785
Medical Record:
A Weekly Jottrnal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
PuSUSHERS
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, November 28, 1896.
THE RELATION BETWEEN EXTERNAL KER-
NELS AND GASTRO-INTESTINAL DISOR-
DERS.
The symptoms of incarcerated hernia are at once so
pronounced and so characteristic as not readily to es-
cape discernment and proper interpretation at the hands
of even the unskilled. Reducible hernias, on the other
hand, often give rise to symptoms whose real origin
is likely to be overlooked unless their nature is thor-
oughly understood and their source looked for. The
relation between these two sets of events is discussed
in an intelligent and interesting manner by Decent
Schiitz, of the University of Vienna, in the Wiener
klinische IVoc/tensr/irift, 1896, No. 27, p. 595. A re-
ducible hernia, he points out, is often responsible for
disturbances not limited to the site of abnormal pro-
trusion, but which may also involve remote portions
of the gastro-intestinal tract, and from which relief
can be secured by means of operation or a properly-
fitting truss. Thus, one of the commonest symptoms
of inguinal hernia is pain, usually colicky in charac-
ter or of the nature of gastralgia. It occurs, as a rule,
some time after meals, as well as in the train of active
physical exercise or much walking, and is at times of
great intensity. Not rarely the pain is dull, occur-
ring independently of meals or at varying intervals
after eating, and being referred to different parts of
the abdomen. In association with this symptom, or
independently, there occurs the group of phenomena in-
cluded in the designation " dyspepsia" — impairment
of appetite, constipation, flatulence, eructation, nausea,
etc. In some cases neurotic symptoms also are pres-
ent. These concurrent manifestations are to be at-
tributed to mechanical influences, such as traction or
pressure, or to reflex disturbances. The causative
condition may appear insignificant, or the hernial
protrusion may be inadequately supported, or, finally,
violent physical exercise may act as the excitant.
Hernias of the linea alba are responsible sometimes
for the most varied gastro-intestinal disorders; but
they are often overlooked by reason of their small size.
I;i their treatment the use of a bandage will usually
fail, and resort must be had to a radical operation.
.\ statistical study by Schiitz of one hundred cases of
this kind, shows that the disorder occurs variously
between once in fifty and once in four hundred cases ;
in patients between seventeen and seventy years of age.
though most frequently between thirty and forty ; and
more commonly in men than in women, in the propor-
tion of eighty-seven to thirteen. Trauma, great mus-
cular activity, including the contractions of parturi-
tion, and the act of vomiting are named among the
causes; but in most cases no cause can be ascertained.
Among the causes assigned for this condition are: (i)
Imperfect apposition of the walls of the abdominal
cavity during embryonal life; (2) congenital weak-
ness of the fascia of the linea alba, with hereditary
predisposition; (3) the protrusion of a subserous
lipoma through the fascia of the linea alba, with the
secondary protrusion of the peritoneum; (4) violence,
resulting in rupture, in greater or less degree, of the
abdominal wall in the linea alba. As a rule, the her-
nias are situated above the umbilicus and usually to
the right side of the median line. They vary from
the size of a pea to that of an apple. At times they
are multiple; and sometimes they are associated with
other forms of hernia in other situations.
The most common symptom to which these hernias
of the linea alba give rise is gastric disturbance with-
out distinguishing characteristics. As a rule, there
also occur paroxysms of pain in relation with the tak-
ing of food. At times the pain radiates from the situ-
ation of the hernia, is aggravated by increased intra-
abdominal pressure — as from coughing, vomiting,
sneezing, etc. — or by any form of active physical ex-
ercise, and is relieved by the recumbent posture.
Pronounced symptoms of incarceration are rare. The
hernial swelling is usually tender and the pain is in-
creased by pressure. The physical examination is best
made in the erect posture or with the body of the pa-
tient inclined somewhat forward.
Besides the hernias of the linea alba others of simir-
lar origin and symptomatology may occur at some
distance from the median line — usually in the mam-
millary line. Finally, umbilical hernias may give
rise to the phenomena that have been detailed.
THE EXTINCTION OF THE DEGENERATE.
Some confusion of ideas might be avoided regarding
the tendency of atypical qualities to result in sterility,
if it were borne in mind that what we inherit is our
bodily constitution, a constitution which varies ac-
cording to the known and the unknown laws of hered-
ity, and that our various tendencies or susceptibilities
to external impressions depend upon such bodily in-
heritance. A variation of type, whether by way of
exaggeration or depression of certain qualities or by
malformation, may not be permanent; but if the at-
tempt to return to the original form fails by extinction,
it may be due, not to sterility, strictly speaking, but to
shortening of life to below the age of reproduction.
Indeed, it would seem that the laws of heredity gov-
erning fecundity and sterility are as distinct as those
governing the number of the fingers, the color of the
hair, or other characteristics, and that when these laws
are appealed to for the regulation of the number of in-
dividuals the object is accomplished in quite a differ-
ent manner, if not for a different purpose, from what
786
MEDICAL RECORD.
[November 28, 1896
is observed when life is shortened. It may be as-
sumed that the individual born into the world even in
the most miserable physical condition has an ancestry
reaching as far back as that of the most perfect speci-
men of his type; and the only questions are how far
back does his frailty extend among his progenitors, and
how far down may he be able to transmit it before re-
turn will take place to the original type or life in the
descendants become so shortened that there will not
be time for further reproduction?
Sterility may be inherited and recur in certain
members of a family, while other members have full
power to perpetuate tiieir kind. It would seem to be
by inflicting sterility that nature prevents the perpetu-
ation of the offspring of too strong a cross-breed,
while marked or long-continued interference with the
laws of health is more likely to result in so shortening
life that the stock will die out for want of time to ma-
ture and reproduce, rather than from inability and in-
disposition to procreate if age would permit.
THE "WIZARD" CURE.
A CERTAIN proportion of every collection of human
creatures is upon the lookout for miracles. Common-
place does not meet their requirements. They will
gladly accept all that is beyond the power of human
ken, but that which has a common-sense basis and is
understandable does not interest them.
Thus one is not at all surprised to find that almost
everything is expected of the newly discovered rays
which still must be denominated by the symbol of an
unknown quantity.
We not only rely upon their power to ]x;netrate the
hitherto impenetrable and establish the diagnosis, but
once having pointed out the cause we expect them to
supply the cure as well. The announcement made by
Mr. Edison that there was some hope of restoration of
sight to the blind by the application of Roentgen rays
has naturally brought forth applications from all parts
and from all conditions of sightless sufferers. Un-
doubtedly there will be those among them who will be
capable of being made to see. Sight has been restored
on many occasions by means which must seem mirac-
ulous to those who are ignorant of the matter. When,
however, the various tissues of the globe which make
sight possible have been destroyed, it would seem as
futile to dream of restoration of sight as it would be
to hope for a reflection of one's image in the empty
frame from which the mirror had been broken and
removed.
There is a merchant who is said to be a millionaire
somewhere in lower Broadway who has received con-
siderable newspaper notoriety and advertisement by
his repeated offer through the newspapers of a million
dollars to any one who will restore his sight.
The medical profession has been the recipient of
numerous slurring reflections which have grown out
of this repeated offer of so princely a sum. It is now-
announced that the gentleman will place himself in
Mr. Edison's hands, after an experimental trial of the
rays have been made upon his " proxy."
It is greatly to be desired that success attend this
effort. Not that Mr. Edison should receive a million
dollars, since he has more than he has need for al-
ready, but that this tantalizing sum should not longer
be made to dangle before the eyes of impecunious
doctors, who, though willing, honest, and perhaps able,
are powerless to aid, because the would-be patient
demands some miraculous cure which will not take
him from his counting-house desk for even a single
day. May the "Wizard" witli his magic tube supply
the ray of light and remove the million-dollar offer
from the public press.
UNFAIRNESS IN APPOINTMENTS.
A LAW has recently been promulgated by the minister
of education of Germany forbidding the appointment
to the position of assistant at any German university
of other than graduates of a German university. It
is much to be regretted that politics, with its cry upon
the European continent of " Russia for the Russians,"
" France for the French," and " Germany for the Ger-
mans," should find a re-echo in the ranks of education.
It has been a signal advantage to many of the Ameri-
cans going abroad to be able, even in exceptional cases,
to obtain such positions as an assistant at some of the
CJerman medical clinics. Would it not be a good time,
now that the .States of New York and Penn,sylvania
have so fi.xed the time required for study and the pass-
ing of a State examination in such manner as to make
the value of a diploma given here second to none, to
suggest reciprocity between France, Germany, and
England, and the States mentioned? The recent
movement in France, by which the foreigner was to
be excluded from receiving a diploma granting him
the right to practise in France, is a second and more
forcible argument in favor of our making some en-
deavor to gain for the two worthy States New York
and Pennsylvania some special advantage justified
by the praiseworthy course these States have pursued.
OUR HEALTH RESORTS.
That this is in many respects a great and remarkable
country goes without saying. Among other things
which add to our greatness are to be numbered the
natural resources which can be utilized in health pro-
duction. It was not to be presumed, therefore, that in
wTiting up the " Winter Health Resorts,'' Dr. McKay
should touch upon all places worthy of notice, and
many excellent stations were omitted in his article
which appeared in the Mkiiicai, Record of (October
31st. Among the many good words and commenda-
tions which this article has received from our sub-
scribers, there have been a few complaints because of
such omissions. Among them is one from Dr. C. F.
McGahan, observer of the winter bureau at Aiken,
S. C. This is a winter resort with a mean winter tem-
perature of 51.89° F., and a mean relative humidity
of ^8.73 per cent. Rainfall about twenty inches; alti-
tude, five hundred and sixty-five feet. These figures
vary somewhat from those given by Dr. McKay, and
November 28, 1896]
MEDICAL RECORD.
787
we are glad to present the authoritative statement of
one connected with the United States signal service.
Another communication conies from Dr. Charles A.
Powers, of Denver, Col., who considers that the State
which should be most prominent in the category of
winter resorts has been omitted.
" Probably the population of Colorado," he says,
'■ presents a greater percentage of people who have
come here for purposes of health than does any other
State in the Union. As a resort for pulmonary inva-
lids it offers the greatest advantages — proper elevation,
a dry, clear, sunny atmosphere. The winters, taken as
a whole, are very delightful ; the tonic and bracing air
makes tuberculous patients desire to be out of doors.
Such cities as Denver, Colorado Springs, and Glen-
wood Springs offer the very best of accommodations,
with all that this implies in the matter of suitable
food and the like; and people in all walks of life find
here that which their taste demands or their means
command."
Dr. Powers' opinion is that his adopted State was
unintentionally omitted. We cannot say how this may
have been, but it occurs to us that the author may have
considered Denver and its neighboring resorts too
well known to need comment.
For the peace of mind of those who recognize the
good qualities of any given region as a health station,
we need but say that, while we are always pleased to
hear from them, the author of " Winter Resorts" dis-
claimed any intention of naming them all or of telling
all there was to tell of the good features of those men-
tioned.
^snvs 0f the ^iSlccU.
"The Courier Record of Medicine," whose editor,
Dr. Brooks, recently died in Dallas, will be continued
under the management of his son.
Dr. Fort Mobbed. — Rio de Janeiro was recently
the scene of a manifestation against Dr. Fort, who was
revisiting the city in which he had successfully prac-
tised for some years after graduating in Paris. Upon
returning to France he had published his impressions
of Brazilians and had commented adversely upon their
system of medical instruction and upon the zeal with
which the students worked. To show the French
physician that they still possessed certain kinds of
zeal at least, some thousand of them visited the hotel
at which he was stopping, with the avowed purpose of
lynching this cahnnniator of their fair land. Not
succeeding in laying violent hands upon the object of
their ire, an effigy was procured and a funeral p.oces-
sion organized, with catafalque, burning tapers, funeral
dirges, and terminating in a cremation upon a public
square. We shall keep an eye upon French journals
to see what Dr. Fort will have to say upon his return
this time about Brazilian zeal.
International Medical Congress. — Section on sur-
gery: Acting upon the advice of Dr. E. Braatz (K6-
nigsberg), the surgical section of the XII. International
Medical ("ongress has decided, in view of the ap-
proaching congress, to collect international statistics
on narcosis for the current year ( 1896). For this pur-
pose the managers of the said section apply to all
their colleagues, and earnestly request them to give
answers to the following questions: i. Number of nar-
coses from January i, 1896, to January i, 1897. 2.
What narcotics were administered. 3. Number of
fatal cases. The secretary of the surgical section, F.
Rein (Moscow, Malaja Dmitro\ka, house Scheschkov),
will be glad to receive such information, and, if pos-
sible, not later than July i, 1897.
Section of nervous and mental diseases: The fol-
lowing themes will form part of the programme:
Neuro-Pathology: i. Pathology of the nerve cell (finest
structure and its pathological changes) ; 2, Patholog-
ical anatomy and pathogenesis of syringo-myelia;
3, Pathogenesis and treatment of tabes dorsalis.
Psychiatry: i, Obsessions and fixed ideas; 2, Path-
ogenesis of general paralysis of the insane and delim-
itation of this disease from its cognate forms; 3, hyp-
notism and suggestion in their reference to mental
diseases and medical jurisprudence. The question
of the surgical treatment of the brain and spinal-cord
diseases will, moreover, be discussed in joint session
with the surgical section.
Jefferson Medical College.— At a clinical meeting
of the Philadelphia chapter of the alumni associa-
tion of Jefferson Medical College, on November loth,
Dr. J. H. W. Chestnut read a paper on '' Intestinal
Obstruction." Following the meeting, the new labo-
ratories of the department of pathology and bacteriol-
ogy were thrown open for inspection, and a reception
was tendered to Dr. H. F. Harris, the new associate in
pathology.
A ThoiTght-Weighing Machine. — The cerebrum is
the organ of the will and it is known that in the exer-
cise of its function there is an increased supply of
blood to that part. Professor Mosso, an Italian phy-
siologist, has invented a thought-weighing machine,
consisting of delicate balances so contrived that they
weigh the varying amount of blood in the brain. The
activity of the brain is in direct proportion to the
amount of blood therein. According to a local news-
paper report, the machine is so delicately constructed
that it readily detects the difference in the exertion
required to read Greek above that necessary to read
Latin. Every youngster is ready to believe in the
machine.
Schuylkill County (Pa.) Medical Society. At a
meeting of the Schuylkill County Medical Society,
held at Pottsville, Pa., on November loth. Dr. C.
Lenker, of Schuylkill Haven, read a paper on "Cho-
rea," and the following officers were elected for the
ensuing year: President, Dr. A. F. Bronson, of Girard-
ville; Vice-rrcsidciit, Dr. H. Bowman, of Mahanoy
City; Secretary, Dr. Cable, of Tamaqua; Treasurer,
Dr. D. Taggert, of Frackville; Censor, Dr. G. H. Hal-
berstadt, of Pottsville. Seventeen delegates to the
Medical Society of the State of Pennsylvania and
nine to the .American Medical Association also were
elected.
788
MEDICAL RECORD.
[November 28, 1896
Twelftn International Medical Congress. — The
American national committee of tlie Twelfth Inter-
national Congress, which is to meet at Moscow, Rus-
sia, from August 19 to 26, 1897, consists, according
to the directions of the general committee at Moscow,
of the following gentlemen: J. S. Billings, M.D., New
York; Frank P. Foster, M.D., New York; S. Weir
Mitchell, M.D., Philadelphia; Charles A. L. Reed,
M.D., Cincinnati; George B. Shattuck, M.D., Boston;
F. J. Shepherd, M.D., Montreal; George F. Shrady,
M.D., New York; \V. S. Thayer, M.D., Baltimore,
and the chairman, A. Jacobi, M.D., iio West Thirty-
fourth Street, New York. The chairman begs to in-
vite the attention of the medical profession of the
United States and Canada to the fact that the profes-
sional gentlemen in charge of the congress are anxious
to make it a success both from a scientific and a so-
cial point of view. Their difficulties are unusually
grave; but it is not their fault that the congress had
to wait for governmental permission to meet in their
country, or that a special ukase was required for the
admission into Russia of Jewish medical men on equal
terms with their Greek, Catholic, Protestant, agnostic,
and Mohammedan colleagues; or that the famous and
meritorious secretary-general was — it appears because
of his liberalism — ousted both from his place and from
his professorship. They should not be held responsi-
ble for the political semi-barbarism of the country in
which they live and to whose laws they have to sub-
mit. Their position in the world of science and their
endeavor to make the twelfth congress equal to its
most famous predecessors will prove an incentive to
American physicians to sustain, both by their pres-
ence and their contributions, the Russian committee
in its exertions to make the next congress equal to its
predecessors. Such information as will be received
from time to time will be published in the medical
journals immediately after its arrival.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
November 21,1896. November i6th. — Surgeon A.
F. Magruder detached from the marine barracks,
Washington, and placed on the retired list. Passed
Assistant Surgeon J. S. Sayre placed on retired list
November i6th. November i8th. — Medical Director
H. M. Wells detached from the naval laboratory,
New York, ordered home, and placed on waiting or-
ders. Medical Director T. C. Walton detached from
the naval academy December 15th and ordered to
the naval laboratory. Surgeon C. T. Hibbett de-
tached from the Iiulfpt-iidericc, ordered home, and
granted three months' leave. Passed Assistant Sur-
geon F. W. Olcott detached from the Enterprise No-
vember 27 th and ordered to the l)uiepend(-ih\\ Passed
.\ssistant Surgeon W. F. .Arnold detached from special
duty and ordered to the Enterprise November 27th.
Passed .Assistant Surgeon J. M. Moore detached from
the Texas December 7th and ordered to the Castine
December 8th. Passed Assistant Surgeon L. H. Stone
detached from the Castine, December 8th, ordered
home, and placed on waiting orders. Assistant Sur-
geon S. B. Palmer detached form the Vermont Decem-
ber 7th and ordered to, the Texas. Passed Assistant
Surgeon P. Leach promoted to surgeon from Novem-
ber isth, and Passed Assistant Surgeon T. C. Craig
promoted to surgeon from October 14th.
Prof. Edmund Lesser, of Berne, has been appointed
director of the Charite clinic for dermatology and
syphilis in Berlin, a post hitherto occupied by Profes-
sor Lewin who died on November 2d at the age of
seventy-six years.
A New Medical Monthly, the Scottish Medical and
Sitrgital Journal, will appear in January, under the
direction of Professors Simpson and Annandale (Edin-
burgh), Professor Stephenson (Aberdeen), and others,
and will be edited by Dr. William Russell.
Obituary Notes Dr. James Graha.m, a widely
known physician of Philadelphia, died on November
I 2th, of pneumonia, after an illness of nine days. Dr.
Graham was born in 1846 and was a graduate of Jef-
ferson Medical College. During the war of the rebel-
lion he served with the United States army, being
connected especially with the army transports. — Dr.
Louis W. Hildenbrand died at Philadelphia on No-
vember 13th, at the age of forty-seven years. He was
graduated from Jefferson Medical College in 1874. —
Dr. Luis F. Sass, seventy-six years old, a well-known
physician of this city, died at his home, No. 56 \\'est
Thirty-ninth Street, early Monday morning from
complications due to old age. Dr. Sass was a native
of Havana, Cuba, but had lived in this city for forty
years. In his fifty years ox practice he made a repu-
tation as a specialist for the nose and throat. He
was the recipient of many honorary degrees in this
country, in Europe, and in Cuba. He was a member
of the County Medical Society. — Sir Benjamin Ward
Richardson, the celebrated English physician and
author, died on November 21st. Death was due to
apoplexy, from which he never rallied. He was sixty-
eight years of age. The late Sir Benjamin W. Rich-
ardson, in 1865, conducted an experimental research
on the nature of the poisons of the spreading conta-
gious diseases, which ended in the detection of a spe-
cial poisonous product, common in these poisons, to
which he gave the name of septine. In 1866 he dis-
covered the application of ether spray for the local
abolition of pain in surgical operations. He intro-
duced methylene bichloride as a general anasthetic,
and discovered the controlling influence of nitrite of
aniyl over tetanus and other spasmodic affections.
Dr. Richardson's principal contributions to medical
and scientific literature have been directed to the ad-
vancement of medical practice by the experimental
method. The study of disease by synthesis, the resto-
ration of life after various forms of apparent death,
the effects of electricity on animal life, methods of
killing animals without the infliction of pain, the main-
tenance of life in factitious atmospheres, the investi-
gation of the theory of a nervous atmosphere or ether,
were among the subjects he treated of in lectures and
essays. In later years his researches were directed to
the study of diseases incident to modem civilization.
November 28, i8g6]
MEDICAL RECORD.
789
OPlinical gepartment.
THE WOODBRIDGE TREATMENT OF TY-
PHOID FEVER.
By CHARLES E. NAMMACK, M.D.,
ASSISTANT PHYSICIAN TO BELLEVUE HOSPITAL, VISITING PHYSICIAN TO
GOUVERNEUR HOSPITAL, NEW YORK.
Fifteen years' experience in treating typhoid fever, in
hospitals and in private practice, has convinced the
writer that the Brand method of tubbing is far and
away the best treatment of that disease. But the num-
ber of the cases that can or will be submitted to the
Brand method, either in cities or in the country, is
small by comparison with the total number of cases of
typhoid fever that occur in the United States. There
are many obvious reasons for this state of affairs, and
the general practitioner will eagerly welcome any plan
of treatment less cumbersome and expensive than the
Brand bath. Dr. W. Oilman Thompson has recently
computed that the average cost of a Brand bath in pri-
vate practice is two and a half dollars, and since some
of his reported cases required more than one hundred
and twenty-five baths, it will be easily seen that a
workingman's chance of receiving the benefits of tub-
bing consists chiefly in his getting into a hospital.
Many families are unwilling to send their sick ones
to a hospital, and many medical practitioners must
live from the fees collected in workingmen's homes.
Any ohe who will read the papers of Dr. V\'oodbridge
must be impressed with their evident earnestness and
sincerity, even though one cannot accept the state-
ments that " typhoid fever can always be aborted," or
"that death is a wholly unnecessary consequence of
the disease if proper treatment is instituted sufficiently
early." ' The weak point in the Woodbridge treatment
■would seem to be that it rests upon no biological fact
in the disease, but upon the symptomatic grounds of
intestinal evacuation and intestinal antisepsis. But
good things have come to us in medicine, ere this,
upon purely empirical grounds; and, with a view of
testing this new aspirant for therapeutical honors, the
writer, upon assuming the fall service of one of the
medical divisions of Bellevue Hospital, requested the
house staff to put all new cases of typhoid fever ad-
mitted at once upon the Woodbridge treatment, and
to follow the details of the originator implicitly, e.xcept
that patients suffering from hyperpyrexia (rectal tem-
perature exceeding 104" F.) were not to be denied the
benefit of the tub bath. It may seem that this was
half-hearted and unfair to the Woodbridge treatment;
but he must have the faith of a little child (and such
are not of this earthly kingdom) in any new procedure
whose conscience would allow him to deprive a ty-
phoid high-temperature case of the results of a Brand
bath when practicable. During the progress of the
test. Dr. Woodbridge visited New York and was in-
vited to examine the cases. A study of the charts did
not show that the usual course of typhoid fever was in
any way modified by the treatment instituted. One
case, which gave us great hope tiiat a specific had been
found, was shown by the serum diagnosis test of Wi-
dal ' not to have been a case of typhoid fever. All
the cases were submitted to this test by Dr. Alexander
Lambert, bacteriologist to the New York board of
health, at the time of Dr. Woodbridge's visit, and the
results demonstrated by him in the laboratory.
The writer sincerely regrets that his hope that the
treatment of the poor man's typhoid fever had been
'Journal of the American Medical Association, August lo and
25, 1895. P. D. & Co.'s reprint.
* Editorial, New York Mkpical Record, October 31, 1896,
page 632. Wyatt Johnston: New York Medical Journal, October
31, 1896, page 573.
found is still ^deferred. Looking back to 1878, he
can see marked progress since the days of large doses
of quinine and the use of the Kibbe cot, through the
period of the antipyretic heart-depressing coal-tar de-
rivatives, to the magnificent results of the Brand meth-
od of tubbing and rubbing, which does many good
things for the typhoid patient in addition to reducing
his temperature. Looking forward along biological
lines, he cherishes the conviction that the serum diag-
nosis of the present will soon be followed by the suc-
cessful serum therapy of the future.'
42 East Twenty-Ninth Street.
NOTE ON THE EFFERVESCENCE OF URINE
WITH NITROSO-NITRIC ACID.
By J. B. NICHOLS, M.U.,
CLINICAL ASSISTANT, UNITED STATES SOLDIERs' HOME, WASHINGTON, D. C.
On adding to urine a considerable proportion of the
impure yellow nitric acid of commerce, a well-marked
effervescence occurs. A similar evolution of gas is
sometimes noticeable in carrying out the test for al-
bumin with heat and impure nitric acid. The phe-
nomenon is also well marked when the urine is under-
laid with the acid, as in Heller's contact test for
albumin; in this case minute bubbles of gas may be
seen rising in the fluid, while larger bubbles slowly
collect on the sides of the tube. A similar evolution
of gas, but less in degree, occurs even with colorless
nitric acid sold as pure. Other acids (hydrochloric,
sulphuric, acetic) do not produce this reaction.
The fact that nitrous acid is capable of effecting the
decomposition of urea, in an identical manner with
the hypobromites, has been long known, and was uti-
lized as a means of quantitative estimation of urea by
Millon, Draper, and others, before the hypobromite
method came into vogue. It is to this action of the
small amounts of nitrous acid contained in commer-
cial nitric acid upon the urea, uric acid, etc., of the
urine, resulting in the evolution of nitrogen and car-
bon dioxide, that the phenomenon under consideration
is doubtless to be attributed. The reaction would be
as follows:
CON.H. + (HNO,), = (H,0), + (NJ, + CO,.
Experiments bearing on the subject corroborate
this supposition as to the cause of the reaction. So-
lutions of urea and of uric acid reacted with impure
nitric and the other acids employed precisely like the
urine, while with solutions of the chief mineral con-
stituents of the urine no formation of gas occurred.
Treatment with nitroso-nitric acid containing larger
proportions of nitrous acid (produced by dissolving
mercury or copper in nitric acid) caused the same ef-
fervescence with urine and urea solutions, but much
more vigorously.
It is important, for purposes of qualitative analysis,
that this evolution of gas from urea should not be con-
founded with the effervescence arising from the addi-
tion of acids to carbonates, to which the reaction
under consideration is apt to be attributed. The dis-
tinction can be easily made by testing with other acids,
as hydrochloric or acetic, which cause etfervescence
with carbonates but not with urea.
Another practical point suggested is the advisability
of using pure nitric acid in making the contact test for
albumin, in order to reduce to a minimum the accumu-
lation of gas bubbles on the side of the glass, which
tend to obstruct the view of the contact reactions.
' Editorial, MF.niCAi. Record, August 17, 1S95. Report of
Paris Biological Society, Medic.\l Record, March i, i8g6, page
426.
790
MEDICAL RECORD.
[November 28, 1896
RECURRENT SCARLATINA.
By E. L. drake, M.D.,
PHlLADELfHIA, PA.
I WISH to report a case in which the patient had two
distinct attacks of scarlatina, exfoliation of the epider-
mis occurring after each attack. The patient, a little
girl, aged six and one-half years, a foreigner by birth,
was taken sick on July 14, 1896. The mother gave a
history of vomiting, and explained that the child '" felt
hot" and was very restless. When I first saw the case,
on the third day of the disease, there was a small
patch of exudate' on both tonsils, fever, and a typical
scarlatinous rash. A culture made from the exudate
failed to show the presence of the Klebs-Loeffler ba-
cillus, and by the fifth day the temperature, which
never was above 101° F., had returned to the normal.
The skin began to exfoliate in good-sized patches, and
the child was about ready to be discharged, when, on
the morning of August 2gth, she vomited twice. She
was put to bed, and by evening her temperature had
gone up to 101° F., and a red punctiform rash was
noticed over the clavicles. The ne.xt morning a highly
characteristic scarlatinous rash was noticed, covering
the whole body. There was also a small spot of exu-
date upon the right tonsil, and a beautiful demonstra-
tion of the so-called strawberry tongue. The tempera-
ture was normal by the eighth day of the second
attack, and she at once started to shed the new coat of
skin which she had received shortly before. This
last desquamation was much finer in character than
the first, and it was not until October 20th that the
skin had regained its smooth character. The patient
developed no complications, and was discharged on
the above date.
STRANGULATED HERNIA IN A CHILD TWO
MONTHS OLD, WITH OPERATION AND
RECOVERY.
By S. NELSOX IRWI.N", M.U.,
NEW YORK.
The profession at large is by no means agreed as to
what method for the radical cure of hernia is the best,
and the question is one of great interest to the sur-
geon. It is not my intention to enter into the subject
of the '"radical cure of hernia," but simply to give
some details in a case which, from the extreme youth
of the patient operated on, may be of interest.
By kind permission of Dr. J. A. Breakell, whose
practice I have been attending to during the summer,
I am permitted to give the following account:
On September 18th Mrs. B came to my office
with her infant (male), two months and a few days old.
The child was crying bitterly, and was evidently
suffering great pain. The mother stated that it had
kept her awake all night, and there had been much
vomiting. Temperature normal; pulse, 120. Exam-
ination revealed a tumor on the right side, well down
in the scrotum, about the size of a pigeon's egg, pres-
sure upon which increased the pain very much. I
had my doubts as to its being a hernia, and examined
it carefully for translucency, which was present with a
dark spot in the centre. I now came to the conclusion
that the child had a strangulated hernia, and proceeded
to reduce it, but without result. After several attempts,
which caused much crying and annoyance, I decided
that an operation was the only means whereby the
tumor could be replaced in the abdominal cavity ; and
so informed the parents, who readily consented. The
operation was performed at their home that evening.
The little patient was placed on the table and put
under chloroform anasthesia. The usual incision was
made by Dr. C. F. Adams, who divided the superim-
posed tissue, layer by layer, until the sac was reached.
Considerable fluid escaped, bringing the gut plainly
into view, very much congested and maintaining a
stubborn resistance to reduction.
Upon closer examination, a little piece of gut, about
one and one-half inches, was discovered protruding
from the bowel proper. This proved to be the vermi-
form appendix. Its appearance suggested removal,
not merely because it was that troublesome piece of
visceral anatomy, but on account of its always getting
in the way in attempts to reduce the hernia, which,
indeed, was not an easy matter, for, after several at-
tempts to replace the tumor, the opening at the inter-
nal ring had to be enlarged, when it was replaced with
ease. Here a complication arose — our little patient
ceased to breathe. The operation was suspended, and
our united efforts were directed toward resuscitation.
By inverting the child and the performance of artifi-
cial respiration, after about ten minutes' hard work, we
were rewarded with signs of returning animation. Our
little soldier was once more put under the ana'Sthetic,
the operation resumed, and completed rapidly as fol-
lows: By the use of a deep catgut suture the internal
ring was transfixed; the suture was carried from the
skin without, down through the ring and back again,
and tied externally, thereby acting as an external suture
as well. The canal was closed by interrupted sutures,
drainage being left at the lower angle, the wound
dressed with iodoform gauze, and the mother directed
to administer one teaspoonful of the subjoined mixture
every third hour:
^ Tr. npii camphorata; 3 ij.
Elixir, simp § ij.
I was to call at nine o'clock that evening, but was
telephoned for long before that time. On my arrival
I found the child crjing as bitterly as when first seen
bv me in the early part of the day. To make sure, I
examined the patient and found the dressing was as
when first applied. To insure rest I gave one drop
of deodorized tincture of opium (Squibb's) ; at the end
of half an hour two more drops were given, and, at the
expiration of the hour, two more — making five drops
in all. Then the little patient fell asleep. Naturally
I felt very anxious about the little one during the
night, for it had undergone a critical operation, a se-
vere shock, and had taken a large dose of opium.
When I examined the eyes before leaving, the pupils
appeared much contracted, and the breathing was in-
dicative of more than natural respiration, showing that
the child was fully under the influence of the narcotic,
which secured for it a good night's rest. Next morn-
ing on removing the dressing the wound appeared
clean and healthy-looking, with signs of union by first
intention. Temperature normal ; pulse, 120. I called
again in the evening and found pulse and temperature
normal. On the third day, when dressing, I discov-
ered a little pus exuding from the sides of the deep
suture, which disappeared after the wound was syringed
with H^O,. and dressed as before. The case proceeded
to complete recovery without a single interruption.
Conclusion : Here was a child, only a little over two
months old, with a tumor well down in the scrotum,
surrounded with fluid and showing translucency. I
might have drawn off the fluid, thereby reducing the
size of the tumor, lessening the tension, and .so reliev-
ing the child of pain. But would this have aided in
the reduction of the hernia? I a"in convinced that in
this case (in which my colleagues. Dr. D. J. Moss and
Dr. C. F. Adams, to whom I return thanks, tried also
in vain to reduce the hernia, and all agreed that the
fluid could play no part in the reduction) we had no
alternative but the performance of the foregoing opera-
tion, which proved so gratifying in its results.
November 28, 1896]
MEDICAL RECORD.
791
It is worthy of mention that I attended the child's
mother at its birth, which was a normal cephalic pre-
sentation, although the forceps were used for delivery.
There was no visible anatomical defect at that time.
HERPES ZOSTER.
By CALISTA V. LUTHER, M.D.,
NEWARK, N. J.
I HAVE been very much interested in the discussion
on herpes zoster in the Medical Record of late. I
have had no experience with blisters, but I have long
been dissatisfied with the routine treatment of this
troublesome disease, and my experience has led me to
feel that most cases run their course uninfluenced by
medication.
For more than a year I ha,ve been treating all my
cases with the application of heat followed instantly
by cold, and the results have been exceedingly satis-
factory to me. I apply water as hot as can be borne
for a few seconds, and follow by very cold water, or,
better still, by frictions of ice until there is slight
aching of the part. The hot water increases the itch-
ing, but the cold instantly relieves it, often for some
hours. I order the applications to be made three times
a day, oftener if demanded by the itching. They not
only relieve this troublesome symptom ; they abort the
disease. When this treatment is applied to fresh
patches, the vesicular stage is never reached, and no
case of mine during the last year has lasted over a
week.
A CASE OF RACHITIC PARALYSIS.
By LOUIS ROSENWASSER, M.D.,
NEW YORK.
On July 6, 1896, I was called to see J. G , aged
three years, male, and was told by the mother that the
child had been coughing for some time, was in high
fever, and had had a convulsion the night before. On
examination I found dulness over the left apex behind,
bronchial breathing, and subcrepitant rales. Temper-
ature, 104.6° F. ; pulse, 140; respiration, 50; and
marked nasal breathing. I therefore made the diag-
nosis of broncho-pneumonia, and treated the child
with the usual remedies, with a good but slow recover}-.
When the child was in a fairly good condition, the
mother asked if I would not give him something to
strengthen him, as he was too weak to walk.
On closer inquiry, I learned that the child had
never walked since birth, and that he cut his first tooth
at eleven months. On examination I found the epiph-
yses thickened, a large square head, forehead cov-
ered with sweat, and the peculiar beading of the ribs.
The legs were thin and flabby, but the patellar reflex
was good. I then recognized that I had to deal with
a case of rachitic paralysis. I put the child on a
proper diet and ordered him to be a good deal in the
air. I prescribed syrup of iodide of iron and Thomp-
son's solution of phosphorus, ten drops t.i.d. The
child is now able to walk and much improved in his
general condition.
540 Fifth Street.
Calomel in Eeart Disease. — Dr. Maldaresco
{Therap. Woch.) has reported very favorable results
from a course of calomel, followed by the iodide of
potassium. He first gives one and one-half grains
every two hours for six doses daily, and keeps this up
for two or three days, when the dose may be increased
to two or three grains for a few days longer, before
the iodide is begun.
^ticvapctittc flints.
Epileptics have at times shown decided improve-
ment under drop doses of a one-per-cent. solution of
nitroglycerin, three times daily after meals. — Camp-
bell.
Vulvar Papillomata.—
I{ Collodion elastic 5 gm.
Acid, salicylic 2 gm.
Apply a few drops to eight or ten lesions at each sit-
ting. The next day treat the same number of new
ones, and again cauterize the original, continuing in
this way until all are cured. — Merciere.
Citrate of Silver has been found by Werter {Ba--
lin. k/iii. It'dc-//., No. 37) to give excellent results in
some fifty instances of acute blennorrhagia. A solu-
tion, I to 8,000, is employed at first, the strength be-
ing subsequently increased. It is reported non-irri-
tating to the mucous surface, and its action is not
limited to the superficial layers.
Consumption. — The colder the atmospheric air the
patient breatiies the better; the more oxygen it con-
tains, bulk for bulk, the more it acts as an antiseptic;
the more it expands when it has been inspired, and,
in expanding, dilates the air cells, the more it tends
to cool the overheated lung tissues, rendering them
less favorable for the multiplication of bacilli. —
Plavter.
The Prevention of Consumption.— Dr. B. W. Rich-
ardson, in Asclcpiad, makes some suggestions which
will prove beneficial to those having a tendency
toward pulmonary tuberculosis. Dr. Richardson says
that pure air for breathing is the first requisite for the
prevention of consumption, and that a uniform climate
and as much active out-door exercise as possible
are essential. Out-door occupation is preventive.
Amusements should favor muscular development and
sustain healthy respiration. The dress of the con-
sumptive should secure uniform warmth, and the
hours of rest should be carefully regulated by the sun-
light. Cleanliness, in the broadest sense of the word,
is of special moment. The diet of consumptives
should be ample, and every precaution should be taken
to prevent colds.
Treatment of Constipation Dr. T. Lauder Brun-
ton {The Lancet, 1896, p. 1,483) says that he regards
this symptom as the reaction of a healthy organism to
unfavorable surroundings, viz. : too soft food, too little
water, or too little exercise. For the first, he advises
bread of the whole grain or with more or less bran,
vegetables in abundance, either cooked or raw, as to-
matoes or celery. Fruits are beneficial, as melons,
apples, oranges, and figs. If stewed prunes are in-
efl^ectual, a few senna leaves tied in a bag and cooked
with the prunes will produce good results. Sugars
are useful laxatives. Orange marmalade, which con-
tains vegetable salts, sugar, and the hard skin of the
orange in small pieces, is a valuable addition to the
breakfast. If insufficiency of water is the cause of
constipation, a tumblerful of hot or cold water should
be drunk on rising in the morning and on going to bed.
Bottled waters should be substituted for waters from a
chalky soil. The habit of evacuating the bowels at a
certain time should be formed. F^xercise is of advan-
tage; massage, rubbing the bowels in the direction taken
by the hands of a watch, is also useful. In women
sufl^ering from ovarian or uterine trouble, exercise may
be harmful. When the floor of the perineum is lax,
it may be necessary to press the fscal mass along
in somewhat the same way in which the accoucheur
792
MEDICAL RECORD.
[November 28, 1896
advances the child's head. Leaning forward to an
acute angle causes a stretching of the floor of the
pelvis and affords support to the fcecal mass, as it is
forced backward by the action of the abdominal mus-
cles. In some cases hydropathic treatment is useful —
wet compresses to the abdomen two or three times
daily and sitz baths, cold in summer and with the
chill taken off in winter.
Vomiting of Appendicitis. —
1^ Menthol gr. viij.
Cognac 5 iss.
Laudanum 3 v.
M. S. Take from ten to twenty drops several times a clay,
in a little sweetened water.
— Pick, Revue Internationale de Medecine et de Chi-
rurgie.
Cocaine is not soluble in vaseline or lard, but is
readily so in olive or castor oil. — Sage.
Ozone is of assistance in pertussis. It diminishes
the number and intensity of the paroxysms, shortens
the entire duration, and improves the general health.
— Lable an'd Oudin.
Hot- Water Bag over the heart in threatened heart
failure.
To Induce Labor. — Inject within the cervi.x five
grams of glycerin. — Kossmann.
Galactifuge after Bandaging the Breast. —
"S, AtropiniE sulph %^- iii-
Magnesii sulph S ''j-
Infus. gentian 3 viij.
M. S. Tablespoonful every two hours.
— Bloom.
Post-Operative Sequelae of Gynecological and
Abdominal Surgery. — Dr. Byron Robinson {Denver
Alcdical Tunes, October, 1896) gives the following as
of common occurrence: i. Pain. 2. Suppurating
ligature. 3. Faecal fistula. 4. Hemorrhages. 5.
Peritoneal adhesions. 6. Hernia. 7. Neurosis. 8.
Development of fat and hair. 9. Atrophy of the gen-
itals. 10. A decrease in sexual desire. 11. Renal
and pulmonary disturbances. This is quite an array
of defects, but every abdominal surgeon of consider-
able experience has seen almost every one follow his
work. Some are unavoidable and the results of life
processes.
Krause Skin Transplantation in Plastic Surgery of
the Face. — Dr. John F. Erdmann writes in the Ameri-
can Medieo-Siirgieal Bulletin, October 24, 1896, as fol-
lows: "The advantages of this method of Krause are
readily observed. The area repaired is covered by
skin of the same character as that over the rest of the
body. There is no scar or cicatrix, as very frequently
follows after the Thiersch method. The new tissue
resists destructive conditions far better than that in
cases of the Thiersch method. The area grafted is
covered by a soft, cushiony structure. The flap does
not bind the underlying tissues, as in some cases of
Thiersch grafting. There is no likelihood of the
great keloid development, as seen occasionally after
the Thiersch method. Hairy areas can be covered by
hairy flaps, in which the hair again grows. An objec-
tion to the method might be offered in cases in which
a large area is to be covered, owing to the fact that it
is desirable to have but one flap. This can be readily
overcome by taking several flaps from various areas of
corresponding thickness and applying their edges wdth
great care to one another, as will be observed was
done in the case reported in this paper, although in
this instance the second flap was due to an error in
measurement, and not to the size of the area to be
covered."
Irritability may be an indication of heart disease,
of gout, or of an impending headache. Bromides re-
lieve the irritable nerve centres. — Lauder Bruntox.
Epididymitis. —
'S, Potass, bitart 3 iv.
Podophyllin gr. ij.
Make twelve powders and give one every two hours.
— Y0UNK.IN.
Milk Diet in albuminuria of pregnancy, deficient
elimination, and threatened eclampsia may materially
decrease the danger of the last-named affection. —
QUEIREL.
Ulcer of the Cornea Touch with tincture of
iodine and wash oft" the excess with formaldehyde
solution, I to 1,000. — Veasev.
Boric Acid, so valuable in cystitis, may cause di-
gestive disturbances, in which case it may be given
best an hour before food and at 10 p.m., making four
daily doses. — Slocum.
Syphilis Dr. Briquet advises the use of iodide of
sodium when the potassium salt is not well borne.
Ammonium iodide is often very serviceable in the ter-
tiary stage.
Dysmenorrhoea Caffeine, bromide of potassium,
and gelsemium make a combination of great value if
given a few days before the period. — Talley.
Hysterical Aphonia. — Ethyl chloride suddenly ap-
plied to the nape of the neck, freezing a patch the size
of a quarter. — Kebhell.
Mucous Membranes can be made anasthetic by oil
of cinnamon (i to 500). — T/ierapetitie Gazette.
Tapeworm. — Salicylic acid eight grains every hour
until five or six doses have been taken, followed by a
full dose of castor oil. — Times and Register.
Emetics — Syrup of ipecac should be discarded as
slow and uncertain. The wine made from fluid ex-
tract can be depended upon. Antimony as an emetic
should be banished from infantile therapeutics. —
^Pediatries.
Quinine in Pertussis Two out of twenty-seven
patients could not retain the drug. The others were
remarkably benefited. After five days the attack was
ended. Dose, one centigram for each month of age
and ten for each year. — Fischer.
Uterine Hemorrhage following abortion and at-
tended with subin\olution :
I? Fluid e.xtract of ergot (Squibb' s) 3 ij.
Fluid extract of viburnum pninifolium I ij.
Tincture of cinnamon Enough to make ; ij.
M. Dose : Teaspoonful in hot water from two to six times
a day.
— Egbert, Philadelphia Polyclinic, October 3 1 , 1896.
Ipecac in proper dose is a vasomotor stimulant,
causing constriction of the arterioles and capillaries,
especially of mucous membranes. It acts in the same
way to relieve headache of the congestive variety.
In glycosuria it may reduce the excretion of sugar,
and, generally speaking, it is a tonic to mucous mem-
branes and glandular cells. — Adoi-PHUS.
Osmic-Acid injections in neuralgia, the needle being
inserted perpendicularly and deeply into the muscles:
If Osmic acid i
Distilled water 6
Glycerin 4
Keep well corked. Inject the equivalent of one-
sixth grain opposite the most painful part. — Franck.
J
November 28, 1896]
MEDICAL RECORD.
793
Society Reports.
SECOND PAN-AMERICAN MEDICAL CON-
GRESS.
Held in Mexico City, November 16, 17, 18, and ig,
i8g6.
(Special Report to the Medical Record.)
Monday, November i6th — First Day.
SECTION ON GENERAL MEDICINE.
The Roentgen Rays in Thoracic Aneurism. — Dr.
WiLLiANt Pepper, of Philadelphia, read a paper in
illustration of the value of the .v-rays in the diagnosis
of thoracic aneurism. He recounted the histories of
several cases and exhibited the skiagraphs of the pa-
tients, in which the outlines of the aortic swelling were
very clearly shown. In one case (possibly of tuber-
culous adenitis), in which the symptoms suggested an
aneurism, the skiagraph showed no enlargement of the
aorta. The arrest of the .v-rays by an aneurismal
tumor was owing to the blood and probably to the iron
contained in it. It had been asserted that tuberculous
deposits were also impervious to the rays, but this was
still a matter of some uncertainty. In the case re-
ported the symptoms were probably due to pressure by
an enlarged tuberculous gland, yet there was no shadow
in the skiagraph indicating the presence of such en-
largement. In the cases in which aneurism existed,
the diagnosis had already been made, but the picture
made by the Roentgen rays confinned this diagnosis,
and instances might readily be imagined, especially
of commencing aneurism, in which certainty could not
be obtained from the objective signs alone. It was
to be remembered also, the speaker said, that our ap-
plication of the Roentgen rays was but in its infancy.
A year ago the suggestion that we might see the bones
or internal organs of a living man would have been
received with derision; and yet, only a few evenings
ago, the speaker had put a healthy young man, wear-
ing all his clothes but his coat, between a tube of
special construction and the fluoroscopic screen, and
in twenty seconds he could see clearly not only the
ribs but the heart pulsating, and the latter was so dis-
tinct that it was possible to tell the ventricles from
the auricles. The possibilities of this discovery were
almost beyond the power of our imagination.
The Urine in Yellow Fever Dr. Manuel Ruiz
Casabo, of Havana, read a paper on the physico-
chemical characters of the urine in yellow fever. He
, had devoted especial attention to a comparative study
of the characters of the urine In yellow fever and
other diseases, taking advantage of the opportunities
afforded by the large number of cases of yellow fever
now in the city of Havana and also utilizing the re-
sources at his disposal as director of the section of
urology in the bacteriological laboratory of the Uni-
versity of Havana. After a general review of the
chemical properties of normal urine, and the micro-
scopical appearances of the sediment in various semi-
normal and pathological conditions, he described the
appearances of this fluid in cases of yellow fever.
These appearances were not uniform but varied con-
siderably with the individual, yet there were certain
characteristics which seemed peculiar to yellow fever
and which were always found in cases of this disease,
although modified by the individual peculiarities.
The paper was largely made up of carefully prepared
statistical tables giving the results of the examina-
tion of the urine in a large number of cases.
Drs. E. Acosta and J. M. D.^valos, of Havana,
followed with another paper on the same subject, of
which the following is a brief abstract: The bacterio-
logical laboratory was established in Havana in 1887,
and since that time many experiments in this field
have been undertaken, a great number of cases of in-
fectious diseases existing in that city having been
studied in the light of the new science developed, if
not discovered, by the immortal Pasteur. Among
these diseases yellow fever is the one that has most
engaged the attention of scientific men in the island,
because it is the one that carries off most victims, and
which offers the greatest obstacle to the prosperity and
wealth of Cuba. The authors of this paper have for a
long time given special attention to the study of this
disease, and have now undertaken that of the urine of
yellow-fever patients. They studied the toxic power
of the urine, and carried out more than one hundred
experiments on rabbits. From these experiments they
arrived at the following conclusions; i. The urine of
yellow-fever patients contains toxins which are sepa-
rated by the diseased system, and which perhaps per-
tain to the agent that produces the disease. 2. The
toxic power of the urine reveals the actual condition
of the patient, so much so that the toxic power is in
inverse ratio to the gravity of the disease. This is
explained by the fact that when there is less toxin in
the patient's system he improves, because the evil
principle is carried off by the urine, while, on the
other hand, when the urine is not toxic, the toxin ac-
cumulates in the patient's body and increases the
gravity of the disease. 3. The urea has nothing
whatever to do with the prognosis of yellow fever, as
the labors of Bouchard have so demonstrated it with
respect to different diseases, and as has been privately
proved by the authors of this paper with respect to
yellow fever. From the urinary analyses that have
been made, they have found that serious cases might
eliminate a good deal of urea, while others of less
gravity might store it up in great quantities within the
system.
Rabbits which were inoculated with urine charged
with urea were a longer time in dying after an intra-
venous injection of yellow-fever virus than others
which were injected with urine containing little urea.
The authors claimed that yellow-fever patients die
through poisoning by the toxins of the germ which
produces the disease, and never from ura;mia.
Biological Characteristics of the Blood in Yellow
Fever. — Dr. Thom.4s Vicente Corhxado, of Havana,
presented an exhaustive paper with this title. Having
ijeen for many years accustomed to make careful ex-
aminations of the blood in order to arrive at a clini-
cal diagnosis of malaria, and having later on carried
out some comparative studies between the blood of
malarial patients and that of healthy people, he deter-
mined to take the first opportunity to extend these
studies to the blood of persons attacked by yellow
fever. The sudden entry into Cuba within a short
period of time of more than one hundred and fifty
thousand men who were not acclimated, and who came
from Spain for the purpose of fulfilling their military
duties, gave new strength to the disease and greatly
disseminated the yellow-fever germ from one end of
the island to the other, and the great number of cases,
both in Europeans as well as in native-born Cubans
who had not obtained immunity through a previous
attack of this terrible scourge, afl'orded him a vast
field in which to carry on his studies in hematology.
The technique for collecting the blood and preserving
it in good condition for study is very simple, and
similar to that which the speaker employed in exami-
nation of malarial blood. A finger of the hand, in a
thoroughly clean and aseptic condition, is pricked
with a common needle, or with a lancet which has
been passed through an alcohol flame. The blood is
collected in small glass vessels having a long sharp
794
MEDICAL RECORD.
[November 28, 1896
neck, which can be broken with the nail and closed,
after filling, with the flame of a match. The blood
which has been collected in this manner can be pre-
served in good condition for one or many days.
The examination in a natural condition can be
made by putting a part of the blood on a cover glass,
and then inverting this over the slide. The perma-
nent preparations must be made by the method of
double staining with eosin and methylene blue.
Both in the serious cases of yellow-fever infection,
in which a fatal result took place a few hours after the
extraction of the blood, as well as in the commoner
mild cases and in a very large number of observa-
tions, the investigations gave surprisingly negative
results.
In fact, the speaker said, he had been surprised to
find that the blood of the yellow-fever patient which
had been taken one or two hours before his death, as
well as that which had been drawn when the disease
was much less advanced and also during convales-
cence, should present all the features of normal blood;
that is to say, similar to that of a healthy and robust
man, full of life and without any pathological stain.
It is therefore evident that the blood is not the seat of
the disease in that terrible form of the infection which
is called black vomit, and which in not a few cases
carries off its victim with the same violence as chol-
era, or poisoning by vegetable or mineral substances.
A direct observation, however, shows the normal red
globules increased in number, while in connection
with these we perceive numerous leucocytes, full of
phagocytic life. These facts, which appear extremely
singular, Dr. Coronado firmly believed, would shortly
carry us to the solution of problems connected with
the pathology first, and afterward with the etiology of
yellow fever.
The author believed, contrary to the general impres-
sion, that the Cubans or natives suffer like Europeans
from true yellow fever whenever they have not ob-
tained immunity through a previous attack.
Cantharidal Blisters in Acute Pulmonary Affec-
tions.— Dr. Josk dk la Cerna, of Calimaya, Mexico,
read this paper. Acute diseases of the chest, he said,
are frequent in the Valley of Toluca, and play an im-
portant part in the statistics of mortality. The use of
blisters is general, both becau.se the public has become
accustomed to them, as well as because many phy-
sicians prescribe them; but the speaker did not ap-
prove of their use.
At the time when pneumonia was considered a local
disease, in which inflammation played an important
part, the action of a blister could be supposed to be
iDeneficial, although it was not proved.
In pneumonia we are not dealing with a local inflam-
matory process, but with a disease of which the patho-
genic agent is known. A blister is almost always
applied for the purpose of easing the pain and dimin-
ishing the congestion, but, seeing that pneumonia is a
general disease, it should not be treated by attacking
one of its symptoms, and still less by the employment
of cantharides. In pneumonia renal congestion is
constant; we are acquainted with the functions of the
kidneys in the expulsion of the toxins produced by
the economy, and consequently we recognize the im-
portance of preserving the renal integrity. A blister
increases this congestion and diminishes the quantity
of urine, and, as in pneumonia one of the indications
is active diuresis, the result is that we obtain the con-
trary effect to what is desired.
In pleurisy a blister exercises no effect on the effu-
sion during the acute period.
The following were the conclusions of the author:
Pneumonia and pleurisy being of a general and infec-
tious character, and the defects of the blister being
known, it ought to be left out in their treatment.
If it is applied, it should never be during the acute
period, but toward the end, when the restitutio ad iittc-
gniin is difficult, provided the kidneys are known to
be sound. It ought to be kept on for from four to six
hours, and while the epidermis rises hot drinks should
be taken. Antisepsis of the skin should also be care-
fully looked after.
Spontaneous Rupture of the Aorta — Dr. J.
Llambias, of Buenos Ayres, Argentina, read a paper
on this accident, in which he endeavored to demon-
strate the anatomical cause of spontaneous rupture,
since he believed that it was not sufficiently explained
by the existence of chronic endarteritis. He cited a
number of authors who had sought to explain the
nature of the accident, but held that their explanations
were unsatisfactory, since they were not applicable to
all cases. Dr. Llambias held that the original lesion
which was the actual occasion of the rupture consisted
in an alteration in the circulation in the vasa vasorum
resulting in an endarteritis of these minute vessels.
Although we cannot demonstrate it, the author re-
garded it as probable that this endarteritis arose from
systemic causes. Its existence was demonstrated by
thrombosis in the vasa vasorum, and thus was caused
a necrosis of the area supplied by the occluded vessels.
A paper on " International Medicine," by Dr. John
W. Trader, was read by Dr. T. D. Wheatley.
SECTION OX GENERAL AND ORTHOPAEDIC SUR-
GERY.
Tuberculosis of the Knee -Dr. Angel Contre-
RAS, of Puebla, Mexico, reported a case of tuberculosis
of the right knee, in a boy six years of age, in which a
cure was obtained by arthrectomy after the method of
Albertin, of Lyons. The diagnosis of the tuberculous
nature of the affection was made from the clinical
symptoms and was confirmed by microscopical exami-
nation. There were no signs of tuberculosis in any
other part of the body. The operation was performed
on August 17, 1895, the limb being immediately after
immobilized in a plaster-of-Paris dressing. During
the first three days there was a slight elevation of tem-
perature, but after this there was no fever.
The antiseptic dressing was renewed on the 20th of
the same month, and afterward on the 31st, being left
without moving during the whole month of September.
During the months of October and November, it was
found necessary to change the dressing several times,
as eczema had develo]:)ed in the operated member and
a fistulous path was found, caused by a small carious
focus. On November 29th this carious part was
scraped, and during the month of December the wound
was completely closed, and perfect ankylosis obtained
of the femur with the tibia. During the first months
of the present year the patient was visited again, and
the permanence of the cure was confirmed ; the patient
was found to have preser\-ed his leg straight with only
a slight shortening and limp. A photograph of the
patient as cured was shown.
The object of publishing this case. Dr. Contreras
said, was to stimulate surgeons to perform an opera-
tion which can radically cure such a common disease
and one of such a serious character as tuberculosis in
the knee, and to show that the treatment by means of
the atypical arthrotomy is preferable to that by revul-
sion and immobilization, as well as to antiseptic and
other injections, or to typical resection.
Laryngeal Operations. — Dr. George W. Crile, of
Cleveland, O., presented a communication entitled
" Researches into the Technique of Laryngeal Opera-
tions, with a Report of Four Successful Total Extir-
pations." The first part of the paper was devoted to
a recital of the results of a series of experiments.
Even slight contact, the author said, with the mucous
November 28, 1896]
MEDICAL RECORD.
795
membrane upon and about the region of the vocal
cords causes sometimes partial but more frequently
complete arrest c' respiration; pressure or dragging
on the larynx causes in addition a considerable, some-
times very great, slowing of the heart beat and corre-
spondingly considerable or very great fall in blood
pressure, in several cases almost to zero. On section
of the inferior laryngeal nerves the phenomena are
not changed; on section of the superior laryngeal
nerves the phenomena are abolished. Atropine in
physiological doses abolishes the heart phenomena
but does not prevent the respiratory alterations or ar-
rest. Cocaine hypodermatically also guards the heart
but not the respiration. Cocaine locally applied abol-
ishes completely both the effect upon the heart and
the respiration. These results having been obtained
by graphic record on twenty dogs under full ether nar-
cosis, we may conclude, Dr. Crile said, that the phe-
nomena are due to reflex action caused by mechanical
irritation of the peripheral terminals of the superior
laryngeal nerves, and that cocaine locally applied
paralyzes the same even under full anasthesia. The
local application of cocaine in certain laryngeal oper-
ations is indicated.
In the second part of the paper the author dealt
with clinical observations and the conclusions derived
from them. Carcinoma, he said, probably cannot
penetrate cartilage. The most frequent point of attack
is the region of the vocal cord, consequently causing
early symptoms. When suspected a specimen should
be early secured and submitted to a competent pathol-
ogist, and, if proven cancer, an early and radical ope-
ration should be performed. Early operations should
be extremely promising as to their results.
In neglected cases, usually ulcerating and foul,
suffering from septic broncho-pneumonia caused by
the discharges or by entrance of food, subjects of
most intense suffering, a radical operation, while it
may not cure, will give a respite and prove to be mer-
ciful and humane. The testimony of patients them-
selves on this point is emphatic. By the technique
described, the pulmonary tract may be safely guarded,
the operating-time may be lessened, the patient will
obtain as long a time of freedom from recurrence as
after the most favored capital operation, and, better
than all, the high mortality will be very greatly re-
duced. In the four cases of total extirpation of the
larj-nx, reported by Dr. Crile, the patients all made a
good recovery.
Fracture of the Clavicle.— Dr. A. D. Spohn, of
Corpus Christi, Tex., exhibited a new form of appara-
tus for use in the treatment of fracture of the clavicle,
to retain the ends of the divided bone in coaptation
and to prevent deformity.
A paper on " Gastro-Enterotomy" was read by Dr.
E. B. Smith, of Detroit, Mich.
SECTION ON OBSTETRICS .\ND GYNECOLOGY.
Uterine Fibroids Complicated with Pregnancy. —
Dr. a. Vandervekh, of Albany, N. Y., presented a
communication with this title. Although cases of this
kind are not numerous, he said, yet the method of
treatment now employed, thanks to recent progress in
abdominal surgery, gives very satisfactory results, at
least as regards the life of the mother. The subperi-
toneal, pedunculated, or sessile fibroids usually give
but little trouble upon the occurrence of pregnancy,
but danger exists in the case of those which are so
situated as to interfere with the cavity of the uterus
or obstruct the outlet of the pelvis. Whenever the
tumor is so located as not to be likely to interfere with
delivery, or its growth is so gradual as to admit of
postponement of the operation until after the viability
of the child, our duty is clearly to wait. Myomectomy
in the interest of the child is justified in cases in
which dystocia would probably occur; at or near
term, when dystocia threatens, suprapubic hysterec-
tomy is probably the safest course to pursue. In such
cases the loss of the mothers ought not to exceed ten
per cent., and the children ought nearly all to be
saved. Dr. Vanderveer then reported two cases illus-
trating this complication of pregnancy in aggravated
form, and emphasizing the necessity of thoroughness
when operation is called for. In such grave cases
delay, in the hope that absorption will occur or that
a living child may be delivered (as we sometimes see
in cases of uterine cancer), is hardly ever justifiable.
We should operate and should remove the appendages
with the uterus, for suppuration and sepsis may follow
an attempt to perform a Cajsarean operation. The
speaker said that his remarks did not apply in the
main to small tumors, but only to large and rapidly
growing ones, in which cases the mortality, when oper-
ation was not done, is very high. They do not admit
of myomectomy, and a uterus with large fibroids, with
cystic degeneration going on, will not admit of the
patient going to full term, and demands prompt surgi-
cal interference. Even though abortion may occur,
still the uterus is septic, and this is one cause of the
great mortality in such cases.
Dystocia in Mexico. — Dr. J. Ignacio Capetillo,
of Mexico City, read a paper on this subject. Dys-
tocia from maternal causes was comparatively rare in
Mexico, and especially so was that from narrowed
pelvis in consequence of rickets or osteomalacia.
Dystocia sometimes was caused in the native (Indian)
women by reason of the greater narrowness of the
vulva and rigidity of the perineum in them as com-
pared with women of Spanish blood. Dystocia some-
times occurs in consequence of the premature rupture
of- the bag of waters, resulting from the common use
of the Montanea fomentosa, or •' zoapatl." Placenta
priKvia and procidentia of the cord are rather common
causes of dystocia, as shown by the statistics of the
Maternity Hospital in Mexico City.
The Management and Surgical Treatment of
Ectopic Pregnancy Dr. Augustus P. Clarke, of
Cambridge, Mass., followed with a paper with this title,
based chiefly upon the results of his own experience
and observation. He divided the treatment into sev-
eral classes. In those cases in which the foetal sac is
situated in the abdominal cavity there will not usually
be an immediate urgency for surgical measures. In
cases of ectopic pregnancy seen at a very early period
the application of the galvanic or faradic current may
be effective in destroying the foetus and thus enabling
absorption of the remains to take place. The liability
of the supervention of shock, hemorrhage, or sepsis,
from rupture of the sac or of some of the larger arterial
branches, especially after the third month of gesta-
tion, is so great that precautions should always be
taken to have everything in readiness for making an
abdominal section. Cases in which rupture has oc-
curred and the child continues to develop should be
treated as circumstances demand. If gestation has
not gone beyond the third month, removal by coeliot-
omy should be advised. When the pregnancy has
passed much beyond the sixth month it may under
proper precautions be allowed to continue until the
end of the eighth month. In those really desperate
cases of rupture of the sac or of blood-vessels, imme-
diate cceliotomy should be regarded as our chief reli-
ance. This precuation should be adopted whether the
hemorrhage is the result of a primary rupture or is a
sequel to the yielding of a partially restored vascular
tissue. The nearer the gestation has reached the close
of its term, the greater will be the probability of sav-
ing the life of the child. The immediate removal of
the placenta in such cases is often attended with ex-
796
MEDICAL RECORD.
[November 28, 1896
treme danger; for this reason the sac may sometimes
be sutured to the peritoneum, and the placental mass,
before its removal, may be given time to undergo con-
traction and become loosened from its attachment.
If it is deemed wise to effect immediate remo\al of
the placenta it can best be done after clamping and
tying the ovarian and uterine arteries; should the
fcetal sac then be found too firmly adherent to allow
its safe removal, suture of its edges to the parietal
peritoneum and the employment of drainage will be
required. In those cases in which the fcetation is in-
traparietal the liberation of the child can be most
safely effected, so far as the mother is concerned, by
resort to hysterectomy. In some cases closure of the
rent by aseptic animal sutures and the stitching of the
opening to the abdominal wound might prove suffi-
cient for overcoming the hemorrhage. Cases that
sometimes give rise to most alarming symptoms are
those in which the fcetation takes place in some por-
tion of the Fallopian tube. Hemorrhage from rupture
of the sac or from the yielding of the vessels near the
fimbriated extremity of the tube can best be controlled
by suturing the ruptured vessels through an abdominal
incision.
The Ambulant Treatment of Certain Forms of
Pelvic Disease. — Dr. Emma B. Culkkrtson, of Bos-
ton, Mass., presented a communication in which she
said that the frequent occurrence of pelvic disease
among women of the laboring classes has of late been
more fullv recognized than formerly, so that now more
accurate diagnosis, leading to more efficient treatment,
great relief from suffering, and frequently entire cure
can be secured while the patients continue their usual
occupations.
It was to emphasize this fact, to make a plea for
more optimistic views of ambulant g)'necology, that
the speaker presented the following statistics. These
were taken from the records of but one institution and
covered but one year, though similar results, she be-
lieved, would be derived from the tabulation of the
dispensary service of the past twenty years.
'I he cases treated in the gynecological department
of the New England Hospital Dispensary during the
year ending September 30, 1896, were classified as
follows: Occupation: Housewives, charwomen, do-
mestics, shop girls, seamstresses, and factory girls.
Diseases: Malposition, inflamed adnexa, neoplasms,
endometritis, subinvolution, and venereal disease.
To all of these patients a stay in the hospital would
ha\e meant serious interference with their daily work.
The problem therefore was to effect good results in
spite of the fact that rest, care, good food, and free-
dom from anxiety could not be secured. Fortunately,
however, we observe in the majority of such cases a
marked toleration of treatment. Measures that could
be employed only with the greatest precaution among
women of the leisure classes become routine treatment
in the dispensary clinics. It would seem, Dr. Cul-
bertson said, as though constant muscular activity
must exert some derivative influence upon the pelvic
viscera. The speaker then described the technique
of various methods of treatment, showing instruments,
tampons, etc., referring also to the general treatment
employed in conjunction with local measures.
Potassium Iodide in Passive Metrorrhagia — Dr.
Antonio Maci'.\s, of Guanajuato, Mexico, read a
paper on the use of iodide of potassium as an indirect
hemostatic in passive hemorrhage of the uterus of as-
t'lenic character. He said that this drug was often
employed to restore the equilibrium of the circulation
in pathological conditions characterized by passive
hyperajmia, and he had merely extended the use of the
remedy to the treatment of passive hemorrhage in gen-
eral, but especially to that occurring from the body of
the uterus in cases not calling for operative interfer-
ence. His treatment was based upon the results of
the extensive studies of the physiological action of
potassium iodide made by Germain See. These were
summarized as follows: potassium iodide presents two
phases in its biological action: one is the excitement
which is characterized by tachycardia, an elevated
pressure, and vasoconstriction. We afterward have an-
other phase, of vasodilatation and low pressure. It is,
therefore, a drug whose action is similar to that of dig-
italis; it first produces a strengthening of the heart and
increases the jjlood pressure. Once this is increased,
the circulation becomes more active in the coronary
arteries and in the arterial system; thus potassium
iodide nourishes the heart and is the regulator of the
pulmonary and systemic circulation. As the drug acts
on the muscular fibres of the vessels, it regulates the
local circulation which is passively disturbed. In fact
iodide of potassium is a stimulant to the muscles of
the cardiovascular system.
Applying these principles to cases of passive hemor-
rhage of the uterus (considering this as an exaggerated
hyperajmia with extravasation) and in view of the
favorable clinical results obtained, the speaker said
that we might formulate the following theory: Potas-
sium iodide is a cardio-vascular muscular excitant
which reduces venous tension in the uterus, whether
simple (hyperaemia) or accompanied by extravasation
(hemorrhage). It relieves congestion and acts thus
indirectly as a hemostatic. Its action is certain,
powerful, and lasting, and it is not poisonous. It re-
sembles in its action that of the normal blood, which is
the physiological stimulant of the circulatory system.
The remedy should be given in moderate doses. The
indications for its use are all forms of passive hemor-
rhage from the uterus, whether from general or local
causes or that which occurs in women staying at great
altitudes.
Other papers read were on " The Treatment of Face
Presentations," by Dr. Josi Torres Anzorena; "A
Contribution to the Surgery of the Female Perineum,"
by Dr. Edward J. Ill, of Newark, N. J.; "Etiology
of Eclampsia," by Dr. Clark, of Chicago; and "The
Therapeutic Value of Rest," by Dr. Sarah H. Ste-
venson.
Tuesday, November ijth — Second Day.
SECTION ON GENERAL MEDICINE.
Pseudo-Hermaphrodism. — Dr. Ignacio Ortiz v
CoRPOHA, of Guernavaca, Mexico, presented an in-
dividual, Maria Hernandez by name, who was a
pseudo-hermaphrodite, and gave in detail an accurate
study of the anatomical, physiological, and moral pe-
culiarities. The condition was one of perineo-scrotal
hypospadias. The sexual apparatus was masculine,
some of the parts being apparently missing, others
imperfectly developed, but the exact condition of all
the organs of generation could not be determined with
absolute certainty. The physical functions were those
of a male. During coitus, which could be but imper-
fectly ijerformed, there was an ejaculation of a liquid
which was seen under the microscope to contain sper-
matozoa in small number. The character and habits
of the individual were distinctly feminine, yet sex-
ually the subject was attracted toward women and not
toward persons of the other sex. The author reviewed
at some length the literature of similar cases and also
discussed the classification as proposed by Pozzi, of
Paris, and concluded with some considerations bear-
ing upon the medico-legal relations of this and other
like cases. In addition to the presentation of the
individual, the report was accompanied by photo-
graphs and microscopical preparations.
Haemology of Tuberculosis. — Dr. A. M. Holmes,
November 28, 1896]
MEDICAL RECORD.
797
of Denver, Col., presented a communication on "The
Diagnosis of Tuberculosis by Means of a Microscopi-
cal Study of the Blood," of whrch the following are the
conclusions: i. The diagnosis of tuberculosis from
the morphological appearance of the blood rests upon
the hypothesis that each individual has a biological
prototype in the leucocytes of his own blood. 2. Leu-
cocytes are independent organisms with functions
analogous to those of the larger organism. 3. These
pass through various stages of growth and decay. 4.
Disintegration of leucocytes may occur at any age.
5. The leucocytes are tissue formers. 6. As are the
leucocytes so is the individual. 7. Tuberculosis is a
disease characterized by tissue disintegration. 8. In
tuberculous blood there is abundant cell-disintegra-
tion, premature development, premature decay, and a
greater or less deviation from the normal average of
the various types of cells. 9. If there is a marked
disintegration in the leucocytes, it is with certainty
that we can predict a similar condition in the larger
organism. 10. Tuberculosis possesses a combination
of blood appearances from which a diagnosis may be
made earlier than by any other means that we now
possess. II. These changes may be recognized by
appropriate microchemical stains and a high magnifi-
cation. 12. They can be recognized even before the
disease manifests itself in the individual. 13. They
are sufficiently marked in tuberculous individuals, or
even in those with a strong tuberculous predisposition,
to enable a diagnosis being made from the blood
alone, without knowledge of the history or physical
condition of the patient. 14. Thus far, no other path-
ological condition has been found which presents sim-
ilar blood appearances. 15. An early diagnosis would
enable many to avail themselves of favorable climatic
changes, and thereby delay or even prevent the destruc-
tive results which would otherwise inevitably follow.
Dr. James K. Crook, of New York, read a paper
on the use o: creosote in the treatment of pulmonary
diseases.
SECTION ON
GENERAL AND
SURGERY.
ORTHOP.«DIC
Linear Electrolysis in Stricture — Dr. J- A. Fort,
of Montevideo, Uruguay, read a paper with this title
in which he described at length his method of treat-
ment of obstinate stricture of the male urethra by
means of linear electrolysis. The method is the same
as that described in a monograph published by the
author when residing in Paris. Special instruments
devised by Dr. Fort for use in this operation were also
exhibited.
Intestinal Anastomosis. — Dr. J. Frank, of Chi-
cago, performed an e.xperiment upon a large dog in
the San Andres Hospital, demonstrating the applica-
tion of his new device for anastomosis of the intestine.
The dog being etherized, its abdomen was opened and
about four inches of the small intestine were resected.
The divided ends of intestine were then united by
means of the bone buttons united by a piece of rubber
drainage tube. The operation was completed in four-
teen minutes, but Dr. Frank said that he had done it
with ease in eight minutes, a longer time being occu-
pied at this operation because of the necessity which
he was under of explaining to his audience the details
of each step in the operation. The button employed
and the method of performing the operation are famil-
iar to the readers of the Medical Record, having
been fully described by the author in a recent issue.
The method was discussed and favorably commented
upon by Sir William Hingston, of Montreal, Dr. Ra-
mon Maci'as, of Mexico City, and others.
Dr. Edwin Bentlev, of Little Rock, Ark., read a
paper entitled "The Claims of General Surgeons."
SECTION ON OBSTETRICS AND GYNECOLOGY.
Hydatidiform Mole — Dr. J. Ignacio Capetillo,
of Mexico City, reported a case of hydatidiform mole
which had been accompanied by considerable hemor-
rhage from the uterus. The woman had been exam-
ined by a number of physicians at different times and
all had pronounced the case one of placenta preevia.
The true diagnosis was not arrived at until the mole
had been extracted.
Puerperal Septicaemia. — Dr. Manuel Barreiro,
of Mexico City, read a paper on puerperal infection.
The routine practice in all cases of childbirth in the
Maternity Hospital of Mexico is to administer a laxa-
tive on the day following deliver)-, and each day there-
after, until the end of the puerperal period, to give
tepid antiseptic vaginal injections. Should the tem-
perature rise, an intra-uterine injection is prescribed
with a weak pressure (not exceeding twenty inches).
If, after the lapse of two days, the temperature contin-
ues high, prolonged douches are administered during
two hours. Continuous irrigation is both dangerous
and inefficacious. If, on the third or fourth day, the
temperature does not fall to the normal, it then be-
comes necessary to curette w ithout loss of time. Both
before and after this operation perfect asepsis must be
maintained. Kxcessive loss of blood is a very serious
complication and militates against the suctess of the
operation. The objections which have been brought
forward against this operation are of no value, (lini-
cally speaking; its advantages are indisputable, espe-
cially when the infection arises from the existence of
placental remains, as it does in the majority of cases,
in the author's opinion. The most convenient anti-
septic is generally iodine, on account of its volatile
character, and of its power to enter thoroughly into
the tissues; but in special cases we obtain better re-
sults with corrosive sublimate, permanganate of potas-
sium, or o.xygenated water. A general tonic treatment
ought to be well attended to, as well as the adminis-
tration of strychnine hypodermically.
Should success not be obtained after a first curet-
tage, this can be repeated a second and even a third
time, and in these cases, should it be found necessary,
the practitioner can have recourse to catheterization
and refrigeration of the uterus.
The clinical comparison of this method with others
in common use has firmly convinced the author that
curettage is an operation that can be executed without
danger, and, if done in due time, is superior to any
other of the means that are now known.
Dr. Gonsalez de la Vega, of Mexico City, fol-
lowed with a paper on the same subject, entitled "Ob-
servations on the Classical Treatment of Puerperal
Septicemia." Although, he said, orrhotherapy has
been found efficacious in the treatment of puerperal
septicemia, it is, however, not the only method worthv
of our careful consideration. The reasons why orrho-
therapy cannot always be relied upon are: Firstly,
because the antistreptococcus serum employed can
combat only those septicaemias which are produced by
the streptococcus; secondlv, because the serum acts on
the toxic products already absorbed, and it is ahvays
a good plan to destroy the causes of this toxic ab.sorp-
tion. Local antiseptic treatment consequently and
also chiefly merits attention.
Before undertaking any treatment, the physician
ought to determine which is the starting point of the
infection, and not at once make intra-uterine applica-
tions that may be useless or even injurious through
some act of commission or omission. In order to dis-
cover this source and utilize all the means for diagno-
sis, it ought to be searched for, according to a deter-
minate plan, from the exterior to the interior, and in
798
MEDICAL RECORD.
{November 28, 1896
many cases it will be found necessary to make use of
the speculum.
When it is clearly demonstrated that the infection
is extra-uterine only, no injection or curettage should
be resorted to. Even should the disease have gone
beyond the third day of fever, the septicemia can still
be combated without resorting to curettage when its
source is e.xtra-uterine.
In those rare cases in which it may be impossible to
diagnose the focus of infection, the applications must
be both e.xtra- and intra-uterine. When some lesion
is found in the canal, intra-uterine injections must be
practised through the speculum, in order to avoid the
carrying of the septic products of the vagina to the
uterus by means of the instrument.
Dr. de la Vega then reported four cases illustrating
the points brought out in his paper. The first case
was one of puerperal septiceemia resulting from a lac-
erated cervix. The treatment was a purely antiseptic
one and resulted successfully after some days. In the
second case septicaemia occurred and persisted, in spite
of antiseptic injections, for thirteen days. At the
end of this period a very careful examination was in-
stituted, and resulted in the discovery of a slight tear
of the perineum. \\'hen this was repaired the temper-
ature rapidly fell to the nonnal, and the patient recov-
ered. The third case was one in which septicaemia
had existed before the patient was seen by Dr. de la
Vega. A Cure speedily followed the use of antiseptic
vaginal douches. The fourth case was one of consid-
erable obstinacy. Antiseptic injections, both vaginal
and intra-uterine, were employed for a time without
result, and then curettage was resorted to. This also
failed, and then the author performed a trachelorrha-
phy under strict antisepsis, with the result that the
temperature quickly fell and the patient made a good
recovery.
Dr. Henrv Schwartz, of St. Louis, Mo., read a
paper on the same subject, under the title of " Anti-
septic Obstetrics and the Antito.xin Treatment of
Puerperal Infection."
Dr. R.af.aei, Norm.a, of Tulancingo, Mexico, also
presented a communication on this subject.
Dr. J. P'rank, of Chicago, said that there was no
absolute therapeutic rule which it was possible to es-
tablish as embracing all cases of puerperal septicaemia,
and each case was a law unto itself and should be
treated according to the individual indications. In
many cases curettage was called for, and he did not
agree with those who condemned the use of the cu-
rette, for he believed it had a definite place in uterine
surgery.
Dk. E. a. Spohn, of Corpus C'hrijjti, Tex., was
strongly opposed to the use of the curette in these
cases, regarding it as a dangerous instrument, the em-
ployment of which, unless possibly in certain extreme
and very exceptional cases, was unjustifiable.
Third General Session — Thursday, November igth.
The closing session was held in the chamber of
deputies on Thursday evening. .After the reading of
the treasurer's report, Dr. Porfirio Parra delivered
an address in which he reviewed the progress made in
medical science of recent years, referring to Pasteur,
Lister, Koch, and other leaders in the triumphant
march. He rejoiced that Mexico had had the honor of
receiving this representative body of American physi-
cians.
Dr. Rked reported that the executive committee had,
in response to the invitation of Dr. Costa Ortiz, de-
cided upon Caracas as the place of meeting of the
third congress, in December, 1899.
Addresses were then made by the delegates from
each government, represented as follows: Drs. La
Chapelle, Canada; Lee, Colombia; Coronado,
Cuba; Vela, Guatemala; De Bayle, Nicaragua;
Ortiz, Venezuela; La Vista, Peru and Ecuador; and
Calneck, Costa Rica.
The latter said he was born in Canada, educated: in
the United States, and practised in Costa Rica, and
he was therefore well fitted to speak of Pan-American-
ism, a spirit which should animate and bind together
all the people of the western hemisphere. To know
thoroughly and appreciate the Spanish Americans, one
should live among them and meet them in their hos-
pitable homes and in the bosom of their families,
where the charming traits of their character find full-
est expression.
Dr. Reed, on behalf of the members from the Unit-
ed States, gave voice to the, friendly sentiments and
gratitude of his associates. "We tame here," he
said, " feeling somewhat as strangers, but go home
feeling as brothers. Vour cordial, your generous hos-
pitality, your splendid entertainments, and your distin-
guished attentions have won our affections and shall
abide in our memories. We return to oiir homes in
the North, and in the fullest meaning of the word we
feel as if we are leaving part of our hearts in the glo-
rious and beautiful land of the Montezumas."
The closing address was by Dr. Gregoria Mendi-
zabal, and at its termination Minister Baranda de-
clared the second Pan-.American medical congress
closed.
Aortic Regurgitation with Mitral Stenosis. —
I^ Tr. strophanthus,
Tr. nucis vomica;,
Tr. digitalis .la p. x.
M. S. gtt. XX. to XXX. t. i. d.
— W. H. Thomson.
Blood Stains. — Dr. Blenkiser in the Sealpcl says
that surgical instruments, sponges, the hands of the
operator, and blood-stained articles may be readily
cleansed by washing them in a tepid solution of tar-
taric acid and rinsing in water without soap.
The Cure of Crying Babies. — In a New York nur-
sery, as soon as a child begins to cry, the nurse
catches it up, holds it gently, and places her hand
over its nose and mouth, so that it cannot breathe.
The crying ceases directly, and the child is allowed
to breathe freely again. Should it a second time at-
tempt to scream, the same simple and effectual method
is applied. This is repeated until the baby imagines
that the painful stoppage of the breath is caused by its
own effort to scream, and so is careful to keep quiet.
— Argus.
Trichocephalus Dispar. — Dr. Moosebrugger (Cor.
Med. Press and Cir., vol. Ixii., No. 2,991) reports three
instances of children, aged respectively one, three, and
three and one-half years, who were affected with tri-
chocephalus dispar, and suffered severely from hemor-
rhage of the bowels, diarrhoea, and great prostration.
One of the children died from intercurrent croup.
Post-mortem examination gave evidence of severe ca-
tarrh of the large intestines, with two small ulcers in
the descending colon and a recent cicatrix in the
transverse colon. In the colon eight hundred and
eighty-nine specimens of the entozoon were found. In
the other two cases large quantities of the ova were
found in the faeces — in one, eighty-eight hundred and
seventy-eight were estimated to exist in one cubic cen-
timetre. Dr. Moosebrugger concludes, from the favor-
able results obtained, that the presence of this parasite
is not so fatal as is commonly supposed.
1
November 28, 1896]
MEDICAL RECORD.
799
A Sudden Decline in temperature during typhoid
fever is a warning of hemorrhage from the bowels. —
TAc' Medical Summary.
Indications for Nephrectomy. — Dr. Kuester gives
the following indications for operation: i. Tumors
of the kidney. 2. Tuberculosis of the kidneys; ex-
perience has shown that renal tuberculosis occurs very
often primarily and unilaterally; it aftects the genitals
and the lower urinary passages more frequently than
some other parts of the body. Severe persistent ca-
tarrh of the urinary bladder is one of the first symp-
toms which tuberculosis of the kidney presents; in
cases of this kind nephrectomy gives excellent results,
and complete recover)' ensues. 3. Suppurating kid-
ney caused by metastasic processes and foreign bodies,
especially calculi. 4. Renal hajmophilia. j. Mov-
able kidney. 6. Injur)- to the kidney. 7. Calculous
diseases of the kidnev. S. Uretero-abdominal fistula.
Small Ovarian Tumors. — Dr. Davenport (Boston
Medical and Surgical Journal, October 8, 1896) gives
the following propositions as helpful in diagnosticat-
ing small ovarian tumors: i. Small pelvic tumors are
usually accompanied by well-marked symptoms. 2.
Pain is usually present, but its seat does not have any
constant relation to the kind of tumor or its location.
3. Menstrual disturbances are the rule, and by far the
most frequent abnormality is menorrhagia or metror-
rhagia, or both. 4. There seems to be a direct causal
connection between severe uterine hemorrhage and
cystic ovaries which are closely adherent to the uterus.
5. Uterine hemorrhage associated with a pelvic tumor
which is uninfluenced by intra-uterine treatment (cu-
retting or electricity) is more likely to be due to an
ovarian tumor than to a fibroid. 6. Reflex .symptoms
are comparatively rare, and occur in the later stages
of the disease.
Peritoneal Wounds — Dr. L. McLane Tiffany
[American Journal of //le Medical Sciences) reports four
cases of wounds of the peritoneal cavity and thinks
the following propositions are justified: i. A pene-
trating wound of tiie peritoneal cavity is not accom-
panied by symptoms commensurate with the extent of
the injury. 2. Many fatal lesions may be present,
yet give rise to no marked symptoms. 3. Fatal le-
sions may exist, yet shock be wanting. 4. The wound
of entrance should be enlarged, and, if the missile have
entered the abdomen, a section is called for. 5. Oper-
ation is proper soon after the injury, before the
peritoneal membrane has become infected or much
blood lost. 6. Flushing the open peritoneal cavity
with hot water or hot normal salt solution is an ex-
cellent stimulant to the heart. 7. The abdominal
wound should be closed when practicable, drainage
being provided for.
Puerperal Self-infection. — Dr. Charles Jewett
[American Gynecological and Obstetrical Journal) read
a paper on this subject before the New York Medical
Society in which he draws the following conclusions:
There is no clinical proof that puerperal infection can
occur from normal vaginal secretions. All childbed
infection in women previously healthy is by contact.
Prophylactic vaginal disinfection as a routine measure
is unnecessary, and even in skilled hands is probably
injurious. Its general adoption in private practice
could scarcely fail to be mischievous. In healthy
puerperae delivered aseptically post-partum douching
is also contraindicated. These rules must hold good
in the simpler cases of manual or instrumental inter-
ference in which the uterus is not invaded. A puru-
lent vaginal secretion exposes the woman to puerperal
infection. In the presence of such discharges at the
beginning of labor the vagina should be rendered as
nearly sterile as possible. Concentrated antiseptic
solutions should not be used, and the process should
be conducted with the least possible mechanical injury
to the mucous surfaces. In case of highly infectious
secretions the preliminary disinfection should be fol-
lowed by douching at intervals of two or three hours
during the labor. Sterilized glycerin or other suitable
material may be used to restore the proper lubrication
of the birth canal. The safest and most efficient
means for correcting vicious secretions is a mild anti-
septic douche, repeated once or more daily for several
days during the last weeks of pregnancy. It is the
duty of the obstetrician to know before labor the
amount and character of the vaginal discharge. Clin-
ically, the amount of the discharge, its gross appear-
ance, and that of the mucous and adjacent cutaneous
surfaces, usually furnish a sufficient guide to the treat-
ment. Probable unclean contact within twenty-four
or forty-eight hours before labor is an indication for
prophylactic disinfection.
Prevention of Hernia after Abdominal Section.
— Dr. Emory Lanphear says : " From a rather extensive
series of experiments, as well as from observation of a
number of cases upon which I have had to operate for
hernia following abdominal section, I am of the opin-
ion that rupture, subsequent to operation, is almost
invariably due to faulty suturing. For this reason, I
always close the peritoneum separately and carefully
with catgut stitches, unless there is the utmost need of
rapidity in completing the operation. If the two cut
margins of the peritoneum be brought into close ap-
position, so there is no little hole through which the
omentum can force itself, and if over this the muscular
tissues be carefully sutured, there is but trifling dan-
ger of post operative hernia. In a large number of
sections I have never had a rupture follow such clo-
sure. In introducing the stitches of silkworm gut
through the skin, muscle, and fascia, it is best to catch
up the raphe formed in suturing the peritoneum, in-
cluding it in about every other one of the sutures, thus
preventing the formation of pockets, which favor the
development of hernia. Another point — I always
make the incision a little to one side of the median
line, through the rectus muscle, as 1 believe union will
be more prompt and strong in the vascular muscular
tissues than in the non-vascular structures of the linea
alba. The sutures should be left as late as the tenth
day before removal, in ordinary cases ; longer in ex-
traordinary ones."
General Rules for the Treatment of Hydatids of
the Liver Dr. Frank (American Journal oj the Med-
ical Sciences, October, 1896) suggests the following
rules: "i. An incision over the most prominent portion
of the presenting mass, be this high or low; or, if no
tumor can be discovered, the area of hardening and
increasing dulness should be our guide for incision.
2. Examine for adhesions: if they be complete, our
work is simplified ; if not, we must sew the peritoneum
all around the mass so as to shut off the abdominal
cavity. 3. Introduction of the aspirator. This needs
no explanation; but it is well to bear in mind that we
do not always obtain the characteristic fluid, as at
times the fluid may be too consistent to enter the
needle. 4. We must wait for three, four, or five days
for adhesions to become firm before opening the cyst.
5. When the cyst is opened a large opening should be
made and the largest-sized rubber-drain introduced.
6. The dressings must be made under strict antiseptic
precautions, as there is a possible danger of secondary
infection. 7. The cyst-cavity should be washed out
with sterilized water for the first week, after this with
carbolic-acid solution, iodine solution, peroxide of
hydrogen, boric acid, creosote, or any of the antiseptic
8oo
MEDICAL RECORD.
[November 28, 1896
solutions. . The point on which there has been more
diversity of opinion than any other is: When there
are no adhesions, should the operation be made in one
or two sittings.' Most authors advise two operations,
claiming that there is too much danger of allowing the
hydatid fluid to enter into the peritoneal cavity, which
would perhaps result fatally, or it might form a nucleus
for another cyst. With care an operation of this kind
can be performed in one sitting, as my first case will
show; but the best plan is, if time will permit, first to
sew the peritoneum to the sac and wait four or five
days for the adhesions to become firm, as was done in
my second case."
Indications for Mastoid Operations in Acute Pur-
ulent Otitis Media. — Dr. Knapp {Arch, of Otology,
xxiv., 3 and 4) concludes from his observations
that: I. There is in acute otitis media no symptom
which by itself constitutes a sufficient indication for
mastoid operation. Neither is there any one symp-
tom which contraindicates it, with the exception, per-
haps, of deep coma. The most important symptoms
are local pain, spontaneous and on pressure, headache,
rise or fall of temperature, dizziness, nausea, vomit-
ing, stupor, aphasia, hemianopsia, optic neuritis, paral-
ysis, and coma. Choked disc from otitic brain disease
may disappear with either operative or spontaneous
recovery of the patient. 2. The indication for ope-
rating is derived from the ensemble of the symptoms
and the course of the disease. 3. Even if the patient
does well and seems cured, he should not be lost
sight of for weeks or months, for acute purulent mas-
toiditis is a treacherous disease. 4. Whatever the
symptoms be, we should, as a rule, begin the operation
by opening the antrum, and then be guided by the
conditions coming into view.
The Limits of Vaginal as Compared with Ab-
dominal Exploratory Section Dr. Henry C. Coe
{Neiv York Polyclinic, June, 1896) gives the conditions
which lead him to select the abdominal method of ex-
plorations: '' I. In the case of neoplasms or obscure
enlargements which are situated in the abdominal
cavity, or have risen above the pelvic brim, especially
if they are more or less adherent. 2. In ascites of
doubtful origin, more particularly when tuberculous
or malignant disease is suspected. 3. In cases of
disease of the adnexa in which the latter are situated
near or above the pelvic brim, as established by bi-
manual palpation. 4. In cases in which the history
and symptoms point to general intestinal adhesions,
and, above all, when appendical complications are sus-
pected. 5. In ectopic gestation before rupture, when
the sac is high up, at the side or in front of the uterus,
instead of in Douglas' pouch. 6. In cases of intract-
able pelvic and abdominal pain of obscure origin,
including the so-called neuroses. On the other hand
explorative vaginal section should be preferred: i.
In all cases in which the presence of pus within the
pelvis is suspected, as in pyosalpinx, pelvic abscess
proper, suppurating dermoids and cysto-adenomata,
and hematocele. 2. In the case of small intrapelvic
tumors situated in the pouch of Douglas, or at least
readily accessible from below. Impacted ovarian
cysts, dermoids, and fibroids belong to this category.
3. Adherent adnexa situated in the true pelvis. 4.
Unruptured ectopic sacs in the same locality. 5. Cir-
cumscribed exudates and indurations in the broad
ligaments or behind the uterus, especially when asso-
ciated with displacement and fixation of the latter
organ."
Treatment of Prolapse of the Rectum by Tor-
sion.— This procedure is based on that proposed by
Gersung for urethrocele in women and which V^reden
has used for rectal prolapse. A circular incision is
made around the anus half a centimetre outside of the
limit of pigmented skin. The rectum is separated
from the surrounding tissues to the level of the levator
ani. All prolapsed parts are replaced, twisted to an
angle of I8o^ so that the external opening will per-
mit only the passage of a single finger, and fixed in
this position by silk sutures. Union takes place
quickly, and recovery is rapid and complete. The
author, having used this method in two cases, explains
the favorable results of this simple and almost blood-
less operation by (i) the tension caused by twisting
all the layers of the rect.-.l wall; (2) the even diminu-
tion in calibre of the lower portion of the rectum from
the level of the levator and by its spiral direction,
which prevents the recurrence of prolapse.— Gazette
ties Hopitciiix.
Cancer of the Cervix. — Early hysterectomy even in
doubtful cases, since microscopic findings are not in-
fallible.— CORDIER.
Adhesive Affections of the Ear. — Inject liquid
vaseline through the Eustachian tube into the tym-
panic cavity. — Delstanche.
Acute Otitis. — For the earache of this affection,
apply dry heat. At no time should the canal be
mopped, swabbed, or syringed. — Burnett.
Ice Bandages are useful in traumatism of the ex-
ternal ear; in inflammatory processes of the auricular
canal; in chronic suppuration, when sensitiveness,
etc., develops over the mastoid. — Boeke.
Corneal Ulcer. — Formalin solution, i to 200 to i
to 500, for touching the ulcer once daily. As a gen-
eral collyrium, i to 1,000 to i to 2,000. — Burnett.
To Prevent Hemorrhage. — An hour before opera-
tion a pint of water containing an ounce of chloride
of calcium was injected into the rectum (to increase
the coagulability of the blood). During the opera-
tion Wright's fibrin ferment .solution was applied to
the freshly cut surfaces. — M'atson Cheyne.
A Perfect Needle should be adapted for use by the
surgeon's fingers without needle holder, excepting for
work in deep cavities. The point must be sharp and
the eye large enough to be readily threaded. Glover's
needles present the best pattern. The trocar-like
point should occupy about one-third the length of the
needle, and its greatest diameter should be near its
middle portion. — John B. Roberts.
Massage in fracture of the clavicle is recommended
by Dr. Dagrou (Jour, de Aled. et tie C/iir.). Fractures
of the extremities of the bone are more amenable to
massage, as they present less deformity than the me-
dian variety. Atanipulation must not encroach upon
the fragments themselves. The arm is fixed in an or-
dinary sling, which, after the fifteenth day, can be put
on outside of the clothing. Consolidation occurs from
the eighteenth to the twenty-fifth day.
Suppositories for Acute Localized Prostatitis. —
I? Iodoform,
E.\tract of hyoscyamus aa gr. ss.
Cacao butter gr. xlv.
— GuKPiN, Journal des Praticiens, August 15, 1896.
Gleet. — The following injection is for daily use in
post-gonorrhceal discharges:
R Mercuric chloride,
Zinc sulphate gr. xij.
Boric acid J i.
Distilled water J vi.
— Neilson, Philadelphia /'olyclinic.
November 28, 1896]
MEDICAL RECORD.
801
Injury at the Elbow-Joint. — Be very guarded in
your prognosis in cases of injury at the elbow. A
fracture into this joint treated with the most'far-seeing
precautions may be followed by more or less stiffness
and disability. Begin passive motion as early as pos-
sible, delaying only long enough to allow the first
pain and reaction from the injury to subside. In most
cases this will allow some manipulation of the joint
by the end of the first week. — Iiiteniatwiial Journal of
Surgery,
Corneal Opacities Electrolysis, the kathode being
applied to the eye by means of a small silver rod with
rounded end. An ordinary sponge anode may be ap-
plied to the opposite cheek. A pressure of from one
and one-half to three volts is sufficient. This should
be at one-fourth milliampere, and one-half should
never be exceeded. The eye is cocainized and the
silver rod is rubbed lightly over the opacity for about
one minute. — Steven.son, Canada I.ancc/, November.
The Etiology and Treatment of Venereal Buboes.
— Dr. Perry, after collecting statistics on the above
subject, draws the following conclusions in the Amer-
ican Journal of the Medical Sciences, November, 1896:
1. That buboes are probably caused by the absorption of
chemical poisons, the result of the action of the micro-
organisms in the chancroid, and not to the entrance of
the micro-organisms themselves into the lymphatics.
2. That the benzoate of mercury yields such satisfac-
tory results that it should be employed in the treat-
ment of non-suppurating buboes, and excision reserved
for those cases in which benzoate has failed. 3. The
injection of iodoform ointment should be used in the
treatment of all freely suppurating buboes, since sta-
tistics show that it yields much more satisfactory re-
sults than the other methods of treatment applicable
to this variety. 4. Incision and curettage should
be used in a few cases in which the skin has been de-
stroyed and the ulcer presents an unhealthy granulat-
ing surf ace. 5. Excision should be reserved for cases
that have not yielded to other treatment, and for those
in which there are several foci of suppuration.
Malignant Disease of the Body of the Uterus.
• — Dr. F. B. Jessett writes, in the Medical Press and
Circular, Octohtr 21st, upon operation in the above
condition, giving the results in seventy-five cases.
He says: "In ordinary cases, in which the uterus can
be completely drawn through the vulva, its removal is
a simple matter, but in my experience these cases are
like angels' visits, few and far between. The lessons
to be derived, then, may be summed up: i. In all
cases of women suffering from leucorrhoeal discharge,
do not hesitate to insist upon a vaginal examination.
2. If on examination a discharge is seen escaping from
the OS in a woman at or past the menopause, which
discharge is occasionally slightly colored and offen-
sive, dilate the canal and curette the cavity of the
uterus for microscopic examination. 3. If the report
is unfavorable, at once urge total extirpation of the
organ. 4. Even in advanced cases, so long as the
uterus is movable, I am convinced that much relief
can be afforded and life prolonged by vaginal hyster-
ectomy. To my mind, the man who will limit the
operation only to those cases in which he can pull the
uterus well down through the vulva is certainly not
doing the best that can be done for his patient. One
might just as reasonably argue that because a carcino-
matous breast is somewhat fi.xed on the glands affected,
the surgeon should not remove it. What surgeon
would hesitate to do this? Moreover, in a somewhat
large experience in the post-mortem room, I found the
lumbar and sacral glands free from infection in many
cases in which the disease was far advanced."
® oricjespondjeuce.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE COMING ELECTION — LONDON WATER " DAVID
LEWIS trust" and hospitals — SOCIETIES DWARF-
ISM— CANCER OF TONGUE — BIGELOw's OPERATION —
THE LATE SURGEON-GENERAL MUNRO — DIPHTHERIA
— GLASC;OW UNIVERSITY — IRISH ACADEMY — SIR
WILLIAM MACCORMACK.
London, November 6, 1896.
As the election of three members to the general med-
ical council draws near, the signs of activity increase.
Our usually apathetic profession has been stirred in
various quarters, and the friends of the several candi-
dates are exerting themselves more than at previous
elections. Alas, there are too many candidates — no
less than eleven for three vacancies. Many votes must
be lost by this division, but it is certainly a better
sign than allowing a walkover. Several meetings of
practitioners have been held during the week to hear
the views of candidates, and have been well attended.
The most important meeting was on Tuesday at the
Medical Society's rooms, and was in support of Mr.
Rivington, who has been brought forward by the soci-
eties of members and fellows of the Royal College of
Surgeons. These two organizations have agreed to
support Mr. Rivington, and, as this college has more
than twelve thousand on its roll, he ought to have a
good place on the poll, although he came forward late.
The college is ruled by a council of twenty-four,
elected by fellows, and Mr. Rivington has always sup-
ported the claim of members to some voice in their
affairs. He is also opposed to the creation of an in-
ferior order of practitioners as midwives, and this is
a crucial question for the rank and file. It will prob-
ably dominate the contest. Dr. Rentoul, who made
such sacricfies to defeat legislation which would have
established midwives in a position independent of
medical men, loses no opportunity of ventilating the
question. He is also a candidate, and if the general
practitioners fail to carry him for one of the vacan-
cies they may have cause for bitter repentance.
The water supply of London seems a more serious
question than for some time was supposed. There is
no longer any doubt that the filtration sometimes fails.
The county council has decided to continue the inves-
tigation, and the revelations already made are likely to
urge on legislation. The previous work of the ana-
lysts has been shown to be defective. Organisms
many times larger than pathogenic bacilli have been
found in the w^ater as delivered. Of course, when
large ones pass the filter beds, smaller ones will find
the road clear. Bacilli coli communis have been
found, so that sewage pollution may be confidently as-
serted to have occurred at intervals. The companies
deserve no consideration, for they have made enor-
mous profits out of their monopolies and often failed
to fulfil their contracts. They have gained by a one-
sided arrangement, and the time has come for Lon-
doners to control their own supply.
The " David Lewis trust" arises out of the will of a
wealthy Jew, who left some ^"300,000 to two of his
friends. To one of these friends he also addressed a
letter, suggesting the use of the money for the benefit
of the people of Liverpool and Manchester. The two
friends accordingly determined to act on this sugges-
tion, although the will gave them the money abso-
lutely, and they associated with themselves leading
Manchester and Liverpool gentlemen to form the
" David Lewis trust." Hospitals were early to benefit.
The Northern Hospital of Liverpool was in need of a
better building, and gladly accepted ^60,000 from the
862
mp:dical record.
[November 28, 1896
trust, on condition of associating the name of the de-
ceased benefactor. So it became the David Lewis
Northern Hospital, and on October igth the founda-
tion stone of the new building was laid by the Coun-
tess of Derby, in the presence of some twelve hundred
citizens.
Manchester was offered a similar benefit. The trus-
tees proposed to give ^,'70,000 to St. Mary's and the
Southern Hospital, which were to be amalgamated,
the name of St. Mary's being retained, coupled with
that of David Lewis. The proposal did not seem to
suit some of the parties, or their mutual jealousies
were allowed to prevail. At length the trustees fi.xed
a date up to which their offer would hold good, and
■ after which they would proceed to devote the money to
other purposes. That date has expired, and now some
of those concerned are crying out for an extension of
time. Owens College was to have some connection
with the hospital, and it is said jealousy of this has
caused the breakdown. There are many hospitals
which would jump at the chance of being renamed on
such terms.
The opening meeting of the Medical and Chirurgi-
cal Society was signalized by a paper describing a
case of "Mixed Premature and Immature Develop-
ment." Mr. H. Gilford was the author, and he had
ransacked the literature of the subject. A similar
case, recorded by Mr. Hutchinson, appears in the
Transactions of the Society, 1886. The interest of
the case lies in its relation to dwarfism and giantism.
While the patient was clearly a dwarf, there were parts
that were more than fully developed, and Mr. Gilford
was led by this case to the study of dwarfism and gi-
antism. He sees a close relationship between these
deviations in nutrition, and suggests the term micro-
megaly as descriptive of his case and others allied to it.
He thinks it not impossible that the cause of acromeg-
aly operating before birth may bring about micromeg-
aly; for many giants have evidently owed their pro-
portions to the former. May the one be the congenital
condition of the other, or are the two opposite states?
Mr. Hutchinson holds that this subject and his own
were dwarfs, though they presented premature senile
changes, but he had not noticed premature develop-
ment of the intellectual faculties. Dr. Norman Moore
said, if disease such as syphilis could be excluded, the
state might be analogous to that seen in some am-
phibia, which may remain for a long time in the
larval stage and may suddenly pass to the adult or
even senile stage.
At the last meeting of the Medical Society of Lon-
don, Dr. Jennings read notes of thirty patients taken in
at the Cancer Hospital, supposed to be suffering from
cancer of the tongue, and pointed out some of the con-
ditions that are difficult to differentiate. Of the thirty
admitted, twenty appear to have been afflicted un-
doubtedly with cancer. Smoking, he considered,
if slight, could not be regarded as a cause, but
would aggravate the growth. Syphilis as a predis-
posing or exciting cause seemed to him beyond
doubt.
Mr. P. J. Freyer read a paper on the best methods
of removing large calculi from the bladder. Out of
three hundred cases of all ages, he had only had to cut
seven times, the other two hundred and ninety-three
cases being treated by litholapaxy. One year he
treated one hundred and six cases, with only one
death. Of forty-nine cases of large stones, i.e., of two-
ounce weight or upward, thirty-one had been cured by
Bigelow's method. When a stone is so large that the
lithotrite will not lock, he advises '"chipping" it by
grasping it on one side and screwing home the instru-
ment. He related one case in which he had removed
a stone of six and one-half ounces by litholapaxy.
He attributed much importance to the rapidity with
which a stone could be removed by Bigelow's opera-
tion.
Surgeon-General William Munro, C.B.,died on Oc-
tober 30th, in the seventy-third year of his age. He
retired in 1881, after thirty-seven years in the army
medical service. He served through the Kaffir war of
1846-47. In the Crimea he took part in the battles
of Alma, Balaklava, and the fall of Sebastopol. In
the Indian mutiny he was present at many engage-
ments and in the relief of Lucknow. In 1863 he was
chief medical officer in the operations in the Umbey-
lah Pass. His C.B. followed in 1865. He was the
author of several works, of which the best known are
" Reminiscences of Military Services with the Ninety-
third Sutherland Highlanders" and "Records of Ser-
vice and Campaigning in Many Lands."
The deaths from diphtheria in the last four weeks
have been 52, 66, 57, 64.
Mr. Chamberlain has been elected by the students
lord rector of the University of Glasgow. Some of
the students carried their excitement to the verge of
riot, and several had to be arrested.
The annual meeting of the Academy of Medicine
of Ireland took place on Friday, when a secretary was
elected in place of Mr. Thompson, who has become
the president of the Irish College of Surgeons.
Sir William MacCormack does not progress as rap-
idly as was expected. The lung, I hear, is clearing
gradually, but there is great weakness.
• GIVE- THE FULL NAME.
To THE Editor of the Medical Record.
Sir: Having been engaged lately in a literary work
involving considerable consultation of papers and veri-
fying of references, I have realized, as any one must
under the circumstances, the extra labor necessitated
by a practice which has always been more or less gen-
eral with authors, of mentioning only the surname of
writers and investigators referred to. Any one who
has had experience cannot fail to have been struck
with the large number of persons of the same surname
who are contributors to medical literature, so that a
reference to Dr. Sydenham's or Dr. Jones' views or to
Dr. Ranklin's papers gives a very imperfect idea of the
individuality of the author. Take, for example, the
name Hoffmann. The student will find in the sur-
geon-general's catalogue this surname more than one
hundred times, and of these many Hoffmanns quite a
number are authors of voluminous and important pa-
pers; so that to be told that Hoffmann believed thus
and so is of little assistance to the reader who desires
to look up his views and papers. Again, to take a
name to which modern medical literature often refers
— Laveran. .'\t least two Laverans, both French army
surgeons, have written papers of importance. The
Laveran whose name is so identified with the malaria
Plasmodium is A. Laveran,' while Louis Laveran is
a very different person. Yet writers quote only " La-
veran." It is needless to multiply instances. They
will occur to any one. My object in asking publicity
for this letter is to beg writers to adopt the practice of
giving the full name of the authority quoted. This, of
course, involves a little trouble at first to hunt up the
Christian name, but, as years roll on and we all are
thus explicit in indicating authorities quoted, it will
become easier and easier, while the amount of labor
saved to those looking up references will be immeas-
urable. Especially important is it that the editors of
the various handbooks and annuals, which are now
filling such a useful niche in medical literature, should
' Unfortunately even the surgeon-general's catalogue has not
the full Christian name.
November. 28,. 1896J
MEDICAL RECORD.
?03
adopt the practice of using the full name, for it is from
suggestions in such books that writers often want to
took up references.
James Tyson, M.D.
October 30, 1896.
CONGENITAL TEETH.
To THE Editor of the Medical Record.
Sir: After reading the article by Dr. E. S. McKee, in
your issue of October 17th, on congenital inferior in-
cisors, it inipresed me that the condition was of such
rare occurrence that it deserved mention ; hence these
short notes on the following case:
On January 11, 1895, I was called to confine Mrs.
M , a multipara. After a somewhat tedious labor
twins were born — a boy and a girl. The boy weighed
four pounds six ounces, the girl four pounds eight
ounces. They were both poorly nourished, the skin
falling in loose folds over the whole of the body, of a
brown-yellow color, almost simulating jaundice. The
fontanelles were large, rachitic to all appearance. But
the abnormality that at once impressed the mother and
the rest of the family as a most deplorable ill omen was
the discovery of an upper incisor tooth in the girl and
two lower ones in the boy. The teeth were all loose,
being held, as it appeared, only by a depression in the
gum, the teeth being free from the alveolar process.
The girl lost her tooth in the first twenty-four hours —
what became of it no one knew. The bov retained
both of his until the second week, when, being greatly
in the way of his nursing, I removed them with my
fingers. The gums after the extraction did not bleed.
Both children died in their fifth month, of the same
ailment — splenic anamia. Numerous microscopical
examinations of the blood were made. The spleens
were so enlarged as almost to occupy two-thirds of
their respective abdominal cavities. No necropsy was
permitted.
A. S. Waiss, M.D.
3,000 St. Charles A\em e, New Orleans, La.
THE IMMORALITY IN CANADA.
To THE Editor of the Medical Record.
Sir: Regarding the truthfulness of the statements
made in the Dominion Aledical Monthly on bicycle
riding which you quoted under the above caption in
the editorial columns of the Medical Record, No-
vember 7th, one hundred per cent, of the reputable
physicians and probably ninety-nine per cent, of the
unethical ones in Toronto, and for that matter through-
out all Canada, will agree in saying that if ever the
dimensions of a libel, as to its absolute falseness,
vileness, and harmfulness, can be measured, these
statements made in the Dominion Medical Monthly will
easily, in height, depth, length, and breadth, trans-
cendently excel all the exhibits of libels ever presented
by either medical or lay press. The editorials in
the Medical Record have three cardinal virtues.
They educate, arouse, and delight. If your caustic
comments on your contemporary of the Dominion Med-
ical Monthly do not contain much of the first and last
elements, they contain more than quantum sufficit of the
second.
The facts, Mr. Editor, are that lady bicyclists in
Toronto, as no doubt they do elsewhere, sit erect and
ride very gracefully, and that the use of the bicycle
has the slightest tendency injuriously to affect morals
by sensuous erethisms or orgasms is most conclusively
refuted by the fact that an ever increasing number of
clergymen's, teachers', and physicians' wives are rid-
ing them and alloaving their daughters to do so. The
consensus of medical opinion as recently obtained by
a reporter for one of our dailies is that, barring those
suffering from certain diseased conditions, bicycling
furnishes, for women especially, a useful,-healthy, in-
invigorating, and very enjoyable recreation.
It may be added in conclusion, and out of respect
for reputable Canadian medical journalism, that this
very article had passed unnoticed into oblivion and
would doubtless have remained in "hades" had not
the Medical Record resurrected it and exposed its
heinousness.
John Hunter, M.D.
116 DovERCoi'RT Road, Toronto.
^edicat Items.
Contagious Diseases — Weekly Statement Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending November 21, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis,
.Measles
Dipiitheria
Small-pox
Hallucinations of Vision.— Facts relating to hallu-
cinations of vision in those from whom the eyeballs
have been removed or in whom the globes are c'ongen-
itally absent are sought by Dr. Thomas M. Stewart,
and any communications bearing upon the question
will be acknowledged with thanks if sent through the
Medical Record or addressed directly to 704 Elm
Street, Cincinnati, O.
Ethics. — The code governing Paris societies says:
"It is good confraternity to accept the consulting
physician desired by the family, no matter what his
age, his grade, or his situation, providing his personal
honor and regular professional standing are not in
dispute."
We Need the Same.— In Germany a law is said
to exist which holds the newspaper as well as the ad-
vertiser responsible for assertions made. If a promise
to cure is held out and the remedy fails, prosecution
is liable to follow.
Acute Urethritis.— At the out-patient department
of Roosevelt Hospital we use as a routine practice the
internal administration of five grains of salol every
three hours, and we think that it does good.— Moul-
TON.
What X-Rays Will Do.— A fond mother reported
that with their aid a coin which her son had swallowed
had been distinctly located in his sarcophagus.
Formaldehyde solution in alcohol has been praised
by Rosenberg {Deutsche med. H'och.) as a disinfec-
tant. The vapor given olT is said to be specially valu-
able for the disinfection of rooms. In pertussis and
phthisis it is claimed to give relief from attacks of
embarrassed respiration. Meat, eggs, and other arti-
cles of food exposed to the vapor and then covered
with a thin layer of the solution will keep for months
free from putrefactive changes, but their value as food
cannot be said to be improved by the process.
Microscopists and Pathologists are entitled to a
fee when their examinations aid in the conduct of
a case. It is a consultation, and the consultant should
not be expected to give valuable opinions, arrived at
8o4
MEDICAL RECORD.
[November 28, 1896
through hard and specially skilled labor, just for the
fun there is in it.
Medical Students. — Munich has 1,502, Vienna
1,370, and Berlin 1,118. — Universitdts Kaknder.
A Double Hymen. — A curious case is recorded in
the Comptt-s Remiiis de la Society Mcdicak dc Tambor,
1895, which concerned a young peasant woman who,
accompanied by her husband, presented herself at the
consultation of Dr. Olenine and gave the following
history: She had always been in excellent health;
began menstruating at the age of fifteen, since which
time she had always been regular. During the nine
months of her married life coitus had never been sat-
isfactorily accomplished, though frequently attempted,
despite extreme pain in the effort. Examination re-
vealed a thickened fleshy hymen with an opening at
its upper part. At one or two centimetres beyond
this, and situated in the inferior third of the vagina,
was a second membrane with a small central orifice.
This completely closed the calibre of the vagina, but
by a crucial incision of both inner and outer barriers,
in the words of the report, the woman was rendue a la
vie conjiigale.
Meat Diet. — The annual consumption of flesh for
each inhabitant of the United States is 120 pounds;
Great Britain, 105 pounds; France, 74 pounds; Ger-
many, 69 pounds.
Poisoning by Plumbo-Solvent Water Supplies. —
A special report to the local government board of
Great Britain, made by Inspector W. H. Power, gives
the results of an original investigation concerning the
effects of moorland waters, in respect of their plumbo-
solvent ability. The results go to confirm the micro-
bic theory of lead solution. The investigation is not
yet ended, but the chief propositions, as contained in
the Glasgow Sanitary /on ma I, are these: i. The lead-
dissolving property of moorland waters is associated
with acidity. Moorland waters that are acid invari-
ably possess ability to dissolve lead. At the same
time they may, or may not, erode this metal. Many
moorland waters which dissolve lead to a considerable
e.Ktent possess, in regard to this metal, no conspicuous
erosive power. Other moorland waters both dissolve
and erode lead in a very decided fashion. Moorland-
peat waters are all, it would seem, not far removed
from possession of one or the other property, or of
both properties. 2. There was indication also of close
relation between amount of acidity and vigor of sol-
vent action on lead. But the correlation does not
amount to complete parallelism. Different waters of
equal acidity did not necessarily possess equal power
of dissolving lead. 3. In certain circumstances moor-
land waters are found to increase in acidity, and
therefore in lead-dissolving potency. This is true of
waters on peat soil. 4. Peat soil, from various gath-
ering-ground.s, was found to be, when moist, invariably
acid. 5. When divorced from the peat, the moorland
waters did not increase in acidity. 6. When "sterile
(neutral) peat-essence" was added to freshly collected
samples of acid moorland water, the result was bac-
terial growth and, in most cases, acid reaction in the
peat-essence. 7. When the acid water was added to
the peat-essence (sterile and neutral), the result was
bacterial growth and, in most cases, acid reaction in
the peat-essence. 8. Thus the water must have con-
tained bacteria that, by acting on some substance in
the peat, were capable of increasing the acidity of the
mixture. 9. These bacteria are derived from the peat.
10. To separate samples of distilled water that was
neutral in its reaction and which did not dissolve lead,
there were added small amounts in each instance of
moist peat soil from different selected gathering-
grounds. As a result, every sample of distilled water
developed in a short while acid reaction and was
found to have acquired ability to dissolve lead. 11.
To separate samples of sterile peat decoction which
did not dissolve lead, there were added minute amounts
in each instance of moist peat soil from different
gathering-grounds. As a result the samples of peat
decoction always developed bacterial growth, and at
the same time were usually found to possess acid re-
action and ability to dissolve lead. 12. Of the
microbes discovered in the above peat decoctions
only two, named provisionally "O" and " Q," were
found to make sterile peat decoction acid, and to con-
fer on it the ability to dissolve lead. 13. Lastly,
moist peat soil from a variety of gathering-grounds
yielded two microbes identical with "O" and " Q,"
which, when inoculated into sterile peat decoction,
multiplied therein with considerable vigor, produced
in the medium acid reaction, and conferred on it abil-
ity to dissolve lead. These brilliant results will now
be applied to the vast areas selected. The distribu-
tion of lead poisoning will be noted and verified.
Doubtless many peculiarities, otherwise unexplained,
will now fall into their place as natural deductions
from the life history of these microbes. And thus,
surely a suflnciently startling conclusion, lead poison-
ing by moorland waters almost leaps into the circle of
infectious diseases.
Wkile the Medical Recokd is pleased to receive all new publi-
cations which may he sent to it, and an acknowledgment will be
promptly made of their receipt under this heading, it must be with
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or reinew any publica-
tion received by it which in the judgment of its editor will not be
of interest to its readers.
Human Anatomy, General and Descriptive, for the Use
OF Students. By John Cleland, M.D., and John Yule Mackay,
M.D. 8vo, 833 pages. Illustrated. The Macmillan Company,
New York. Price, $6. 50.
A Treatise on Surgery by American Authors. Edited
by Roswell Park, M.D. Vol. II., Special or Regional Surgery.
8vo, 804 pages. Illustrated. Lea Brothers & Co., PWladelphia,
Pa.
Manual of Disf.ases of the Ear. By Thomas Barr, M.D.
Second edition. 8vo, 415 pages. Illustrated. The Macmillan
Company, New York. Price, $3.50.
Transactions of the Fifty-First Annual Meeting of
the Ohio State Medical Society. May, 1896. 8vo, 493
pages.
A Practical Method for Easy and Thorough Self-
Instruction IN THE German Language. By Solomon
Deutsch, A.M. Second edition. Svo, 512 pages. J. H. Vail
& Co., New York.
Anatomical Atlas of Obstetric Diagnosis and Treat-
ment. By Oscar Schaeffer, M.D. l2mo, 234 pages. Illus-
trated. William Wood and Company, New ^'ork. (Wood's
Medical Hand Atlases.)
The Medical Record Visiting List for 1897. William
Wood and Company, New York
The Medical News Visiting List for 1897 Lea Brothers
&Co., Philadelphia, Pa.
Essentials of Physical Diagnosis of the Thorax. By
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The Cell in Development and Inheritance. By Ed-
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Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 50, No. 23.
Whole No. 1361.
New York, December 5, 1896.
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THE SERUM TEST OF WIDAL AND THE
POSSIBILITY OF ITS APPLICATION WITH-
OUT MICROSCOPIC EXAMINATION, WITH
A REPORT OF CASES AND DEMONSTRA-
TION OF METHOD.
By CHARLES LYMAN GREENE, M.D.,
INSTRUCTOR IN PHYSICAL DIAGNOSIS AND CLINICAL MEDICINE IN THE UNI-
VERSITY OF MINNESOTA ; VISITING PHYSICIAN TO THE CITY AND COUNTY
HOSPITAL, UNIVERSITY FREE DISPENSARY, ETC., ST. PAUL, MINN.
The great importance of the serum test of Widal for
the diagnosis of typhoid fever must serve as my ex-
cuse for appearing on the programmes of two succes-
sive meetings of this society.
In a former report I stated that with such evidence
as we then had it would appear quite possible that we
had at last found the long sought pathognomonic sign
of typhoid fever, and in the light of a more extended
personal experience I desire to express the opinion
that the test is absolutely pathognomonic, whether per-
formed with fresh or with dried blood. In support of
this view I shall cite a series of cases, make a brief ref-
erence to the recent contributions to this most interest-
ing discover)-, and call attention to the fact, not hitherto
mentioned, that even macroscopic methods may suffice
for its application.
As has been the case with most important advances
in bacteriology and serum diagnosis and thera|3y, we
are able to trace the test of Widal through several
successive steps and must gi\e credit to Pfeiffer, Gru-
ber, Grijnbauni, and Durham for important preliminary
obsen^ations, and to Dr. \\'yatt Johnson, of Montreal,
for the first application of this method to board-of-
health work, and for having, independently of Widal
and without knowledge of the latter's prior announce-
ment, shown that equally good results were obtained
if dried blood were used instead of the fresh serum.
Pfeiffer in May, 1894, found tliat cholera vibrios,
mixed with the serum of an immune animal and in-
jected into the peritoneal cavity of a guinea-pig, lost
their motility and underwent a peculiar change in
physical characteristics. In November, 1894, he
found that typhoid bacilli underwent similar changes,
and he also found that the blood serum of a typhoid-
fever patient would produce the same results. Gruber
in 1895 found tliat if the serum of an immune animal
were added to a bouillon culture the bacilli became
agglutinated and lost their mobility. No use was
made of these discoveries, however, save as a means
of identifying the bacillus, and to Widal belongs the
credit of transposing these findings and adapting them
to the needs of clinical diagnosis by studying the
effect of the blood serum of a typhoid patient upon
the pure culture of the bacillus typhosus.
He first reported his clinical results on June 26,
1896, and later suggested the use of dried blood in-
stead of the fresh serum, when the latter could not
easily be procured. The present status of the test
justifies the following statements:
(n) That the blood or lilood serum, and very fre-
quently the urine, of a typhoid patient, by virtue of a
specific antitoxin, causes, when added to an emulsion
of the pure culture of Eberlh's bacillus in hanging
drop or ordinary cover-glass preparations, a character-
istic loss of motility with agglutination and grouping
of the bacilli.
(/') That this reaction may and generally does occur
as early as the fourth or fifth day and is variable on
the eighth or ninth, lasting generally throughout con-
valescence and very often for many months after com-
plete recovery. (Widal thinks for years in some
cases.)
(f) That the antitoxin of a typhoid patient acts thus
only upon the bacillus of typhoid. (This has been
denied as to the colon bacillus, but the denial is im-
material from a clinical standpoint.)
{d) That the blood serum or urine of patients sufTer-
ing from diseases other than typhoid does not so aft'ect
the typhoid bacilli.
((■) That dried blood retains the antitoxin un-
changed and may be used when the fresh blood or
serum is unobtainable. The antitoxin remains un-
changed in dried specimens for weeks and probably
for several months.
(_/) That the test is therefore pathognomonic of
typhoid and easily applicable to the use of public
laboratories.
The fact that no adverse reports have appeared
attests the simplicity and reliability of the test. Its
application requires only the possession of a moder-
ately high-power lens, :^— i- objective (an immersion
objective is not necessary), a tube containing the pure
culture, such as may be easily obtained from a public
laboratory, and such a rudimentary knowledge of bac-
teriological technique as w'ill serve to prevent the
contamination of the pure culture used and permit
proper reinoculation of fresh culture tubes from time
to time (about every two weeks). For such as do not
possess these facilities the public laboratories should
offer a means of ready assistance. The practitioner
would then need only to sterilize the skin of his pa-
tient's finger or ear, draw a drop or two of blood,
transfer it to a cover glass, visiting card, or any other
similar object, and send it closely sealed to the labo-
ratory.
Dr. Harry P. Ritchie, senior house physician, and
myself have made the following tests at the City Hos-
pital with results as stated below, using indifferently
fresh and dried blood. We have not found it neces-
sary to use the serum alone. We have so far experi-
enced no difficulty in the application of the test, and
iiave had frequent occasion to note its great differen-
tial value in doubtful cases.
Cases Tested. — i. Mary F., typhoid. Widal's re-
action on fourth day. Diazo marked. Spleen (?).
Rose spots. Temperature, 101-104° F.
2. Rinholt S., typhoid. Widal's test marked. Di-
azo marked. Seventh day, temperature, 102-103.5 ^'■
Spleen enlarged. Rose spots.
3. .\ndre\v P., typhoid. Widal's present Novem-
ber 6th. Diazo present November 7th. Tenth day,
rose spots. Enlarged spleen.
4. George F., typhoid. Widal's marked. Diazo
marked. Second week of a relapse, rose spots. En-
larged spleen.
8o6
MEDICAL RECORD.
[December 5, 1896
5. Jacob C, typhoid. Widal's marked. Diazo
marked. Middle of second veek, (ambulator))
temperature, 104-106 F. Spleen enormous. Rose
spots. Pulmonary stasis. Albuminuria.
6. W. J. M., typhoid. Test of Widal made on
twenty-fourth day after admission. Temperature
nearly normal. Reaction present.
7. J. N., typhoid. Test on fortieth day. Temper-
ature normal. Reaction present.
8. F. D., typhoid. Test on forty-si.xth day. Tem-
perature normal. Reaction marked.
9. A. G., typhoid. Test on sixteenth day after ad-
mission. Reaction marked.
10. J. J., typhoid (mild). Test on twenty-fourth
day. Reaction present.
11. R. Y., typhoid. Test on twenty-eighth day.
Reaction marked.
12. Mrs. C, typhoid. Test on thirtieth day. Re-
action marked.
13. M. P., typhoid (mild), 'i'est on twentieth day.
Reaction present.
14. Lizzie, typhoid. Test on sixtieth day. Re-
action present.
15. M. G., typhoid. Test on thirty-eiglith day.
Reaction present.
1 6. L. F., typhoid. Test on twenty-first day. Re-
action marked.
i6i. A. G., typhoid. Test on seventy-second day.
Reaction. (Case No. 7.)
17. D. D., ulcerative endocarditis. No reaction.
18. Laura, ulcerative endocarditis. No reaction.
19. G. T., broncho-pneumonia. No reaction.
20. Mrs. B., lobar pneumonia. No reaction.
21. F. S., lobar pneumonia. Widal's test, Novem-
ber 3d, negative. Diazo, November 2d, negative.
Duration of disease four days. Typical typhoid
tongue and countenance. Temperature, 104.4" F-
Spleen not palpable.
22. Mrs. H., pyloric stenosis. No reaction.
23. Mrs. S., septicEeraia (abortion). No reaction.
24. Diphtheria. No reaction.
«5. Diphtheria. No reaction.
26. E. W., gonorrhceal bubo with fever. No re-
action.
27. Phthisis. No reaction.
28. Phthisis. No reaction.
29. Phthisis. No reaction.
30. Tuberculous pleurisy. No reaction.
31. Erysipelas. No reaction.
32. Mr. B., erysipelas. Widal's test negative. Du-
ration of disease, three days. Temperature, 104 F.
33. Holtum J., alveolar abscess. Widal's negative,
November 5th. Diazo negative, November 5th.
Duration of disease five days. Temperature, 102.8
F. Spleen not enlarged. Sent in to hospital as ty-
phoid.
34. D. C. T., gastro-enteritis. Widal's negative,
October 31st. Diazo negative, October 3i.st. Dura-
tion of disease, five to six days; prodromata about ten
days. Diarrhoea gave good preliminary history of
typhoid. Temperature, 103-104° F. ; in three days
came to normal. Spleen enlarged (?) (not palpable).
35. Altin G., gastro-enteritis. Widal's, November
15th, negative. Diazo, November loth, negative.
Duration of disease, five days. Temperature, 100' F.
Spleen not palpable.
The total number of typhoid cases tested is not large
(si.xteen), but they are representati\e, and, being ward
cases, were carefully studied and thoroughly proven.
You will note the presence of the reaction on the
fourth day, its persistence until the seventy-second,
and the fact that in no disease other than typhoid has
any reaction been obtained. If it be not present on
the seventh or eighth day of fever, you are not dealing
with typhoid.
1 have here the dried blood of typhoid which has
been kept for ten days and will endeavor to demon-
strate the test, using as control the blood of pulmonary
tuberculosis and some from my own finger.
I first place upon a slide a large drop of distilled
water, sterilize my loop, and take from the culture tube
a bit of the pure culture, using every precaution to
prevent contamination of the growth. This bit of the
pure culture is stirred very thoroughly into the dis-
tilled water ancl another drop of distilled water is
placed upon the dried blood, which is thoroughly
moistened, a drop transferred to the emulsion of bacilli
and distilled water already prepared, and the whole
thoroughly mixed. The cover glass is dropped on and
the specimen is ready for examination.
If the reaction be absent, as will be the ca.se in the
slide prepared from the normal blood or that from the
case of tuberculosis, we shall find the bacilli in rapid
motion and not grouped, nor will they show any ten-
dency to group within fifteen minutes. On the other
hand we shall find in our typhoid-blood mount that
motion is rapidly lost and grouping well under way in
five or ten minutes. This going on until after a vari-
able period, the bacilli appear like islets in a sea,
and the slide viewed with the naked eye will present
the peculiar appearance described below.
The time required is very variable. Oftentimes
grouping is well under way before the field can be
brought into focus, and at other times five or ten min-
utes may elapse before it is well marked, and a half
hour or more be required for its completion.
The method described is simple but sufficient, and
the use of hanging drops, definite amounts of a bouillon
culture, etc., seem to be unnecessary for clinical work.
Nor does it seem to me necessary to wait for a com-
plete cessation of motion throughout the whole field,
inasmuch as decided grouping has not been observed
in any other disease.
.A. bouillon culture is preferable as being more eas-
ily and thoroughly mixed with the blood, and in using
it one need not place any distilled water on the slide.
Here a fine pipette should be used instead of the loop.
In using the cultures upon solid media, it is of
course necessary to bear in mind the necessity for
taking very little of the growth and stirring it in very
thoroughly, otherwise little clumps of bacilli might
mislead an inexperienced observer.
Both Dr. Ritchie and myself have observed a fact
not hitherto mentioned, viz., that the diagnosis can
very generally be made with the naked eye, a fact
which might sometimes be serviceable, though of
course the microscope is to be used when at hand. In
cases in which the reaction occurs, the whole mount in
cover-glass preparation may be seen with proper light
to assume a characteristic mottled appearance, not
present in mounts from cases in which the reaction is
absent.
It is to be hojied that the test will stand thorough
and extended investigation, for by it one of the most
difficult of diagnostic problems is made easy, and. so
far as diagnosis is concerned, Jaccoud's "greatest
problem of the nineteenth century" has found its
solution.
150 I.uwHV Akcakr, November 17, 1896.
lillll TOOK.\rMfY OF SERUM I)I.\GNOSlS I.\ IV-
rilOID FEVER.
K. I'feiffcr and W. Kolle : Zeitschr, f. Hyg., Bd. 221, p. 203.
Deutsche ined. Woch., i8g6, No. 12.
R. I'feifTer: Deutsche med. Woch., 1896, Nos. 7 and S. Cen-
tralblatt f. liakt., T9, iSqfj. p. 593.
M. (Iruber: Wiener klinische Woch. , i8g6, Nos. 11 and 12.
Mtinchener med. Woch., 1896, No. g. Wiener klinische Woch.,
iSgfi, No. 14.
Herbert Durham: Uritish Medical Journal, March 14, l8g6.
Grtinbaum: London Lancet, .September ig, t3g6, p. 806.
F. Widal: Soc. des Ilopitaux, June 26, i3g6. Bulletin Medi-
December 5, 1896]
MEDICAL RECORD.
807
cal, 1896, p. 613. Congres Fran^ais de Medecine, August 6,
1396. Bulletin Medical, 1896, p. 766. La Semaine Medicale,
August 3, iSi/i. Soc. des Hopitaux, July 31. iSg6. La Se-
maine Medicale. 1896, p. 303. Bulletin >ledical. 1S96, p. 736
and 934. La I'resse Medicale, July 2g, iSqO. Medicai, Rec-
ord, September 19, 1S96. La Semaine Medicale, July I, 1S96.
Widal and Sicard: Acad, de Med., September 29, 1S96. Bul-
letin Medical.
Widal, Chantemesse, Acliard: Soc. des Hopitau.^. La Semaine
Medicale, 1S96, p. 30.
Widal, Courmont, Achard, Hayem; La Semaine Medicale,
July 29, 1S96.
.■\chard: Soc. des Hopitau.s, July 31, iSgfi. La Semaine Medi-
cale, 1896, p. 395. •
.\chard and Bensaude: Acad, des Sciences. Bulletin Medi-
cal, 1S96, p. 933.
Dieulafoy: Acad, de Med., July 6, 1896. Bulletin Medical,
i3o6, p. 768. Journal des Praticiens, July II. 1896. La Semaine
Medicale, July 8, 1896.
Courmont: Soc. de Biol. (9 cases). La Semaine -Medicale.
1896, p. 294.
Haushalter: Troisieme Congres Franjais de Med. a Nancy (39
cases). Bulletin Medical, 1896, p. 7G9.
Thoelen and Mills: La Clinique (Brussels), August 6 and Sep-
tember 3, 1896.
New York Medical Journal, August 8, 1896 (note).
Medical News, October 17, 1896 (note).
London Lancet, October 24, 1896, Sheridan Delephine (dem-
onstration).
Wyatt Johnson: N. V. Medical Journal, October 31, 1S96.
Editorial: Medical Record, October 31, 1896.
Greene, Chas. Lyman: Report of Cases, Northwestern Lancet,
Noiember 14, 1896. Medical Record, November 14, i8i)6.
Catrin-Widal: La Semaine Medicale, October 21, 1896.
THE RADICAL CURE OF FEMORAL HER-
NIA, PREFERABLE OPERATION: THE
SURGICAL ANATOMY OF THE TRANS-
VERSALIS FASCIA AT THE INTERNAL
INGUINAL AND FEMORAL RINGS.
By J. COPLIN STINSON, M.U.,
S\S FK.\NCISCO.
Ix an earlier paper on the operathe treatment of in-
guinal hernia ' I reported seventy-nine cases in which
I had performed or assisted at a radical operation.
In this I shall report five cases of femoral hernia in
which radical operations were performed. Before
proceeding with this mijthod of the treatment of
femoral hernia, I shall give a concise description of
the transversalis fascia at the internal inguinal and
femoral rings, basing my report on excerpts from sev-
eral authorities ■' and on notes of some dissections I
have made. The subjects I used were two children
under five years of age, four children from five to fif-
teen, four adults form twenty to thirty, and two old
people from si.\ty to seventy. The transversalis fascia
is strongest and best developed in the inguinal region.
At the internal ring it consists, in most cases, of firm
and almost tendinous fibres. On the outer side of this
ring it forms a well-marked band called the outer limb
of the internal ring (Hesselbach, Henle), or the outer
portion of the tran.sversalis fascia (Sir A. Cooper).
This band passes along parallel with Poupart's liga-
ment and spreads out toward the anterior superior
spinous process. On the inner side of the ring is an-
other band of fibres similar to the one described. It is
the internal limb of the internal ring (Hesselbach,
Henle), or the inner portion of the transversalis fascia
(Sir A. Cooper). It proceeds from near the angle be-
tween the rectus and the pubis, and turns upward as
it approaches the internal ring, forming its inner
boundary. Some of these strong fibres can be traced
as far as the fold of Douglas. On the deep surface of
' New York .Medical Reihrd. .\[arch 7. 1S96.
-(17) J. Macready's "Treatise on Ruptures." (/>) H. Morris'
".A.natomy." (c) P. Tillau.K: " Traite d'.\natomie Topogra-
phique avec .\pplications a la Chirurgie. " (,/) C. Heath's " f)is-
sector. "
Oimbernat's ligament this fascia blends with the iliac
fascia and together, as they turn around its free bor-
der, gi\e the ligament a round edge. It is best marked
at its attachments:
1. To Poupart's ligament.
2. To the ileo-pectineal line (Gimbernat's liga-
ment) beyond the conjoined tendon.
3. Where it descends to the femoral vessels.
4. Where it separates the transversalis muscle and
the conjoined tendon from the peritoneum.
After it passes under Poupart's ligament it unites
with the iliac fascia to form the femoral sheath, the
transversalis forming the anterior, the iliac the pos-
terior layer. Under Poupart's ligament the sheath is
large, loose, and funnel-shaped. Well-defined con-
nective-tissue septa separate the artery from the \ ein
and the latter from the femoral canal. The internal
inguinal ring is a funnel-shaped expansion of the
transversalis fascia which the cord carries on it. This
expansion may be weakened, but is not an opening
except when made so artificially. When the perito-
• eum and subserous fat are removed, this ring appears
a- crescentic edge, over which at its most dependent
poi.ion, close to the pubic bones, turns the cord. This
ring is situated one and a half inches below the cen-
tre of Poupart's ligament. Its artificial measurements
are approximately one inch by half an inch. After
the descent of the testicle the internal ring is carried
upward and outward from the external ring, the result
of the growth of the bony pelvis. The outer and inner
sides of the internal ring are well defined, as already
described, and the spermatic cord, entering it at the
most dependent part, near the pubic bone, passes down
to the base of the bladder. An operation for the rad-
ical cure of hernia should restore the structures dur-
ably to their normal positions and physiological
relations." In four of the cases of femoral hernia I
report, the method used was high ligation of the Sac
and closure of the saphenous opening only by uniting
by a purse-string suture the iliac and pubic portions
of the fascia lata. In the other case the sac was tied
off with silk and the ends, left long, were used to close
the saphenous opening by uniting the iliac and pubic
portions of the fascia lata. The cases were operated
upon since 1893. The mortality was «//. All the
wounds healed by primary union and there has fortu-
nately not been a relapse. Two of the patients were
children under twelve }ears of age.
The other principal methods which have been used
for radical cure of femoral hernia are Hackenbauch's,"
" a modified form of osteoplastic operation originated
by Trendelenburg;" Bassini's,^ '"which consists in
twisting and ligating the sac, and closure of the
wound as follows: a suture applied close to the pubic
spine through Poupart's ligament and the pectineal
fascia, several sutures being inserted in a similar
manner approaching the femoral vein. The fourth
suture includes the falciform process and the pectineal
fascia. No suture is tied till all are introduced, and
the skin is closed separately;" Fabricius',' which
consists " in suturing Poupart's ligament to the hori-
zontal ramus of the pubis and the spine, care being
taken to include the periosteum. At the same time
the external inguinal ring is sutured to prevent ingui-
nal hernia."
A study of the surgical anatomy of femoral hernia
shows that all these operations are open to serious
objections. The neck of the sac of any hernia should
not be twisted nor tied off. The ligature is liable to
slip off; a piece of bowel or omentum may be included;
' " The Operative Treatment of Inguinal Hernia," Medical
Record, March 7, 1896.
■•' Berl. klin. Chir., ii.. No. 3.
^ .Xrchiv fiir Chir., 1894, vol. xlvii., p. i
■•Centralbl. f. Chir., Bd. 6, 1894.
So8
MEDICAL RECORD.
[December 5, 1896
the tying or twisting causes puckering of the perito-
neum, which favors the formation of adhesions and
interferes with the free movement of the intestines
over the surface. The neck of the sac should not be
anchored in the canal nor at any other place, as this
favors a relapse by keeping the ring and canal open ;
the neck, being fixed, forms a cone of the peritoneum
into which intestine or omentum slips, and the cone
by the pressure of a protrusion from within and behind
acts as a wedge which will be apt to reopen the ring
and canal. The suturing of the saphenous opening
alone is incomplete. Relapse is favored, as the fem-
oral ring and canal continue patent. The suturing
of Poupart's ligament to the pectineal fascia is also
incomplete, as the femoral ring and upper portion of
the canal are left open. It is plain that the entire
opening should be repaired, by first closing the breach
at the femoral ring and then reinforcing this by as
many barriers as possible. It is as important to close
the femoral ring and canal as the internal inguinal
ring and canal. No one could expect to cure many
inguinal hernias by closing the external ring only, or
the external ring and part of the canal. The same
applies to femoral hernia. The falciform process
sliould not be sutured to the pectineal fa.scia, as the
latter does not bear any physiological relation to the
former. It is dangerous, at times impossible, and
altogether unnecessary for the needles and sutures to
include the pectineus and the periosteum. The nee-
dles are liable to be broken in trying to include the
periosteum; the contractions of the muscle cause irri-
tation in and around the stitches, producing pain, etc.
Better results can be obtained by simpler means. Any
osteoplastic operation is not even to be considered, as
it is dangerous and unnecessary. The hammering
and chiselling increase the gravity of the operation
and may do irreparable damage. The following ope-
rarton I consider fulfils all the indications and over-
comes the objections to the methods described:
1. The external incision begins about one-half an
inch below the spine of the pubis and is carried up-
ward and outward for about three inches parallel with
Poupart's ligament. This exposes the sac and the
saphenous opening. Poupart's ligament and the spine
are well exposed by dissecting up the superficial fas-
cia. The iliac and pubic portions of the fascia lata
bordering the saphenous opening are each in turn
Jifted and freed sufficiently by blunt dissection from
the structures beneath to expose clearly the canal and
femoral ring.
2. Any adhesions of the sac to the surrounding
structures should be separated high up within the fem-
oral ring. The sac is opened, and if any adhesions
€xist internally these should be separated. If the
content is omentum, it should be removed, ligating
the vessels only. To insure the ligatures not slip-
ping, the " fixation" ligature should be used. The
vessel to be tied is defined by spreading out the
■omentum, and a needle carrying the catgut is passed
round the arterj* by piercing the tissues of the omen-
tum surrounding the vessel. The ligature is tied and
the vessel severed beyond it. By this means the
ligature is fixed in the omentum and cannot slip.
After clearing out the sac, its neck should be dragged
■down with forceps. The sac, neck, and peritoneum
as high as possible are to be removed and the cut
edges united by catgut sutures (supracorrection of the
peritoneum at the internal ring). Phe sutured edges
when released slip back.
3. The adipose and glandular tissues, etc., are re-
moved from the saphenous opening and femoral canal.
4. The femoral ring is exposed by retracting the
iliac and pubic portions of the fascia lata, Poupart's
ligament, and the deep crural arch. Any masses of
fat, glands, etc., which bulge into the ring from the
subperitoneal connective tissue should also be re-
moved. The femoral sheath is now lifted with the
forceps. The excess is trimmed away and, the opera-
tor keeping the immediate work well in view, the in-
ternal opening is closed by bringing togetlier the
anterior and posterior layers of the femoral sheath at
the femoral ring. The first stitch is inserted close to
the outer side of Gimbernat's ligament and also in-
cludes some of its fibres. Several stitches are inserted
as described, approaching the femoral vein. The last
one is placed near the septa separating the ring from
the vein, but must not be inserted close enough to
constrict or in any other manner interfere with the full
vein. The number of sutures required depends upon
the size of the ring. When Gimbernat's ligament is
not well developed, sutures may be required as far
inward as the pubic spine.
5. The iliac and pubic portions of the fascia lata
are retracted, and, commencing close to the pubic
spine, Poupart's ligament and the deep crural arch are
sutured to the contiguous portions of the fascia lata
covering the pectineus and the reflection of this fascia
passing behind the femoral sheath, each stitch ex-
tending to but not including any muscular fibres of
the pectineus. Several sutures are passed in a similar
manner approaching the femoral vein. The last must
not be inserted near enough to constrict or in any
other manner interfere with the full vein.
6. Next the saphenous opening is closed. The first
stitch is inserted above close to Poupart's liagment,
the needle being passed first through the pubic portion
of the fascia lata on the inner side of the saphenous
opening, then through the iliac portion of this fascia
on the outer side. Suture from above downward, leav-
ing only sufficient room at the lower angle for the full
saphenous vein. The number of sutures required bere
depends upon the size of the opening.
7. The skin is closed with catgut or fine silk with-
out drainage.
The most suitable material for a buried suture is
chromicized tendon, as it is non-irritating and is not
absorbed for two or three months. Busse ' in his ex-
periments showed that perfect tendinous union does
not occur under ten weeks, or just about the period
required for the absorption, of chromicized tendon."
For the accurate approximation of the separate lay-
ers the continuous stitch described by Dr. C Ford'
should be used. This is the indi\ idual stitch in-
serted continuously. In my last four hernia cases
I have used it with every advantage. .\ detailed
description of this .stitch can be found in the Facifc
Medical Journal, July, i8g6, vol. xxxix.. No. 7. As
the stitch is new and very ingenious I shall briefly
describe it. Pass the threaded needle through the
divided structures and, without cutting, tie a reef
knot. For the next stitch pass the needle, thrusting
the point well through. Pick up the thread leading
from the formier knot and turn it toward the eye or
heel of the needle and around under the point. Draw
the needle on through and adjust the tension. This
forms the first half of a reef knot. Complete it by
passing the needle under the thread between the knots
in the opposite direction from which it was inserted
into the tissues, drawing the needle out in the loop
fonned. I u.se the first half only of the stitch to su-
ture the femoral ring and saphenous opening, but to
close the canal I use it complete. Tliis stitch may
also be used for applying the fixation ligatures in ty-
ing vessels in the omentum. .After tj'ing the first
fixation ligature in the usual way, do not cut the
' Busse: Deutsche Zeilschr. fiir Chir. , iSqi-c;2, .\.\.\.
* The chromicized kangaroo tendons I have been using for the
past four years with such good results were sterilized by Messrs.
V?n Horn and Ellison, Park Avenue, New York.
^C. Ford: ' The Interrupted Stitch by a Continuous Method."
December 5, 1896]
MEDICAL RECORD.
809
threads, but to save time tie each of the otlier vessels
continuously, and when all are ligated make tlie liga-
tures interrupted by cutting away the excess of thread
between the knots.
Dressing. — Sublimate gauze held firmly in place
by strips of adhesive plaster; then a layer of cotton
and firm spica bandages.
After-Treatment. — Dress the wound on the seventh
day, or earlier if there are indications for interference.
In removing the adhesive strips pull the ends toward
the wound, to avoid tearing the freshly united edges
asunder. Apply gauze, strips, cotton, and bandages
as before. Keep the patient in bed two weeks, or
longer if possible. If primary union is not obtained,
do not allow the patient out of bed until cicatrization
is complete. The firm bandages are not removed till
one month after the operation; then the patient is
allowed to go without any dressing, pad, or truss.
The removal of the sac and, as high as possible,
the peritoneum continuous witli its neck, the separation
of adhesions internally and externally high up within
the femoral ring, and the suturing of the cut edges
with fine catgut cause total obliteration of the sac,
cliange the outer surface from a conve.x to a slightly
concave one, carrying the sutured edges high up
within the abdomen away from the femoral ring, lea\-
ing a smooth surface to the peritoneum, and allowing
free movement of the intestine over the surface. It
is better to overcorrect, as the peritoneum is sure to
relapse a little. Clearing out the rings and canal of
fat, glands, etc., removes the material which would
interfere with cure by keeping the rings and canal
open. The closure of the femoral ring is a veiy im-
portant step of the operation, as it is at this ring that
the breach hrst occurs. This layer of sutures forms a
firm wall and the other layers closing the canal and
saphenous opening form additional barriers against a
relapse. It will be noted in closing the different lay-
ers that the femoral ring is closed by a transverse line
of sutures, the canal by an oblique line, the saphenous
opening by a nearly vertical line, and the skin by an
oblique line which follows the natural crease of the
groin. I unite each of the la)'ers separately, as it is
by this means alone that accurate appro.ximation is
obtained and strong and lasting union results. The
chief reason for failures in operations for inguinal as
well as this kind of hernia has been due to surgeons
in not repairing and restoring the structures durably
to their nomial physiological relations and uses, but
by illogical and unscientific introduction of extrane-
ous substances, the disarrangement or displacement of
structures, to improve on nature.
The operation I have described in detail has every
advantage. It is simple, easy to follow, and may be
quickly performed. It has all the advantages of the
other methods, with none of their disadvantages, and,
having additional advantages which I have sunmied
up in my paper, should be followed by the best results.
326 Kearny Street.
Permanent Artificial Perforation of the Drum-
head. -Ur. Miot (Rc-r. Hcbd. de Lnryngol. et d'Otol.,
June li, 1896) concludes, from his observation of cer-
tain cases of dry otitis media, that the best means of
completing the diagnosis is to make an incision in the
posterior half of the drumhead, along the bony case,
which improves the hearing and should be large
enough to see the incudo-stapedial articulation. To
obtain permanent opening it is necessar)- to remove
the drumhead and the long process of the malleus, and
place a plug of cotton for a few days in situ. The
hearing after this operation is very variable, being
sometimes better and sometimes much worse.
THE USK OY CONGK.ALED OILS TO PRE-
VENT THE REUNION OE NERVES AFTER
THEIR SUBCUTANEOUS DIVISION; A CON-
TRIBUTION TO THE RADICAL TRE.AT-
MENT OF CERTAIN FORMS OF NEURAL-
GIA.
By J. LEONARD CORNING. .A..M.. M.l).,
.\E\v Yof;K.
When, in dealing with infiammation of a sensory
nerve, the resources of local and general therapy
seem at length exhausted; when the changes have
been rung on blister, cautery, and injection ; when the
coal-tar derivatives have left us in the lurch; and
when, finally, etiology, so far as one is able to appre-
hend it, has been scrupulously regarded, yet to no
purpose, one is certainly excusable for looking about
in search of some radical expedient to gain exit from
what, to say the least, is an intolerable dilemma.
To one thus situated — certainly to most neurologists
— two operations are liable to suggest themselves, to-
wit, neurotomy and neurectomy.
The first of these consists, as every one knows, in:
simple division of the nerve; the second — by common
consent a more promising procedure — in removal of a
small segment from a suitable portion of its continu-
ity.
Simple diA'ision of the nerve, neurotomy, cannot^
as heretofore practised, boast of much success ; for, to-
say the truth, the nerve is exceedingly prone to re-
unite, so that in no long time a return of pain is.
practically inevitable.'
This re-establishment of conduction is, moreover,
very rapidly achieved, so rapidly in fact as to tax one's
physiological credulity to the utmost. Thus Gliick,
who has put the whole question to the touch of proof,,
found that in fowls restoration of conduction after
simple section took place in two instances in twenty-
four hours, when the ends were coaptated. Usually,
however, after division of the sciatic and suturing of
the cut surfaces, paralysis of the muscles supplied by
the nerve persisted for fifty hours. Thereafter a grad-
ual resumption of motion was observed in the aft'ected
muscles, so that recovery was practically complete by
the fourth day.
In man, howe\er, the process of restoration is evi-
dently slower, for Paget found after division of the
median ner\-e that sensation began to appear within
two weeks, while complete recovery did not ensue till
two weeks later. Nor is it to be forgotten that re-
union may take place in the absence of suturing when
the nerv^e is of small calibre and the cut ends are ap-
proximated by the pressure, or, as Rouvier puts it.
" support" of the surrounding tissues.
The histological details of this self-restoration of
the nerve are the source of considerable disagreement
among pathologists. Some, like Waller and \'aulair,
maintain that the reparative process proceeds from
the central end of the divided nerve; while others,
notably Eichhor.st and Mayer, are convinced that the
reorganization takes place from the nerve fibres below
as well as above the incision. The former of these
theories seems to me the more probable, though ni)'
own observations do not as yet permit me to speak
with any degree of positiveness; nor is the question
especially relevant to the purposes of the present
paper. There is, however, a further element in the
process that to me is significant; I mean the dictum
of Rouvier regarding the "supporting" part played
by the surrounding tissues in nerve repair.
But, to return to the original proposition, it is not tc^
be forgotten that, while the inefficacy of simple section
as a means of permanently arresting conduction is
thus demonstrated, most neurologists are agreed that
resection — the removal of a segment of the nerve —
8io
MEDICAL RECORD.
[December 5, 1896
offers, if not the promise of absolute success, at least
decidedly greater likelihood of it. On the other hand
resection, though not as a rule a formidable proce-
dure, except when (as in the case of the fifth nerve) it
is necessary to penetrate bony coverings to arrive at
the branch to be operated upon, is still an elaborate
undertaking as compared with simple section. Thus,
to be specific, while several of the more superficially
located ner\-es — notably the great and small occipital,
the supra-orbital and the auricularis magnus— may be
divided w^ith a minimum of traumatism, to resect
them involves more or less extensive incision — in
short, operative inroads that are not lightly regarded
by most patients. The affair looms still greater in
the eyes of the timid when it is a question of operat-
ing upon two or three branches.
Realizing these things from daily contact with ner-
vous patients, and especially with those who are subject
not only to pain but to nervous irritability of a high
degree as well, the thought came to me that it would be
a marked advantage gained if by the introduction of
some new factor, not too complicated, we could retard,
ay, absolutely prevent, the reunion of the nerve after
its simple subcutaneous division.
Without pausing to indicate the further evolution of
the idea in my own mind — a matter rather of personal
than general interest — I will state at once that the
project resolved itself ultimately into a determination,
I, to devitalize the nerve as much as possible at the
point of section, and 2, to interpose a substantial
barrier between the cut ends, thereby checking the
prolongation of the axis cylinders and preventing the
rehabilitation of conduction.
To carry the above-mentioned principles into prac-
tical effect I decided to invoke the assistance of an
oil, which after section of the nerve trunk, I could de-
posit in the wound, and then, by the application of
cold, congeal, so that it (the oil) should form an im-
passable barrier between the cut ends. And in order
that the solidified oil should not be liquefied (melted)
and carried away by the blood stream, I decided that
its melting-point could not be less than from three to
five degrees above the normal blood temperature. A
non-irritant oil was accordingly prepared by melting
the oil of theobroma over the water bath and adding
sufficient paraffin to bring the melting-point to about
105' F. The mode of application is as follows: An
ordinary hypodermic syringe, armed with a somewhat
coarser needle than that in common use, is filled with
the melted oil, and immediately thereafter the needle
is thrust into the tissues in such a manner that its
point is brought as near as possible to the locality in
the nerve where section is to be made. The syringe
is then gradually emptied, care being taken, by mov-
ing the needle to and fro, to deposit the oil at right
angles to the nerve stem. The oleaginous zone so
formed should completely envelop the nerve and ex-
tend along the longitudinal axis of the same for at
least an inch and transversely for an inch and a half.
Immediately after the completion of the injection,
which may be repeated if necessary, cold in the form
of a rhigolene spray or ice is applied above the in-
jected zone. .\s a consequence of this manoeuvre the
oil is immediately congealed.
To carry out the second stage of the operation, the
svringe is filled once more with the melted oil; but
now a cannulated knife' (Fig. i) two and one-half
inches in length is substituted for the hypodermic
needle. Its cutting surface, however, is but three-
quarters of an inch in length by one-eighth in breadth ;
and the canal, thanks to skilful workmanship, de-
' This is a modification of a device identic.il in principle but de-
signed for a different purpose, described by the author more than
two years ago. Vii/,' the author's brochure on "' Local -Anns-
thesia," D. .Vppleton & Co., New York, 1886.
bjuches at the point without impairing in the least
the sharpness of the latter (^^-Z, Fig. 1). I am indebted
to Mr. Ford, the instrument maker, for the careful
manufacture of this pretty bit of mechanism.
Grasping the barrel of the syringe, which serves in
lieu of a handle, the operator thrusts the point of the
knife through the skin ; and, carrying the
blade beneath the integument and across
the nerve." di\'ides the latter by a simple
downward cut. Then, with the aid of
altemating lateral pressure to right and
left, with the flat of the blade, the cut
ends are pressed apart; and, thanks to the
cohesiveness of the hardened oil, are pre-
vented from again appro.ximating. From
this it is evident that a hiatus, a veritable
chasm one-eighth of an inch or more in
breadth, is found between the cut surfaces
of the nerve; for, as just hinted, it is not
to be forgotten that the wax-like consis-
tency of the congealed oil causes it to
remain in place, a thing impossible in
the case of the normal tissues, whose nat-
ural resiliency would cause them to spring
back immediately.
And now, as the knife is slowly with-
drawn, the injection of the oil is begun;
and, as it flows from the orifice at the
point of the knife, the subcutaneous
chasm is completely filled. Again, the
knife having been extracted, cold is ap-
plied; and, sooner than it takes to tell
it, the oil congeals, forming a solid wall between the
cut extremities of the nerve, whereby the subsequent
reunion of the latter is rendered impossible. Nor are
there later any noteworthy signs of inflammation, the
oil maintaining its rigid state, yet without apparent
detriment to the surrounding structures.
Fig. 2 is a diagram showing the topographical rela-
tions as seen in horizontal section; /', /', ner\e; <', <" ,
hardened oil, in which the nerve is first embedded; </,
hiatus between cut ends made by lateral pressure with
the flat of cannulated knife and filled with plug of
hardened oil.
.■\s already mentioned at the beginning of this paper,
occipital, or, more strictly speaking, cervico-occipital
neuralgia lends itself with esjjecial appropriateness to
this form of treatment. A\'ending upward between the
muscles of 'the neck, the nerves involved — the great
and small occipital and the auricularis magnus —
Fig. 2.
spread out upon the posterior and lateral siir'aces of
the head, where, owing to their exposed situation, they
are especially liable to injury from changes of tem-
perature. This is well shown in Fig. 3, where a is
the great occipital, /' the small occipital, and c the
auricularis magnus. Topographically noteworthy is
the fact that the occipitalis minor runs upward along
December 5, 1S96]
MEDICAL RECORD.
811
the posterior border of the sterno-cleido-mastoid mus-
cle, while the auricularis magnus pursues a diagonal
course across the latter to supply the external ear and
the integument immediately behind.
All these nerves may be the seat of neuritis, but in
mv experience tenderness is more often present in but
one of them, although, as shown by the wide distribu-
tion of the pain, the others may be in\olved by sym-
pathy. Nor is this astonishing when their relative
community of origin is borne in mind. It follows
from this that great care should be exercised to deter-
mine with precision which nerve is primarily affected:
for neglect in this respect may lead to the cutting of
the branch which is only secondarily affected; while
that which is primarily involved, which is the seat of
the neuritis, escapes, with the result that relief, even
of a temporary kind, is not forthcoming. As a rule,
tender points — sometimes one, two, or even three —
are discoverable along the course of the affected nerve,
more especially where it wends across the cranial
bones ; the cervical portion, on the contrary, being the
more protected, exhibits relatively few signs of vehe-
ment inflammation.
The course of occipital neuralgia is sometimes com-
paratively brief; more often, however, it is severe and
tedious to a degree. Especially about the fall of
night, when the sufferer, deluded by a period of im-
munity, drifts into brief oblivion, are the pains prone
to make their appearance. Sometimes they are inter-
mittent, fulgurating, severe; at other times less velie-
ment, especially at their inception, when, with the un-
canny stealth of an ignis fatuus, they flit across the
field of consciousness, vague forerunners of the greater
evil to come.
It is true that occipital neuralgia is commonly re-
garded, and rightly so regarded, as a less severe
affection than faceache, yet occasionally it rises to a
dolorous pre-eminence, comparable only with tic dolou-
reux. Nor, to say truth, do the secondary phenomena
of one of these severe cases lag much behind tliose of
facial neuralgia; for, indeed, the irritability, melan-
choly, insomnia, loss of appetite, and weight are
sometimes such as to excite tlie grave-st apprehensions.
Precisely here is to be found the warrant for energetic
interference, the kind of interference previously rec-
ommended, where internal remedies and ordinary
local measures have failed to afford permanent relief.
So much for the exposition.
Turning now to inductions for final confirmation of
the argument, I am glad to be able to add tlie synopses
of two typical cases of occipital neuralgia treated in
the manner herein advocated.
Miss C. D , spinster, of middle age, ananiic
and feeble, went for a drive during the cold weather
immediately following the period of unusually hot
weather that characterized the closing days of August.
Her sister and a friend occupied the rear seat, and
hence she was compelled to sit en fa a, her back to-
ward the horses, the wind playing upon her neck and
head — as she expressed it — in a continuous stream.
On her return from the drive, which was long and
fatiguing, she was aware of a sensation of chilliness
and slight pain in the back of the head, at first dull
and constant, later sharp, fulgurating, intermittent.
That night she slept but little, the pains increasing in
vehemence to such a degree that her physician was
summoned in the morning. During the two weeks
following she suffered greatly; indeed, in the absence
of opiates, copiously administered both by day and by
night, she could neither eat nor sleep, and being of a
liighly nervous temperament she was very difficult to
manage. Electricity, counter-irritation, and internal
medication were alike barren of permanent result.
This, in a word, was her condition when I was sum-
moned in consultation. On palpation the region over
the great occipital was discovered to be very hyper-
aisthetic, and two points of exquisite tenderness were
found in the course of the nerve. No such character-
istic evidence of inflammation could, however, be
found in the regions supplied by the small occipital
and the auricularis magnus, though, to be sure, the
distribution of the pain pointed clearly enough to the
secondary " sympathetic" involvement of the nerves.
In view of the failure of conventional measures, and
the patient's condition, that was now become truly
deplorable from loss of appetite, sleeplessness, and
depression, I decided to sever the great occipital. I
was the more ready to do this, as she had parted with
all faith in what was undertaken in her behalf, even
to the extent of frequently declining the remedies that
were prescribed for her.
Immediately after obtaining her acquiescence in
this decision, I injected two drachms of the melted oil
at the most centrally located point of tenderness. A
spray of rhigolene was then thrown upon the integu-
ment above the injected zone, \\ith the result that the
oil congealed forthwith, forming a hard wound, of
which the longitudinal axis, about an inch and a half
in length, extended directly across the nerve, in such
a manner as to incarcerate the latter in the waxv mass
(Fig. 3,1)-
Again the syringe was filled with the melted oil,
the cannulated knife substituted for the hollow needle,
and the latter, after introduction beneath the skin, was
made to traverse the waxy mass, and, in so doing,
divide the nerve stem. The cut ends were then sepa-
rated by lateral pressure with the flat of the blade,
substantially as indicated in the general description.
By this manoeuvre, as already noted, a subcutaneous
tunnel-like excavation is produced in the oil-impreg-
nated tissues, and, thanks to the cohesiveness of the
hardened mass, the ends of the nerve at the point of
division are held apart. The injection of the oil
through the cannulated knife was now undertaken
while the latter was slowly withdrawn, and immedi-
ately thereafter the rhigolene spray, projected once
more upon the integument, caused the oil to congeal
in the tunnel, whereby an impregnable barrier was
formed between the cut ends of the ner\e stem. And
here let me observe parenthetically that, .should the oil
congeal prematurely in the canal of the knife blade or
in the syringe, it can be reduced at once to a fluid
state by dipping the implement in hot water.
To tell in few words the result in this case, I may
state that, with the exception of slight, transient local
soreness at the point of section, the relief experienced
was instantaneous. Nor is there now — se\'eral weeks
8l2
MEDICAL RECORD.
[December 5, 1896
after the operation — any likelihood, so far as one may
predict, of a relapse; the ridge of fat still remains in
place; sensibility is still obtuse below the point of in-
cision : the patient still continues to improve in
general health. Indeed, the progress made in the last-
named regard has been truly amazing; for the insom-
nia, irritability, and melancholy have quite dis-
appeared; and, thanks to simple tonic measures, her
appetite and assimilative powers have so far reasserted
themselves that she has not only recovered what she
lost in weight but added several pounds thereto as well.
This intensification of vital activity after the in-
dividual has been relieved of the depression of the
higher cerebral functions, which, to a greater or less
degree, always accompanies severe physical or mental
pain, is capable of being interpreted as an additional
proof in favor of Schoppenhauer's famous dictum which
affirms the positive nature of pain and tiie purely
negative quality of pleasure.
With an apology for this bit of metaphysical solil-
oquy between the lines, I return to the argument, and
more esixcially that part of it which finds a further
elucidation in my second case.
On a certain evening, about three months since, Mr.
N , aged sixty, fell asleep as he lay stretched upon
the lounge in his bedroom. A friend of fresii air, he
had opened all the windows; and so it befell that for
several hours he was e-xposed to a strong draught.
Awaking shortly after midnight, he was aware of a
sensation of stiffness in the back of the neck, a feeling
that became positive pain when rotation of the head
was attempted. Deeming the matter of little conse-
quence, he closed the windows, got to bed, and in no
long lime fell once more into a restless sleep. At
dawn, however, he was suddenly awakened by an ac-
cess of pain, severe, shooting, intermittent, involving
the hack and side of the head on the right, and extend-
ing thence to the muscles of the neck. .\s the day
wore on tlie pain increased in vehemence; the mus-
cles of the neck became more rigid, the periods of
exemption grew hourly shorter. He was induced to
invoke the services of a physician, but, despite the
good offices of the latter, he obtained little relief.
Blisters, anodynes, hot applications, local injections
— all were tried, but to so little purpose that, except
\\\\&n, fijii/i (k mii'iix, he was given considerable doses
of morphine, he suffered with scarcely an intermission.
Irritability and depression had mastered him now
so wholly that he could neither eat nor sleep, and to
these were added the usual sequences — derangement
of nutrition, defective metabolism, and loss of weight.
He began to run from one practitioner to another, and
at length in the course of his peregrinations drifted to
the consulting-room of a prominent practitioner of this
city, who in turn referred iiim to me.
On examination the occipital and right parietal
regions were discovered to be the seat of hypera?.sthe-
sia, the sensitiveness being especially exquisite
throughout the region supplied by the small occipital.
Two points of tenderness were found in the course of
this nerve, and one in the auricularis magnus near
the cranial attachment of the .sterno-cleido-mastoid
muscle. No such .sensitiveness could, however, be
made out above the great occipital. Moreover, the
cervical portions of the two nerves first mentioned
were devoid of painful points, tiie neuritis confining
itself largely to the ramifications about the head.
This predilection of the inflammation for the exposed
portions of the nerves is quite characteristic of the
type of neuralgia under consideration, and the fact
itself has a favorable bearing upon the plan of treat-
ment here advocated. Indeed, to say the truth, it is
easier to divide the nerves subcutaneously as they
spread out upon the cranial bones than lower down,
where they spiral up between the cervical muscles.
Finding this patient set in his determination to
submit no longer to medication of any kind, and en-
couraged not a little by the success obtained in the
previous case, I proceeded to divide bodi the small
occipital and auricularis magnus, choosing as before
the most centrally located painful point. The point
of section of the occipitalis minor is shown at 2, Fig.
3, that of the auricularis magnus at 3 of the same dia-
gram. As'to tiie manipulations, they were precisely
the same as in the first case, viz. : (1) Injection of
the melted oil about the nerve, at the point of section,
and subsequent congelation of the same by the appli-
cation of cold. 2. Passage of the cannulaled knife
into the mass of congealed fat, immediate division of
the nerve, and separation of the cut ends by lateral
pressure with the flat of the blade. 3. Expulsion of
melted oil through the canal of the knife, during with-
drawal of the latter, and prompt congelation of the oil
by the application of cold, whereby the canal is filled
and a substantial barrier formed between the cut ends.
I may add that the hemorrhage caused by burrow-
ing thus into the tissues — and more especially by the
lateral movements of the knife — ceases coincidently
with the solidification of the oil in the canal.
The result in this case was as happy as that ob-
tained in the first, viz.: innnediate cessation of pain
about the head, and indeed of all pain, if we except
slight soreness and stiffness in the neck — a condition
that disappeared completely within the next two or
three days. Nor is there now, several weeks after the
operation, the slightest token of a relapse. With this
emancipation from pain could be obser\-ed the passing
of the irritability and melancholia, and the speedy
restoration of the power of attention and the zest of
living. He began to sleep as never before, remaining
unconscious for fifteen hours at a time — a remarkable
performance for a man of sixty. His appetite returned
and he ate ravenously of all kinds of food. Soon his
weight began to increase, the lines of his face to relax,
and in no long time he was completely restored.
These cases are their own best commentary, and I
shall therefore spare the patience of the reader by re-
fraining from further disquisition.
In conclusion, however, let me recall the fact — for
it may well happen that what I have here invoked for
neurological purposes may receive a further applica-
tion at other liands in other fields — that I have em-
ployed this same principle of treatment before, notably
for the fixation of remedies (analgesics) in painful
areas, and for the purpose of inhibiting the exagge-
rated action of the muscles in torticollis and other
forms of local spasm.'
53 Wf.st THiRTv-Err.HTH Street.
After-Pains. — Dr. Winterburn (Journal of Olst.t-
rics) says that in many cases a nice warm meal is bet-
ter than any medicine; but, when pains are exhaust-
ingly severe, he uses amyl nitrite. This potent
drug is a very efficient controller of after-pains, and,
used with caution, it need not result harmfully. A
neat way of using it is to saturate a small piece of tis-
sue paper with five or six drops, stuff this into a Iwo-
drachm vial, and request the patient to draw the cork
and inhale the odor when she feels tiie pain coming on.
It acts with magical celerity.
' " The Localization of Remedies about the Sensor)' Nen-es of
the Skin: Induction of F'rotracted Local Anssthesia," The
Xew York Medical Journal, December 2fi, 1S91. ViJe also the
author's monojjraph on " I'ain," J. H. Lippincott & Co.. I'hila-
delphia. 18S4, p. 216 <■/ scij. Also, " Ela'omyenchysis, or the
Treatment of Local Spasm by the Injection and Congelation of
Oils in the Affected Muscles," The New York .Medical Journal,
April 14, 1S94.
1
December 5, 1896]
MEDICAL RECORD.
81
HEREDITARY SYPHILIS AND GENERAL
PARESIS OF THE INSANE.
By EDWARD H. WILLIAMS, M.D.,
ASSISTANT I'HVSICIAN, MATTEAWAN STATE HOSPITAL, FISHKILI. LANDING, N. V.
I.\ cases of general paralysis of the insane, the histor}-
of dire;ct syphilitic infection, together with a life of
general dissipation and excitement, is so often found
that the disease has become very generally credited
to, or at least associated uith, prinuuy syphilitic in-
fection. The temperament of the majority of " paret-
ics," the past history, and the general train of delu-
sions are so characteristic that in a large percentage
of cases the description of one will answer almost
equally well for any other. For, as is well known,
general paralysis presents more uniformity in symp-
toms than perhaps any other form of mental disease.
The cases in which there is positive proof of pri-
mary svphilitic infection (practically seventy-five per
cent, of all cases) form such a majority that tiie small
number of cases in which the history of such infec-
tion is lacking is generally ignored. The typical
'■ man of the world" — ambitious, fond of society and
high living, a light sleeper and a deep drinker — forms
so characteristic a picture of the forerunner of the de-
plorable " paretic," with his delusions of grandeur, that
we usually overlook a minor number of cases that pre-
sent at first few typical symptoms and whose past his-
tory may be different in many respects from that of the
majority of cases. If such cases are examined, it will
be found that many of them, while having no history
or proof of direct syphilitic infection, do bear unmis-
takable marks of hereditary syphilis — usually shown
by the presence of Hutchinson's teeth. These cases
are often obscure, even to the alienist, in the begin-
ning, and the diagnosis is not facilitated by the lack
of a characteristic syphilitic history.
As a marked contrast to the highly-organized, bril-
liant-minded, general paralvtic, we often see in this
man a dull and sluggish-minded being, who may
have been more or less dissipated, but who has never
attempted what might be called mental work of any
kind, and who is in no sense of the " paretic tempera-
ment."
Yet this man is sometimes the victim of general par-
esis. I say "victim," because his more brilliant pro-
totype is generally counted not so much a victim of
the disease as an inviting host to it.
I have selected four cases from among quite a large
number showing the syphilitic teeth and giving the
in .some respects at
Fic. 1.
histories which do not coincide,
least, with those of a typical case.
In Fig. I are shown tlie teeth of J. T , who
was thirty-nine years of age when committed to an
asylum. He was a harness maker by trade, was mar-
ried, and had always lived a quiet, indu.strious life.
He had been an habitual but rather a moderate beer
drinker, and had been intoxicated several times, but
was not a drunkard in tiie ordinary sense of the term.
After a family reunion and feast, at which he indulged
freely both in eating and in drinking, he had an attack
of " acute mania." This lasted for about three weeks,
during which time he was emotional but happy, ex-
pressing no characteristic ideas of grandeur, only oc-
casionally remarking that "he\vas a very fine man"
and that " he felt splendid." There were no muscular
Fig. 2.
tremors of the tongue or lips, or ataxia of the throat
muscles, and the diagnosis of general paresis was not
made at the time. He remained in an apparently
semi-demented condition, however, and was confined
in an aslyum. After nineteen months with practically
no change, he had an epileptiform convulsion, which
left him with marked paresis of the left side, irregular
pupils, lip tremor, and weU-de\eloped ataxia of throat
muscles. From this condition he did not fully re-
cover, and gradually developed into the happy, talk-
ative, ataxic-spoken "paretic," with unmistakable
symptoms. These symptoms progressed rapidly, and
he died eleven months after the first epileptiform sei-
zure. At no time did he exhibit many delusions of
grandeur — in fact, they were conspicuously absent.
.Vs was stated before, he had no history nor evidence
of primary syphilitic infection; but, as is shown in
the cut, his teeth had the telltale marks of hereditary
syphilis.
Fig. 2 shows the teeth of J. B , a grocery
clerk, who was admitted to the asylum at the age of
twenty-seven. He had always been quiet and indus-
trious, was not given to venereal excesses, and had
never had syphilis. He had been a steady drinker all
his life, but was not given to e.xcessive drinking. In-
sanity was first suspected when he began claiming
other people's property as his own. The diagnosis of
general paresis was not made until after he had been
confined in the asylum for eigiiteen months. After
that time he developed lip and tongue tremors, and
gradually developed into a well-marked case of the
disease. From the cut it will be seen that he had
well-marked Hutchinson's teeth.
In Fig. 3 are shown the marked teeth of heredi-
tary syphilis. This man, a stone-cutter by trade, was
thirty years old on admission to the asylum, had no
history of venereal excesses nor of primary syjihilitic
infection, but had been a hard drinker and given to
frequent drunken debauches. Lip and tongue tremors
were pre,sent almost from the beginning, and he devel-
oped delusions of grandeur early, and became a tvpi-
cal case after the first year of his confinement.
In Fig. 4 the riglit incisor shown is an artificial
tootli; the left, however, shows the characteristic
notch of hereditary syphilis. This man was a black-
smith by trade, was rather a '"thick-headed" and in-
8i4
MEDICAL RECORD.
[December 5, 1896
different workman, and a periodical drinker. There
was nothing peculiar in tiie nature of his attack of par-
esis, but he had absolutely no histor)- or evidences of
ever having had primary syphilis, and the temperament
of the man was quite opposite to that of the majority
of general-paresis patients.
I have found that in about seventy per cent, of cases
of general paresi.s, in which no history or evidences of
Fig. 3.
primary syphilitic infection could be found, there
were evidences of hereditary syphilis in the teeth.
In fully si.xty per cent, of these cases there was no
history of excessive dissipation, although almost to a
man tliey had been addicted to the use of alcohol, and
sometimes to an excessive degree. In ninety per cent,
of these cases they were men of anything but the " par-
etic type" — men of rather sluggish mentality, with
corresponding habits.
Since it is .so definitely established that at least sev-
enty-five per cent, of all cases of general paresis ha\e
had primary syphilitic infection, and as so large a
percentage of those not showing primary syphilitic
infection have marks of hereditary syphilis; and, fur-
thermore, since almost all of both classes have been
confirmed alcoholics, it is certainly interesting to no-
tice the pathological conditions which closely resem-
ble each other in primary syphilis, hereditary syphilis,
chronic alcoholism, and general paresis. We know
tliat both in primary and hereditary syphilis a thick-
ening of the cerebral meninges, not unlike the condi-
tion found in general ]3aresis, is a common thing;
wliile a thickened condition of these membranes is
also common to chronic alcoholism.
As yet we are unable to tell tiie exact relation whicji
&>»
the thickened membranes have to the mental condition
in any of these diseases, but that they do have a defi-
nite relation cannot be doubted. It is possible that
hereditary syphilis, which is sometimes manifested in
the thickened membranes, not unlike those found in
general paresis, may, through their agency, act as a
predisposing cause to this disease. If we assume this
hypothesis to be true, it would be reasonable to sup-
pose that a man with syphilitic meninges might de-
velop general paresis without the great amount of dis-
sipation and primary syphilitic infection of the
ordinary general paretic patient. \\'ith such a man, it
would be natural to infer that a less amount of alcohol
might tend -to produce changes in the cerebral me-
ninges, since alcoholism tends to jsroduce a somewhat
similar change even in primarily her.lthy membranes.
Of course, any theories concerning the relative con-
dition of the cerebral meninges in general paresis,
hereditary syphilis, and chronic alcoholism are purely
tentr.tive ; and whether or not the thickened membranes,
caused either by primary or by inherited syphilis,
could cause or assist in causing general paresis, aided,
perhaps, by the effects of alcohol, is mere speculation.
If, as many alienists think, alcohol ])roduces insanity
only in those who have some pre-existing neurosis, it
may be that that neurosis is sometimes of syphilitic
origin. Since syphilis is so closely associated with
general paresis, one disease might thus be a manifes-
tation of the other, or a factor in producing it.
Of course, until we establish the exact relation of
syphilis to general paresis, we can do no more than
draw relative inferences from existing conditions; but
I believe that closer ob-servation of the teeth in doubt-
ful cases will assist in making a diagnosis in many
cases of general paresis whose history and symptoms
might be otherwise misleading.
ORRHO THERAPY AT MRSKRV ANT)
CHILD'S HOSPIIAL, 1895-96.'
Bv ALLEN M. THOMAS. M.D.,
ATIE.NDING I'HVSICIAN, NL'RSI■:R^■ AMI CHILl/s HOSIMTAI.. N (■ W \i>KK.
DuRixt; the past year the orrhotherapy of diphtheria
has excited much additional interest among us on
account of the brilliant results recorded, covering a
large field both in private and hospital applications
of it, and because of the more or less unique dis-
cussions which have gone on at the academy meet-
ings. A little over a year ago a report was made to
the society of the results of the immunizing eflect of
diphtheria antitoxin under the direct auspices of the
late brilliant house physician. Dr. Mapes, of the
Nursery and Ciiild's Hospital. It may be of passing
interest, at this time, to relate a little incident of that
report. .Shortly after publication it ha])]iened to the
author of the paper to meet a physician of prominence
in the case of a child of another physician of this
city. The case being considered sufficiently indica-
tive of diphtheria to warrant immediate treatment for
that disease, without waiting for a culture test, the
question arose at once as to the nature of the treat-
ment to be installed.
In the course of ensuing discussion, upon referring
to the report and asking what was thought of the
result of immunization obtained at the hospital, the
reply was: "It could only be considered a coinci-
dence." This circumstance is narrated, not in a
spirit of personal antagonism, but solely in the inter-
est of the subject and to emphasize the ridiculous
assumption of such opposition should it continue its
adhesion to similar untenable statements in the face
of the stultifying facts which the records of a suc-
cessful orrhotherapy are constantly accumulating. In
other words, the value of diphtheria antitoxin, in the
record of results achieved and ])ublished, was never
more conclusively in its favor than now, and no factor
of that value more successful in its practical appli-
cation than its use as an immunizing agent. What-
' Read before the New York Clinical .Society, October 23. iSg6.
December 5, 1896]
MEDICAL RECORD.
815
ever future trials may determine, our judgment of it
must continue to be weighed in this balance of re-
sults obtained, and will be rightly formed for that
future, as it has been for the present, solely upon such
evidence.
An honest purpose does not permit of continued
miscalculations of '' the returns," but rather guaran-
tees us unprejudiced observations and ultimately true
and easily reconcilable conclusions. Setting aside
ail personal issues and applying this principle to our
practice, we may fairly assume that future work in
the premises will bring to us still more wonderful
and satisfactory results, sufficiently convincing in
their simplicity to make all of one mind at the final
settlement.
The object in addressing you to-night upon this
topic is especially to present, in continuation of the
report read last year, the results of our further work in
this line at the Hospital from April, 1895, to July, 1896.
Following upon the cessation of our epidemic of
diphtheria, which was so successfully controlled by
the immunization of the entire hospital in April, 1896,
no case of diphtheria occurred in the institution for a
period of si.x months thereafter, i.e., until October 26,
1895. On account of the fatal illness of Dr. Mapes,
the work has been chieHy carried on, since the time
of the last report, by Dr. Neumann of the house staff,
who, under my direction, has kindly collated the
results of our subsequent work in the following re-
port. Culture tests showed the case of October 26th.
above spoken of, to be one of true diphtheria by the
presence of the Klebs-Loeffler bacillus. The child
was immediately isolated and antito.xin administered.
All the other children in the ward, twenty-three in
number, were given immunizing doses of serum, the
amount varying from fifty to two hundred units, ac-
cording to age. Although directly exposed for a
number of hours, not one of these twenty-three chil-
dren contracted diphtheria. A certain number (un-
fortunately not recorded) had nasal discharges prior
to the development of the initial clinical case. Cul-
tures taken from those having such discharge showed
the presence of diphtheria bacillus in nine. These
cases were all kept isolated until the bacilli were no
longer demonstrable in subsequent cultures.
During and since the epidemic of diphtheria last
year, a peculiar feature among the children, in regard
to nasal discharges, has been that many of these
patients, apparently well in other respects and with no
visible or constitutional disturbance, would evidence
upon culture test (for more or less prolonged periods)
the Klebs-Loeffler bacillus in the discharge, and
seemed, in some instances at least, to be the cause
of outbreaks of decided cases of diphtheria in the
same wards before showing any clinical signs of it
themselves. The lesson it taught us was to be-
ware of a nmning nose, each case of which is now
considered worthy of special investigation. Cultures
were then invariably taken from nasal discharges as
well as from all suspicious sore throats, and if the
Klebs-Loettier bacilli were present children were
isolated and subjected to treatment as a means of
prophyla.xis, and, as before, all the remaining chil-
dren in the respective wards were given immunizing
doses. Up to August, 1896, three hundred and
twenty-si.\ children have received antito.xin. Of this
number fifty-nine were twice, and nine three times
subjected to treatment, the youngest child to receive
treatment being two weeks old.
The ages of the children were as follows: Under
three months of age, 58: from three to si.x months of
age, 45 ; from six to twelve months of age, 69 ; from
one to two years of age, 75; from two to four years
of age, 79; total, 326.
In all, there were eighty cases having the above
mentioned muco-purulent or bloody discharge from
the nose, in which the diphtheria bacilli were fouud
upon repeated examinations and confirmed by the
bacteriologists of the health board. These children
manifested no local or constitutional symptoms of
diphtheria, yet, in many instances, the characteristic
bacilli could be demonstrated in cultures three and
four weeks after the most persistent and energetic
local treatment. In one case, the bacilli were found
in the nasal secretion and also in the discharge from
a chronic otitis media and persisted for four weeks.
Of these eighty special cases immunized, none
developed a clinical diphtheria or other untoward
eftect, though the majority at the outset were in poor
physical condition, as the following shows: Chronic
otitis media, 10: moUuscum contagiosum, 3 ; maras-
mus, 5; syphilis, i; suppurating tuberculous glands
of neck, i ; chronic catarrhal gastro-enteritis, i :
pleurisy with effusion, i : hypertrophied tonsils and
adenoids, 3 ; catarrhal enteritis, i ; bronchitis, 2 ;
rickets, 2; convalescent from broncho-pneumonia, i;
dentition and diarrhcea, i ; chronic eczema of scalp
and face, i : broncho-pneumonia, 2 ; enteritis, i ;
pertussis, 6.
These continued good results from our use of anti-
toxin as an immunizing agent are surely most satis-
factory, and in full accord wiih last year's work and
that simultaneously done elsewhere. Xo serious ill
effects from its use have been obtained in any of the
three hundred and twenty-six cases. On the other
hand, its positive value as a prophylactic agent is
very pointedly evidenced from last year by the sud-
den cessation of our epidemic immediately after
immunization was practised, and in this year by our
escape from the usual and, for the past many years,
more or less severe and fatal epidemic of diphtheria
in various wards of the hospital.
Urticaria and erythema, circumscribed and diffuse,
were observed in less than five per cent, of the cases.
In one case (that of an adult) adema, with redness and
tenderness, followed a deep injection in the arm. In
another case (that of a child) oedema extending from
the hip to the toes was observed three days after a
deep injection into the buttock. A moderate eleva-
tion of temperature followed the "injection in some
cases, and a slight diarrhcea was of frequent occur-
rence.
Of the persistent nasal-discharge cases, four showed
cultures of Klebs-Loeffler bacilli for a period of at
least two months after immunization and local treat-
ment. Dr. Park, of the board of health, reported
upon special examination that these bacilli showed
no virulence when injected into guinea-pigs. Smears
were also taken from the intestine of one child who
died of entero-colitis and who had previously shown
Klebs-Loeffler bacilli in the nasal discharge. Dr.
Park reported upon the case that he found bacilli
which looked like the diphtheria bacilli, but could
not get them in pure culture and so had no means of
demonstrating whether they were virulent or not.
This single investigation of Dr. Park, upon the
four cases spoken of above, would, if supplemented
later on by others in similar condition, with the same
result, simply confirm the logical conclusions of our
clinical obser\ations and experience in the premises.
.As, however, our work in this direction is necessarily
incomplete, no definite conclusion can at present be
drawn from this class of cases. The very interesting
question of the period of protection warranted in a
given case of immunization is still unsettled, and our
experience of the year adds little of value in this par-
ticular beyond the knowledge already obtained. As a
rule, it was from four to six weeks or longer, though
the following irregular cases are of interest in regard
to this matter of time limit:
8i6
MEDICAL RFXORD.
[December 5, 1896
Case 1. — Child received two hundred units on Jan-
uary i2th, 1896; on January 24th, patient developed
measles, which was followed in four days by diph-
theria, the membrane involving the uvula, soft palate,
and roof of mouth, spreading to the tongue and out
•on the corners of mouth. In this case the child devel-
oped the disease sixteen days after receiving an im-
munizing dose of two hundred units.
Cask II. — June 3, 1896, twenty-two children were
admitted to the reception house, and, as is the custom,
all received two hundred units of antitoxin as a means
of prophylaxis. On June 27th, twenty-four days after
immunization, one of the number, a rachitic child
fourteen months of age, developed a severe diphtheria
ophthalmia and died on July 2d.
Cask III.— Two children were found with Klebs-
Loeffler bacilli in nasal discharge fifteen days after
injection of two hundred units. (The condition of nasal
■discharge was not known in these cases at time of injec-
tion and its virulence at time of observation was not
tested.)
Case IV. — June i, 1896, child received two hun-
dred units, and on June 3d developed a severe diph-
theria ophthalmia. (In this instance only two days
•elapsed between the time of injection and the develoji-
ment of the disease, and here too the condition of the
conjunctival mucous membrane was not known at
the time of injection. The observations in Cases III.
and IV. are consequently of doubtful value.)
In several instances in which a mother with true
diphtheria refused to be separated from her suckling
infant or young child, she was permitted to keep her
child with her in the diphtheria ward during her
•entire illness, the child being carefully watched and
immunized. In no case of this sort did the child
develop diphtheria.
15oard-of-health virus was invariably used in the
concentrated solutions and in the regularly estab-
lished rules of dosage of that department. The
following summary of all cases given prophylactic
treatment by immunization, since its inception at the
hospital, A])ril, 1895, will be of interest:
Previously Present
Age. • reported. report. Total.
3 weeks to 3 months 19 58 77
3 weeks to 6 months 36 45 Si
<j months to I year 22 69 91
I year to 4 years 59 154 213
136 ;,2f) 462
In conclusion; the facts established for future
guidance are, as forecast in the report of last
year :
1. The safely of the agent (properly prepared and
administered), even when given to patients of tender
years and poor physical condition.
2. Its evident control for a variable jJeriod (about
one month) over the inception of diphtheria by those
who, having been exposed or subject to exposure, are
protected by proper immunizing inoculations.
3. Its positive value as a therapeutic agent, in
established cases of true diphtheria, particularly when
given early in the course of the disease and admin-
istered in full doses, according to age and imder
■careful aseptic precautions.'
.■\1GI'SI 21. 1896.
' .\Ithough this third deduction is made independently of the
foregoinjj report, it does not appear irrelevant to the tenor of the
paper ; tliat the statement may not .seem presumptuous, it should
be understooti the deduction is made from personal obser\'ations
and experience, but these are not at present in shape for statisti-
cal report. This, however, cannot detract from the sigTiificant
fact that the conclusion wholly agrees with the accepted opin-
ions of those whose broader observations and larger experience
combine to give the added weight of recognized authority.
PUISONTXG BY AMVL NITRITE.
Bv K. CADWALLADEK, M.D.,
F.\LL KIVEK MILI-^, CAL.
Casks of poisoning from amyl nitrite are so rare that
each is deserving of notice. Especially is the history
of the following case peculiar, and I regret that I did
not keep more careful notes of the same. My excuse
is the personal interest I had in the result, and the
strain and fatigue I was under, which have blended
details into a confused remembrance. Eor many de-
tails of dates and sequence of events 1 am indebted to
William H. Vale, D.D.S., of San Eranci.sco, who was
present and saw the case to the end.
While reporting a fatal case, I am also paying the
last tribute to a friend and brother practitioner, who,
at the age of twenty-four years, with a brilliant future
before him, has contributed by his tragic death the
material for the article.
On Wednesday, October 14th, I)r. E. A. Lutz, of
Bieber, Cal., demonstrated the effects of amyl to several
persons by inhaling the drug. Thursday he was un-
well from indigestion, and made the remark that he
believed a pain in his head was due to the amyl of the
day before. .Some state that his actions were peculiar
that day, but this did not occur to them until later.
Thursday evening he stocked a new buggy case and
put in a bottle all the amyl nitrite he had, one-half
ounce of Merck"s. .\ defective cork was used as a
stopper. This case he placed in his room : then he
made several calls, and retired at 10:30 p.m. He was
not disturbed until 12:45 ''•■^'- Ir'day, when he was
foimd uncon.scious, with face dusky red, breathing slow
and regular, pidse rapid and weak. He had evidently
vomited during tlie night. The windows were closed,
but were at once opened. Those present at first report
the room "very close." Dr. L. I'. Cate, of Adin, and
myself were called. Dr. Cate reached him about 4 :3o
and I arrived about 7 }'.M. Dr. Cate gave him iced
milk and cold applications to the head.
A little after 6 p.m. he became semi-conscious, and
was so when I arrived. I found him able to recognize
every- one. His face was suffused and dusky red;
tongue swollen, dented by the teetli, and partially par-
alyzed. He could only with difticultv and after sev-
eral attempts partially protrude it. Articulation was
impossible. He was in no pain, but there was a spas-
modic jerking of the muscles of the left leg. The
pulse was full, bounding, regular. Temperature was
97.3° F. ; respiration, 18, full; and urine normal upon
examination.
We ojaened his case and found the cork still in the
bottle, but the volatile amyl had soaked through and
wet the case. It was too volatile to endure e\en until
the labels could be looked over.
That night he rested well, and on Saturday, the 16th,
dressed and came out to a sofa. His ])ulse was rapid
and weak, and he complained of muscular relaxation
and weariness; but he joked and tried to speak of his
condition, but could not arlictilate. There was a ten-
dency to sleep.
Saturday afternoon I returned home, but was sent
for Sunday at dark. Tlie messenger said his pulse
was wor.se.
I arrived at his side about 1 1 p..m., and found him
much the same — tongue enlarged and helpless, face
tlusky, temperature subnormal, respiration 12 to the
minute and deep. Urine was drawn by the catheter.
While he recognized persons, I found a condition of
aphasia. He could pronounce names after me as well
as his tongue would permit, but would misname even
his best friends. Deglutition was never lost until his
death; in fact, he was hungry continually and asked
for food.
Up to this time no medicines were given; rest, food,
December 5, 1896]
MEDICAL RECORD.
817
cold applications to his head and hot to his feet em-
braced the treatment. About 2 p.m. the heart was 70,
but the pulse became soft, full, and the beats run to-
gether. I gave one drachm of fluid extract of ergot
and ten minims of tincture of digitalis. By daylight
Monday the pulse was 55, strong, and the radial arte-
ries were well filled. The condition of somnolence,
or partial coma, became persistent and lasted until
his death; but he could always be aroused, and then
seemed fully conscious of all going on around
him.
Monday night the urine was discharged during his
sleep. That night and Tuesday forenoon I gave one-
si.xtieth of a grain of strychnine sulphate and one-
sixtieth of a grain of sparteine sulphate hypoderniically,
a few drops at a time, every few hours, as the heart
seemed to require it.
Tuesday, about 3 p.m., the first failure to breathe
occurred. Prior to this the respiration had been full,
regular, and deep. I was called instantly and told
that he stopped all at once, but upon being aroused
he had begun again regularly. That morning I drew
urine and cleaned the rectum by a solution of P'.psom
salts and glycerin. The urine was tested and found
normal.
Tuesday night and Wednesday there was no change.
Small shots of atropine were given every few hours.
The heart was fair only, breathing normal. He slept
most of the time, but was easily aroused.
Thursday morning, at ten o'clock, there was a mo-
mentary failure to breathe, but it passed off in a few
minutes. The pupils were now somewhat dilated, and
no more atropine was given. It had failed to affect the
respiration noticeably, and was unsatisfactor}-. From
this time on strychnine was used in minute doses every
hour or two.
Friday, at 2 130 .a..m., there was another failure to
breathe, and when I reached the room Dr. Yale had
begun artificial respiration, which was kept up fifteen
minutes before he could be aroused.
Friday afternoon, about 2 :3o, while I was talking
to him, he ceased breathing absolutely, and for two
hours only did so when told to take a breath. He
breathed for that time mechanically ever}- so many
seconds when told to do so. One-half grain of caffeine
and the same of strychnine were given. The pulse
was then for the first time irregular, running 60 to 70
per minute, and, as usual, weak.
Saturday morning, after sleeping well during the
early part of the night, he suddenly failed again, and
for four hours artificial respiration was kept up. The
pulse was 60 to 70, weak and irregular, improving un-
der strychnine, but the twitching muscles showed that
our limit was about reached. .\t 6 a.m. digitalis was
given, and by 10 .a.m. the pulse was regular, fairly
good, at 38 to 45 per minute. He was only semi-con-
scious all day. Brandy in eggnog and by injections
was given. All that forenoon he breathed only when
punched and told to do so. Saturday night he rested
well.
Sunday, at 4 a.m., there was a momentary failure to
breathe. Pulse, 36 to 42; respiration, 14, full and
regular. During the day he was semi-conscious when
aroused.
Monday morning', at one o'clock, it was found im-
possible to arouse him. Pulse, 36 to 38 ; respiration,
Cheyne-Stokes. This coma lasted until his death.
From 7 until 11 .a.m. he was kept alive by artificial
respiration. The pulse was weak and irregular, inter-
mittent, from 70 to 120. He rallied a little, but ceased
to breathe again at 2 p.m. From 2 to 2:45 artificial
respiration was used, the pulse ranging from 90 to
180. At 2 :45 he began to breathe alone faintly ; pulse,
180. At 3:10 only an occasional breath was drawn :
pulse, 180, and very weak. The face became con-
gested and purple. At 3:20 the last breath was drawn,
and at 3 :28 the last flutter of the heart occurred.
During the first few days he would complain occa-
sionally of violent neuralgic pains in the occiput and
branches of the fifth nerve.
No post-mortem was allowed, but I embalmed the
body and noticed the great difficulty of distinguishing
the femoral artery from the vein ; both were equallv
relaxed.
The reader must draw his own conclusions. I have
been unable to learn of another even serious case: in
fact, authorities seem to ignore the dangerous side of
this drug. I would call attention to the fact that life
was prolonged so long and that the heart seemed to
show the eft'ects long before the respiration. Were I
to hazard a theory of its action, I would suggest that
the drug exerts its effects directly on the centres con-
trolling the muscular fibres of the blood-vessels, para-
lyzing them, and especially those of the brain; that
this results in an extravasation of serum and increase
of intracranial pressure, deranging the nuclei of origin
of the spinal nerves. This would account for the
symptoms of involvement of the fifth, tenth, and twelfth
nerves.
There is no doubt that amyl nitrite alone was the
cause. The presence of it in his room and his state-
ments to me, together with my certain knowledge of
his private affairs, forbids any mixed poisoning, either
intentionallv or bv accident.
progress of Medical .Science.
Vaginal Hysterectomy. — In a paper discussing bi-
lateral suppurative processes of the uterus and adnexa.
Dr. W. D. Haggard, Jr. (T/ie Southern Practitioner.,
November, 1896), says: " In suppurative disease of the
uterus and appendages requiring removal, the vaginal
method is preferred to the abdominal for the following-
reasons: I. The preliminary step, vaginal section, al-
lows thorough exploration and the application of anv
appropriate conservative treatment, with a minimum
of risk. 2. The vagina is the natural approach and
logical avenue for drainage of the pelvis and its con-
tents. 3. It is immune from the unpleasant sequela-
of laparotomy, possibility of ventral hernia, of stitch
abscess, of infected ligature and sinuses, and the ab-
dominal supporter. 4. There is less immediate shock:
the convalescence is smoother and shorter. 5. There
is no exposure or handling of intestine. 6. The mor-
tality is lower."
Infantile Syphilis — Dr. Coutts (^British Ah;/iial
Jflurniil, 1896, No. 1,843) gives the results of his
studies on this subject, summarized from the Hunte-
rian lecture. He thinks a syphilitic mother much more
potent in infecting than a syphilitic father. .-Xs far
as prognosis in the treatment goes, it makes no differ-
ence whether the father or the mother is the infecting
agent. In syphilis by conception, the mother's entire
or partial immunity is caused by the production of
antitoxins in her body, which increase with successive
pregnancies. Marasmus and congenital atrophv of the
secretive and absorptive surface of the intestinal tract
are considered among the most important symptoms of
inherited syphilis. First symptoms commonly appear
in the second month, but may be delayed twelve
months. Enlargement of the spleen and liver was
found in most cases. Bone lesions are less often ob-
served: pain was often absent in syphilitic epiphysitis;
suppuration is rare and is usually seen in the long bones
of children old enough to walk. .Acquired syphilis is
always accompanied by a chancre, followed by roseola
and often by sore throat. Dr. Coutts calls attention to
8i8
MEDICAL RECORD.
[December 5, 1896
two propositions embraced in Colles' law — the mother
of an infant with inherited syphilis cannot acquire it
from the infant, but such an infant would infect a
healthy wetnurse. Inherited syphilis is very feebly
contagious, while acquired syphilis is actively so.
The limitations he would place on nursing would be
that the mother or wetnurse should have no excoria-
tions on the nipples, and that no ulcerations or fissures
be present on the mouth of the infant.
Congenital and Pathognomonic Symptoms of Syph-
ilis.— L)r. Silex (A/i/ni/s of Opiitltalmology and Otii/o^y)
says the diagnosis is more difticult after the fourth
year, especially when complicated by scrofula or rick-
ets; after this time the eye specialist is in a better po-
sition to judge of the e.vistence of inherited syphilis
than the general practitioner. Fournier reported that
the eyes were affected in one hundred and one out of
two hundred and twehe congenital syphilitics. In
eighty-two only were osteoplastic changes noted. In
sixty-tw'o to eighty-three per cent, of cases we find
keratitis. The peculiar form of teeth described by
Hutchinson and Knies were referred to. Hirschberg
stated that choroiditis areolata, serpiginata, and dis-
seminata were all believed by him to be the results of
congenital syphilis. The writer would add Virchow's
sign of congenital syphilis, the smooth base of the
tongue.
Practical Treatment of Typhoid Fever. — Dr. C.
K. Skinner writes as follows in the JVaci York Medical
Journal, October 24, 1S96: "It is a prevalent notion
that a too rapid return to solid from a liquid diet is
capable of inducing a relapse of the disease. I do not
believe this. This fever is infectious, and if, in any
given case, it started to run another cycle, there must
certainly have occurred another infection with fresh
germs. It is much more logically explained by the
probability that the fa-ces had not been thoroughly dis-
infected early enough to kill all the micro-organisms,
and that some article — clothing, bedding, or the car-
pet, for instance — had suft'ered contamination. As
their virulence is not destroyed by drying, it would be
quite possible for some of them to effect a re-entrance
into the patient's intestinal tract and set up mischief
anew. Too heavy (/>., indigestible) a diet would be
likely to produce acute dyspepsia, with its accompany-
ing systemic disturbances, and this would be rendered
more intense and easier of induction by the debility
present; but I do not believe that it ever directly
caused a relapse into true typhoid fever."
Erythromelalgia. — Not much has been added to
our knowledge of the symptom complex designated by
Weir Mitchell as erythromelalgia since his first de-
scription of the disorder in 1872. As the name indi-
cates, the condition is characterized by pain and red-
ness, not of an inflammatory nature, usually confined
to an extremity, wor.se on dependency and in hot
w-eather, with hyperalgesia and increased local tem-
perature, and without definite trophic disturbance. Of
the ultimate nature of the disorder we have no posi-
tive knowledge, although hypothe.ses as to its pathol-
ogy are not wanting. One of Mitchell's cases w-as
believed to be of spinal origin. In another the symp-
toms were attributed to a terminal neuritis; and this
view seemed to receive support from the relief afforded
by exsection and stretching of the nerves presumably
involved in the morbid process. A number of cases
of erythromelalgia have been recently reported by
German observers, two of whom, Lewin and Benda
[Dciitsihe mcdicinisdic W'ochtnsihrijt, 1894, Nos. ^, 4,
5, 6), have collected a total of forty cases from the
literature. A study of these leads to the conclusion
that the affection is not a disease sui generis, but a
manifestation at times of spinal or cerebral disease, at
others of some general neurosis, while in some in-
stances it is to be viewed as the expression of a neu-
ralgia, or of a neuritis, or even of a reflex influence.
In reporting in detail a case recently, Dehio {Rciimcr
klinisihc Wot/nnsihrijt, 1896, No. 37, p. 817), after an
analysis of the symptoms, comes to the conclusion that
the manifestations of erythromelalgia are due to ab-
normal irritability of the posterior and lateral horns
of the gray matter of the spinal cord and, perhaps,
also of the medulla oblongata. In this case examina-
tion of the ner\es of the part of the body in which the
symptoms of the di.sorder were manifested failed to
disclose any morbid alteration. The local arterial
sclerosis found was a.scribed to the persistent diminu-
tion in vascular tone. The evidence thus far accumu-
lated would seem to justify the conclusion that the
group of symiJtoms included in the designation erythro-
melalgia may result from a multiplicity of causes act-
ing upon different parts of the nervous system, and
prognosis and treatment will vary accordingly.
Nervous Manifestations of Syphilis. — The diag-
nostic features of \alue are enumerated as follows in
a paper by Dr. Hodges, read at the Richmond Acad-
emy of Medicine: 1. Headaches, which disappear if
paralysis occurs. 2. Insonniia, nearly always associ-
ated with headache and disappearing with the ap-
pearance of convulsion or paralysis. It differs from
the insomnia of neurasthenia and melancholia in that
it occurs in the early night, the victim arising in the
morning ready for his daily labor. 3. Vertigo, occur-
ring usually with the headache. It may be transient,
but becomes worse as the disease progresses. 4.
Tremor, present in one-half of the cases. It occurs
most often in the order named: In the hands, tongue,
and over the whole body, and is accompanied by head-
ache. If it occurs in a limb, it is the precursor of
paralysis of the limb. 5. Hemiplegia. 6. Erratic
distribution of paralysis, as aphasia with or without
hemiplegia, ptosis, insanity, or epilejisy. with paralv-
sis of one arm or leg. It is suggested tliat ptosis oc-
curring suddenly points nearly always to syphilis.
7. The use of electricity to determine central or pe-
ripheral lesion. 8. The presence of great weakness
and mental dulness. This is one of the most valua-
ble of the ner\ous manifestations, being out of pro-
portion to the .seeming condition of the patient. 9.
History of the case. In women, the history of many
abortions in succession would point to syphilis.
Are Microbes Necessary to Human Life?-.\
correspondent writes to the J'lulaihlpliia J\d\(lini( in
opposition to the theory that microbes are necessary
to physiological digestion. The experiments of Nut-
tall and 'i'hierfelder indicate that the animal body is
independent of bacterial life, for they have shown that
in the absence of all micro-organisms an animal may
live and thrive. Their experiments were as follows:
" A young guinea-pig was secured by C'a-sarean sec-
tion, under strict aseptic and antiseptic precautions,
and immediately transferred to an apparatus consist-
ing of a bell jar placed o\er a small vessel containing
water covered w ith a layer of oil. Over this vessel
was laid a piece of wire netting, upon which the ani-
mal could move about. In the sides of the bell jar
were two apertures — in one a rubber glove, in the other
a suction tube communicating with a bottle of steri-
lized cow's milk. The glove was connected with a rub-
ber bag containing wads of cotton, which by manipu-
lation of tile glove could be placed on the wire screen,
and after use could be dropped into the water beneath.
The coating of oil prevented the evaporation of the
water. From time to time the apparatus was venti-
lated with sterilized air. For a time the animal lay
on its side, but soon rose on its legs, and, as it became
December 5, 1896]
MEDICAL RECORD.
819
•dry, grew active and lively. It received milk for the
iirst time twelve hours after birth; thereafter, ever)-
hour, day and night. After eight days it was removed
from the apparatus, killed, and opened under antisep-
tic precautions. A microscopic examination of the
intestinal contents, in stained and unstained prepara-
tions, revealed a total absence of bacteria. Tubes in-
oculated with the contents and kept under both aerobic
and anaerobic conditions remained perfectly sterile;
not a single colony develo]Ded." From these results
the e.xperimenters conclude that bacteria need not nec-
essarily be present in the intestinal canal of guinea-
pigs, nor in other animals, nor in man — at least, not
s« long as the food is purely animal.
A New Method of Artificial Respiration Calli-
ano {British Mctiica! Joiinial) describes a new method
of artificial respiration, which he has practised suc-
cessfully in cases of asphyxia. Place the patient in
Sylvester's position, draw the arms up so as fullv to
expand the thorax, and fix above and behind the head
by tying the wrists together. Respiration is then pro-
duced by simply pressing with the hands on the tho-
rax some eighteen or twenty times a minute. The
advantages claimed for this modification of Sylvester's
method are its greater simplicity, the smaller amount
of labor required, and lessened fatigue of the operator;
the absence of danger from contusion of the shoulder-
joints, and the ease with which such a method could
be taught to and practised by uneducated and un-
trained people.
Massage Movements and Bandaging in the
Treatment of Displaced Semilunar Cartilages. — Dr.
Douglas Graham, in a paper puhlislied in Tlu Amcriujii
Journal of the Medical Sciences, November, 1896, con-
cludes: I. That neither in theirnatural nor in their un-
natural positions can semilunar cartilages often be dis-
tinguished from the surrounding tissues. 2. That the
position of the leg affords the best means of inferring
whether one or the other semilunar cartilages mav
have been dislocated when it cannot be felt, the leg
being usually fiexed and the foot turned out when the
internal meniscus is dislocated, the leg flexed and the
foot turned in when it is the external. 3. To attempt
to replace a dislocated semilunar cartilage, it is wise
to flex the leg, then extend suddenly, rotating the leg
inward if it be the internal cartilage, outward if it be
the external, while e.xerting pressure over the oft'ending
region. 4. That there is a natural tendency in some
cases of dislocated semilunar cartilages to slip back
into place when the leg is not artificially restrained.
5. That if the knee bo immovably fixed by plaster or
splints before the cartilage has gotten back into its
natural situation, the joint is locked and restrained
from gentle instinctive movements that might favor its
return. 6. That cases of displaced cartilage are at-
tended by voluntar)' and involuntary restraint of mo-
tion, on account of pain and mechanical impediment;
and in some cases by synovitis and the formation of
adhesions. Forcible passive motion might then have
the double purpose of breaking the adhesions and rec-
tifying the displacement. 7. That even after a menis-
cus has been restored to its natural situation, it is not
so securely and comfortably held by plaster and splints
as by a pad of a few folds of bandage and a figure-of-
eight bandage applied over this, which affords sup-
port and comfort and a safe limit of motion 8.
That it is possible, by carefully applied massage, re-
sistive movements, home exercises, and electricity,
so to strengthen the muscles on the front of the thigh,
the fascia, ligaments, and attachments of the knee-
joint that they will safely hold a previously dislocated
seinihuiar cartilage without artificial support. 9.
These remarks do not apply to cases requiring surgical
operation, though the above-mentioned combination
of treatment might be safely tried in some cases before
cutting into a knee-joint, but more especiallv after
operation for restoring motion and strength to the knee.
Cholagogues — Dr. F. Stadelmann {Berliner klin.
U'och.) thus classifies the so-called cholagogues: 1.
Substances having no true cholagogue action: bicar-
bonate of sodium, chloride of sodium, sulphate of so-
dium, etc. 2. Drastic substances, having no assured
cholagogue action and often diminishing the biliary
secretion : gamboge, jalap, aloes, scammony, senna,
calomel. 3. Substances diminishing the biliary se-
cretion more often than they increase it: alcohol,
olive oil. 4. Substances certainly diminishing the
biliary secretion: atropine, pilocarpine (?). 5. Sub-
stances having a doubtful cholagogue action ; antipv-
rin, acetanilid, caffeine, diuretin, santonin, Durand's
remedy. 6. Substances which are cholagogue: sali-
cylate of sodium, bile.
Hydronephrosis. — i. Lumbar nephrotomy, fol-
lowed by packing and aseptic drainage. If urinary fis-
tula remains after three months: 2. Operation for the
stenosis, namely, for (<?■) stricture of the ureter, or (/)
valve formation and oblique insertion. If the fistula
still remains with the ureter patent, which occurs only
when there is obstruction above the ureter: 3. Ope-
ration for sacculated kidney as designed bv me,
namely, bisection of the kidney and division of the
partition walls between sacs. When the entire terri-
tory of the sac is thus laid open and the ureter is pat-
ent, as demonstrated by free passage of bougies from
the kidney to the bladder, and by free passage of in-
jected fluid, then — 4. Closure of the fistula by reun-
ion of the bisected kidney. This last operation may
confidently be expected to be followed by disappear-
ance of the fistula. It should not, however, be done
until the pyelitis, if present, has been cured by thor-
ough irrigation from the kidney to the bladder. Kus-
ter obser\'ed a case of nephrotomy in which the fistula
closed spontaneously, with patent ureter, but the pye-
litis persisted, giving an incomplete cure. I have
seen, however, when we closed the fistula before the
pus has disappeared entirely from the urine, the pus
in the urine having remained unchanged in amount
for a considerable time, that the closure of the fistula
acts as a curative measure and causes the pyelitis to
cease. — Fexger, Annals of Surgery, June, 1896.
Etiology of Lobular Pneumonia. — Dr. Kreibich,
in a monograph published by fSraumuUer, Vienna,
1896, examined twenty-seven cases of pneumonia,
twenty of which were of the inspiration variety. In
twenty-three he found the diplococcus pneumonia-,
eleven times in pure culture, five times with bacillus
coli communis, four times with staphylococcus pyo-
genes aureus, once each with bacillus pneumonia,
streptococcus poygenes, and another unrecognized
microorganism. l)r. Kreibich asserts that broncho-
pneumonia, and especially inspiration pneumonia, aie
generally caused by the diplococcus pneumonia; but
he notes that in man bacillus coli is also capable of
causing lobar and lobular pneumonia. As an auto-
infection from the cavity of the mouth, the occurrence
of lobular pneumonia dependent upon the diplococcus
pneumoniae is favored by such conditions as heart
failure, hypostatic hypen-emia, etc. In most cases of
coli pneumonia there is infection by the blood from
the intestine or from inflammatory processes in the
urogenital tract. Inspiration pneumonia may end in
suppuration, in gangrene, or in induration. With re-
gard to the first termination, the variety of exudation
is not generally influenced by the question whether
the diplococcus was alone present or in company wiih
other organisms, though the exudation has a tendency
820
MEDICAL RECORD.
[December 5, 1896
to he bloody if large isfective masses are suddenly in-
spired. Gangrene is generally caused by anaerobes
and saphrophytes, probably present in the inspired
mass, which induce putritl changes in the contents of
the bronchi, and by their katabolic products lead to
necrosis of the inflamed portions of the lung. Indu-
ration apparently occurs when the metabolic products
of the bacteria constitute a long-continued stimulus to
productive inflammation.
Th2 Cause of Warts. — Mechanical irritation of the
p.ipilla: is thought by Schaal (Archiv fiir Derm. 11.
Syp/i., Bd. XXXV., H. 2) to be the cause of warty
growths. In his own person, spicule of glass seemed
to lead to increased formation of epidermic cells and
the development of warts. The exposed surfaces be-
ing those on which warts habitually develop would
lend weight to this theory. The delicate tissues of
childhood also favor easy penetration of foreign bodies.
Hayseed Sprouted in the Ear. — Dr. Macnaughton
Jones reports, in \.\\q /oiinni/ of Laryiigo/ogy, Rhiiiology,
and Otology, a case in which the patient had been suffer-
ing from noises in the ear for some years, and had
other evidences of middle-ear deafness. He sought
advice for the deafness, being quite unconscious of the
presence of any foreign body. On examining the
meatus, what appeared to be a pink sprouting mass of
fungus was seen with the transmitted light. The ap-
pearance was most puzzling, and it was not until the
sprouting hayseed was withdrawn that its nature was
discovered. It was quite firmly attached to the wall
of the meatus, being removed clean with the lever for-
ceps. The patient then remembered having, over two
years previously, at harvest time, suddenly felt as if
something had entered his ear, and the tinnitus began.
Myxodermia At a recent meeting of the Paris
Academy of Medicine, Dr. H. de Krun presented a
communication based upon the observation of a girl
of seventeen years, who had entered his hosjjital ser-
vice with the diagnosis of typhoid fever, and upon the
further observation of a similar case by \)x. Haidar.
an externe of the service. The conclusions presented
were to the effect that there exists a disease charac-
terized by the following ensetublf of phenomena:
Rapid onset, with high fever, malaise, vomiting, and
headache, followed at once by the development of the
typhoid phenomena common to all infectious diseases,
with predominance of agitation during the night, when
the delirium takes on a particularly violent character.
The temperature range is characterized by three peri-
ods : A primary period, during which the thermometer,
after having registered 39^ C. from the first, oscillates
during eight or ten days between 39^ atid 40° C. ; a
second period (apyrexia), during which the tempera-
ture falls for about eight days to below normal; a
third period, in which the temperature goes up again
rapidly to the neighborhood of 39' C There is a
generalized contraction of the whole muscular system,
especially pronounced in the masticatory muscles
(trismus), the muscles of the face (special facies),
and the muscles of the neck (stiffness of the neck
and impossibility to turn the head). Here are also
special alteration of the skin, which becomes like
soft wax; subcutaneous hemorrhages coming on at the
onset of the third period; multiple ecchymoses, which
are voluminous, painful, and characterized by a large
white zone, which surrounds them and distinguishes
them from ecchymoses which may be produced in other
infectious diseases and in scorbutus. This disease is
equally remarkable for the absence of meteorism and of
rosy lenticular spots or other eruption. Its duration
is from three to four weeks. Its infectious principle is
still to be determined; however, we may affirm that it
has nothins: in common with the bacillus of F.herth.
The prognosis is grave. The di;ignosis of this affec-
tion is relatively easy, thanks to the existence of a
certain number of symptoms truly pathognomonic,
which permits us clearly to establish its autonomv and
to call it, until a better name is agreed upon, myxo-
dcrmie coii/rai/nniiik hcmorrhagiqiie.
Vaginal Caesarean Section. — Dr. Diihrssen de-
scribes the Vaginal method as less dangerous than the
classical Cesarean section. His operation was done
in spite of closure of the cervix, and without opening
the peritoneum. He delivered a living child by the
vagina. The vaginal portion was exposed by a large
speculum, and sagittal openings having been made in
the anterior and posterior vaginal vaults, the bladder
and vesical fold of peritoneum and that of Douglas'
pouch were detached from the cervix and lower seg-
ment of the uterus, which were then divided in the
median plane. After the bleeding had been arrested
by ligatures, he introduced his hand, and turned and
extracted a child of nine and one-half pounds weight.
The operation is indicated when, with an undilatable
cervix, the mother's life is imperilled by circum-
stances which may be improved, or set aside, by emp-
tying the uterus; for example, in severe eclampsia or
uremia: in cases of serious internal hemorrhage from
a normally situated but prematurely displaced pla-
centa; in gra\e pulmonaiy or cardiac disease; in the
interests of the child, when the condition of the mother
is expected to prove rapidly fatal ; and, finally, in
pathological conditions of the cervix or of the lower
segment of the womb. In new growths of the cervix
the operation may be supplemented by vaginal hyster-
ectomy, which, directly after delivery, can be performed
in a few minutes, by Doyen's method. Diihrssen con-
siders these procedures as logical developments of
Czerny's vaginal myomotomy and total extirpation,
and as instances of the influence of the advances of
gynecological surgery upon the field of obstetrics. —
Birlincr kliiinihi \]'ocluii<:chiiJI.
Tuberculous Hernia. — .\ccording to Dr. Renault,
tubercle developing in a hernial sac or in its contents
may assume two forms: Gross tubercle or miliary.
These two forms may be either primary or may coexist
w ith other lesions of the same kind in different organs,
and the author points out as curious that femoral her-
nias are much more rarely tuberculous than inguinal,
and that tuberculous umbilical or obturator hernias
have never been observed. In general, it is tho.se
hernias of long standing that are more likely to become
tuberculous. It is probable that the propagation of
the tubercle takes place by the intestine, and th.e author
believes that traumatism, being fairly frequent in
hernia, may have a marked influence in the develop-
ment of tubercle. He also suggests that variations in
the local circulation may have an important bearing.
Tubercle in a hernia may be found in either children
or adults, and in the former it is imijortant to bear it
in mind, for a child already the subject of a congeni-
tal hernia may develop tubercle very insidiously, as
a slight loss of weight and irritability may be the only
general symptoms. Locally there may be an increase
in the size of the hernia and marked pain on palpa-
tion, as constituting the only physical signs. That
the diagnosis is important is shown by the fact that
the tubercle may be confined to the sac and its con-
tents, but can, and often does, spread to the general
peritoneum. If diagnosed before extension takes
place it is possible, the author believes, to obtain sat-
isfactory results by treatment. This latter should be
the ordinary treatment of hernia, the tubercle under
these circumstances appearing to subside, as in the
case of a general peritoneal invasion. — Journal de
Afi'deci'ie de J\iris.
December 5, 1896]
MEDICAL RECORD.
821
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, December 5, 1896.
LEGAL RESPONSIBILITIES OF THE OPER-
ATING SURGEON.
A RECENT suit for damages against a surgeon in Lon-
don for exceeding the wishes of a patient regarding the
e.xtent of an operation has just been decided for the
defendant. The case was one of double oophorec-
tomy, against the express wishes of the patient that
but one ovary should be removed. During the prog-
ress of the operation it became evident to the surgeon
that the removal of the remaining offending organ was
necessary for a radical cure. The patient, in conse-
quence of this act, was compelled to break a mar-
riage engagement which had been pending. The tes-
timony in the trial bore upon some very im.portant
questions of professional responsibility in this and
similar cases. While the course to be pursued must
be governed by individual circmnstances, the general
reasons for specific action are admittedly controlled
by well-understood general principles. The result of
the case in hand carries with it a lesson of danger in
lawsuits which every surgeon should thoughtfully con-
sider. It is legally held in this country and in other
civilized communities that the consent of the patient,
when such can be obtained, is always necessary in
dividing the responsibility of any operative treatment.
In the case of a child or of an insensible patient in
imminent peril, the nearest relatives or friends are
competent to decide for or against surgical interfer-
ence. When such precautions are not or cannot be
taken on the part of the operator, he assumes the sole
responsibility of the result. No surgeon cares to do
this when he can avoid it, and as a consequence he
protects himself against the possibility of subsequent
misunderstanding accordingly. A refusal to take
proper advice under given circumstances is the affair
of the patient and that of no one else. Hence, in the
eyes of the law the patient has the right to decide his
own chances; in other words, is privileged to take his
life in his own hands, in spite of the judgment of the
person who is summoned to his aid.
In the actual course of an operation the case is en-
tirely different, and the discussion of the duties of
the operator opens up a wide field for the e.xercise of
his judgment in assuming unlooked-for risks, in meet-
ing unsuspected conditions of emergency, or pressing
matters of expediency. It is just here that a line can
be drawn between what may be actually necessarj^ to
avert immediate death or subsequent disability and the
surgeon's ideal of a complete operation. Especially
is this true when the loss of an important organ is to
be considered, and when the patient has forbidden its
removal under any circumstances. No good operator
would care to undertake the treatment of any case
with such an embarrassing handicap; but when he
does, he must, save in very exceptional instances, re-
ligiously abide by the conditions.
In the present case, the testimony showed that the
operator, when asked to promise that but one ovary
should be removed, replied that he would use his best
judgment in complying with the request. The tacit
consent to such a proposition was legally implied by
the patient voluntarily placing herself upon the ope-
rating-table, although she positively declared that she
had given no direct assent to the proposal of the sur-
geon. Although it was not claimed that the removal
of the second ovary was necessary to save the life of
the patient at the time, but that it was for the sake of
an ultimate cure, the jury, fortunately for the defen-
dant, took the lenient side and most liberally endorsed
what on general principles might be considered a
laudable motive. Strictlj- speaking, however, there
was a dangerous possibilitj' for an entirely opposite
view. That such chances should not be taken again
is the real moral to this particular tale. One of the
experts for the plaintiff expressed his belief that the
second ovary was not sufficiently diseased to require
removal, but he evidently merits the pity of every
practical g)'necologist.
While this case may be looked upon as a leading
one in protecting the surgeon in doubtful emergencies,
the pros and cons cannot be weighed too carefully to
prevent a disastrous reversal of the present ruling. If
it were necessary that one more word should be said
on this point, it is better in cases of doubt, when such
can be safely done, to perform an exploratory opera-
tion and obtain consent for more radical measures af-
terward, than to be called to account for what the
patient may term to be disobedience to his or her
commands; but safest and best of all is never to un-
dertake any operation whatever without the freest pos-
sible liberty for the use of personal judgment on any
and every contingency.
MEDICAL FEES AND MULTI-MILLIONAIRES.
It is said that since John W. Mackay refused to pay
the bill of the physicians who extracted the assassin's
bullet from his body, amounting to $12,500, he has
paid an attorney bill of $26,160, for taking a will of
which he was executor through the probate court — an
automatic procedure requiring neither skill, great abil-
ity, learning, nor judgment.
The California press was unanimous in condemn-
ing the physicians for rendering so large a bill, and
in congratulating the lawyer upon receiving a hand-
some fee. We have only ourselves to thank for the
way the public look upon these matters. Lawyers
often think better of us than we have thought of our-
selves, to judge from the excitement which is occa-
822
MEDICAL RECORD.
[December 5, 1896
sioned when a physician dares assert his rightful
claims.
In a recent speech to the Charing Cross medical
students, Justice Vaughan Williams dwelt upon the
affinity of law and medicine. Both required the same
qualities. Both lawyer and physician were the recipi-
ents of confidences from their clients, and clients
rarely found their confidences misplaced. As a law-
yer he came into contact with doctors in the law
courts, where the most important issues were often de-
termined solely on the evidence of medical experts,
who were for the most part safe guides in the admin-
istration of justice. One point, however, in which the
professions differed was that the medical profession
was essentially progressive, while the legal profession
was in a sense stationary. If the doctors of the last
century should come to life again, they would know
comparatively nothing of contemporary medical sci-
ence; but if the judges of former times were installed
in the law courts to-morrow, they would try the cases
quite as well, if not better than the judges of to-day.
This eminent representative of the bar might have
proceeded to designate one other point in which the
professions differed. If the legal profession is sta-
tionary in one sense, it has advanced in knowledge of
how to secure at least fair remuneration from men of
great wealth. This the medical man has yet to learn
— and in learning it, the public will be taught.
ITCHING AND THE ITCH.
In a recent number of La Midecine Moderne, the fre-
quency with which formula are published in American
medical journals for the relief of pruritus vulva; is
made a subject of comment. The question is asked
whether there are peculiarities of race, climate, or en-
vironment which tend to make the affection so preva-
lent among American women that editors have become
possessed of the necessity of bringing the matter for-
ward so frequently in their publications. We do not
know how others may account for the fact that pruritus
vulvae receives so much attention at American hands,
but our itch editor, to whom we referred the matter,
informs us that personally he is a great admirer of
French journalism, and constantly flatters French edi-
tors in the sincerest way by imitating them. Now,
as every one knows who reads the Paris journals, it
would be considered an unpardonable oversight for
an editor to send out a weekly issue which did not
contain the recipe for at least ont poviviade coiitre la
gale.
Having little or no scabies in this country, and
much more pruritus scribendi than any other variety,
these formulffi are reproduced and made to do service
under the faked caption of " pruritus vulva;."
Now, will our esteemed friend of "modern medi-
cine" enlighten us upon the prevalence in France of
la gale, to which his own and his contemporaries' jour-
nals devote so much attention?
Syphilis has been recognized as a cause for divorce
by a Paris court.
^cxuB 0f the 'e^Ejefe.
"Ian Maclaren " to Physicians — The Rev. John
Watson, D.D., "Ian Maclaren," author of "A Doctor
of the Old School," w-ill preach to medical men and
medical stuclents in the Fifth Avenue Presbyterian
Church, Fifth Avenue and Fifty-fifth Street, on Sun-
day, December 7th, at 8 p.m. Tickets can be obtained
free by medical men, medical students, and other col-
lege graduates, on personal application at the Stu-
dents' Club, 129 Lexington Avenue. An opportunity
is thus offered to the medical profession of this city
to see and hear one who, by his charming creation of
" Dr. Maclure," has endeared himself to the hearts
of every one of his thousands of enthusiastic readers.
Pigeon Calls. — Dr. Harrey, a Scotch physician, is
said to make a practice of leaving with such patients
as are likely to require his prompt attendance one or
more carrier pigeons to be dispatched with messages.
He also takes the winged messengers with him on his
rounds and sends them back to his office with pre-
scriptions to be filled. It is not stated whether or not
they carry back the medicine to the sufferer.
A Photo-Fluoroscope has been invented by Dr.
Bleyer, of this city, by means of which it is said pic-
tures of interior parts can be taken which are a sur-
prise to scientists.
The New York Civil Service Commission will
hold the following examination at its office in the
new criminal court building, at 10 a.m. on the date
named. Citizens of the United States, who are resi-
dents of the State of New York, and hold the degree
of M.D. are eligible for this examination. Appli-
cations may be obtained from S. William Briscoe,
secretary, new criminal court building. New York
City. December 15th. — House physician, Bellevue
Hospital, department of public charities. Candi-
dates must hold degree of M.D., and will be exam-
ined on nervous and mental diseases. Salary, $1,200
per annum.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
November 28, 1896. November 21st. — Surgeon A. G.
Cabell detached from the Michigan, ordered home, and
granted three months' leave. Passed Assistant Sur-
geon F. J. B. Cordeiro detached from the Constellation
and ordered to the Michigan. Assistant Surgeon L.
Morris detached from the naval hospital, Philadelphia,
December 5th, ordered to examination for promotion at
New York, December 7th, and then placed on waiting
orders. Assistant Surgeon R. G. Brodrick ordered to
the Constellation. November 24th. — Medical Director
T. C. Walton detached from the naval academy, Jan-
uary 1 8th, in.stead of December 15th, and ordered
to the naval laboratory. New York, January 19th.
Medical Director H. M. Wells detached from the
naval laboratory. New York, January 19th instead of
December 19th. November 25th. — Surgeon W. S.
Dixon detached from special duty in Washington and
ordered to the Brooklyn, December ist.
December 5, 1896]
MEDICAL RECORD.
823
Paediatric Society of Philadelphia.— At a well-
attended meeting of Philadelphia medical men on
November 19th it was agreed to form a pjediatric
society.
Vienna Medical Society.— Dr. Adam Liewicz, a
prominent member of this society, has been expelled
for securing a patent upon his " cancroin," a cancer
remedy.
The Late Dr. Thomas H. Burchard.— The North-
western Medical and Surgical Society adopted the
following resolutions in regard to Dr. Thomas H.
Burchard :
Whereas, It has pleased God to take away Dr.
Thomas H. Burchard, distinguished by twenty years
of active and faithful membership in the Northwestern
Medical and Surgical Society of New York ; and
IV/tereas, Our hearts are touched with a deep sorrow
by the suddenness of his decease; therefore,
Resolved, That we desire to place on record an ex-
pression of our esteem of our late colleague, who had
endeared himself to us by a long line of friendly and
generous offices — that we desire to commemorate his
devotion to the medical profession; e.xemplified in so
high a degree by his many contributions to this and
to other medical bodies, and by his acknowledged
skill as a surgeon — and that we realize in the life of
our friend the large equipment of mind and body es-
sential to the success of a true physician.
Resolved, That a copy of these minutes be sent to
the bereaved wife and sons and near relatives of our
late colleague, to whom we extend our sincere sym-
pathy in their great affliction.
Resolved, Further, that a copy of these resolutions
be sent to the various medical journals of New York
for publication.
For the society,
Edward S. Peck, Committee.
Mortality in the State — There were 8,676 deaths
in the State in October, according to the monthly bul-
letin of the State board of health. The decrease in
the mortality from all causes, which was reported in
the last bulletin to amount to 500 fewer deaths than
in the corresponding month of last year, has contin-
ued during October, the reported mortality being 600
less than that of October, 1895. There is also a de-
crease of 800 in the number of deaths reported from
the preceding month. The estimated death rate is
16 per 1,000 population annually, against 17.50 in
September and 17.20 in October, 1895. The number
of deaths from diarrhceal diseases is unusually small,
and has diminished from 1,077 '" September to 338,
and this decrease is distributed over all parts of the
State. The number of deaths from diphtheria, com-
pared with ihe mortality of a year ago, is less for the
month by 100, but there is an increase from 294 deaths
in September to 361 in October. This increase
occurs in all parts of the State except the central and
southern. Its prevalence is reported from tliiity-five
towns in the northern and eastern parts of tlie State.
In New York City there were fewer deaths than in
September, but the disease has increased in Brooklyn
and Long Island. Diphtheria caused less than 2 per
cent, of the mortality in rural towns and 4.5 per cent,
of the urban mortality. Scarlet fever is reported as
prevalent from twenty-five towns in the southwestern
counties; thirty-five deaths occurred, which is a slight
increase over last month. Typhoid fever has slightly
decreased; it caused 5.50 per cent, of the rural and 2
per cent, of the urban mortality. From acute respira-
tory diseases the mortality is excessive, the 1,123
deaths reported being 300 more than either that of the
preceding month or the corresponding month of last
year. No special cause for this increase has been re-
ported. From other local diseases the mortality is
diminished.
Obituary Notes — Hiram Henry Darr, Caldwell,
Tex., died November 22, 1896. He was born April 4,
1853, on the old Darr homestead in the vicinity of
Yellow Prairie, Tex., and obtained a general educa-
tion in the local schools and by private study; attended
lectures at Louisville Medical College, Louisville,
Ky., from which he was graduated February 25, 1875,
with first honors, receiving the gold medal for general
proficiency in all branches, and also the first prize in
surgery. He then took an ad eundem course at the
Kentucky School of Medicine, and was graduated from
that institution in June of the same year, 1875. Locat-
ing near Hearne, Tex., he practised medicine there
until 1879, and spent the winter of 1879-80 in study
at the College of Physicians and Surgeons in the city
of New York, giving special attention to diseases of
the eye, ear, and throat. Returning to Texas, Dr.
Darr located at Caldwell, in his native count}\ He
was a member of the following-named organizations,
having joined them in the years given : Texas State
Medical Association, 1877, vice-president in 1884;
American Public Health Association, 1882; American
Medical Association, 1883 ; Burleson County Medical
Society, which he helped to organize in 1885 and of
which he was the first president. International Med-
ical Congress, 1887; National Association of Rail-
way Surgeons, 1891; American Academy of Politi-
cal and Social Science, 1892. — Dr. Pinckney Web-
ster Ellsworth, who had been a physician and
surgeon of Hartford for fifty-three years, died Decem-
ber 1st, from a paralytic shock. He was born in Hart-
ford on December 5, 1814. He was a descendant
of Governor Bradford of the Ma};flou'er and also of
John Webster, one of the first governors of the Con-
necticut colony. Dr. Ellsworth graduated at Yale in
the class of 1836 and from the College of Physicians
and Surgeons of New York in 1839. He was one of
the organizers of the Hartford Medical Society, a
member of the Connecticut Medical Society, and an
honorary member of the New York State Medical
Society. His distinction as a surgeon led Governor
Buckingham to appoint him surgeon of the Connecticut
brigade of volunteers, and he participated in the first
battle of Bull Run. He was a member of the Centre
Church for over fifty years, the same church in which
his father, Governor Ellsworth, was deacon for over
half a century. He leaves a widow and six children. —
Dr. Jacob T. Field, who died at his home in Bayonne,
824
MEDICAL RECORD.
[December 5, 1896
N. J., was fifty-seven years old, and was born in North
Branch, Somerset County, N. J. His academic educa-
tion was received at Rutgers College, and his medical
degree was conferred by the College of Physicians and
Surgeons. He was a war veteran, and leaves a widow
and one son.
Generous Endowment. — The children of the late
George Leib Harrison have added $150,000 to the en-
dowment fund of the '• George L. Harrison Memorial
House" of the Episcopal Hospital of Philadelphia,
thus completing the total of $300,000.
Typhoid is reported very prevalent at Paterson,
N.J.
The Late Dr. Francis H. Rankin. — At a special
meeting of the Newport Medical Societ}', held at the
residence of Horatio R. Storer, presided over by First
Vice-President Dr. C. F. Barker, the following pre-
amble and resolutions were adopted :
Whereas, In His inscrutable wisdom Almighty God
has seen fit to remove from the scene of his earthly
labors, our beloved president; therefore,
Resolved, That we bow in submission to His divine
will.
Resolved, That in the death of Dr. Francis H. Ran-
kin, the medical societj' of which he was the founder
has met with an irretrievable loss.
Resolved, That the profession of medicine has parted
with one of its brightest leaders, a man who was al-
ways working for the sanitarj' welfare of this city, for
the good of the poor, and the benefit of the profession
of which he was so bright an ornament.
Resolved, That no man could have led a purer or
more useful and disinterested life, and that the urban-
ity of his manners, the gentleness of his disposition,
the truthfulness of his character, and the manliness of
his nature served to bind with bonds of sincerest love
the enduring friendship which he always inspired in
all who had the privilege of knowing him.
Resolved, That we offer our sincere sympathy to his
afflicted wife and relatives.
Resolved, That the society attend his funeral in a
body.
Resolved, That a copy of these resolutions be pub-
lished in the daily papers of this city and in a promi-
nent medical publication in New York, Boston, and
Providence, and that a copy be presented to his
family.
V. MoTT Francis, M.D.,
Second Vice-President,
Henry E. Turner, M.D.,
Stephen C. Powell, M.D.,
Committee.
Philadelphia County Medical Society. — At a stated
meeting ot the Philadelphia County Medical Society,
on November nth, Dr. J. T. Rugh read a paper enti-
tled " Eight Primary Movements of the Normal Spine
as a Basis for Gymnastics in the Treatment of Scoli-
osis and Allied Conditions." These movements con-
sist in bending forward, bending backward, bending
to the right, bending to the left, combination of these
movements in circumduction to the right, combination
of these movements in circumduction to the left, rota-
tion of the spine upon its vertical axis to the right,
and rotation of the spine upon its a.xis to the left.
By special invitation, Mr. Tallerman, of London, ex-
hibited a localized hot-air bath apparatus, and de-
monstrated its extraordinar}' efficacy in a case of satur-
nine gout ■ and in one of lumbago. This device
promises to prove of large service in the treatment of
such disorders, especially, as chronic and painful
affections of the joints and muscles of varied kind,
and has for several years been in successful employ-
ment at the hands of English surgeons and physicians.
Dr. Max J. Stem made a '' Report of Work with Roent-
gen Rays at the Polyclinic Hospital, with Exhibit of
Skiagraphs."
Traffic in Corpses — The department of charities
has suspended Morgue-Keeper White for selling bod-
ies to the Polyclinic. Lender the section of the penal
code which makes it a felony for any person to sell a
human body for dissection purposes, Mr. White was
arrested. The penalty for each offence is $1,000 fine
or five years' imprisonment, or both. It has long been
suspected in certain institutions that the difficulties
in obtaining autopsies when bodies were not claimed
by friends was because they were too valuable to some
one.
Leprosy in Russia — In July, 1895, the Russian
government issued a decree that every case of leprosy
must be notified to the authorities. In July of the
present year it was found that in the course of the
previous twelve months 894 cases had been notified.
Of this number, 63.3 per cent, suffered from the tuber-
cular form of the disease. As regards the age of the
patients, 3 per cent, were under five; 14.42 percent,
under twenty; 28.2 per cent, over fifty; and 4.1 per
cent, over seventy. In eighteen cases the disease ap-
peared to have been transmitted from man to wife, or
vice versa. There afe already five leper asylums and
two leper colonies in Russia, and it is in contempla-
tion to increase the number of these places of isola-
tion.— British Medical Journal, November 7, 1896.
College of Physicians of Philadelphia. — At a
stated meeting of the section on gynecology of the
College of Physicians of Philadelphia on November
19th Dr. C. B. Penrose reported a case presenting an
enormous fibroid tumor of the uterus, weighing upward
of eighty pounds. The patient died from heart fail-
ure several hours after the operation, in consequence,
it was thought, of the sudden removal of the intra-
abdominal pressure that had previously existed. Dr.
Penrose also reported a case of spontaneous rupture
of an oophoritic cyst, in which removal was practised
successfully. By invitation of the executive committee
Dr. W. A. Newman Dorland read a paper entitled
'"Gestational Disturbances and Dystocia Subsequent
to Anterior Fixation of the Uterus." Dr. Richard C.
Norris reported the course of two labors following
suspensio uteri, and Dr. Barton Cooke Hirst also re-
ported two deliveries succeeding the operation of sus-
pensio uteri. Dr. Hirst also read a paper entitled
"Technique in Caesarean Section."
December 5, 1896]
MEDICAL RECORD.
525
Brooklyn Hospital. — Three members of the medi-
cal staff of the County Hospital in Brookh'n recently
submitted a report to the commissioners of charities
in regard to the overcrowding of some of the build-
ings. In the hospital nearly seven hundred patients
•were crowded into a space originally intended for four
hundred.
The Late Dr. F. W. Ring Resolutions adop^d
by the medical board of the Manhattan Eye and Kar
Hospital on the occasion of the death of Dr. Frank
Whitman Ring, on July 17, 1896:
Whereas, The hand of death has removed from our
midst our executive surgeon, Dr. Frank W. Ring:
Resolved, That, in submitting to the will of Almighty
God, we wish to express our personal sorrow at the loss
of a most faithful and efficient colleague.
Resolved, That we extend to his widow and family
our deepest sympathy in their bereavement.
Resolved, That the surgical staff of the hospital
attend his funeral services in a body, and that a com-
mittee of four be appointed to accompany his remains
to their final resting-place.
Resolved, That the flag of the hospital be displayed
at half-mast until after his interment.
Resolved, That a copy of these resolutions be for-
warded to his widow.
Resolutions adopted by the board of directors at
its stated meeting, November 17, 1896:
Whereas, we are called upon to record the death of
our associate. Dr. Frank Whitman Ring, which oc-
curred on July 17, 1896; and
Whereas, Dr. Ring has, for the past twelve years,
been actively connected with the Manhattan Eye and
Ear Hospital, New York :
Resolved, That we heartily indorse the action taken
by the medical board at the time of his death.
Resolved, That we hereby express our love and ap-
preciation of Dr. Ring as a man, a surgeon, and a
director of this hospital, and our own sorrow, as well
as the loss to the institution, by his untimely death.
Resolved, That a copy of these resolutions, in con-
junction with those passed by the medical board, be
published in our annual report, the New York med-
ical journals, and the Maine Journal oj Medieiiie and
Science, and that a copy of these resolutions be sent
to his widow with the sympathy of this board.
David Webster, M.D.,
J. B. Emerson, M.D.,
John Stewart,
Committee.
Army Department, Bureau of Medicine and Sur-
gery, Washington, D. C. The following changes in
the stations and officers of the medical department are
ordered under date of November 14th: Major John J.
Hall, surgeon, will be relieved from duty at Madison
Barracks, New York, by the commanding officer of
that post, and will report to the commanding officer
of Fort Wadsworth for duty at that post, to relieve
Major Edward T. Comegys; Major Comegys, upon
being relieved, will report to the commanding officer
of Fort Sill, Oklahoma Territory, for duty at that
post. Lieut.-Col. Albert Hartsuff, deputy surgeon-
general, and Capt. Norton Strong, assistant surgeon,
have been ordered to Chicago to assist in examination
of officers for promotion. Major J. V. Lauderdale,
surgeon, was placed on the retired list.
COliituuxn\.
EDWARD HAZEN PARKER, A.M., M.D.,
I'OUGHKEEI'Slf, N. ^ .
Dr. Edward Hazen Parker, for many years one of
the leading physicians of I'oughkeepsie, N. Y., died
in that city on November loth, in the seventy-third
year of his age. Widely known as a physician and
surgeon, he was still more widely known as the author
of that beautiful poem in which occur the following
lines, which were inscribed over the remains of the
late President Garfield:
" Life's race well run,
Life's work well done
Life's victory won ;
Now cometh rest."
Dr. Parker was born in Boston in 1823, and was the
son of Hon. Isaac and Sarah (Ainsworth) Parker, and
nephew of Hon. Joel Parker, chief justice of New
Hampshire and afterward Dane professor of law at
Harvard University.
Dr. Parker graduated from Dartmouth College in
1846, and received his medical degree from Jefferson
Medical College in 1848. After graduating in medi-
cine he was at once appointed lecturer on anatomy
and physiology at Bowdoin Medical College, and was
connected editorially for several years with the New
Hampshire Medical Journal. In 1853, on being called
to the chair of physiology and pathology in the New
York Medical College, Dr. Parker left Concord, N.
H., and established himself in practice in New York
City, two of his confreres in the college being the late
Professors Peaslee and Fordyce Barker. During the
three years that Dr. Parker held this professorship he
established the Ne7i< York Medical Monthly, which he
continued to edit personally for many years with great
ability and success.
In 1854 he received the degree of A.M. from Trin-
ity College. In 1858, at the solicitation of manv
friends and patients. Dr. Parker was induced to re-
move to Poughkeepsie. where he practised with distin-
guished ability to the time of his death, a period of
nearly forty years.
Dr. Parker was at one time president of the State
Medical Society, to which he made several important
contributions in the way of medical papers. He
also was president of the Dutchess County Medical
Society for the year 1861, was one of the prime mov-
ers in the establishment of the St. Barnabas Hospital,
and for many years was attending surgeon and at the
time of his death consulting surgeon to the ^'assar
Brothers' Hospital.
Dr. Parker was a physician of signal competency
and skill, and as a surgeon he had few superiors. He
was also a man of extremely fine fibre, of unusual cul-
tivation, and high scholarly attainments. His classical
education was liberal and sound, his .sympathies were
most acute, and he was also possessed of a fine poetic
talent, which in his busy life was less frequently exer-
cised than his friends could have desired. The single
poem mentioned has already enjoyed a world-wide
fame, and is one on which many an author would will-
ingly rest his claims for immortality. Surely, as we
review the long arduous career now closed, and recall
the conspicuous purity and sweetness of character and
the self-sacrifice which marked our friend and col-
league's long years of devotion to his work, we can
think of no other life to which his own tender lines
will more fittingly apply.
826
MEDICAL RECORD.
[December 5, 1896
^ocictij Reports.
SECOXD PAX-AMERICAN MEDICAL CON-
GRESS.
'Special Kepurt to the MtuiCAL Record )
IVcdiu'Siiay, November i8th — Third Day.
SKI TlOX (J.\ GENERAL MEDICINE.
Autumnal ^vers of the Southern Atlantic States,
and Their Treatment.- -I )k. liKindKU Hrown, of
Alexandria, Va., presented a paper with this title.
The forms of autumnal fe\er are intermittent, or ague,
remittent, and pernicious congestive. The remittent
is subdivided into the acute, with sudden onset without
premonition, chill, followed by acute active sthenic
form of fever, temperature ranging from 103" to 105"
F., followed by remission. In this form the curves of
temperature are angular, extreme, sudden.
In the prolonged form there are certain premonitory
signs lasting several days, as lassitude, neuralgic
pains in the head, back, and limbs, loss of appetite,
constipation. These are followed by a slight rise of
temperature in the evening and remission toward
morning. The curves of temperature in this form
are slight, gentle, moderate. They never rise high,
and during remission fall to the normal or near that
point. During the first week of fever they rarely rise
higher than 102'' F. ; in the second week to 103° F. ;
in the third week to 104' F.; and in the fourth week
to .05'= F.
ThiS is the form usually mistaken for typhoid fever.
Etiology: The autumnal fevers of the Southern
States are almost invariably of malarial origin. Occa-
sionally there are cases of true typhoid. But the epi-
demic fevers in nineteen out of twenty cases are mala-
rial in origin. The carriers of the malarial parasite,
the author held, are both water and air, although the
evidences are now greatly in favor of the belief that
water is the principal means of the introduction of the
parasite into the system. Dr. Brown then discussed
the action of the plasmodium malarias on the blood in
its relation to the phenomena of fever.
The season of prevalence of autumnal fevers of the
South is from early in .\ugust to the middle of Octo-
ber. They cease to prevail after the appearance of
frost, which is antagonistic to malaria. The symp-
toms of malarial fever were described, especial note
being made of the rhythmic features of the disease.
The differentiation between the symptoms of prolonged
malarial fever and typhoid was also dwell upon ; and
then Dr. Brown discussed the onset, .symptoms, morbid
phenomena, and course of pernicious congestive fever.
The prophylactic measures discussed were the puri-
fication of water, deep and surface water, artesian
wells, sterilized water, filtered water, and the steriliza-
tion and filtration of water combined. The prophy-
lactic powers of quinine and cinchona were also in-
sisted upon. The author also discussed separately the
treatment of intermittent fever, or ague; of remittent
fever, acute and prolonged; and of pernicious conges-
tive fever.
Quinine will ever be the chief and only reliable an-
tidote to th^ malarial parasite. The important tiues-
tion in its administration is the manner of giving the
remedy.
Malaria in Morelia. — Dr. Mari.^.no CoRnonA, of
M jrelia, Mexico, presented a paper containing a study
of the causes from which arises the endemic character
of malaria in Morelia: the forms under which the dis-
ease generally presents itself; the treatment which
the experience of many years has indicated as the best:
and reflections on the hygienic works which it will be
necessary to undertake with the view of suppressing
this general scourge.
Facts of Practical Utility with Respect to Mala-
ria Dr. Jii^t I'erres, of Mexico ("ity, said th.u he
was about to repeat what he had already said before
other medical gatherings, and he did so because he
deemed these facts of great practical importance, and
they could not be stated too frequently or too emphati-
cally. He had remarked that there was no apprecia-.
ble difference, either in the number of the parasites or
in the form tuider which they appear in the blood ex-
tracted from the finger tip, at whatever period of the
attack the examination was made — that is to say, that
the Plasmodia are equally found during the access of
malarial fever, shortly after its appearance, in full
apyrexia, or shortly before the next attack comes on.
In malarial cachexia, and when the attacks do not
present themselves at stated periods, the parasites are
scarcer, and the half-moons and the grains free of pig-
ment are then more frequent.
Ever since the year 1892 he had insisted that it is
of the greatest importance in diagnosis to find in the
blood, whether free or not, granulations of dark coflee-
colored pigment, as such discovery almost guarantees
the diagnosis, seeing that the pigment which results
upon destruction of the red globules is of a very light
coffee color, really yellow, and that the pigment of
melanotic cancer is rarely found in the blood.
It being easier to see the pigment than to distin-
guish the Plasmodia, the author considered it both
useful and practical to recommend that the former be
.searched for rather than the latter, by physicians who
are not very expert with the microscope or who have
not one of high power at hand. The examination for
Plasmodia ought always to be made with one that in-
creases at least seven hundred diameters.
The administration of quinine to the patient causes
the disappearance of the ha^matozoa from the blood
only when it cures the di.sease, and in this cahc it
causes them to disappear within twodavs after the ad-
ministration is begun: on the intermediate day im-
movable forms are seen, which are almost alwavs of
an irregular shaj^e.
The h;tmatozoa can li\e a long time in the blood,
multiplying only slightly and without making their
presence manifest. Their ordinary course is to make
themselves manifest in such cases by destroying the
red corpuscles; this is the mechanism of production of
the true malaria anamia, which presents itself without
any access of fe\er.
This anamia is the inuiiediate cause of neuralgia,
which therefore immediatelv ckpends on the action of
the parasites. It is probable that they act directly or
by means of their secretions on the nervous system,
and thus favor the production of the neuralgic form of
latent malaria.
\\'hen a jjerson whose blood is known or supposed
to contain hamatozoa is about to suffer from an attack,
he can avoid it by taking, two days previously, the
dose of quinine that in that locality prevents the ac-
cess. This is an important fact for the application cf
hydrotherapy in the cure of malarial anamia.
Contrary to what is stated by liurdel, the speaker
had never seen any glycosuria after the accesses, even
after administering one hundred and fifty grams of
syrup to the patients.
Quinine ought to be administered immediately after
the diagnosis is made. It is an error to believe that
it should be given anv specific number of hours before
the attack.
Orrhotherapy of Leprosy. Dr. Ji.v.n iii. 1). C.^r-
RASQUILLA, of Bogota, I'nited States of Colombia, pre-
sented a communication upon " .\ New Serotherapeutic
Process for the Treatment of Leprosy," of which the
following is an abstract:
I. The leprous patient is bled, and the terum sepa-
rated from the blood.
Decemler 5, 1896]
MEDICAL RECORD.
827
:!. The serum of the leper is injected into a liorse.
3. 'I'lie horse so prepared is bled, and the serum
separated from the blood.
4. Patients are treated with hypodermic injections
of the horse serum.
5. A horse is injected with thirty cubic centimetres
of human serum three times, at intervals of ten days.
He is bled ten days after the last injection, and is
injected afresh after the bleeding. He is bled twenty
or thirty days later, and so on successively.
6. The patient receives -^ hypodermic injection of
one to tive cubic centimetres every third day, or at
longer intervals if any reaction should set in.
7. The injection produces a normal reaction, chill,
fever, perspiration or accidental myalgias, arthralgias,
neuralgias, cutaneous eruptions, asphyxia, vertigo, etc.
8. The lesions which are characteristic of the dis-
ease are at the same time modified; the tubercles are
smoothed down and eliminated bv absorption, suppu-
ration, or scaling; the spots lose their color or disap-
pear; the ulcers are healed; the sensibility becomes
normal ; the lost senses are recovered, and the general
condition becomes satisfactory.
9. Xo medicine is administered to control the
symptoms of reaction, unless it is lemonade to calm
the thirst, and aromatic drinks.
10. The body is washed every day with a warm so-
lution of permanganate of potassium, one to two parts
per thousand. The ulcers are dressed with the same
solution, aseptic cotton, and a bandage to cover the
^vhole.
1 1 . There are no special requirements as to diet.
12. The injection is not administered when the
pulse is accelerated, the temperature is above the nor-
mal, or any other symptom of reaction is shown.
13. The horny ulcers on the feet are treated with
salicylic acid in collodion. Those on the nasal and
pharyngeal mucous membranes are treated with a so-
lution of borate of sodium; the conjunctivitis, with
sulphate of copper in a weak solution.
Acute Yellow Atrophy of the Liver. — Dr. Man-
uel Car.mona V \alle, of Me.\ico City, reported the
following case: A man, thirty-eight years of age; a
merchant, native of Mexico City, married; a moderate
drinker; had never suffered from any previous serious
illness. He was obliged to go to Vera Cruz on busi-
ness, remaining there a week, and returning to the
City of Mexico about the end of M.iy. Three days
after, and without any known cause, he sutlered an
intense chill at night, accompanied by cephalalgia,
great lassitude, intense fever, and a feeling of nausea
without vomiting. On June 24, 1883, he was admitted
into the San Andres Hospital. He awoke the next
day jaundiced, and suffering from an abundant epis-
taxis.
At the time of admittance to the hospital his tem-
]3erature was 40.6" C; the facies was animated: he
showed a marked jaundice color, both of the skin and
of the mucous membranes, together with a slightly
delirious loquacity, but was able to give rational
answers to any questions asked.
He complained of pains in the whole body, but said
that he had no fixed pain except in the head; never-
theless, on examination, it was found that a pain ap-
peared with the exercise of pressure on the right
hypochondrium. The hepatic dulness was notably
diminished and the spleen was very much swollen.
During the four days that the patient was in the
hospital, his temperature varied between 39' and 41
X". (102.2 -105.8' ¥.); he suffered from frequent epis-
taxis, hemorrhages from the gums and mucous mem-
brane of the mouth, and, what was most remarkable,
a spontaneous sanguineous flow through the urethra,
but the urine did not contain any more blood than that
svhich was carried by its natural flow. The symptoms
of ataxo-adynamia shortly set in, and the patient died
on the fourth day after admission to the hospital and
the seventh of his sickness.
In the post-mortem the liver was found to be very
much reduced in volume, and weighed six hundred
and fifteen grams. It was of a yellow color like wash
leather, of a soft consistency, and contained very little
blood. The spleen was swollen and difHuent, and the
blood in the vessels was dark and glutinous.
A microscopic examination of the liver -showed that
the cells had completely disappeared, and that the
hepatic parenchyma had been transformed into a net-
work of connective tissue, with its meshes entirely
empty. The veins, especially the suprahepatic veins,
had their walls thickened and their lumen was ob-
structed by thrombi.
The doctrine that now prevails with respect to the
nature of icterus gravis can be summarized in the fol-
lowing formula, taken from the " Manual of Medi-
cine" by Debove and .\chard : "Icterus gravis is the
visible sign of the rapid destruction of the hepatic
cells, manifested by a typhoid condition w ith jaundice
and hemorrhages."'
Probably it is not necessary that the cellular de-
struction should be very rapid, seeing that there are
certain forms of icterus gravis which last for a year
and even more.
This being the case, it may be asked: Why is it
that in ordinary cirrhosis and in simple atrophy of the
liver there are no symptoms of icterus gravis? On
the other hand, how can we explain the apjrearance of
jaundice by the sole fact of the cellular destruction,
when we know that the hepatic cell is that which pro-
duces the bile?
In the case presented there was evidently a supra-
iiepatic endophlebitis, resulting in an obstruction of
these vessels and a consequent destruction of the he-
patic cells.
Comparing this result with that obtained by the
study of the disease called by the speaker '' intercel-
lular hepatitis," and which consists in a swelling and
hardening of the liver, accompanied by all the phe-
nomena that are characteristic of severe jaundice, it is
seen that in the latter disease the anatomical lesion is
the periphlebitis that commences in the suprahepatic
veins, obstructing their ciiannels through the abundant
conjunctive proliferation, and later on destroying the
cells that form the hepatic lobes. From this. Dr. Car-
mona concluded that icterus gravis is produced bv a
disturbed circulation (produced by microbes or not)
in the suprahepatic veins; that these disturbances first
exaggerate the cellular functions, and later on destroy
the cells themselves.
The variations in the progress of the disease and in
the concomitant symptoms depend on the extent of the
lesion and the form of the phlebitis.
Among other papers read by title or by the authors
in this section were tiie following: "Connection Be-
tween the Temperature of the Patient and the Species
of Bacteria which are Found in .Appendicitis," by Dr.
Robert T. Morris, of New York; ".Antitoxin of Tu-
bercle," by Dr. Paul Paquin, of St. Louis, Mo.; "'Per-
nicious Malaria," by Dr. H. L. Bibb, of Colonia Sta-
tion, Mexico; ''Scrofula,'" by Dr. Fred. R. Weber, of
Milwaukee, Wis.; "On Medicine,"" by Dr. Joaquin
Martinez, of Pachuca, Mexico; "Tuberculosis in ^lex-
ico,*" by Dr. Francisco lilasquez, of Mexico City;
'■ Notes for the Study of Typhus in Mexico," by Dr.
Jesus Jimenez, of >Iexico City; " Results of Several
Original Fxperiments on Cancer in Animals," by Dr.
Joshua M. Van Kott, of Brooklyn, X. Y. ; "Narcotic
Intoxication in .America," by Dr. Mattison, of Brook-
lyn, N. v.; ■■ Treatment of Tubercidosis with Products
of the Cultivation of Bacillus of Tuberculosis," bj' Dr.
Karl Von Ruck, of .Asheville. X. C; ".Xntitoxic Se-
828
MEDICAL RFXORD.
[December 5, 1896
rum," by Dr. Joseph McFarland, of Philadelphia, Pa.;
" Melanotic Sarcoma of the Spleen — History of Two
Cases," by Dr. Hughes Crouse, of Rockport, Tex. ;
"On the 'Mai del Pinto,' " by Dr. Amador Espinosa,
of Jojutla de Juarez, Mexico; "Mildness of Pulmo-
nary Diseases in San Diego de la Union," by Dr. Do-
naciano Cano, of San Diego de la Union, Gto., Mexico;
" Medical Philosophy," by Dr. Juan X. Revueltas, of
Coyoacan, Mexico; "Functions of Physical Agents in
Infectious Diseases," by Dr. Jesus E. Monjaras, of
San Luis Potosi, Mexico; "Diseases of the Stomach
and Intestines," by Dr. J. Jesus Chavarria, San Ga-
briel, Mexico; "Poisoning by Strj'chnine," by Dr.
Manuel Delfin, of Havana; "Glanders in Havana,"
by Drs. J. M. Davalos and E. Acosta, of Havana;
" Hydrophobia in Havana," by Dr. E. Acosta, of Ha-
vana; " Pathogenesis of Influenza," by Drs. Tomas V.
Coronado and Y. Calvo, of Havana; " Orrhotherapy
of Erysipelas," by Drs. Garcia Rijo and Y. Calvo, of
Havana; "Specific Medication," by Dr. Joseph D.
MacCann, of Monticello, Ind. ; "Typhoid Fever," by
Dr. Miguel Tena, of Morelia, Mexico; "Yellow Fe-
ver," by Dr. Luis D. .\brisqueta, of New York;
"Modern Therapeutics," by Dr. C. J. Fox, of Connec-
ticut; "Treatment of Hemorrhage with Large Doses
of Acetate of Lead," by Dr. Llewellyn F.liot, of Wash-
ington, D. C; "Application of Hot Damp Cloths to
the Intestines," by Dr. Joseph William Stickler, of
Orange, N. J.; "Tuberculosis in Southern California,"
by Dr. George B. Rowell, of San Bernardino, Cal.;
"Tuberculosis in Colorado," by Dr. S. G. Bonney, of
Denver, Col. ; " Multiple Abscesses of the Liver with
Diabetes Mellitus," by Dr. H. W. McLanthin, of Den-
ver, Col. ; "Treatment of Tuberculosis and Anaemia
by Means of Rarefied .\ir Baths," by Dr. Daniel Ver-
gava Lope, of Mexico City; "Diphtheria," by Dr.
William B. Travis, of Covington, Ga. ; " Cis- Atlantic
Medical Ideas," by Dr. E. Cutter, of New York;
" Treatment of Whooping-Cough by Means of Asa-
prol," by Dr. Moncorvo, of Rio de Janeiro, Brazil;
" Pyrexias Observed in the Island of Cuba," by Drs.
Tomas V. Coronado and D. L. Maday, of Havana;
"Treatment of Chronic Invalids by Diet and Exer-
cise," by Dr. J. H. Kellogg, of Battle Creek, Mich. ;
"A New Clinical Symptom," by Dr. Silvio Tatti, of
Buenos Ayres, Argentina ; " Recent Plans of Treat-
ment of Pulmonary Tuberculosis," by Dr. Louis Fau-
geres Bishop, of New York ; " Malaria in Mexico City,"
by Dr. Antonio A. Loaeza, of Mexico City; "Gastro-
intestinal Septic Fever," by Dr. Efren Ornelas, of
Chihuahua, Mexico; "Typhoid Fever of Malarial
Origin," by Dr. John Herbert Claiborne, of Peters-
burgh, Va. ; " Modern Method for Treating Diseases
of the Intestines," by Dr. Fenton Turck, of Chicago,
111. ; " The Use of Tincture of Gelsemium in Malaria,"
by Dr. F. Bulman, of Mexico City.
SECTION OX GENERAI. AND ORTHOP.-EDIC
.SURGERY.
Arterial Catheterism. — Dr. Roque Mancozet, of
Morelia, Mexico, reported two cases of amputation,
one of the thigh at the junction of the lower and mid-
dle thirds, the other at the point of election in the leg.
The disease necessitating amputation in both cases
was dry gangrene.
In the first case, a rheumatic endocarditis produced
embolism of the femoral artery, thereby causing gan-
grene of the foot and leg up to the upper third. Hav-
ing made certain of the diagnosis, the speaker ampu-
tated the thigh in the lower third, and to his great
surprise, on removing the tourniquet, no arterial blood
issued, but only venous. The femoral artery was
completely open and empty, and he then decided to
perform an arter.ial catheterism, with the object of re-
moving the obstruction in the artery and saving the
patient from an operation for disarticulation of the
thigh. This operation was carried out by means of a
urethral bougie, made of whalebone and carefully dis-
infected. Dr. Mancozet lightly pressed against the
obstacle, and with the help of the left hand, practised
a soft massage in its neighborhood and over the artery.
He commenced by moving the embolus and then
loosened it, immediately after which a torrent of arte-
rial blood burst forth.
The history of the other case was similar to the
above, and in both cases the method resulted in a
perfect and lasting success.
Radical Cure of Prostatism. — Dr. Ram6n Ma-
ciAS, of Mexico City, presented a communication on
this subject. Prostatism, he said, is generally initi-
ated in youth, is confirmed at the adult age, and is
complicated by terrible accidents, which unfortunately
are often mortal, during old age. Masturbation some-
times, and blennorrhagia almost always, are its first
causes. The neglect of patients on the one hand, and
the insufficient or erroneous treatment on the other,
account for its passing on to a chronic condition.
The imprudent conduct of some old men, careless-
ness on the part of the physician, and the want of
surgical therapeutics of a wise and timely character,
explain its sad mortality.
That blennorrhagic infection engenders prostatitis is
beyond a doubt. What is open to discussion, although
for the speaker it is a fact, is that many cases of pro-
found urethritis, and all those cases which up to now
have been called cystitis of the neck, are nothing more
than inflammation of the prostate.
Prostatism in youth and in mature age is not simi-
lar to that of old age, just as the anatomo-pathological
condition of the urinary organs at these ages is not
similar.
In the youth and in the adult man, congestion and
enlargement predominate in the cells, though mostly
of a transitory character, together with inflammation,
exudation, and suppuration. In old age, passive con-
gestion, new formation with cellular transformation,
permanent enlargement of the tissues, neoplasms, and
degeneration jjredominate.
In the youth and the adult, the hamatic infection is
of a vital origin through toxins. In old age. the blood
is infected through the products of disassimilalion,
which are not eliminated, or which are reabsorbed to-
gether with certain chemical products, which mostly
arise from putrid or ammoniacal fermentation.
The symptomatology of prostatism between the ages
of eighteen and forty-five is not uniform. The books
treating of genito-urinary diseases speak of sperma-
torrhoea, of chronic prostatitis, the existence of which
some accept and others deny, of deep urethritis which
is propagated or not to the seminal ducts, of cystitis
of the neck, of vesical or renal calculus, etc.; but in
none of them do we find any consistent doctrine which
shows that all or the greater part of these diseases
have originated in the prostate gland.
The principal intention of this paper was that of
unifying the pathology of the uro-genital apparatus, de-
monstrating that prostatism exists as a constant cause
for the sufferings of a great number of patients who
up to this date have been treated only for secondary
affections. We should be able to have uniform symp-
tomatological tables that would lead us to reasonable
medical or surgical therapy.
Internal medication exercises a very limited action
on prostatism and its consequences. Surgical treat-
ment constitutes the only means we have for the
prompt and radical cure of confirmed prostatism.
The author includes among surgical measures anti-
septic washings, medicinal instillation, catheterism,
and, naturally, bleeding; also perineal cystotomy.
December 5, 1896]
MEDICAL RECORD.
829
prostatotomy, curettage, and direct or indirect canali-
zation.
Prostatic hypertrophy can not only be alleviated but
also radically cured in many cases. The urethral
form ought to be treated by the process which Dr.
Macias calls "enucleation."'
When the vesical form is greatly exaggerated, it re-
(luires a total extirpation of the growth and the resti-
tution of the vesical funnel. 'I'he author's method by
four sections with the galvano-caustic loop realizes
this intention, he believes, with less danger and with
a better guarantee of cure than any other procedure
known up to this date. He proposes the use of an
instrument which he calls an "enlarging speculum"
of the bladder.
Diphtheria of the Penis. —Dr. Wili.i.a.m P. Minn,
of Denver, Col., reported three cases of this condition,
which he regarded as one of rare occurrence, there
being, so far as he could discover, no previous refer-
ences to it in medical literature. It may occur when-
ever any operative treatment of the penis has been
undertaken under circumstances that have permitted
of diphtheritic infection. Before bacteriological meth-
ods of diagnosis were perfected it is probable that this
condition was confounded with erysipelas, gangrene,
or simple septic infection following operation.
The three reported cases occurred in the practice of
three different surgeons, in the persons of children
and subsequent to circumcision. In two, the diagno-
sis was made by bacteriological diagnosis, confirmed
by a perfect succession of clinical signs. In the other,
clinical appearances alone led to the diagnosis. In
one instance, the child's mother was suffering from a
mild sore throat at the time of operation and the in-
fection probably came from her. In another the
patient's mother and brother were found to have diph-
theria after the operation ; it could not be stated wheth-
er they infected the child or whether the child was
first infected and conveyed the disease to them. In
the other case, there was no recognizable history of
infection, although the patient suffered from faucial
diphtheria one year later.
.\11 cases of infection of circumcision wounds, in
children at least, should be subjected to bacteriologi-
cal examination, both to promote exact diagnosis, to
guide in the treatment of the case, and to pemiit of
proper precautions for the prevention of contagion.
.\ntitoxin should be administered without delay,
and local antiseptic measures should be resorted to.
Catheterization should not be permitted, as there is
danger of infecting the urethra and bladder.
Suprapubic Cystotomy. — Dr. Miguel Otero, of
San Luis Potosi, Mexico, read a paper on cystotomy
in which he expressed the con\iction that perineal
cystotomy was being gradually abandoned and that it
was not long before it would cease to be a recognized
surgical procedure, except under special and very rare
conditions. The suprapuliic operation was the one
which would be chosen by preference, as it is free from
the dangers of perineal section, such as hemorrhage,
laceration of the prostate, persistent fistula, etc.
Other papers read in this section, either by the au-
thors themselves or simply bv title, were the following:
" Kraske's Operation for Imperforate Rectum," by
Dr. Rudolph Matas, of New Orleans; "Asbestos Fire-
])roof Surgical Dressing as Adapted to .Army and
Emergency Practice," by Dr. Evan O'Neill Kane, of
Kane, Pa. ; " Surgical Treatment of Bladder Diseases,"
by Dr. Ramon Guite'ras, of New York; "The Surgi-
cal Treatment of Flpilepsy," by Dr. Edmund J. A.
Rogers, of Denver. (Jol. : "The Treatment of CoUes'
Fracture," by Dr. Leonard Freeman, of Denver, Col.;
"Treatment of Stricture of the Urethra by Continuous
Elastic Dilatation," by Dr. Robert J. Wilding, of
Malone, N. Y. ; "Treatment of Chronic Gonorrhcea,"
by Dr. Ferd. C. Valentine, of New Y^ork ; " The Value
of the Roentgen Rays in Surger\-," by Dr. Carl Beck,
of New York ; " The Effect of Operations /cv- si- in
Tuberculosis and Malignant Growths," by Dr. A. C.
Bernays, of St. Louis, Mo. ; " Cerebral Tumors and
.Abscesses,'' by Dr. George N. Lowe, of Randall, Kan.;
" The Surgical Treatment of Movable Kidney," by
Dr. \V. Easterly Ashton, of Philadelphia, Pa.; "Sur-
gical Treatment ot Gall Stones," by Dr. James T. W.
Ross, of Toronto, Canada ; " New Method for the
Radical Cure of Crural and Inguinal Hernias," by
Dr. Adrian de Garay, of Mexico City; "On Surgery,"
by Dr. Guillermo Parra, of Mexico City; '"Personal
Experience in the Treatment of Gunshot Wounds
during the late Civil War in the United States as
Contrasted with the Modern Aseptic Treatment," by
Dr. Robert Reyburn, of Washington, D. C. : "The
Deformity Following Fracture of the Femur," by Dr.
Edward Martin, of Philadelphia, Pa.; "Hypnotic
.Anesthesia," by Dr. Thomas Bassett Keyes, of Chi-
cago, 111. ; " Surgical Treatment of Insanity," by Dr.
Ernest Laplace, of Philadelphia, Pa.; "A New Ope-
ration for the Radical Cure of Femoral Hernia," by
Dr. George M. Edebohls, of New York; "The Electro-
Cautery as a Hsemostatic in Surgery," by Dr. Alexan-
der J. C. Skene, of Brooklyn, N. Y.; "Suturing of
-Arteries Injured in Continuity, Experimental and
Clinical Research," by Dr. John B. Murphy, of Chi-
cago, 111.; "On Surgery," by Dr. Joaquin Martinez,
of Pachuca, of Mexico; "Renal Calculus" (the au-
thor presented a specimen weighing forty-five grams),
by Dr. Ignacio Espinosa, of Morelos, Mexico ; " La-
paratomy and Fi.xation of Rectum by Sutures to Ante-
rior Abdominal Wall in Several Cases of Prolapsus of
the Rectum, with Report of a Successful Case," by
Dr. Herman Mynter, of Buffalo, N. \.: "Mastoid
Diseases and Operations," by Dr. Selh Scott Bishop,
of Chicago, 111.; " A'arix in the Lower E.xtreniity," by
Dr. Thomas H. Manley, of New York.
SECTION ON OBSTETRICS AND GYNECOLOGY.
Intestinal Anastomosis Dr. J. Fr.ank, of Chi-
cago, read a paper on this subject, showing his decal-
cified bone button and numerous specimens in which
divided ends of intestine had reunited while held by
it in apposition. The dog which had been operated
upon the previous day at the San Andres Hospital
was shown and was then killed by chloroform. Upon
opening the abdomen, the portion of the intestine on
which the operation had been performed being < ut
out, it was found that a perfect union had resulted in
the twenty-eight hours intervening between the opera-
tion and the animal's death. The bone plates were
partially dissolved, and the continuity of the intestine
was practically demonstrated.
Statistics from the Maternity Hospital of Pueb-
la. — Dr. Jose M.\ria de Ita, of Puebla, Mexico,
read a paper based upon the statistics of this hospital
for the two years ending September 30, 1896. The
mortality was one-half of one per cent., and no case
of puer)Deral septica-mia occurred in this time. The
antiseptic used was bichloride of mercury, and the fol-
lowing was the mode of its employment: Before labor,
tile genital organs having been washed externally and
internally with soap and water, after the tepid-vater
bath and thorough evacuation of the rectum and blad-
der, an injection of solution of bichloride of mercury
1-2,000 was made, care being taken to disinfect thor-
oughly the fundus of the vagina by swabbing with the
finger. The douche was repeated every six or eight
hours during laiior. .After labor a vaginal injection
of the same .solution was made. In ca.se of surgical
interference or when rupture of the membranes had
occurred before the arrival of the physician or mid-
830
MEDICAL RECORD.
[December 5, 1896
wife, an intra-uterine injection was made with the
same solution. The bichloride injections were con-
tinued also during the first three days after parturition.
The following papers were read by the authors or
by title: "Management of Occipito-Posterior Posi-
tions," by Dr. Louis Faugcres Bishop, of New York;
'• I'reatment of Post-partum Hemorrhage,'' by Dr. J.
C. Currie, Chicago, 111.; "Intestinal Obstruction," by
Dr. George W. Woods, U. S. Navy; "Vaginal Inci-
sion and Drainage in the Treatment of Peri-uterine
Septic Diseases," by Dr. W. F,. B. Davis, of Birming-
ham, Ala.; "Electrolysis in Endometritis," by Dr.
Gustavo O'Farrill, of Puebla, Mexico; "A Contribu-
tion to Abdominal Surgery," by Dr. Alfonso Ortiz, of
Alamos, Mexico; "Penetrating Wounds of the Abdo-
men," by Dr. Santos Medina, of Juchipila, Mexico;
" On the Treatment of Puerperal F'ever," by Dr. Ra-
fael Norma, of Tulancingo, Mex. ; " On the Technique
and Results of Abdominal Hysterectomy," by Dr.
Ernest Cushing, of Boston, Mass. ; " Hysterectomy, its
Applications and Technique," by Dr. Charles Bing-
ham, of Philadelphia, Pa.; "Indications Respecting
the Best Technique in the Operation of Shortening
the Round Ligaments, with Favorable Results in Sev-
enty-five Cases," by Dr. Lapthorn Smith, of Montreal,
Canada; "Treatment of LIterine Diseases and Ap-
pendages through the Vaginal Channel," by Dr. R.
Stansbury Sutton, of Pittsburg, Pa. ; " Rational Treat-
ment of Pelvic Abscesses," by Dr. H. J. Boldt, of
New York; " Hysterectomy," by Dr. Albert H. Tuttle.
of Cambridge, Mass. ; " Hysterectomy," by Dr. J. T.
Joiinson, of Washington, D. C. ; "Septic Endometritis
and Its Cure," by Dr. T. Griswold Comstock, of St.
Louis, Mo. ; " The Relation that Pelvic Deformity
Bears to Unassisted Instrumental and Surgical Ob-
stetrics," by Dr. Hugh Hamilton, of Harrisburg, Pa. ;
" Review of Disputed Points in the Treatment of In-
flammatory Trouble of the Pelvic Organs," by Dr.
Joseph Price, of Philadelphia, Pa.; "Remarks on
Hydrocele of the Lfmbilicus with a Report of a Case,"
bv Dr. Charles G. ('umston, of Boston, Mass.
P.\X-.\MF,RIC.\N COXGRESS NOTES.
The Inaugural Session was held in the Teatro
Nacional, which had been specially and most effect-
ively decorated for the occasion. The background of
the decoration of the body of the theatre was scarlet.
The fronts of the boxes were artistically draped with
the Hags of all the republics of America and with their
coats of arms. The Hags and escutcheons of Spain,
France, and England were also displayed. The stage
decorations were Aztec. .\n imitation of the calendar
stone rose behind the dais of the President. The
sides of the stage were enclosed with scenery repre-
senting Aztec architecture and trophies. In the cen-
tre of the tiers of boxes opposite the stage was a
m.nnmoth star of tricolor electric lights, in the centre
of which was the mortar with coiling serpent. Flow-
ers were everywhere in reckless profusion, such as can
be seen only in this land of roses. Between each of
the addresses a musical selection was rendered by an
excellent orchestra. Following the report of Dr. Li-
ceaga the Mexican national hymn was sung by the
pupils of the Conservatory of Music, the audience in
the mean while standing.
The President's Address. — The following is the
full text of the address of welcome pronounced by
General Diaz at the ©i^ening session, as stenographi-
cally reported by the Mixiain Hcralii:
"Gentlemen: In the name of the government and
the people of this republic, I extend to you the most
cordial welcome. The Mexican nation, and the peo-
ple of this capital in particular, rejoice at your pres-
ence, for it signifies not only the brotherhood of all
the nations on this continent, but the community of
their efforts to promote a science which is of more
interest to humanity than any other. The aim of that
noble science is to preserve or restore the priceless
blessing of health, and when it fails of attaining that
aim to the fullest extent, it at least alleviates the ills
that constitute the sad inheritance of humanity and is
a timely auxiliary in warding off ailments.
" On this account, gentlemen, your coming to Mex-
ico is for me and for all my countrymen a source of
profound and sincere gratification, and, on this ac-
count, too, the Mexican government takes pleasure in
aiding you in your labors to the best of its ability.
" We are cordially grateful for your choice of this
city as the scene of the sessions which have to-dav
been inaugurated. It is to be hoped that those ses-
sions will strengthen the cordial understanding and
growing intercourse among the physicians of the New
World, to the immense advantage of the useful science
to which you have devoted your lives. I hope, too,
that your short stay in this country , besides being use-
ful in promoting the cause of science, will also be
agreeable to you personail% and that you will carry
away with you as pleasant a memory of Mexico as I
am sure your visit will leave among us "
The Number of registered members of the congress
was four hundred and forty.
The Entertainments. — On Sunday evening preced-
ing the opening of the congress, a reception was ten-
dered the visitors in the School of Medicine by tlie
physicians of the city. On Wednesday evening the
members of tlie congress were entertained by the city
council in the rooms of the Municipal Palace, the
Cathedral Square and the principal approaches to it
being illuminated. There were also fireworks in the
plaza in honor of the guests. The rooms were beauti-
fully decorated, and supper was served in the patio,
or central court, of the building, which had been trans-
formed into the semblance of a grotto brilliantly illu-
minated with incandescent lights. The crowning
entertainment of all was a reception tendered to tlie
visiting physicians and their ladies by the President
of the Republic and Mrs. Diaz on Thursday afternoon
in the Castle of Chapultepec. The palace 'S built
upon a high mound which rises from the plain about
two miles from the city. It was the ancient seat of
the Aztec kings, later the residence of the Emperor
Maximilian, and now the home of the President. The
view from the broad balconies of the palace is ac-
counted one of the most beautiful in the world. On
Iridav evening those members of the congress who
still lingered in the city v.ere pleasantly entertained
at a reception given in the handsome rooms of the
Jockey Club. The various hospitals, the schools, the
new slaughter house, the penitentiary, the libraries, and
all of the public buildings were open for inspectit n
of the visitors. Excursions were also made in small
parties to the drainage canal, the Shrine of Guadalupe,
the gardens of Tacubaya, and other points of interest
in the neighborhood. On the Sunday preceding the
opening of tiie congress, the churches and the prome-
nade in the .Manieda were visited in the morning, and
the Basque ball games, the bull fight, the horse and
bicycle races, and the drive on the Paseo de la Re-
forma all received their quota of strangers in the after-
noon.
The Spirit of Investment which is abroad in Mex-
ico invaded the sacred precincts of the congress halls.
Those attending the general session had thrust into
their hands a circular of a Mexican physician who
claimed to know a remedy for pulmonary tuberculosis,
and desired to establish a sanatorium in a favorable
locality of which he also knew. He modestly asked
for a partner willing to put $20,000 (good American
gold, not Mexican silver) into the enterprise. Several
December 5, 1896]
MEDICAL RECORD.
Sof
others of the visitors were approached to take up and
exploit an herb growing in some secluded spot in Mex-
ico, which was asserted to be an unfailing remedy for
rheumatism of all sorts, acute and chronic. Others
were solicited to throw medicine to the dogs and in-
vest in coffee plantations in a country where the wages
of the laborers could he paid in silver while the prod-
uct of the soil would be sold for gold.
The Speakers at the First General Session were
in most cases inaudible. They occupied a little bo.v
at one side of the stage, and addressed the President
of the Republic, nearly turning their backs on the
audience. A notable e.xception was Dr. Pepjjer, who
stationed himself in the centre of the stage, seemingly
to the consternation and horror of those who were es-
corting him to the little box, and turned toward the
President only when he was directly addressing him.
but toward the audience when his remarks were di-
rected to them. His voice also was that of a practised
speaker, and it was evident that his words were under-
stood by many, even of his Spanish-speaking auditors.
The First Medical School in America was estab-
lished in Mexico; the hrst printing-press on the west-
ern continent was set up in the same city.
The Altitude of Mexico (the city lies about seven
thousand feet above the level of the sea) affected most
of the visitors rather unpleasantly, causing them to
suffer from shortness of breath on slight exertion.
Several were even more seriously inconvenienced, and
some had to descend at once to a lower level, on ac-
count of threatening heart symptoms, before the con-
gress was over.
The Weather of the Congress Week, like weather
everywhere and always, was exceptional. The tem-
perature was abnormally low a part of the time; the
mornings, which should have been brilliant, were
usually dull, cloudy, and chilly; and the rain, which
ought not to have come at all or at most in brief,
smart showers, fell on several occasions in a persist-
ent drizzle.
NEW YORK ACADEMY OF MEDICINE.
Anniversary Meeting, November ig, iHg6.
ju^EPH D. Bryant, M.D., President, in the Ch.^ir.
The Object of the Anniversary Meeting. ^ The
President, before introducing the essayist, explained
the purpose of the anniversary meetings to that portion
of the audience, composed largely of the lay public,
not familiar with the academy. It was customary, in
commemoration of the birth of extraordinary events
and of persons, to have an anniversary. The academy
had regularly held an anniversary since its establish-
ment. At that time it was customary to review im-
portant medical history. It seemed to him that an
anniversary was a very wise provision, inasmuch as it
connected with great distinctness the past with the
present and the present with the future. The anticipa-
tions of the past became the realizations of the present,
and we appreciated that the realization of the present
gave hope for the future. At the last anniversary the
library contained fifty-five thousand volumes, to which
there had been added during the year twenty-five hun-
dred more — a most healthy increase. That which
might be of greater interest to the profession and the
public was the fact that by the efforts which had been
put forth during the year the library fund had been
increased $30,000. making a total amount of $52,000.
The aim of the academy was to secure a sufficient
amount of money so that, with what it already pos-
sessed, it should have a round sum of $100,000, the
income of which should be devoted to no other purpose
than that of adding to the librar}-. The president an-
nounced that some time in January the academy would
celebrate its semi-centennial, for which purpose the
use of Carnegie Hall had been secured. President
Cleveland would honor the occasion by his pre.sence
and by his speech.
The Evolution of the Surgery of the Twentieth
Century. — Dr. George R. Iowler delivered the an-
niversary address. In choosing for his subject the
evolution of the surgery of the twentieth century he
sought to do more than simply chronicle the brilliant
achievements accomplished during that period. It
was his endeavor to point out the relations which the
more important events bore to those processes of intel-
lectual evolution \vhich had made all things possible
which had come to pass during the century. Discov-
ery had followed discovery in unceasing and rapid
succession. In looking back over the century, how-
rich the harvest had been, and jet how much had not
yet blossomed! The development of the ligature for
the control of hemorrhage, the discovery of anarsthesia
and of antisepsis, stood in as important a relation to
surgery as did Newton's discover)- of the law of gravi-
tation to astronomy. It was upon the development of
these three es.sentials to the perfection of the surgery
of the twentieth century, and the discovery of the
Roentgen ray, that the orator dwelt in his essay. " The
lessons of the past gather about us like the falling
leaves of a summer's departing glory. But these les-
sons are not wasted. They but serve to emphasize
man's opportunity now present and his hopes for the
future. Not the least among these is that which
teaches us that the unfolding of nature's secrets is but
a part of the law of creation : that irresistible forces
are at work evolving truth and casting out error; and
that man's present position in this great work removes
him from the place of the creation of the hour, and
stamps him as the product of time and the heir of all
eternity. The century upon the threshold of which
we stand is lighted with jewels of hope in golden set-
ting, and its atmosphere is filled with the sweet music
of promise."
NEW YORK COUNTY MEDICAL ASSOCIA-
TION.
Stated Meeting, November i6, i8g6.
Joseph E. Janvrin, M.D., President, in the Chair,
Appendicitis Complicating Pregnancy. — Dr. Rob-
ert Abrahams read the paper. If appendicitis in
general merited so much attention as had been given
it the past few years, how- much more in pregnancy,
when two lives instead of one were in jeopardy I Yet
up to a short time ago appendicitis in pregnancy was
unknown in medical literature, if a brief report of one
case were excepted. It was not quite two years since
Dr. Munde''s celebrated case was put on record, but
now physicians everywhere realized the possibility of
its occurrence, and were on the lookout to diagnose it.
Up to the present, eleven cases had been placed on
record, ten of them suppurative, one catarrhal. The
author in this paper added four new ones, and their in-
terest lay in the fact that the mothers as well as the
children escaped an untimely death. The first case
was one of catarrhal appendicitis, seen with another
doctor in the city, October i, 1895. The symptoms
related to pain at McBurney's point, tumor, increased
pulse, some elevation of temperature. These symp-
toms gradually disappeared, but on October 20th labor
set in and a child was born at seven and a half
months. It lived six days. The mother fully recov-
ered, and had no pain after deliver)-. The second case
was in a woman seven months pregnant. There were
the constitutional symptoms referable to the pulse and
832
MEDICAL RECORD.
[December 5, 1896
temperature,- and locally pain, but no tumefaction.
Diagnosis, catarrhal appendicitis. This patient was
much constipated. The symptoms subsided after nine
days, under cathartics, etc. She was delivered of a
healthy child at term. He had treated her in two
attacks of recurrent appendicitis since, but she refused
operation. In the third case the patient was also ha-
bitually constipated; the temperature, pulse, localized
pain, vomiting, and later some tumefaction established
the diagnosis, and the patient was sent to the hospital,
where the diagnosis was concurred in and an operation
was about to be performed, but improvement began
and she recovered without operation. He had not
seen this patient since. The fourth case was one of
traumatic appendicitis, which was also seen by Dr.
Munde, who concurred in the diagnosis but suggested
waiting for a time. The patient markedly improved,
but still had some pain in the region of the appendix.
She was in the ninth month of pregnancy.
The pathology and etiology were for the most part
the same as in women not pregnant, but the enlarge-
ment of the uterus would allect adhesions; and in all
of his cases but one tiiere was a history of obstinate
constipation, which he thought might have been a cause,
and pointed to the necessity for attention to the bowels
during the pregnant state. As to diagnosis, the pres-
ence of the enlarged uterus would interfere somewhat
with palpation and percussion, but with care local
signs could be recognized if present. In all obscure
cases, anaesthesia should be employed. The chief
disease in differential diagnosis was tubal pregnancy,
but here the duration of the tumor before rupture was
only four months, and it need hardly be thought of
after that period. As to hx-matocele, in only one of
the cases on record had a tumor of doughy feel at the
vault of the vagina proven to be a case of appendici-
tis. Inflammation of the pelvic organs, ovaritis and
salpingitis, was almost always infectious in origin, so
that the history would be found of value in diagnosis.
Floating kidney and renal calculus might occasionally
be mistaken for appendicitis, but patience and care
would clear up the error. Typhoid fever offered some
difficulties in diagnosis.
-As to prognosis, in reported suppurative cases tliere
had been seven deaths out of ten, or a mortality of
seventy per cent. In all of the cases of catarrhal ap-
pendicitis the patients had recovered. Of subjects
operated upon, only one child had lived; the others
had perished before or after the operation. Of the
total number of reported cases of pregnancy compli-
cating appendicitis — fifteen — eight resulted in recov-
ery, and eight in death.
All cases, unless running a very mild course, should
be operated upon early. He gave the following rules,
partly his own and partly from Willy Meyer: i. Ope-
rate cxrly, within twelve hours, in acute perforative
ap|)endicitis. 2. Take tiie pulse as a guide, 106 to i 20
being an indication for operation. Dr. Abrahams
added to this rule that the pulse should not only be
rapid, but should be out of proportion to the tempera-
ture. 3. In cases of doubt operation is better than
waiting. 4. Sudden lull of the symptoms, and within
ten or twelve hours sudden recurrence. 5. In ca.ses of
old appendicitis lit up during pregnancy, operation
ought to be done, even if the attack is a mild one,
especially if it occurs early in pregnancy. Laparot-
omy is then easy and removes the possibility of
future attacks when operation may not be easy.
Commends Early Operation. — Dr. I'aii, ¥. Mtxni';
referred to his case which had been mentioned in the
paper, and said that when it was published it became
the subject of general attention, as if it had never oc-
curred to anybody that a woman who was pregnant
could have appendicitis. But after his attention had
been called to the subject by this case, he could see no
reason why a woman who was pregnant might not have
appendicitis as well as anybody else. Since then he
had seen several cases, and had published a very in-
structive one in the Medical Rkcord. He would not
hesitate to operate, no matter what the period of preg-
nancy, and would e.xpect to get as good results as in
non-pregnant women. He was under obligations to
the author far having put several cases into his hands,
and was glad to share any honors with him.
Dr. Robert T. Morris thought appendicitis had in
all probability occurred frequently in pregnant women,
but had been overlooked on account of there being
other diseases which simulated it. We could fairly
e.xpect it to occur rather more frequently during preg-
nancy, for two reasons; i. In pregnant women the ap-
pendi.x hung over the pelvic brim in about thirty-five
per cent, of the cases, and in this position was liable
to become bruised by the enlarging uterus. 2. In
many cases adhesions existed, and as the uterus en-
larged and rose out of the pelvis they were likely to
be broken up and excite appendicitis. He thought he
had had four or five cases of appendicitis in wliich
pregnancy had played a role, but had not published
them separately from his other ca.ses. Regarding ca-
tarrhal appendicitis, he had not seen it in any case
operated upon, yet he did not doubt that catarrh of
the intestine might extend to the appendix. When
symptoms arose peculiar to appendicitis, infection and
exudation had taken place, which put the case out of
the category of catarrhal apisendicitis. Regarding di-
agnosis, he supposed there was some difliculty in dis-
tinguishing in some cases between typhoid and appen-
dicitis. At least, he had seen a few cases with
eminent phvsicians in tliis city, in which there was a
difference of opinion, and, inasmuch as an operation
was not performed, the diagnosis was not settled.
Resisting tonic spasm of the abdominal wall served
to distinguish acute appendicitis from typhoid and ;.al-
pingitis. It was very seldom that surgeons made a
mistake and operated for appendicitis wiien it did not
exist. Dr. Morris said doubt was disappearing among
the exi^erienced with regard to abilitv to palpate the
normal appendix.
Tubal Pregnancy Mistaken for Appendicitis. —
Dr. Wii.i.ia.m 1. Li .^k related a case which showed
that even experienced surgeons as well as gynecolo-
gists sometimes made a mistake in diagnosticating
appendicitis. The patient was a girl of nineteen
years, of excellent character, excejitional family, who
had an attack of pain in the right side and other
symptoms of appendicitis. The symptoms subsided,
and she had another attack, in which he was called to
examine the pehic organs. The pain was in the right
side. He found the tumor behind the uterus on the
right. .\ surgeon of distinction saw the patient and
diagnosticated appendicitis, and recommended o|)era-
tion. -All who examined her thought they felt the
thickened appendix. On operation Dr. Lusk found in
this young girl of exceptional character, who had given
no history of passing by a menstrual period, tubal
pregnancy. In this instance, the clearness with which
his experienced friends had felt the supposed diseased
appendix through the abdominal walls, was certainly
very delightful !
Dr. H. J. Garrigi"es had operated upon one case
of appendicitis complicating pregnancy, and while he
thought before the operation that the mass might be
the diseased appendix, yet there was no reason to sup-
pose that it might not be a neoplasm. The operation
decided tlie diagnosis. The patient did well, but sub-
sequentlv dexelnped pleurisv. which led to exliaustion.
The Appendix Better Nourished in Females.—
Dr. W'ili.v Mever had operated in about two hundred
cases of appendicitis, and in only one did the disease
complicate pregnancy. He had seen one of Dr-
December 5, 1S96]
MEDICAL RECORD.
833
Munde's cases also. It seemed to be a clinical fact
tl1.1t appendicitis occurred more frequently in males
than in females, and in trying to account tor it he was
disposed to think it might be due to better nutrition of
the organ in females, and in them this was at its height
during pregnancy. The case seen by him was a pa-
tient of Dr. S. ^larx. She had had her first attack of
appendicitis about the eighth month of pregnancy.
It subsided under expectant treatment. A week later
she had pain again, and gave birth to a child. A few
hours after delivery sii:: had a chill, high temperature,
and symptoms of acute appendicitis. She was again
treated on the expectant plan, recovered, and Dr.
Meyer saw her afterward with Dr. Marx in a third at-
tack, and they operated. An unusual condition was
found. Fhe appendix was situated in a sheath of new
tissue, and when withdrawn was found to measure eight
and one-half inches in length. Dr. Meyer had seen so
many cases of recurrent appendicitis that he had come
to the positive conclusion that all persons should be
operated upon who had had one well-defined attack.
The conscientious physician should turn them over
to the surgeon at a time when ideal surgery could be
done, guaranteeing the patient against future attacks
of appendicitis and also against hernia in the opera-
tion wound.
Another Mistake in Diagnosis. — Dr. Howard
LiLiEN'THAL agreed with what seemed to be the con-
sensus of opinion, to operate in time in all cases of
severe appendicitis. He then mentioned a case of
what seemed clearly to be appendicitis complicating
pregnancy, although the possibility of typhoid fever
was not excluded. He saw the case with Dr. Vine-
berg, who had already made up his mind to operate,
but at the request of the family called Dr. Lilienthal
in consultation. They operated and found an abso-
lutely normal appendix, and nothing to account for the
patient's symptoms. The patient growing steadily
worse. Dr. Vineberg emptied the uterus. The collapse
became more profound, and nobody supposed she
would live, but there was a sudden turn for the better
and she recovered. Regarding the diagnosis between
appendicitis and typhoid fever, it should be remem-
bered that the appendix might become perforated in
the latter disease. He had seen two such cases.
Catarrhal Appendicitis — Dr. Bernard S. Talmev
said, with regard to one not seeing the appendix in a
state of catarrhal infiammation, the reason was clear:
one did not operate in such cases. To deny the possi-
bility of its occurrence was as reasonable as to deny
the existence of catarrhal nephritis or catarrhal infiam-
mation of the lungs, because not found in cases ope-
rated upon. Perhaps in not more than ten per cent,
of all cases of appendicitis was it necessary for the
physician to call in the surgeon; the other ninety per
cent, got well. Xow, since but few of the other forms
of appendicitis recovered without operation, it was fair
to infer that the ninety per cent, were catarrhal.
Constipation and Appendicitis. — Dr. Hewrv Illo-
WAv referred to the fact that in most cases of operative
appendicitis fa;cal concretion had been found, and to
the further fact that in many instances, especially in
])regnant women, there was a history of constipation.
He thought the constipation might be an important
factor in lighting up an attack of acute appendicitis by
the pressure exerted through the hard masses upon the
fjEcal concretion, which really was a foreign body
within the appendix. In this way the fact was ac-
counted for that appendicitis was set up from within
the organ and not from without, the pressure simply
being the means of opening the way to infection from
within.
Dr. .Abrahams made some closing remarks.
Fatal Secondary Hemorrhage Following Nephrec-
tomy— Dr. Thomas Manlev presented a kidney, the
seat of pyonephrosis from multiple abscess, which he
had removed. He lost his patient the next day from
secondary hemorrhage, although he had taken the extra
precaution to put two li[^;atures around the vessels at
the time of the operation.
Resection of Intestine in Hernia Dr. Manley
al.so presented twenty-six inches of small intestine, re-
moved for gangrene in a case of strangulated hernia,
the anastomosis practised being that of Connel, of
Milwaukee. It was the operation which he commended
above all others. His patient recovered.
MEDICAL AND CHIRURGICAL FACULTY
OF MARYLAND.
Semi-Annual Meeting, Held at Hagcrstown, Mi/.,
Tuesday and Wednesday, November 10 and it, rSgd.
William Osler, M.D., President, in the Chair.
First Day — Tuesday, November lotli.
After an address of welcome by Dr. J. W. Hvmric-
HOUSE, of Hagerstown, which was responded to by Dr.
WiLLiA.M Osler, of Baltimore, the regular order of
business began.
Continued Fevers. — This was the subject of a
paper by Dr. C. Birnie, of Taneytown. He related
several cases of fever lasting from two to six weeks,
or sometimes longer, lacking the characteristic symp-
toms or lesions of typhoid or malarial fever and not
due to any definite lesion. He gave the points of
distinction between the two cases related and typhoid
fever. In many instances he treated the patients
symptomatically. He found that antipyretics were use-
less and harmful. Phenacetin was very successful in
his hands.
Dr. John C. Hem meter asked what were the latest
views concerning gastric fever: some insisted that such
fevers did exist and others that they did not.
Dr. Birnie said that no microscopic examination
had been made in these cases, and he was of the opin-
ion that gastric fever was more of a gastric catarrh.
Dr. Osler said that he had no personal knowledge
of gastric fever.
Dr. Charles Vl. Elli.s, of Elkton, said that he had
had an experience similar to that related bv Dr.
Birnie.
Dr. a. S. Mason, of Hagerstown, said that such
cases as those related by Dr. Birnie were known to
physicians and he was inclined to call them continued
fevers; he did not know how else to classify these
cases if not as simple continued fevers. In some
cases quinine had no effect at all. He referred to an
epidemic that spread over this country twelve years
ago. He had had sixty or seventy such cases and ty-
phoid cases from polluted water, but also many cases
with no local disturbance. He did not know the
classification of these fevers.
Dr. George J. Preston said that the subject of the
continued fevers was of great practical importance, and
spoke of the physiology of heat and cold production
in fevers. \Ve did not give due weight to the physio-
logical questions in the study of this fever. We often
had distinct hysterica! fever running over weeks: these
were rare cases but they did occur. We rarelv saw
such cases in the hospital, because these mild cases
did not usually enter the hospital. We did have cer-
tain cases, in typhoid fever, as a rule, such as walking
typhoid fever, which was made known by the relapse.
The enlargement of the spleen and liver was not diag-
nosed. The diazo reaction had not met with much
success in his hands. There were many cases of fever
in which quinine was of no use.
834
MEDICAL RECORD.
[December 5, 1896
The NatHre a?nd Treatment of Gastric Acidity.
■ — This was the subject of a paper by Dr. John C
He.mmetkr. He asked if there was a distinct lesion
in these troubles or not. The question had often been
asked, but, not having arrived at conclusions, he had
examined the gastric contents with the double test
meals of Saizer. These two consecutive meals repre-
sented an ordinary diet, and by them one could deter-
mine the number of important pathological states in
gastric digestion almost without further analyses.
These test meals consisted, first, of a cup of milk and
a plate of rice with a piece of bread, followed four
hours later by a roll and a glass of water. If the
stomach contents were removed one hour after the sec-
ond meal, there should be no remnants, if the stom-
ach was healthy. Proteid remnants, such as meat and
eggs, would point to anacidity, while a iiyperacidity
would be indicated by a large amount of carbohy-
drates in the remnants. After a few words on the
digesting power of the stomach, he concluded by some
important directions on the dietetic treatment in this
trouble.
Cerebral Syphilis. — This was the subject of a
paper by Dr. George J. Prestox. The symptoms of
this trouble were very varied and the histor)- of the
primary lesion was often uncertain. Moreover, the
inter\al between the primary lesion and the brain
troubles might be so long as to make the connection
between the two uncertain. .Meningitis from syphilis
was nearly always chronic, the symptoms coming on
gradually, the first one being headache; then there
might be paralysis of the third pair of nerves, or of
the fourth or sixth, with hemianopsia. The most com-
mon form was great mental depression, or rather
apathy. He related six typical cases, illustrating
some of the most important svmptoms of the cerebral
syphilis. We should make our diagnosis and then
treat vigorously. This method of treatment was much
more used in this country than in Europe, hence the
better results obtained here. He had given as much
as three hundred to five hundred grains of iodide of
potassium a day and felt justified in doing this. He
thought that mercury very materially helped the
iodide.
Dr. K. X. Brush thought that the interval between
primary lesion and the brain troul)les was much longer
than Dr. Preston intimated in his paper. In one case
he had given nine hundred grains of iodide of potas-
sium a day. He did not believe in the therapeutic
test, and did not think that because a patient could
take large doses of the iodide that he should be treated
for mental troubles as for the specific complaint.
.Some syphilitics could not take large doses, while
those who had never had the disease ' could often
stand \ery large doses.
Malaria Complicating Gynecological Operations.
— This was the subject of a paper by Dr. Jf)HX Whit-
RinoE Wii.i.i.A-Ms. He spoke of the importance of ex-
amining the blood in all febrile conditions and the
necessity for great accuracy, and said that post-partum
fever was more frequently attributed to jnierperal fever
than to malarial fever and that in the text-books
there were few references to malaria as post-partum.
He had had two cases recently. In the first, the ex-
amination of the blood had given him great confi-
dence and had allowed him to exclude sepsis. In the
second case neglect of the blood examination had re-
sulted in a faulty diagnosis, and as a consequence an
operation was performed, although as it turned out this
operation was entirely ju.stifiable. These two cases
convinced him of the importance of blood examina-
tions in all febrile cases after labor, even though
malaria be suspected. He was confident that malarial
fever was often mistaken and treated for other post-
partum troubles.
Dr. J. M. HrNni.Ey said that he had had several
cases of late in which malaria complicated gynecologi-
cal operations, and the blood examination had made
the diagnosis certain. He thought that this year,
especially, such malarial complications were more
common.
The Cystoscope in the Diagnosis and Treatment of
Diseases of the Female Bladder. — This was the sub-
ject of a paper by Dr. J. M. HrNr)[.EV. Heretofore
the treatment of these diseases had been unsatisfactorv;
drugs internally and washing out the bladder were tlie
two methods of treatment commonly used. Through
the skill of Dr. H. A. Kelly, the modern cystoscojie
had been so perfected that the interior of the bladder
could be examined and treated, and the openings of the
ureters could be seen. The bladder was more fre-
quently subject to organic disease than was belie\e(l
before the use of the cystoscope. Not only uterine
but also rectal diseases caused an irritable bladder.
He thought that the routine examination of the blad-
der with the cystoscope should be made in every gyne-
cological case, whether the complaint was referred to
that organ or not. He related two cases attesting tiie
value of the cystoscope in this line of work and urged
the profession not to neglect this modern means of
diagnosis.
Dr. .\. C. Wentz, of Hanover, Pa., related a case
in which he applied ichthyol ointment by balloon
to the interior of the bladder, as recommended by ] )r.
("larke. He also used applications of ten to fifteen
per cent, of nitrate of silver.
To What Extent Does the Hypertrophied Pharyn-
geal Tonsil Atrophy at or about Puberty ?— This
was the subject of a paper by Dr. .S. K. Merrhk.
He had been struck by the frequency with which tiie
family physicians had told parents that the enlarged
pharyngeal tonsils of their cliildren would disapjiear
spontaneously at from twelve to fourteen years of age.
Indeed he had found that several of the text-books
gave this same opinion or else avoided the question
altogether. He had been able to collect a few statis-
tics from his own practice, and in none of the subjects
whom he had seen who had refused ojjeration in child-
liood had the tonsils disap))eared at jniberty. Some
information was obtained in obser\ing the ages at
which patients applied to him for treatment : out of
fifty subjects operated on in 1895 and 1896, sixteen
were under fourteen years of age, while thirty-four
were above that age. If the tonsils atrophied after
puberty it was strange that so many cases came to op-
eration after puberty. We might conclude that an
insignificant number of liypertrophied glands would
disappear at puberty if left to themselves. Not only
this, but adenoids made a patient prone to repeated
colds, as well as other throat affections that may be-
come tuberculous in character.
Dr. J<)H.\ N. Mackenzie said he had never allowed
such a case to reach puberty without operation. It
was amazing what troubles these pharyngeal growths
might cause and what fearful inroads these troubles
might make on the health. He had operated on in-
fants in arms. The growth should be operated on as
soon as discovered, and should ne\er be allowed to
proceed unchecked. He spoke of the great liability to
disfigurements of the countenance from this trouble
and the ati'ections of hearing, etc.
The Early Symptoms of General Paresis. —This
was the subject of a paper by Dk. (Ieorc.e H. Roh^;.
We should look for the early symptoms, although the
results of treatment are not encouraging. The diag-
nosis must be made from a collection of symptoms
partly physical and partly psychical. The disease
generally begins after the thirty-fifth year and rarely
after the fiftieth. Those in the higher walks of life
are attacked by preference and men more than women.
December 5, 1896]
MEDICAL RECORD.
83;
Clerg)-inen are almost exempt and actors are most fre-
•quently affected. Syphilis may be one of the causes.
The symptoms are various and the treatment is un-
satisfactory, and rarely does more than prolong life a
few years. The iodides may be given.
Dr. Edward N. Bush was much pleased with Dr.
Rohe''s paper. He thought that the early symptoms
of paresis occurred in this order: 1st, vasomotor: 2d,
motor: and 3d, psychic. Sometimes depressing ideas
usher in the disease.
Dr. Wii.lia-M Osler presented a case of diffuse
scleroderma. The patient was a white man, about
thirty years old, who had suffered from a hardening,
tiiickening, and gradual immobility of the skin.
There had been inflammation, erosion, and finally
disability. This trouble was most marked in the
hands and arms and face, although the skin of the
whole body was somewhat hide bound. It was hard to
pinch the skin. The patient could not close his hands
tight. There were two forms of this disease — the dif-
fuse form and the local form. This was a case of
diffuse scleroderma. The etiology of the disease was
not known and the pathology was very obscure. Thy-
roid extract was sometimes efficacious in this disease
and sometimes not. In this case the man had been
helped very much by it, and there were chances that it
would stop the progress of the disease, if not cure it.
He could not elevate his shoulders. Scleroderma was
a slow progressive disease and it was very rare; he
himself had been in practice twenty years before he
saw a case and had seen only six cases altogether.
The Pathology and Bacteriology of Typhoid
Fever. — Dr. Simon Flexner made some remarks on
this subject, ^^'e have every reason to believe that
the disease comes from the germ, the bacillus, in the
anatomical tract. There is no ground for believing
that it gets into the body in any other way than
through the intestines. This fact is based not only
on the pathological anatomy but on experiments as
well. We cannot produce the disease in animals.
Not all parts of the intestines are alike prone to infec-
tion to the same extent. Infection takes place where
the lymphatic follicles are in aggregation. Not all
the lymphatic aggregations are affected to the same
extent. There is a general distribution of these lym-
phatic follicles throughout the whole tract of the in-
testines, but not all are affected in typhoid fever.
The agminated glands are more susceptible to the
poison than the solitary ones, and those nearer the
lower part of the small intestine are especially affected.
Here the infectious material of typhoid fever is kept
a long time, owing to the anatomical character of the
parts. The ulceration produced by the bacilli may be
very superficial, affecting only the mucous membrane,
or the whole thickness of the intestinal coats may be
affected, causing perforation. Many epidemics are
from an infected water supply. The organism of this
disease is not particular as to where it lives and can
thrive in water a long time, also in milk. It is hard
to discover and separate it from other organisms.
The growth is often invisible and causes no change
in the color or taste of the milk infected, nor does it
cause coagulation. This fact helps in its recognition,
because the organisms with which it is confused grow
visibly, and recent methods allow the typhoid germ to
be discovered in the intestines. Hy the use of the
differentiation method of Eisner in culture media of
varying acidities, the growth of the typhoid organism
in plate culture may be easily separated. The meth-
ods of Pfeiffer and Widal, by which the disease is
made out in its early stages, is very ingenious. A
bouillon culture of typhoid germs is mixed with blood
from a suspected case of typhoid. If the disease really
exists, the effect of the serum from the typhoid case
causes a loss of motility, a clinging together, and fi-
nally a disintegration of the osganisms. Wyatt John-
ston has been able to make a diagnosis of tvphoid
fever in many cases in a short time by means of a
hanging drop of a pure culture of the typhoid organ-
isms to which serum from a typhoid patient has been
added. This is a great advance in our diagnostic
methods and should be made use of by all physicians.
Dr. William O.sler spoke of the prevalence of
typhoid fever, and said there were too many cases in
the State of Maryland and in Baltimore. He said
this prevalence was an index of the sanitary intelli-
gence of the community and of the physicians, and
that with the help of the public and of the politicians
it could be stamped out within three years. He then
called on Dr. Fulton, the new secretary of the State
board of health, to make remarks on typhoid fever.
Dr. John S. Fulton said that within his one month
of service as secretary of the State board of health he
had made one observation, and that was that, while the
countr\'-bred bacillus enjoyed great prevalence in the
city, the city-bred bacillus seemed to be especially
prevalent in the country. As a preliminary step to
obtain statistics he had written to fifty-six physicians
throughout Baltimore and Maryland and had received
twenty-three replies, and to explain his opening re-
mark he had found that the city physicians maintained
that the cases in their care had originated frcm infec-
tion in the country, while the countrj- physicians
blamed the city infection for their cases. He said
there was also many cases of typhoid fever concealed
under the name of typho-inalarial fever, the majority
of persons apparently thinking that this combined
form of the disease was less serious than either one
disease alone. To show how unreliable the stati^ics
were, he would quote from one of the hospital reports
(Bellevue Hospital), which showed sixteen cases of
typhoid fever with a mortality of sixteen and seventv-
six cases of typho-malarial fever with no death's.
Either the diagnosis was very bad, or the therapy was
murderous. He had been studying the health re-
ports of the State of Michigan since 1886 and had
noticed that at first many cases of typhoid and tvpho-
malarial fever were reported, but gradually, year by
year, the typho-malarial cases had been disappearing,
while the malarial and the typhoid cases were slightly
increasing. He said that the State board of health
of Maryland would shortly make a complete investiga-
tion to ascertain the sanitary conditions in reference
to typhoid in Maryland, and letters would be written
to every physician in the State. This would be the
happiest and most profitable investment Maryland
ever made. If we could place with the board of ex-
perts enough money to make a substantial beginning
of the reform, its members would realize the possibili-
ties that Dr. Osier had maintained.
Modern Method of Examining Urinary Sediment.
— Dr. William B. Ca.vfielh made some remarks on
this topic. He said that, as a rule, the chemical ex-
amination of urine was easy, but the examination of
the sediment not so easy unless it was especially
abundant. U'hen the sediment was scarce or appar-
ently absent, important ingredients might be over-
looked. The method of allowing the urine to stand in
a conical glass had some disadvantages, especially in
warm weather, when decomposition might occur: also
casts might remain suspended, and often they adhered
to the sides of the glass and escaped observation.
Moreover, this method of examination involved a waste
of time. For this reason he would advocate the more
general use of the centrifugal machine. The centrifu-
gal had been long known and used; for example, in
sugar refining and also in many physiological experi-
ments; but only of late had a smaller and portable
machine been made which could be easily used. It
was surprising to find so little mention in books of the
836
MEDICAL RECORD.
[December 5, 1896
use erf this machine, in even the most modern text-
books on urinary analysis, and he also thought that,
with the exception of the larger hospitals and a very
few physicians, the centrifugal was still unknown. He
then exhibited the machine which he had used and
demonstrated the method employed.
Dr. J. M. T. Finney then made some remarks on
the use of the .i-rays in surgery. Agents of the Edison
Company first explained the use of the machine ex-
hibited by them, and then Dr. Finney explained the
advantages of it in diagnosing dislocations, fractures,
or other deformities made visible by it, and suggested
that by the use of photographs, which could be easily
taken in the light without a lens, the surgeon could
keep a complete record with illustrations of every case
adaptable to the machine, and thus protect himself
against malpractice suits. In conclusion Dr. Finney
related some cases and explained the advantages of the
machine from a surgical standpoint. After this gen-
eral discussion followed and there was a demonstration
with the machine of various cases which had been
brought in by local physicians.
Second Day — IVcdiicsday, November nth.
Cancer of the Tongue. — Dr. Frank Martin read
a paper on this subject, in which he described the
character of the growth usually present, the epithelioma-
tous: the age when it was most prevalent, forty-five to
sixty-eight; the length of time it took the growth lo
develop, six months to three years; and the various
operations for its removal. He said that the symp-
toms at first were very undefined, with very little pain.
It visually began on the side of the tongue and in its
anterior half, and the duration of life without opera-
tion had been recorded as from one year to eighteen
months. He spoke of the various operations, such as
that done with tracheotomy, with excision of the jaw,
and with operation through the mouth. He found
that the operation by excision of the jawbone gave the
most complete results and in his experience the wound
healed kindly.
Dr. John M. T. Finney said that his experience
with the wound left by the excision of the jaw was
that it granulated very slowly and gave much trouble.
He referred to several cases that he had had with such
a result.
Dr. J. W. Hu-MRiCHousE, of Hagerstown, then read
a paper on some of the results of bacteriological re-
search, in which he reviewed what is known up to
the present time of the various diseases and their
specific organisms, and outlined the treatment. This
paper was discussed by Dr. David F. UNf;EK, of Mer-
cersburg. Pa.
Dr. Randolph W'in'seow then reported two cases
of gastrostomy for rcsophageal obstruction.
Dr. Joseph Gichnicr read a paper on "The Present
Status of the Treatment of i'uberculosis," in which
he reviewed various methods of treatment of that dis-
ease in vogue at the present day.
Dr. H. O. Reik read a paper on "The Practical
Use of Skiascopy."
Extra-Uterine Pregnancy Differential diagnosis :
\\'e must differentiate between: i. Retrofiexed preg-
nant uterus, possibly complicated by a cervical polyp,
bleeding occasionally. 2. Pregnancy in bicornuate
uterus. 3. Intra-uterine pregnancy complicated by
an adnexa tumor. 4. Ruptured pus tube. 5. Rup-
tured varicose veins of tube, broad ligament, haemato-
cele from ruptured (Graafian follicle, ha?matosalpinx.
6. Rupture of an ulcer of llie gastro-intestinal tract
and appendicitis. — Franklnihal, Medical Standard,
November.
OUR PARI-S LETTER.
(From our Special Correspondent.)
ANNUAL meeting AND DINNER OF THE ANGLO-AMERI-
CAN CONtlNENTAL MEDICAL SOCIETY — REMARKABLE
CASE OF CATALEPTIC SLEEP LASTING OVER THIRTEEN
YEARS CONSULTATIONS BY CHARCOT AND BROUAR-
DEL — AGITATION AGAINST EXPENSES ATTENDING THE
STUDY AND PRACTICE OF MEDICINE IN FRANCE —
LAY.MEN DO NOT WISH THEIR SONS TO BECOME
DOCTORS, ETC.
Paris, November 15, 1896.
One of the most important professional events of the
year took place on November loth — v.'e refer to the
annual meeting of the Continental Anglo-American
Medical Society, whose object is to serve as a bond
of union between the British and American practition-
ers established on the continent of Europe, the Ri-
vieras, French as well as Italian, and in northern
Africa. To become an active member of the society
it is necessary to have a French qualification, which
is calculated to keep the membership somewhat lim-
ited, although there are at present on the roll a hun-
dred and more names, including, of cour.se, the hono-
rary presidents and members, among whom we note
Sir Richard (^uain. Sir Joseph Lister, Sir Spencer
Wells, Dr. S. Weir Mitchell, Dr. J. P.. ISillings, Dr.
W. M. Polk, and Dr. W. T. Lusk. On the executive
committee are such men as Dr. the Hon. Alan Herbert,
Dr. Clarke, Dr. Halsted Boyland, Dr. Austin, Dr. Bull,
and Dr. Baldwin.
This society has been productive of great good in
holding together the luiropean physicians, chiefly the
English and Americans, in upholding the dignity of
the medical profession in general, and in elevating the
tone thereof. Seventeen new members were elected,
quite a phenomenal number. It is always customary
to invite some distinguished guest to preside at the
dinner, which comes off the same evening. This year
the society delegated the Hon. Alan Herbert, Dr. Hal-
sted Boyland, and Dr. Barnard to invite Mr. Austin
Lee, C.B., H. I!. M.'s attache, to preside at the annual
banquet, which invitation he accepted, and referred
in a neat speech to the amity of the two nations, Eng-
land and .America, between whom so many ties existed,
professional as well as other, proposing the health of
the Queen and President Cleveland. The orator was
of opinion that the society should exert its influence
to obtain some mitigation of the present draconian
laws, which really debar English and .American prac-
titioners from exercising tiieir profession in Prance.
He spoke in highly complimentary terms of Baron de
Rothschild, who, with his great wealth and social po-
sition, had elevated himself still more by becoming a
physician and practising his profession. Dr. Roths-
child has also founded a polyclinic, in which he is
doing valuable work for science and for the poor.
Dr. the Hon. .Alan Herbert replied in a few well-
chosen words, referring to the high standing, both pro-
fessionally and socially, of physicians in England, the
United Stales, and France, and thought that the medi-
cal profession was about to surpass all others in these
respects.
The most curious and longest-lasting case of cata-
lepsy known to .science is still to be seen at the little
village of Therelles, some hours distant from Paris.
On May 29, 1883, Marguerite Boyen\al, then nine-
teen years of age, frightened by the appearance of a
squad of gendarmes, who, she probablv imagined, were
coming to arrest her, suddenly uttered a cry and fell
in a nervous attack. She was placed upon the bed
December 5, 1896]
MEDICAL RECORD.
y-.".
'^0/
and went to sleep in a short time; from that day to
this —that is, about thirteen years and ti\e months —
she has never awakened. The most distinguished
physicians in France have seen her, and everything
has been done, in vain. The young girl has become
a woman sleeping. Charcot went four times to see
her — the first time alone, the others in company with
other consulting physicians; Professor Brouardel also,
then Professor Berillon. Dr. C'harrier, the local prac-
titioner, calls every day. The patient, reduced to a
skeleton, lies with her head slightly bent upon the
pillow, her arms concealed under the covers; pale and
with hollow cheeks, she seems more dead than alive.
The mouth and eyes are closed. If the eyelids are
■drawn up, only the white of the orbits is visible, the
pupils being rolled upward under the orbital arches;
and Marguerite Boyenval, with her white cap, has
upon her fact an ecstatic expression, such as we see in
hystero-catalepsy less profound, reminding one of the
pictures of nuns by the old Italian masters. At the
beginning she made several starts, as if going to
awaken, but the deep cataleptic sleep overtook her
again in five or si.x minutes, to continue until the
present writing. For a time she was nourished bv
sliding a teaspoon between her teeth, but for eight
years past nutrient enemata, four times a day at regu-
lar hours, have been and are still resorted to. Of
course, she has largely consumed herself, being now
only skin and bones, with stiffened and fleshless fin-
gers. The body to the touch shows some hyperther-
mia, for which the hot-water bags kept constantly at
her feet are not sufficient to account.
The physicians who have seen her are of opinion
that during the first months she could hear what was
passing around her, but to-day the organs are too much
weakened. It was during this period that the thorax
still rose and fell a little with the respiratory move-
ments. Now, the only sign of breathing is a slight
mist upon the glass. The functions of menstruation
and defecation are accomplished, tliough, of course, in
an e.vtremely limited and irregular manner.
There is nothing hereditary about this truly won-
derful case. Her only attendant is her mother.
Madam Boyenval is a large, buxom peasant woman, in
rugged health and exuberant spirits, as her parents
were before her, and ddfes not know what illness is.
The subjects of the practice of medicine and of med-
ical education, which liave for several years past been
agitating the profession and government, having been
settled as far as foreigners are concerned, the French
laity is now anxious lest its sons should study med-
icine and graduate in the ranks of a profession al-
ready overcrowded. Consequently, leaders and com-
munications of different sorts are appearing in the
daily press, notably in the Figaro, the most influential
journal in France, showing why young Frenchmen
ought not to embrace the profession of medicine.
Here is about what it costs a father to-day who wishes
to make his son a doctor: Ten years of university
studies, at 1,800 francs a year: say, 18,000 francs.
At least five years of medical study, at 2,500 francs;
12,500 francs. The year of military service costs 2,000
francs. Total, about 40,000 francs, or eight thousand
and some dollars. This sum does not include the
amount necessary for instruments, say 2,000 francs;
nor for books, say a like sum, 2,000 francs. If the
young doctor establishes himself in a large city, he
will have his rent and furniture, to amount to six or
seven thousand francs. In a word, the expenses of the
average doctor in Paris are between four and seven
thousand francs a year at the very beginning and be-
fore he has begun to subsist, with nothing allowed for
horse and carriage.
This agitation against the study of medicine is very
wise, and should be imitated in New York, where the
profession is as overcrowded as it is here. In Paris
the field of practice is always a hotly contested one,
even among the older members of the profession. So
what a hopeless warfare must the young doctor wage
in his comparative youth and inexperience, not only
against his own confreres, but against his enemies,
such as quacks, bone setters, veterinarians, often drug-
gists, rich young doctors who found polyclinics where
his patients can get advice and medicine gratis; older
doctors, some of whom receive him in practice on un-
equal terms, and insist upon having their full consul-
tation fees when called in by him and half of his
hard-earned money besides : others, whose equal he
certainly is, often their superior in many respects,-
give the patients he sees with them and others to un-
derstand that he is only a promising tyro, an assistant,
and consequently to be appreciated and remunerated
accordingly. (Indeed, he would not have been called
in at all oftentimes, if the elder doctor had known to
whom to turn.) These are only a few of the difficul-
ties that beset him at every turn; the heavy pi7ft-///e or
tax that he will have to pay annually for the privilege
of practising his profession, in addition to the tax upon
his furniture, etc., is not included in the estimate given
above.
OUR LONDON LETTER.
(From our Special Correspondent.)
IRISH COLLEGE OF SURGEOXS POOR-LAW MEDICAL
OFFICERS IN IRELAND— EDINBURGH STUDENTS
MEDICAL COUNCIL — PATHOLOGICAL SOCIETIES EX-
HIBITION OF SPECIMENS AND REMARKS ON THEM —
SOME RECENT DEATHS.
LoNDO.s, November 13, 1896.
The Royal College of Surgeons in Ireland is a teach-
ing as well as an examining body. The president, Mr.
Thomson, opened the session on the 2d inst. with an
introductory address. Both Irish and Scotch schools
open a month later than English. Mr. Thomson, ac-
cording to a newspaper report, warned the students
that the medical life is by no means one of delectable
ease, that they will be not masters but servants of
their patients, and that there are no comfortable pen-
sions or sinecure appointments to retire on. He then
pressed upon them the importance of general educa-
tion, and especially urged them to master the English
language; and as to the defence of bad spelling some-
times heard, that some good scholars have been exam-
ples of it, he declared that such defence flattered
neither the schcfl.ir nor his teacher. Bad spelling, he
held, was the result of bad teaching or else of a boy's
carelessness. There was no excuse for a young man
to be illiterate in his own tongue, and Mr. Thomson
urged the students to familiarize their minds with the
writings of the great P.nglish authors.
This day week an important deputation waited on
the chief secretary for Ireland, Mr. Gerald Balfour,
brother of the leader of the Commons, to lay before
him the abuses of the Irish poor-law system and seek
some consideration for the medical officers. The
presidents of the two royal colleges, the Academy
of Medicine and the Irish Medical Association, were
present and advocated the cause cf the distressed
medical officers. But the dignified deputation does
not seem to have impressed the minister, wiio was con-
tent to repeat the ridiculous fictions which have been
doled out by the local board to successive secretaries.
Evils were admitted, as they could not all be denied,
but no remedy was offered, no hope of amelioration
held out. It is a strange sight for a strong govern-
ment in this year of grace to acknowledge injustice
and admit nothing can be done but ''grin and bear."
The Edinburgh students have elected Lord Balfour
of Burleigh lord rector. I am sorrv to sav that some
838
MEDICAL RECORD.
[December 5, ib>96
of them emulated the follies of their noisier brethren
at Glasgow.
Electioneering literature is being freely distributed
b)- the rival candidates for the General Medical Coun-
cil, and the question how to vote is exciting a good
deal of attention.
At the last meeting of the Pathological Society, Mr.
J. Hutchinson, Jr., showed a specimen of rodent ulcer
of the forearm. Among the large number of cases of
true rodent ulcer referred to and exhibited before the
society in 1895, not one was on the limbs, and some
doubted the possibility of its occurrence in such a
position. This growth was situated on the outer as-
pect of the forearm of a woman aged forty-five years.
It measured about an inch in long diameter and had
existed for over a year. \'ertical sections showed
reticular downgrowths of cells from the rete muco-
sum, having the typical structure of rodent ulcer as
met with on the face. Cell nests w^ere practically
absent and the corneous layer took no part in the
downgrowth. Mr. Hutchinson, Jr., said he had seen
a typical case in the groin also, and thought its occur-
rence in other patts of the body than the head and
neck not so rare as supposed. Dr. A. A. Kanthack
said that, in deciding the position from which rodent
ulcer started, the growth should be examined before
any ulceration had taken place. When examined
early enough the rete mucosum is always found nor-
mal ; the sweat glands are unaffected, but the .sebaceous
follicles disappear. Mr. A. A. Bowlby agreed with
this view.
Mr. \V. G. Spencer thought that a slow-growing
epithelioma presented much the same characters as a
rodent ulcer.
Mr. James Berry said he had examined many cases
of rodent ulcer and in all of them the growth had be-
gun below the rete mucosum. He had seen one case
in which the growth occurred in the groin.
Mr. H. T. Butlin said that one distinctive feature
of a rodent ulcer was the scarring over the surface
which took place, the structure of the rodent ulcer
being demonstrable below the skin; this never oc-
curred in epithelioma. Mr. Shattock said that the
finding of cell nests definitely proved that a growth
was not a rodent ulcer.
Mr. J. Hutchinson, Jr., also showed a series of sec-
tions of adeno-chondroma of the left submaxillary
gland in a young man who, nearly two years later, was
free from any recurrence. The innocent nature of
these tumors has been proved in a considerable num-
ber of cases. •
Dr. Rolleston showed a specimen of extensive
tuberculous disease of the thyroid gland. There were
caseous areas through the gland which were of the
normal size. In the left lobe the caseous material
had softened down and formed an abscess, which had
discharged into the upper part of the cesophagus on
the left side. The lymphatic glands around the in-
nominate artery were caseous and had softened down,
and the resulting abscess had tracked up into the neck
and opened into the cesophagus by several sinuses,
the highest and largest being nearly oppo.s'ite that of
the tuberculous abscess in the left lobe of the thyroid
body. Half an inch below these roughly .symmetrical
openings the cesophagus showed slight cicatricial
contractions. The rarity of tubercles in the thyroid
gland and the extreme rarity of large tuberculous ab-
scesses were mentioned in the conversation that fol-
lowed, and it was stated that no specimen existed in
the museum of any London hospital.
Dr. H. H. Tooth described under the name of mul-
tiple bronchiolectasis the appearance of the lung of a
boy, aged eighteen months, which was found to be
riddled with small cavities from one-sixteenth of an
inch to a quarter of an inch in diameter, smooth-
walled and containing only air. They were probably
dilated bronchioles, a sequence of peribronchial in-
flammatory processes. Dr. Xornian Moore said that
similar cavities were seen in children who had died of
whooping-cough.
Dr. A. A. Kanthack and Mr. E. H. Shaw read a
paper on the use of formalin in the preservation of
museum spe;,cimens. Excellent results had been ob-
tained in preserving eyes. Some specimens were
shown which had preserved their original color most
excellently, among them a broncho-pneumonic lung
and a granular kidney, both of which had all the ap-
pearances of fresh specimens.
Dr. Rolleston showed specimens of secondary poly-
poid sarcomatous (melanotic) tumors in the mucosa of
the small intestine.
Favell, of Sheffield, died on the 31st ult., aged
sixtj-four years. He had been invalided by heart
disease for some time and a change for the worse was-
rapidly fatal. William Fisher Favell was consulting
surgeon to the Sheffield Infirmary, having been sur-
geon to it for above thirty years. He was also presi-
dent of the medical school and vice-president of the-
college which is to be connected with Victoria Uni-
versity. He was a justice of the peace and an im-
portant supporter of all local movements for the benefit
of the poor. In 1876 he delivered the address in sur-
gery at the meeting of the British Medical Associa-
tion. On his retirement from the infirmary in 1893,
there was a manifestation of the esteem in which he-
was held. It was proposed to place his portrait in the
institution and ^'1,000 was raised in a very short time
to secure the services of a first-rate artist. Mr. Shan-
non was selected and his portrait pronounced excel-
lent, and a replica was presented to Mr. Faxell's only
daughter.
Mr. Thomas Chambers, of Sydney, N. S. W., vvhcH
died at the end of August, was well known in London,,
where he achieved considerable success as a gynecol-
ogi.st. It was with regret his friends learned in 1882
that his health was so broken that he had determined
to seek a better climate. Tom ('haml)ers. as we famil-
iarly called him, accordingly went to Australia, and
there, too, he achieved success in the same specialty.^
An attack of bronchitis terminated his successful ca-
reer. He leaves a widow and^ix sons.
Dr. Henry Trimen, who became director of the
Royal Botanic Gardens in Ceylon sixteen years ago,
died there on the i6th ult. His " Flora of Ceylon,"
of which three volumes have appeared, is a masterly
production, but he has not lived to complete it. His
joint work with the late Professor Bentley on " Me-
dicinal Plants" may be better known to your readers.
The name of Morris, of Spalding, was a prominent
one for many years. He was surgeon to the infirmary
and held many local public offices. He practised at
Spalding for fifty years, retiring in 1890. He died
lately, aged eighty-one years. Dr. Morris was author
of a work on " Neuralgia" and one on " Shock in
Railway Accidents,'' besides contributions to the jour-
nals. He was M.D. of St. Andrew's and F".R.C.S.
Eng.
Deputy Inspector-General Francis Robert Waring
died on the 31st ult., at the advanced age of eighty-
seven years.
THE CONTAGIOUSNESS OF
PHTHISIS.
PLLMONARV
To THE Editor of the Medical Record.
Sir: a little common sense cannot fail to meet with
your approval, and I therefore venture to address a
few words to you.
The notices in street cars prohibiting spitting are
December 5, 1896]
MEDICAL RECORD.
839
treated with contempt, and are consequently valueless.
In spite of this fact, our health authorities in this city
of Buffalo are anxious to prohibit expectoration upon
the streets, e.xcept in the gutter — or, rather, in what is
called a gutter. The intention is, of course, good,
since spitting is a most objectionable habit, for which
there is no e.xcuse. But the regulation could not be
carried out in practice, and would not be of any im-
portance if it could. The streets of Buffalo are chiefly
asphalt; the portion of the asphalt next the sidewalk
is quite as dry as the centre of the road, and men are
employed to collect the dust and dirt in heaps. If
there were a gutter containing water, the case would
be different ; but, as it is, the accumulations are dry
and are being continually stirred up.
Suggestion No. i : Let us cease to try to make laws
or regulations which cannot be enforced, and which
would be valueless if they could.
Spitting upon the streets or in public places is vir-
tually unknown in Great Britain. So disgusting is the
practice considered that cuspidors are not mentioned
in decent society, and consumptives, I fear, very often
swallow their sputu]n or expectorate into their hand-
kerchiefs. Pulmonary phthisis is a disease as old as
medical science itself, and the extreme contagionist
who has persuaded himself that it can be conquered by
such a simple process as taking care of the sputa of
its victims is deceiving himself, because he is only
taking one source of contagion into consideration.
Nor is this all. It is the fashion in this country to
laugh at the idea of a tuberculous diathesis, without
which nobody ever succumbs to tuberculosis. But no
writer whose work I have been able to consult denies
its existence, and Koch specially recognizes it. The
(words of Ur. Flick, of Philadelphia, the most extreme
contagionist in America — or anywhere else, I hope —
are : " Persons who have healthy stomachs, and who do
not overburden them, and who take sufficient exercise
in a pure atmosphere to secure them a free circulation
of well-oxygenized blood, will not contract tuberculo-
sis, no difference what the exposure.'"
Suggestion No. 2 : Let us cease talking about the
"e.xtreme contagiousness" of consumption, for it is not
contagious in the sense in which a zymotic fever is.
Paterfamilias has been so frightened that he is liable
at any moment to protest against hospitals for con-
sumptives being erected within city lines! One word
more. There is great difference of opinion as to the
contagiousness of this terrible disorder. I can give
the names of a small army of German and English
writers who are opposed to the contagion doctrine;
and the report of the committee of the British Medical
Association throws serious doubt upon the accuracy of
the opinions of the extremists. About ten years since,
Koch remarked that American interpretation of his
views was " perfectly ridiculous." The opinions of
Williams, James, Powell, \^'ilson-Fox (English), Dett-
weiler, Brehmer, Spinna, and Aufrecht (German) — all
recent writers and men of great experience — seem to
be that "the degree to which contagion ordinarily ex-
tends is singularly small."
We do not know how nature works. The genesis of
a disease is not the same thing as the artificial trans-
plantation of it, although every contagion enthusiast
appears to believe tliat it is. This subject cannot be
discussed in a letter.
Finally, Suggestion No. 3: Let us cease to talk or
write about what we have accomplished, for we have
accomplished very little. Phthisis has been on the
decrease for about forty years in Boston, for about
thirty years in Philadelphia, for about seventy years in
New York, and for about seventy-six years in London.
This decrease has been due to the process of natural
selection, and to nothing else. I have not been able
to discover any place in which there has been an ap-
preciably increased rate of decrease since the revival
of the contagion doctrine in 1882. The real decrease
of tuberculosis will come when persons of the phthisi-
cal type are sufficiently educated to realize that they
ought not to marry. In the mean time, the few who
are saved from the bacillus tuberculosus appear to suc-
cumb to other pulmonary complaints.
I cannot imagine any habit that is more offensive
than the American practice of spitting — unless it is
the American habit of swearing. But I submit, with
great respect, that the educational process alone will
prevent it, and that, as a source of tuberculous conta-
gion, it is being exaggerated beyond all reason, while
little is being attempted to reduce the consumption of
the milk of tuberculous cattle.
Lawrence Irwei.l, M.A., B.C.L. Oxon.
Buffalo, N. V., November i6, 1896,
l^edical gtcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending November 28, 1896:
Cases.
Deaths.
142
88
31
10
121
12
3
4
92
0
215
30
0
0
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-pox
Onions are popularly supposed to have a decided
effect in preventing scarlatina and diphtheria, besides
being generally healthful, inducing sleep and keeping
away worms. It would really seem that the fragrance
of the fruit should have power in at least a few of
these directions.
Cardiac Movements — Professor Benedikt has re-
cently found that thin layers of blood cast so deep a
shadow with the .v-rays that during systole the apex
can be seen approaching the base. During systole the
heart is not wholly emptied, as the shadow shows.
During deep inspiration the heart is drawn away from
the diaphragm.
Professional Contagion of Cancer Dr. Guermon-
prez, of Lisle, has communicated to the Paris Academv
of Medicine two cases in which the contagion of can-
cer appeared to be quite probable. The first instance
relates to a physician suffering from a cancerous ulcer-
ation, whose starting-point was in an acne pustule.
This physician had no cancerous antecedents, but had
the habit of scratching his face. As he had several
women affected with uterine cancer under his care, and
as he was somewhat negligent in the matter of asepsis,
it is believed that an inoculation took place in this
manner. The second case relates to Dr. Guermonprez
himself. He was operating on an epithelioma of the
face and his index finger was in the patient's moutii.
when his nail was suddenly turned back violently by
a movement on the part of the patient. Following
this a papilloma occurred under the nail, and resisted
for nineteen months all forms of cauterization.— iV/w
W^i'k Therapeiitk Rciku^
Anaesthesia during Sleep. — It does seem to me
that chloroform may be administered during normal
sleep, to the degree of |3erfect anasthesia, without
arousing the sleeper, more frequently than we gener-
ally believe. — Isk.\ki. Cleavek.
I operated upon a little girl, who had been run o\er
840
MEDICAL RECORD.
[December 5, 1896
by a trolley car. We went to the house at 10 i'.m.,
and found the child asleep. We gave chloroform and
amputated two toes. The child awoke later and knew
nothing about the operation. — Longaker.
One element of danger is that in many persons dur-
ing sleep the vitality is at much lower ebb than during
waking hours, and a fatal termination might result. —
Burr.
Cocaine Dangers. — A recent death under cocaine
an irsthesia in a physician's operating-room is a warn-
ing of the dangers of this most useful drug. Only
qualified and responsible persons should prescribe or
apply the remedy.
A Cycle Saddle has been introduced in England,
which provides complete bifurcation with an adjusta-
l>le interval to suit individual requirements, and takes
all pressure from the perineum. A really good saddle
is greatly to be desired, and physicians will welcome
one which obviates the danger of undue pressure.
The Plague in India. — Views differ as to the ori-
gin and nature of the plague as it has developed at
Bombay. On the one hand, it is ascribed to a specific
germ, disseminated by clothing, merchandise, etc., and
encouraged by filth; while on the other it is attributed
to the use of poisonous grain. Overcrowding, foul
air, sewage-soaked soil, and defective drainage would
appear to infiuence its spread more than contagion
from person to person, according to latest reports from
the infected districts.
Cocaine Anaesthesia. — In an address commemorat-
ing the introduction of ether, delivered by Dr. Roswell
Park at the University of Buffalo, tlie following trib-
ute was made to the discoverer of cocaine, which is
worthy of reproduction : " I will spend no further time
upon the subject, save to do justice to modern antes-
thesia by a very different method and by means of a
very different drug, which is to-day in so common use
that we almost forget to mention the man to whom we
owe it. I allude to cocaine and its discoverer, KoUer.
Cocaine is now such a universally recognized local
anaesthetic that there is the best of reason for refer-
ring to it here — the more so because it affords another
opportunity to do honor to a discoverer, who has ren-
dered a most important service to not only our profes-
sion, but to the world in general. The principal ac-
tive constituent of coca leaves was discovered about
r86o by Niemann, and called by him cocaine. It is
an alkaloid which combines with various acids in the
formation of salts. It has the quality of benumbing
raw and mucous surfaces, for which purpose it was ap-
plied first in 1862 by Schroff, and in 18,68 by Moreno.
In 1880 Van Aurap hinted that this property might
some day be utilized. Karl Koller logically con-
cluded from what was known about it that this anes-
thetic property could be taken advantage of for work
about the eye, and made a series of e.xperiments upon
the lower animals, by which he establisiied its effi-
ciency and made a brilliant discovery. He reported
his e.xperiments to the congress of German oculists,
at Heidelberg, in 1884. News of this was transmitted
with great rapidity, and within a few weeks the sub-
stance was used all over the world. Its use spread
rapidly to other branches of surgery, and cocaine local
aniEsthesia became quickly an accomplished fact.
More time was required to point out its disagreeable
possibilities, its toxic properties, and the like; but it
now has an assured and most important place among
anresthetic agents, and has been of the greatest use to
probably ten per cent, of the civilized world. To
KoUer is entirely due the credit of establishing its
remarkable properties. Had he patented his discov-
ery he would have been vastly richer in pocket, though
poorer in fame, than at present. He is now estab-
lished in New York, where he enjoys a modest com-
petency, but is by no means in receipt of the income
which is properly his due from the world at large. To
a man who has been the means of relieving so much
pain as Karl Koller, no amount of pecuniary return is
too great."
Foreign Clinics. — But what I do wish to emphasize
is the undo\ibted fact that we can find as good a clinic
of any given kind in such cities as New York or Chi-
cago as anvwiiere in the world. And so far as hos-
pitals are concerned, I must say, to put it mildly, I am
very proud of our own. — Boves, I'iciina I.ctlcr.
The Female Intestine is fi\e feet and three inches
shorter than that of the male. — Byron Robinson.
Treatment of Flatulence Dr. Stephen McKenzie
states that a certain amount of air is swallowed in the
process of mastication and deglutition, but this has
never produced any of the phenomena associated with
flatulence. This condition is also attributed to fer-
mentation occurring in the stomach, but he does not
believe the gas of flatulence is the result of food fer-
mentation, for fermentative processes are too slow for
the rapid development of the flatulence observed in
dyspepsia. Sir William Roberts has shown that a
certain amount of llatulence may occur in acid dys-
pepsia through the action of an acid mucus upon the
alkaline saliva swallowed with the food ; but this is
certainly a rare and minor cause in the production of
gas. Tiie regurgitation of carbonic-acid gas from the
duodenum may sometimes occur and cause a flatulent
distention of the stomach, but this is also a rare phe-
nomenon and occurs only when the gastric juice is
hyperacid. The writer, after discussing other theories,
concludes that flatulent dyspepsia is due to a lack of
gastric tonicity. In other words, the wall of the stom-
ach being weak, flabby, and lacking in tone, suddenly
dilates, and a volume of gas which was before .some-
what compressed expands and fills out the enlarged
viscus. The gas does not increase in quantity in the
stomach, but only in \olume. Associated with this
gastric atony and perhaps dilatation, there is often a
slight catarrhal condition of the stomach which less-
ens the power of normal gastric digestion and helps
also to weaken the walls of the stomach. The most
important thing in the treatment of flatulent dyspepsia
is to use remedies which will increase the ner\'ous
vigor; hence tonics, and especially nerve tonics, are
of the greatest importance. Nux vomica and stiych-
nine should be placed at the head of the list, \\hen
there is gastritis associated with flatulent dyspepsia,
with a coated tongue, the author gives bicarbonate of
soda, strychnine, and spirit of chloroform, dissolved
in a bitter infusion of calumba or gentian; two ounces
three times a day, between meals. If pain is associ-
ated with the flatulence, bismuth is added to the mix-
ture, or a pill containing carbolic acid, valerianate of
zinc, and alum is gixen. The compound asafatida
pill and the extract of belladonna are sometimes use-
ful. In cases in which pain is located lower in the
bowels, Indian hemp in doses of one-third of a grain
often answers better than any other remedy. For the
violent spasmodic attacks which these sufferers often
have, associated with distention of the stomach and
intestines, a mixture is given composed of equal parts
of spirit of cajuput, aromatic spirit of ammonia, and
spirit of chloroform: a teaspoonful in a wineglass of
water everv lialf or quarter of an hour. The writer
does not believe in the use of charcoal in flatulence,
nor does he place great .stress on the value of bi^muth.
The purpose of his paper is, he says, to urge the im-
portance of tonics and antispasmodics as the rational
and effective treatment of flatulence by improving tlie
muscular tone of the stomach. — Fraciitioner.
Medical Record
A IVeekly youmal of Medicine and Surgery
Vol. 50, No. 24.
Whole No. 1362.
New York, December 12,. 1896.
$5.00 Per Annum.
Single Copies, loc.
©rifliual Articles.
THE RADICAL TREATMENT OF PROSTATIC
ENLARGEMENT BY PROSTATECTOMY.'
By SAMUEL ALEXANDER, A.M., >L1>.,
PROFESSOR OF CENITO-l"Rl.NARV SVRGERY AND SYPHILIS IN THE BELLEVL'E
HOSPITAL MEDICAL COLLEGE, ATTENDING SURGEON TO BELLEVUE HOSPI-
TAL.
Prostatic enlargement is purely a local affection.
Its consequences are due primarily to the obstruction
which it offers to the outflow of urine. Treatment
becomes necessary when it begins to interfere with
the function of the bladder. The prostate may attain
a very considerable increase in size without causing
any symptoms of note, and it is certain that in at
least one-half of all those cases in which the pros-
tate is enlarged no treatment is required. In these
cases the obstruction is so slight, and the muscular
power of the bladder is so good, that the patient re-
mains unconscious of the enlargement. Whenever,
however, the enlargement begins to interfere with the
functions of the bladder, when there is sufficient ob-
struction to prevent this viscus from emptying itself
and to weaken its expulsive power, treatment becomes
a necessity. The more promptly such a condition is
recognized and treatment begun, the better for the
patient's future comfort and safety. Delay is danger-
i ous. The bladder and kidneys are threatened, and
' unless the obstruction is relieved promptly these or-
gans must inevitably suffer.
The choice of treatment lies between the habitual
use of a catheter for the remainder of the patient's
life, or the complete removal of the obstruction ; and,
when neither of these is possible, the establishment
and maintenance of an artificial channel through
which the urine may pass.
It should be stated at the outset that, in the ordinary
cases of prostatic enlargement of however long stand-
ing, in which the obstruction is not great and the
power of the bladder is fair, in which there is not an
excessive amount of residual urine, in which catheter-
ism is easy and painless, and in which cystitis, if it
exists, is not severe and can be controlled by aseptic
washings and regular catheterism, operative treat-
ment is not indicated.
The value of regular, careful aseptic catheterism,
as a palliative measure in the treatment of many cases
of prostatic enlargement, cannot be too highly esti-
mated. There are many individuals who have pros-
tatic enlargement who live in a fair degree of comfort
for many years — often for the rest of their lives — by
the more or less frequent passing of a catheter and by
following strictly a proper course of treatment.
There are many others, however, who either cannot
or will not use the catheter; and still others to
whom, in spite of all precautions, catheterism gives
little or no relief. In these patients the symptoms
continue, more or less rapidly, to grow worse. The
expulsive power of the bladder grows less and less,
the quantity of residual urine gradually increases,
' Read in a discussion before the New Vork State Medical
Association, on October 1 6, 1896.
the irritability of the bladder and prostatic urethra
also increases, the introduction of the catheter becomes
more and more difficult, cystitis of a severe type inter-
venes, and the condition of the patient becomes most
pitiable. But the value of catheterism in the treatment
of prostatic enlargement depends largely upon the care
with which its details are carried out. Catheterism
and vesical washing, when properly done, are a valua-
ble means of treatment; unskilful and uncleanly cath-
eterism is the active cause of many of the unfortu-
nate complications of enlarged prostate.
There are certain patients who have a peculiar im-
munity from infection, who may disregard all estab-
lished rules of cleanliness, and who may continue for
long periods to use a dirty catheter without infecting
the bladder. These cases are exceptional. There are
also patients whose bladders easily become infected
at the beginning of catheter life, but who may, later
on, acquire a certain degree of immunity, so that
some of the aseptic precautions which were at first
necessary to prevent cystitis may be given up. But
in most prostatics the bladder is liable to become in-
fected at any tiine, from causes seemingly slight, so
that it is never safe to neglect the precautions neces-
sary to prevent this accident.
It follows, therefore, that if catheterism is to be of
service, the patient should be of sufficient intelligence
to understand the necessity for the precautions taken
to prevent infection, should have sufficient manual
dexterity properly to use the catheter, and should be
so situated that the necessarj' precautions in using
the catheter can be thoroughly and invariably carried
out.
But there are many cases in which, even under the
most favorable circumstances, catheterism fails to give
relief, owing to the character and conformation of the
enlarged prostate and the obstruction which it offers
to micturition. In these cases catheterism may seem
to act admirably for a time, the symptoms are relieved,
and all goes well ; but sooner or later the disease be-
comes rebellious, and palliative treatment is undoubt-
edly a failure. This should be early recognized, and,
before it is too late, radical treatment should be em-
ployed.
The conditions that demand operative treatment
for prostatic enlargement may be summarized as fol-
lows :
I St. When there is complete, or almost complete, re-
tention of urine, due to prostatic outgrowths about the
internal urethral orifice or projecting into the prostatic
urethra, making the patient entirely dependent at all
times upon the use of his catheter. The consequences
cannot be doubtful in such cases, and operation affords
the only means of averting fatal disaster.
2d. When there is marked and continuous vesical
irritability, due to intravesical outgrowths, which can-
not be allayed by the most careful catheterism and
washing of the bladder. These patients usually sutler
from frequent attacks of haematuria, and cystitis, when
it develops, is usually severe.
3d. When, in spite of careful catheterism, the amount
of residual urine is steadily and surely increasing,
showing a gradual failure of expulsive force in the
bladder.
84:
MEDICAL RECORD.
[December 12, 1896
4th. When catheterism is becoming more and
more difficult, in spite of all precaution, and when it
is frequently followed by hemorrhages.
5th. When catheterism, in spite of all precaution,
is frequently followed by attacks of cystitis.
6th. In cases of long-coniinued vesical intlamma-
tion which do not yield to treatment.
7th. In cases in which the patients cannot or will not
use a catheter and take the necessary aseptic precau-
tions to make its use of value.
In a word, it may be stated that catheterism, with
all that the term implies in the treatment of prostatic
enlargement, should be employed in all cases until it
fails to give relief; but that when it fails, and the in-
tegrity of the bladder and kidneys is threatened, we
siiould resort to operative treatment before these or-
gans have become hopelessly damaged.
The question is then presented: What operations
may be performed for the permanent cure of prostatic
enlargement?
In the first place, I believe that any oiDerations de-
signed for the permanent relief of prostatic enlarge-
ment should fulfil tiie following conditions:
I St. The obstruction should be tiioroughly and im-
mediately removed.
2d. -As little damage should be done to tiie mucous
membrane of the bladder and prostatic urethra as pos-
sible.
3d. Efficient drainage of the bladder should be es-
tablished.
In order that the relief shall be permanent, it is
necessary not only to remove the portions of the pros-
tate which are causing obstruction at the time of oper-
ation, but also all those portions which, if they be
left, may cause obstruction by their progressive en-
largement. If this proposition is true, then any oper-
ation that does not take away all portions of the
prostate that are enlarged cannot be regarded as a rad-
ical operation. This I believe to be a sound position,
in spite of the opinion of those who claim that only
portions of the prostate should be removed, and that
the danger of the oi^eration depends largely upon the
amount of tissue removed. Many of the failures to
give permanent relief by prostatectomy ojxjrations, and
the relapses which have occurred after the removal of
portions of the enlarged prostate are, without doubt,
due to the removal of an insufficient amount of the
enlarged gland.
The only prostatectomy operations which fulfil
these conditions are those devised by McGill, Belfield,
Nicoll, and .\le.\ander. McGill's operation is that
wliich is usually performed at the present day. In this
operation, the bladder is opened abo\e the pubes. The
mucous membrane covering the projecting portions of
the prostate is cut through by scissors, and the ob-
structing portions are removed, partly by enucleation
with the finger, partly by cutting with forceps. E.
Euller, of this city, has modified the technique of this
oi^eration by making a comparatively small opening
in the mucous membrane and enucleating through this
tiie prostatic growths with the finger. .McCiill drains
tile bladder through the suprapulaic opening. Fuller,
foliowing Keyes and Belfield, opens the membranous
portion of the uretiira and drains through the peri-
neum.
In cases of prostatic enlargement in which the lat-
eral lobes are principally enlarged, it is sometimes
extremely difficult to remove these by the suprapubic
incision, and it was mainly to meet these cases that
Belfield first employed the combined perineal and su-
prapubic incision. By passing the finger into the
prostatic urethra through the opening in the perineum,
he was able to bring the lateral lobes within reach of
the finger passed into the bladder through the supra-
pubic opening.
Although these operations, in the hands of skilful
surgeons, have given gratifying results, and as e.xperi-
ence is gained the death rate will undoubtedly be low-
ered still further than it has been, there are certain
objections to the suprapubic method.
The chief of these are:
I St. That the mucous membrane of the bladder and
that of the. prostatic urethra are cut through and more
or less torn and bruised.
2d. That the hemorrhage is frequently severe, and
requires packing of the wound to control it.
3d. .\nother and still more vital objection to these
methods is that, after prostatic obstruction is re-
nioved, a cavity is left which is freely accessible to
the urine. In this the urine collects, and, as this is
often foul in the cases operated upon, there is great
danger of septic infection. Nor can this cavity from
which the prostate has been removed be efficiently
drained. Suprapubic drainage alone is entirely in-
efficient, and even when perineal drainage is em-
ployed the tube, in order properly to drain the blad-
der, must be placed above the level of this cavity.
To overcome these objections, Nicoll's operation
and my own operation were devised. Since the pub-
lication of our respective methods, in 1894, several
writers have confounded the two operations, which are
essentially different in their technique. In order to
correct this misapprehension, I shall give a descrip-
tion of my own method, and then call attention to the
points of difference between it and that devised by Dr.
Nicoll.
Alexander's Method. — The patient is prepared,
when possible, by giving a cathartic the night before
the operation, and by emptying the lower bowel by a
large enema the following morning. The bladder is
washed immediately before the operation with a solu-
tion of nitrate of silver (i to 6,000). The patient be-
ing anresthetized, the bladder is emptied by atheter,
and is then distended with borax solution, from eight
to ten ounces being sufficient in most cases to bring
the organ well above the pubes. I have discarded the
use of a rectal bag. The bladder is then exposed by
vertical incision between the recti muscles, and two
retraction sutures are introduced through its wall.
Between the.se an opening is made into the bladder,
large enougli to allow the operator to insert two fin-
gers. The bladder and the projecting portions of the
prostate can now be examined thoroughly.
The suprapubic opening is then covered with gauze,
and the patient placed in the lithotomy posture. A
broad median -grooved staff is passed into the bladder
through tiie urethra and held by an assistant. The
membranous urethra is then opened by a median peri-
neal section, the fioor of the urethra being thoroughly
cut from just behind liie bulb back to the apex of the
prostate. This must be done thoroughly. The staff
is then withdrawn and the gauze removed from the su-
prapubic wound. The surgeon now washes and dis-
infects his hands. Two fingers of the left hand are
then passed into the bladder through the suprapubic
wound, and by these the prostate is pressed downward
into tiie perineum. With tlie forefinger of the right
hand tlie surgeon begins the enucleation, which is per-
formed entirely through the perineal opening. The
fibrous sheath of the prostate covering its posterior and
inferior surface is broken into by the finger, and the
capsule entered: the entire prostate is shelled out from
within its sheath by digital dissection. The inferior
and posterior surfaces of the prostate should be first
separated from the capsule. The mucous membrane
of the bladder and prostatic urethra covering the en-
largement, with the underlying muscular tissue, is
stripped up from the part to be removed, but is not
opened. Tlie lateral lobes are first removed, after
which, if there is a middle enlargement or a projecting
December 13, 1896]
MEDICAL RECORD.
84:
tumor or tumors, these can be pressed downward into
the perineal wound and enucleated in the same man-
ner. During the enucleation the prostate can be
drawn down into the perineum by forceps, and for this
purpose I use an ordinary ring sponge holder with a
strong lock in the handle.
After the removal of all the prostatic growths, the
lower wound is flushed with a i to 5,000 bichloride
solution, a perineal tube is inserted into the bladder,
and a rubber drainage tube of moderate size is placed
in the bladder above the pubes. The retraction su-
tures are removed, and the bladder is allowed to drop
back behind the pubes. The upper part of the supra-
pubic wound is then closed by sutures, and a dressing
of gauze pads applied, which is perforated to permit
the drainage tube to pass.
The after-treatment consists in daily washings of
the bladder, the fluid being injected into the suprapu-
bic tube. All urine flows out of the perineal tube.
The upper tube is removed on the fourth day, and the
lower tube three days later, after which the bladder is
washed by catheter through the perineum for a few^
days. A full-sized sound is passed at the end of the
second week, and then every five days until the peri-
neal opening closes. Both wounds have usually
healed in the course of five weeks.
If this description be compared with that of Dr.
Nicoll's method, published in The Lancet, April 14,
1894, it will be seen that the tw-o methods are essen-
tially difi^erent. In each, the combined suprapubic
and perineal incision is made, and the prostate is enu-
cleated through the perineal wound, the suprapubic in-
cision being used for the purpose of pressing the
prostate into the perineum w'ith the fingers, and thus
facilitating its removal. In neither operation is the
mucous membrane of the bladder or that of the pros-
tatic urethra injured. But Dr. Nicoll exposes the
prostate by a rather elaborate dissection, stripping the
rectum away from its under surface; while in my
operation a simple perineal section is made. Dr.
Nicoll does not open the urethra, but drains the blad-
der by means of a catheter passed through the urethra;
while I open the membranous portion of the urethra
for the purpose of securing vesical drainage through
the perineal wound. For the purposes of enucleation.
Dr. Nicoll recommends, in difficult cases, the use of
a blunt periosteum elevator and specially designed
scissors and cutting forceps.' In the operations which
I have done, the enucleation has been performed en-
tirely with the finger. Dr. Nicoll packs the perineal
wound and cavity, left after the removal of the pros-
tate, with iodoform gauze. I simply allow the cavity
to drain into the perineal wound, and keep it sweet and
clean by frequent flushings with a mild antiseptic solu-
tion.
Dr. Nicoll's o[3eration is certainly to be commend-
ed, and has been, I believe, eminently satisfactory in
his hands. I have not personally performed it upon
a living subject, but upon the cadaver it requires a
much longer time than does my own operation. It has
also the disadvantage that the bladder must be drained
by a catheter tied in the urethra, a proceeding which
is badly borne in most cases, and which in many be-
comes intolerable.
Dr. Nicoll states that in the cases operated upon by
his method, up to the publication of his paper in Jan-
uary, 1894, he had not encountered a median projec-
tion of the prostate, the obstruction in his cases being
due entirely to the enlargement of the lateral lobes.
He recommends that when a median enlargement is
present, it should be left at the time of the operation
and removed some days later through the suprapubic
opening. I can see no reason for this course, for it
' Letter in Journal of Cutaneous and Genito-Urinary I Useases,
August, 1895.
seems as easy to remove such a projection through the
perineum at the time of the original operation as to
remove the lateral lobes. To do as Dr. Nicoll sug-
gests is, practically, to perform McGilTs operation as
a secondary measure.
The operation which I have described above I first
performed in January, 1894. Since then I have oper-
ated by this method in eight cases, with two deaths.
The result in the six successful cases was complete
restoration of voluntary micturition. The ability to
empty the bladder completely was regained by all but
one patient, and in this case the amount of residual
urine is now only six drachms. I have removed by
this method both lateral lobes entire, the lateral lobes
and a median projecting mass, a lateral and median
enlargement, the lateral lobes and two large projecting
intravesical growths. These masses have been taken
out entire. In none of these cases was the mucous
membrane of the bladder or prostatic urethra cut or
torn. The patients were usually confined to bed
for three weeks, and both suprapubic and perineal
wounds were closed in all the cases at the end of five
weeks after operation. In one case in which I re-
moved four very large masses, the patient had partial
incontinence for several weeks after the wound had
closed, but he subsequently gained good control over
the sphincters. In none of these cases was the hemor-
rhage troublesome. In one of these cases the bladder
contained six calculi, each about the size of a chest-
nut. In another about fifty small prostatic calculi
were removed, together with the prostate. In all the
cases the expulsive power of the bladder was greatly
lessened at the time of operation ; in most of the cases
there was complete vesical atony. In one of the cases
the bladder wall was greatly thickened and the mu-
cous surface was markedly trabeculated. In all the
cases but one the entire prostate was shelled out from
its capsule. In the first operation performed by this
method, the prostate was enucleated piecemeal; in all
of the others, it was taken out in large masses.
The advantages I have claimed for this method of
operation are :
1. The entire prostate is thoroughly and immedi-
ately removed by enucleation.
2. The mucous membrane of the bladder and pros-
tatic urethra is uninjured, and the danger from septic
absorption is thereby lessened.
3. Hemorrhage is reduced to a minimum.
4. The most efficient and thorough drainage is se-
cured.
5. The time required by practised hands to perform
the operation is comparatively short.
The Fatal Cases.— Case I. — L , aged fifty-
eight years. Patient had been a hard drinker. His-
tory of prostatic obstruction for several years, frequent
attacks of retention. On admission to Bellevue Hos-
pital, patient could pass a very little urine voluntarily.
He had great frequency and some overflow. The
urine was ammoniacal, loaded with pus and blood;
specific gravity, 1.018; twent)'-five per cent, by bulk
of albumin; hyaline and a few granular casts. He
had a mitral regurgitant murmur, and a general athe-
romatous condition of the blood-vessels. A catheter
was passed, and the bladder emptied and washed. Ca-
theterism was difficult and produced hemorrhage.
Operation, September 30, 1895 : Two large lateral
lobes and a median enlargement were removed without
much difilculty. Patient appeared to do well until
October 2d, when he developed a pneumonia, urine be-
came scanty, the perineal wound sloughed, and a small
fistula formed between the rectum and the perineal
wound. He died two days later. There W'as entire
suppression of urine during the last twelve hours.
The patient was operated on only as a last resort, and
his death was not a surprise. This case is an exam-
?44
MEDICAL RECORD.
[December 12, 1896
pie of those iii which operative measures are employed
too late. I should prefer, with my present experience,
to use vesical drainage in a similar case, rather than
prostatectomy.
Case II. — M , aged sixty-four years. Patient a
hard drinker; had several attacks of renal colic pre-
FiG. 1. — Both Lateral Lobes Removed from Case IIL (exact size).
vious to his fortieth year. One year after his last
attack he passed three calculi by the urethra. His-
tory of frequent micturition for several years. Five
or six months prior to admission he began to have
the acute symptoms for which he now sought relief.
He had burning pain, especially severe after micturi-
tion, great frequency and urgency, which were increased
by jolting. The stream of urine was feeble, and was
suddenly arrested. He had never passed blood. I'rine:
specific gravity, i.oio; small amount of albumin and
large amount of pus. A microscopical examination
showed many blood cells; no casts. Rectal and ure-
thral examination showed a moderate enlargement of
both lateral lobes and a projecting median portion.
The amount of residual urine was about five ounces.
Examination of the bladder by searcher showed a num-
ber of calculi.
Suprapubic cystotomy performed, April 20, 1895,
under ether ana;sthesia. Six calculi, each about the
size of a chestnut, were removed. Digital examina-
tion of the bladder showed that the prostatic enlarge-
ment formed a thick ring or collar about the ves-
ical orifice, making thereby a very deep bas-fond
behind the prostate. A perineal incision was made,
and the entire prostate removed through the lower
•opening. Patient rallied well from the operation, but
upon the second day developed urjemic symptoms, with
almost complete suppression, and died April 24th,
four days after operation.
The autopsy showed a general arterio-sclerosis,
valves of the heart thickened, calcareous deposits in
coronary arteries, lungs Q;dematous. Emphysema well
marked, moderate bronchitis. Liver friable; weight,
five pounds. A single renal calculus in pelvis of left
kidney. Kidney showed chronic parenchymatous ne-
phritis. Xo evidence of suppuration about the oi^er-
ative wounds. Mucous membrane of the bladder and
prostatic urethra intact.
The Successful Cases. — Case I. — Prostatic calculi
and enlarged prostate. C. B , aged fifty-three
years, admitted to liellevue Hospital, January, 1894.
Symptoms of prostatic obstruction for over one year.
Great frequency day and night. Intense tenesnuis at
€nd of act of micturition; frequent ha;maturia.
Passed about one-half ounce at each act of micturi-
tion. Had never used catheter regularly. Rectal and
urethral examination showed prostate rather irregular
in outline, right lobe larger than the left, and small
median projection. Pressure upon the prostate caused
great pain and revealed the presence of calculi in its
substance, which could be rubbed together. Searcher
showed presence of calculi projecting into the prostatic
urethra. Residual urine about six ounces. E.xpulsive
force of bladder fairly good. Crine showed chronic
cystitis; kidneys were sound.
Operation, January 22, 1894, under ether
anassthesia. About fifty calculi and the entire
prostate were removed. This being my first
operation by this method, the prostate was
shelled out piecemeal. The perineal tube
was removed on the fifth day, as the patient
complained of pain, and was reintroduced every
two hours for the next twenty-four hours; the
suprapubic tube was removed on the si.xth day.
Both wounds healed kindly. Patient passed
all his urine by urethra at the end of the fourth
week. He was kept under obser»'ation until
March 22, 1894, when he was discharged cured.
He could then empty his bladder completely,
and his urethra admitted easily a No. 32 F.
sound. Patient reported himself well in April,
1896.
Cask II. — E. R. B , aged fifty-six years.
Symptoms of prostatic obstruction for past six
years; micturition difficult. During the past
two months he had from time to time sufiered from
overriow. He had an attack of complete retention two
years ago, after exposure to cold. This was relieved
by catheter, and since then he had passed urine with
greater difficulty, about e\ ery hour. Six months ago he
had a second attack of retention, relieved by catheter,
followed by severe cystitis. He had used a catheter
since then every four hours, with little relief. Patient,
when first seen by me, had complete retention — his
third attack. Prostate was uniformly enlarged in the
lateral lobes, and was rather tender. Coude catheter
passed with some difficulty; sixteen ounces of urine
withdrawn. For two weeks patient was regularly ca-
theterized and bladder treated. The residual urine,
after voluntary micturition was restored, was nearly
eight ounces. He absolutely refused to follow out di-
rections as to catheterism and washing, and demanded
an operation. This was performed by me early in
F'ebruary, 1894. Tubes removed on the fourth and
sixth days respectively. Wounds healed kindly, and
were completely closed by the fifth week. Patient left
for his home in another State, and has since then re-
ported that his urine remains clear and that he emp-
.«^p^
Fig.
-Lateral and Median Enlargement Removed from Case IV. (exact
size).
ties his bladder completely. In this case, both lateral
lobes were removed entire.
Cask III. — J. F" , aged sixty-six years. Pros-
tatic symptoms dated back twelve years, when he began
to have frequency. He had used a catheter every four
hours for the past six years, and had washed his blad-
der once daily with various aseptic solutions. Six
December 12, 1896]
MEDICAL RECORD.
845
months ago he had complete retention, and since then
had suffered with severe cystitis. The intervals of
catheterism had been becoming shorter for the past
two months. He v.as now obliged to pass his catheter
every two hours, nigiit and day. Bladder had little
expulsive force. He had eight ounces of residual
urine. Rectal examination showed a smooth, rather
soft enlargement of both lateral lobes. Urine:
specific gravity, 1.021; alkaline, ammoniacal;
thick, purulent sediment, trace of albumin, no sugar,
no casts. As the patient's condition was growing
very much worse, an operation was proposed and ac-
cepted.
Operation performed in October, 1895. Two large
lateral masses were removed without great difficulty.
The bladder was somewhat thickened. Drainage tubes
removed on the sixth and tenth days respectivelv.
Patient made an uninterrupted recovery; passed all
his urine on the thirtieth day.
Case IV. — This and the ne.xt case have been pre-
viously reported. T. O'C , aged sixty years. Ten
years ago he had a sudden attack of retention, which
was relieved by catheterism; he was admitted to one
of the city hospitals, and was there taught to pass a
catheter, which he continued to use for several years.
Three months ago he had a second attack of reten-
tion; this was also relieved by catheter. He was ad-
mitted to my service at Bellevue on February 11, 1895,
with retention for the third time and considerable
vesical distention and overflow. He was
catheterized, and thirty-two ounces of resid-
ual urine were drawn. Rectal e.xamination
showed an enlargement of the prostate, the
right and median portions being affected.
The catheterism was not difficult when a
Mercier instrument was used. A soft catheter
could not be introduced. The bladder had
no expulsive force. He was catheterized four \
times daily and the bladder washed once a
day until March 17th. At the end of this
time the patient could pass about half an
ounce of urine voluntarily, there being about
ten ounces of residual urine. It was found
impossible to teach him to use a catheter and
wash his bladder, and, as he had no fa- Fic. ;
cilities for performing this for himself out
of the hospital, an operation was offered and accepted.
Operation, March i8th. Ether anesthesia. A
large right lobe and smaller median portion were re-
moved through the perineal opening after enucleation
without much difficulty. Bleeding slight. Bladder
trabeculated and thickened. Suprapubic tube removed
on si.xth day. Perineal tube removed on thirteenth
day. No. 32 sound passed. Suprapubic opening
nearly closed. No urine escaped.
April 24th, perineal wound closed. .Ml urine
passed by urethra. .\t the present time he makes
water every four or five hours and empties his blad-
der, except six drachms of residual urine.
Case V. — James D , aged sixty -two years;
weight, two hundred and thirty-five pounds. Admit-
ted March 26, 1895. Patient came in with a histor)-
of difficulty in passing water and great frequency, of
several years' duration with a condition of acute re-
tention of urine of twelve hours' duration, ("atheter-
isni was attempted by the house surgeon, but he was
unable to pass any instrument into the bladder. Af-
ter some difficulty I succeeded in passing a No. 6 E.
styleted catheter, bent to an exaggerated curve, the
stylet being withdrawn gradually as the catheter was
introduced, so as to cause its point to override the ob-
struction presented by the middle portion of the pros-
tate. Thirty-two ounces of ammoniacal bloody urine
were withdrawn. Rectal examination showed an enor-
mous prostatic tumor encroaching upon the cavity of
the bowel, the upper margin of which was well above
the reach of the finger. The patient's bladder was
washed and a catheter was passed by the above-de-
scribed method every six hours. The urine contin-
ued to be fcetid and to contain blood.
On March 28th the house surgeon again failed to
make the instrument enter the bladder, and I succeed-
ed only after a long trial. I decided to open the ure-
thra through the perineum, as a preliminary to pros-
tatectomy for the purpose of draining the bladder
and disinfecting its cavity; I therefore, under ether
anfesthesia, performed a perineal section, and attempt-
ed to dilate with my finger the prostatic urethra. I
could not, however, pass my finger into the blad-
der, owing to the length of the prostatic portion of
the urethra and the very great resistance offered by the
prostatic growths. .Accordingly, I simply introduced
through the perineum into the bladder a No. 26 F.
tube, and, having washed the bladder, secured this
in place by tapes. This drainage I continued for a
week; the loss of blood ceased, the urine became
clearer, and the patient's condition improved. At the
end of the week the perineal tube was taken out, and
I then found no great difficulty in introducing through
the urethra a Mercier catheter. Knowing, however,
from the size of the prostate, that this improved con-
dition would be only temporary, I decided to remove
the prostate, which I did on April 11, 1895. The
operation, owing to the depth of the perineum, was-
" j^.
-Lateral and .Median Enlargement Kenio\-ed from Fatal Case IT. (e.vact size).
difficult to perform. I succeeded, however, in remov-
ing the entire enlargement — two large lateral lobes
and two large median tumors — without injury to the
bladder or prostatic urethra. The tubes were removed
on the tenth and sixteenth days respectively. The
wounds healed slowly, but both were entirely healed
at the end of the fifth week. The patient at first had
almost complete incontinence, but now has con-
trol over his sphincter, and empties his bladder com-
pletely.
Case VI. — O. D. H , aged sixty-five years.
Symptoms of prostatic enlargement for fifteen years.
Had had retention, with overflow, for past two years,
and had had to depend entirely upon his catheter for
relief. His urethra was extremely sensitive, and cathe-
terism was always followed by hemorrhage. He was
obliged to pass the catheter every two hours, night and
day, and these intervals were rapidly becoming shorter.
He had a symmetrical enlargement of both lateral
lobes, which projected far up into the bladder.- He was
put to bed, and an attempt made for a week to institute
more perfect aseptic catheterism, but, as his symptoms-
showed no signs of improvement, I proposed an oper-
ation, which was accepted, and this was perfonned in:
September, 1895.
Two large lateral lobes were removed without diffi-
culty. The drainage tui)es were removed on the fourth
and sixth days respectively. The patient entirely'
emptied his bladder on the thirtv-fifth day. He re-
846
MEDICAL RECORD.
[December 12, 1896
turned to his home, and I have not heard from him
since his departure.
Prostatectomy, when it is performed before the kid-
neys have become seriously diseased, does not, I be-
lieve, involve much more risk than a suprapubic cys-
totomy for the relief of other conditions. The perineal
incision does not increase the risk. In cases of ad-
vanced prostatic disease, however, when the bladder
is the seat of severe cystitis, when the kidneys are se-
riously crippled, especially when pyelo-nephritis is
present, the dangers of prostatectomy are greatly in-
creased, as the principal cause of death after prosta-
tectomy is failure of the kidneys to perform their func-
tion. In these cases I believe that it is better surgery
to open the membranous urethra as a preliminary
measure, and to
drain the bladder by
a large catheter or
tube introduced
through the peri-
neum; and later,
when the conditions
are more favorable,
to do a prostatec-
tomy. This course
was pursued with
good results in one
of the cases which I
have reported. The
value of vesical
drainage in cases
of advanced pros-
tatic enlargement is
very great, and in
these cases, unless
the object of the of)-
eration be to make
a permanent fistula,
I prefer perineal to
suprapubic drain-
age. In many cases
in which catheter-
ism has become dif-
ficult, especially if
due to outgrowths
from the lateral
lobes into the pros-
tatic urethra, dila-
tation of the latter
by introducing the
finger through a perineal opening and drainage of the
bladder make the introduction of a catheter compar-
atively easy for a time. This effect, however, is only
temporary, and sooner or later these cases relapse un-
less the prostate is removed. I do not believe that
prostatectomy should be performed during a period of
acute congestion. It is better to wait until the con-
gestion has subsided, as a result of careful catheterism,
or, if this fails, to drain the bladder through the per-
ineum for a few days, before deciding whether a more
radical operation will be required. It may be stated,
further, that an operation upon a highly congested
prostate is certain to be accompanied by much more
severe hemorrhage.
The question of relapse after prostatectomy is one
deserving, some consideration. If the operation has
been thoroughly and skilfully performed and the entire
prostate has been removed, it can be positively stated
that no obstruction can occur in the future. If the
prostate is only partially removed, return of the ob-
struction by progressive enlargement of the portion re-
maining is possible, and such cases have been re-
ported.
Another question which requires careful considera-
tion is: To what e.xtent will the bladder regain its
power after prostatectomy? This cannot be positively
answered in all cases. Cases have been reported in
which the operation was performed after the bladder
muscles had undergone structural change as the result
of severe and prolonged cystitis and obstruction, and
in these voluntary micturition was not restored by
prostatectomy. Mv own experience has been that, in
all cases in which structural changes of a severe type
have not occurred in the vesical walls, even if the
bladder is completely atonied, the power of voluntary
micturition can be expected in the great majority of
cases if the entire obstruction be removed. Kven
should the bladder fail in some cases to recover its
power, and the use of a catheter be necessary after
prostatectomy, it w ill be found that the difficulties and
dangers of cathe-
terism are far less
than before the
operation.
The mortality
after prostatectomy
is still high — about
eighteen or twenty
per cent, for all op-
erators. It is grad-
ually becoming less
as the indications
for the operation are
better understood.
The death rate of
individual operators
will undoubtedly
continue to grow
less as they be-
come more expert
in performing the
operation, and the
cases of relapse and
failure will be much
fewer as more ex-
perience is gained.
I n concluding,
I desire to state
that prostatectomy
promises to be a
more satisfactory
method of radical
treatment than any
other yet proposed,
provided that the
operation is performed before the kidneys have become
hopelessly diseased.
5 WkST FlFT^-ElGMTH StKKKT, NeW VoKK CI'I V.
Tetanus and Its Antitoxin. — Dr. Ferdinand Blu-
menthal {Zci/s. J. klin. Alai., xxx., Xo. 5-6, pp. 538-
549) reports two cases of tetanus in which he had an
opportunity to make a few researches as to the action,
localization, and chemical nature of the tetanus toxin
formed within the human organism. He concludes
that the tetanus toxin circulating in the human body
is soluble in water containing common salt, and that
it does not belong to the albumin substances. The
tetanus toxin is rendered inactive by the injection of
curative serum (Heilserum). The tetanus toxin is
found in the spinal cord. In this location the anti-
toxin circulating in the organism does not render it
inactive. The tetanus toxin produced in the human
organism does not produce an increase of temperature
in guinea-pigs, as it does in man, but, on the con-
trar)-, lowers it. There is no tetanus toxin in active
concentration in the urine of tetanus patients. Urine
of animals not affected with tetanus can produce tet-
anoid symptoms in mice and guinea-pigs.
he Two Latrral I,<ihes and Median KnlarKcment. with an Intravesical Projection, Re
moved from Case V. (exact size}.
December 12, 1896]
MEDICAL RECORD.
847
EXPERIENCES WITH THE PHYSICAL AND
SCHOTT TREATMENT OF CHRONIC HEART
DISEASE. '
Bv 11. NEWTON" HEINEMAN, M.D.,
SEW >OKK.
Seven years ago I had the pleasure of presenting to
this society a paper' upon this subject. With the nat-
ural prejudice of my professional training, it was not
strange that, while thinking well of the Schott treat-
ment, the distinguished name of Oertel and his work
should have impressed me somewhat more than that
of Schott and his investigations. Careful studies
continued since then, both at Bad Nauheim, where I
had the opportunity of seeing many hundreds of cases,
and at Berlin and Paris, where I put to the scientific
test the physiological problems connected with this
subject, have convinced me that the balneological and
the Schott treatments, applied in accordance with my
experience and under conditions which I will indicate,
offer us far greater promise of relief in heart disease
than any other method. Then, too, the scientific basis
of the Oertel treatment has been much impugned, and
the practical application of the same narrowed down to
small limits.
Balneological Treatment. — Twenty-five years ago
Beneke, professor at Marburg, determined scientifically
that the saline waters of Bad Nauheim had a potent
influence in relieving diseased cardiac conditions, and
that it could be accepted without question that in
cases of rheumatism with valvular disease, infiamnia-
tory deposits on the valves were to a large extent ab-
sorbed and the heart condition materially improved.
Despite his statements, the baths of Bad Nauheim
received little recognition in this direction, and for
many years the majority of patients visiting Bad Nau-
heim were sufferers, as a rule, from chronic rheumatism,
who only sought relief from their rheumatic diathesis.
It was at this time that Dr. August Schott brought
forward his " treatment by resistance exercises." He
carefully went over the entire ground of the physiology
of the baths, and by dint of unswerving scientific devo-
tion and original methods of thinking so modified the
manner of application of the baths as to avoid injurious
effects, and by combining with these the resistance
exerci-ses, gave birth to a system, the so-called " Schott
system of treatment for chronic cardiac disease."
The early death of Dr. August Schott threw upon
Dr. Theodore Schott the labor of its elaboration and
of its introduction to the profession.
For several years it has been a labor of love with
me to stand at the side of Dr. Theo. Schott and de-
vote my best efforts to the laying of a scientific basis
for the work, and to act as an assistant in the pro-
paganda of the system.
If my personal views differ from those expressed by
any other authority upon the subject, they are those
for which I alone am ready to assume complete re-
sponsibility.
Bad Nauheim, a well-drained and healthy village
(distant forty minutes by railroad from Frankfort on
the Main and a pleasant night's journey from Hamburg,
Bremen, or Paris), contains (in addition to its several
springs of drinking-water) two springs known as No.
7 and No. 12, which are used for bath purposes. The
analysis of these two springs is given below, includ-
ing the analysis of the mother lye (Mutterlauge), to be
referred to hereafter:
ANALYSIS OF BAD NAUIIEI.M SPRINGS.
(Gram contents in 1,000 grams of each.)
No. .2. No, 7. Mutterlauge
' (mother \ye).
Sodium chloride 30.00 20.00 20.00
Ammonium chloride i.oo 0.50
' Address delivered before the Academy of Medicine, New
York, November 5, 1896.
' See New York Medical Record, iSgo.
Calcium chloride 2.50
Potassium, ca-sium, and rubidium
chloride 1 .00
Calcium bicarbonate 2.50
Iron, magnesium, and zinc bicarbonates i.oo
Lithium chloride 0.05
Magnesium chloride o. 50
Strontium chloride and sulphide (with
baPita) 0.05
Calcium sulphide 0.04
Magnesium bromide, iodide, and bi-
carbonate 0.01
3 So. 00
60.00
2.50
5-50
I.oo
0.05
15.00
0.50
75.00
0.05
10.00
0.04
0.40
1.50
A Nauheim thermal saline bath in 500 litres of spring No. 12
(at S6° !•".) contains 18.17 kgm. salts and 254 gm.= 127 lit. car-
bonic acid. A Nauheim thermal saline bath in 500 litres of
spring No. 7 (at 86° F.) contains 13.43 l^g™- salts and 571 gm.=
324 lit. carbonic acid. The Nauheim sprudel (effervescent) bath
contains from three to four times the amount of carbonic acid.
It will be seen that these waters are iron waters,
contain large quantities of the chlorides of sodium,
lithium, calcium, and magnesium, of bicarbonate of
calcium, considerable of the chlorides of caesium, ru-
bidium, and potassium, bromide of magnesium, besides
other rarer elements in appreciable quantity. The
third and most important characteristic is the large
quantity of carbonic acid (free and in combination)
present in these waters. The Nauheim waters consti-
tute the strongest thermal carbonated saline (ferru-
ginous) waters of Europe. No other ferruginous bath
contains more iron and carbonic acid, no known ther-
mal saline bath contains so much carbonic acid. The
fact of their being naturally warm (85' F. and 95°
F.) avoids the necessity of heating them, as is done
with the non-thermal saline waters, and by which the
latter lose some of their elements and become changed
in composition. The waters are made use of in sev-
eral ways. Either they are drawn from reservoirs (in
which they are stored and have lost some of their car-
bonic acid and have become somewhat cooler), or they
are permitted to flow directly from the source in the
earth through iron tubes into the bathtub itself.
The latter are called sprudel or natural efl'ervescent
baths (Sprudelbad). They are further modified by
allowing the water to flow into and out of the tub by
openings near the upper level of the bath ; thus the tub
remains full, but it is constantly replaced by a fresh
supply. These are named flowing effervescent baths
(Sprudelstrombad), and resemble a surf bath in some
of their effects.
.According as the waters are drawn from the reser-
voirs or directly from the earth, the temperature and
amount of carbonic acid are varied similarly by mix-
ture of the two springs, and by other usual means
every desirable grade of temperature and degree of
effervescence and strength of saline contents can be
obtained.
The so-called mother lye (Mutterlauge) contains a
nearly similar proportion of sodium chloride, but three
hundred times the amount of lithium, two hundred
times the amount of calcium, one hundred times the
amount of magnesium, sixty times the amount of cae-
sium, rubidiuin, and potassium, and two hundred times
the amount of bromide of magnesium of the natural
springs. It is used in quantities gradually increased
of from one to three litres added to the natural spring
bath, and very materially strengthens the saline con-
tents. The mother he is not a lye, but is the liquid
residue of the waters Nos. 7-12 which is left over
after the crystallizable salts are removed; it is a
brown and somewhat oily liquid.
Mode of Application. — The baths are given at a
temperature varying from 83° to 93° F., ordinarih'.
We begin at the highest temperature and recede slowly
and gradually, being guided by the condition and
habits of the patient, to the cooler temperature. The
patient's sensations are an important guide in this
direction, until we have had a large experience.
848
MEDICAL RECORD.
[December 12, 1896
The length of time of the immersion should never
exceed twenty minutes, beginning with six or eight
minutes, and increasing gradually. At first it is wise
to interrupt or give pause on the alternate days; later
two baths may be given in succession with pause on
the third day. For myself, I prefer not to give three
successive baths, save in e.xceptional cases. It is of
great importance that the patient should be assisted
during the bath, and even professionally watched.
After the bath the patient is to be wrapped and served
with warm bath towels, and the circulation of the ex-
tremities well looked to. An hour's rest (without
sleep) is urgently to be recommended after each bath.
The period of time required for the entire treatment
is ordinarily from four to six weeks. In cases in
which the treatment must for one cause or another be
interrupted, the duration may be extended over six or
eight weeks. After a course of completed treatment,
or after treatment for the latter length of time (even
if incomplete; the patient should rest for from two to
four weeks at some mountain resort, or in some quiet
place. Then, in the incomplete cases, the treatment
may again be taken up and completed, to be again
followed by a rest after completion.
Physiological Action. — Time does not permit me as
a preliminary to my work to consider the curative
effect and its physiology in cases of rheumatism and
gout for the relief of which conditions these waters
have long held an unquestioned position.
It is not unusual, however, that sufferers from these
affections, who, however, seek relief from their cardiac
trouble, are obliged after a few baths to contend with
what seems an acute attack or exacerbation of gout or
rheumatism. In gouty cases the deposits very soon
become softened and while circulating in the blood in
their exit from the body, give rise to various symp-
toms of the disease. All these attacks are very soon
recovered from, at times by the aid of a little medica-
tion.
If a patient with relaxed muscular fibre and conse-
quent flabby heart, or a patient with diseased heart
witli loss of compensation, takes a saline bath at Bad
Nauheim, the effects upon the patient are as follows:
At first, after a few moments of immersion, there is a
feeling of oppression or weight over the sternum or
epigastrium. Tiiis soon disappears and the patient
breathes more freely. The pulse almost invariably
becomes fuller and generally slower. The arterial
|5ressure taken of the radial or temporal arteries usu-
ally indicates sliglit increase, to l)e followed later by
diminution of the same.
The capillary pulse, a subject of very recent inves-
tigation, for knowledge of which I a"m indebted to
Dr. Max Herz, of Vienna, varies in a similar manner.
An examination of the heart made before and after
the bath will reveal in at least one-fourtii of the cases,
and i^articularly if it be the first batli or the first effer-
vescent bath after a series of ordinary saline baths, an
appreciable and frequently well-marked diminution in
size and change of shape. In all cases, with few ex-
ceptions, this change in the heart's size and shape
could be determined and appreciated after a number
of baths, when it could not be noted after the single
saline bath. Lest this phenomenon be wrongly as-
cribed to diagnostic error, or natural change of shape
and size, the result of intervening time, I acid that
every precaution against error and self-deception was
used. In the first place, I made a series of investiga-
tions to determine tire changes in size and sliape of the
heart as the result of diurnal work, mental and physi-
cal, and as the result of changed position. No such
changes in size and shape occur naturally within the
period of time usually required in this examination.
It is true that sometimes twenty minutes inter\ene be-
tween the first and second examinations, but in cases in
which the demonstration is to be made to others, eight
minutes only are allowed to elapse; that is, the examina-
tion is made the instant prior to the patient's entering
the bath, and again the moment the bath is ended and
the patient has been only gently dried, sufficient to se-
cure him against cold during the examination. Then,
too, this change of shape and size has been shown in
the presence of the most distinguished and critical of
European physicians — Eotkin, Rauschenbach, I'awlin-
ski, and Von Dehn, of Russia ; liroadbent, ISow les, Alex-
ander Morison, liezly Thorne, Gi fiord Ransford, and
Saundby, of England; Grainger Stewart and Robert-
son, of Scotland; Sir Francis Cruise and Sir Philip
Smyly, of Dublin, and others.
In all of my own investigations, differences of half
a centimetre or under were left out of consideration,
because such slight dift'erences, if they constituted the
most important ones to be relied upon, were considered
within the limits of personal error.
The physical examination included the relative and
absolute limits of dulness of the heart, the lower bor-
der of the lungs, the detemiinatSon of the level of the
diaphragm, the upper and lower limits of the liver, of
the spleen when possible, and the diameter of the
chest, both antero-posteriorly and laterally, besides its
circumference above and below the mammary line.
Occasionally the abdominal circumference was like-
wise taken. In the measurements which were made
both before and after the bath, the pulse pressure was
taken by the V. I'.asch sphygmomanometer, the calibre
of the arteries was determined by the arteriometer, the
pulse trace was taken by the Dudgeon spliygmograph,
the capillary pulse by the Herz instrument — the
position of the patient and the artery examined always
being the same, before and after the batli.
As to the local action upon the skin, the efi'ects in
the case of tlie effervescent bath are much more
marked, the skin as a rule being reddened and the
patient having a distinct sense of warmtli beyond that
of the temperature of tiie bath. The same applies
with greater force to the flowing effervescent bath.
Naturally, aLso, after the latter (the efi'ervescent and the
flowing effervescent), the effect upon the heart and cir-
Gulation is more decided.
The statement made by a Russian chemist, that the
bubbles of free carbonic acid could not produce the
effect, because such bubbles are surrounded by a layer
of atmospheric air, is easily demonstrated to be un-
true. For, if the bubbles of carbonic acid are bru.shed
away from any portion of the body during the time of
the batli, the skin of that portion remains pale, in
sharp contrast to that of the rest of the body.
The question. Are the effects of the baths the result
of absorption in its ordinary sense by the human in-
tegument? must be answered in the negative. Through
the outer layer of the skin, a slight degree of imbibi-
tion takes place. It is surmised that the saline fluid
penetrates the outer layer, at least as far as the nerve
endings. Viewed from whichever side, it is beyond
question that the heart is enabled to work with less
muscular force and stimulated to more regular action
by the effect produced upon the enormous capillary
network of the integument. The relief of the internal
organs while the blood is circulating in the previously
congested cutaneous capillary vessels, the more equa-
ble distribution of the circulatory fluid, or the sending
of a larger volume of blood to the heart in cases in
which the amount flowing to the heart was at times
either deficient or irregular — these and similar effects
are too important not to lead us to accept the claim
that the change in the capillar}' circulation of the
skin must be a potent factor, even if it be disputed
what rank is to be assigned to it.
When we next consider the great network formed by
the nerve endings in the integument, it should not be
December 12, 1896]
MEDICAL RECORD.
849
surprising to us that the nervous influence reflected
from these should produce an effect upon the circula-
tion and heart. For the present, the theory of reflex
action, to which no serious scientific objection-can be
raised, seems the more acceptable, although the role
of the capillaries is a not unimportant one.
It would be a source of great comfort to us and
make the explanation simpler, if we could accept the
idea of absorption by the blood-vessels of the integu-
ment. For recently Ringer has proven that the cal-
cium salts have a strong stimulating effect upon the
heart, and the Nauiieim springs, and the mother lye in
particular, contain these salts in large proportion.
It is of great importance that I draw^ attention to
the difference in the effect produced upon the animal
economy by fresh-water and saline baths. Zuntz and
Roehrig have determined that saline baths give rise to
greater tissue metamorphosis than fresh-water baths.
Other authorities (Dapper and others) have since
claimed a still greater difterence. The fact that we
are dealing with saline baths of a definite percentage
constitution and of a certain temperature must alwavs
be borne in mind by the practitioner. To expect sim-
ilar results from anv bath and at any haphazard tem-
perature is to foster disappointment and invite injury
to tiie patient.
Artificial Bath. — While the baths of Bad Nauheim
give us effects that cannot be entirely obtained from
the artificial bath, yet the latter, as Schott ' pointed
out years ago, are capable of producing precisely
similar if not equally great results. The manner
of their preparation is not difficult, save in the case of
the effervescent bath, which requires some caution be-
cause of the use of hydrochloric acid. I am in hopes
that within a short period of time processes for car-
bonating waters will enable us to produce effervescent
baths, and even the flowing effervescent bath be made
without difficulty.
Ordinarily we commence by preparing a bath of a
one or two per cent, solution of chloride of sodium, to
which we add a half per cent, of chloride of calcium.
Later we increase the strength of the bath by the use
of the Nauheim Mutterlauge, or else in the equivalent
mixture of its components salts. In making the effer-
vescent bath we commence with a solution of bicarbo-
nate of sodium, to which we add after the tub is
properly filled, a little less than an equal (to the bi-
carbonate of sodium) quantity of hydrochloric acid.
AUer the stopper of the bottle (turned upside down)
has been removed beneath the surface of the water,
the acid is poured out slowly, the bottle being moved
about at different layers of the bath water, .\fter
three minutes the effervescence begins, and, having
taken the precaution to see that the acid is everywiiere
well mixed with tjie water, we fan awav the carbonic
acid that at first accumulates above the level of the
bath, and ail is in readiness.
Exercises. — The Swedish gymnastics have long
been known to a limited number of the profession.
Under the name of the Zander movements they have
been extensively employed in the larger cities of the
world for the relief of difterent conditions. In cer-
tain kinds of nervous cases, in conditions of mal-
nutrition, and as an antifat remedy, I have made use
of and well know the results of this system. Stokes
long ago noted the effects of mountain climbing in
cases of heart disease, but he never adopted it or pro-
mulgated it as a system. It was the genius of the late
Dr. August Schott who recognized the effects of cer-
tain movements upon the circulation and heart, and
by careful study formulated a system of movements
which enabled him to produce direct effects upon the
heart muscle. 'I'he movements which he made use of
were carried out by the patient in the following man-
' New York MnnicAl, Record.
ner: The patient was ordered to make a certain move-
ment in a given direction, while the doctor or attend-
ant would make resistance with the hands, so that the
patient in completing the given mo\ement had to
overcome the hindrance or resistance thus made. To
this system, the .Schott system, the name of move-
ments with resistance (Widerstands-Gymnastik) ' has
been given, .\mong the rules as originally laid down
by August Schott are the following: ,^11 movements
must be made slowly, without exertion, evenly, and
without jerking. Each successive movement should
bring a different group of muscles into exercise.
.\fter each movement there should be a momentary
pause.
In addition to the abo\e the attendant should care-
fully watch the movements of the ate nasi for signs
of dyspncta, even when the patient does not complain
of it. The pulse must be watched for any sign of
intermission.
I desire to emphasize this latter, for any movement
followed by this result should be omitted. It is more
apt to occur in connection with the greater excursions
involving the entire extremity. Experience has like-
wise forced me to abandon carrying any movement of
both upper extremities above the level of the shoulder,
and especially above the head. Likewise empirically
it will be found that some persons with cardiac disease
are hypersensitive to movements made with the left
upper extremity, be it riding, exercising, or even hold-
ing anything in the left hand.
In every case the physician should at first either
give the first movements himself or have them given
in his presence, so that he can watch the pulse and
the general effect upon the patient. It is wise to
begin with the shorter simpler movements, and then,
as the patient's improved muscular sense makes it
manifest that he can bear the greater excursions and
resistance, we can increase them, though the increase
should be less than the jaatient can support with great-
est ease. A brief explanation to the patient of the
principle underlying the movements aids in securing
his more exact co-operation. And it must be equally
impressed upon the minds of both doctor and patient
that these movements are not a course of athletics.
It is the fact that the patient in executing any given
movement must overcome resistance which lies at the
bottom of the effect. Hence every movement, however
simple or slight, produces an effect. Even the move-
ments of the fingers resisted as though playing piano
upon the fingers of the attendant give results similar
in kind and differing only in degree from the larger
movements.
When baths are emploved, exercises should be given
once a day. When, however, exercises are used with-
out baths, the exercises, though given once a day at
first, may later be employed twice daily. Lender all
circumstances begin slowly, giving from five to ten
minutes of exercise at the outset, and increase gradu-
ally until you have reached thirty minutes. When
exercises are given twice daily the second exercises
should not exceed fifteen or twenty minutes. The
time indicated includes the pauses as well, so that in
thirty minutes about eighteen minutes are taken up by
tiie exercises themsehes.-
Physiology of Exercises Both August and The-
odore Schott have contended that the effect of these
exercises is to produce change in the size of the heart
and, as a rule, displacement of the apex beat upward
and toward the median line. The difficulties result-
ing from percussion, the inability always accurately
to determine the apex beat, have during the past years
of active discussion of the method often caused doubt
in the minds of many examiners as to the correctness
' .\ modincation railed Seibsthemmungs-C.ymnastik will be
referred to in future articles.
850
MEDICAL RECORD.
[December 12, 1896
of this assertion. It is four years ago that I became
satisfied of the truth of the claim, and numerous in-
vestigators have since added their testimony and the
results of their personal inquiry to it. B. Thorne led
the crusade in England, and, although his technical
and physiological claims were somewhat e.xaggerated,
yet his practical results compelled attention and in-
vestigation. In the month of July I was privileged to
be present while naval surgeons IJerendsen and
.Schumburg and Prof. N. Zuntz, the eminent i)h}siol-
ogist, applied the Roentgen ra}-s to the hearts of a
number of persons. The results obtained by them
made me extremely desirous of securing testimony
bearing upon the subject of " resistance exercise and
its beneficial effects upon the heart." Zuntz had
proven "that overexertion, however moderate, tended
to dilatation of the heart."
Alter investigating with the barium-platino-cyanide
fluoroscope I found that while my results showed the
he.irt smaller than before the resistance exercises, yet
the shadow thrown by the bifurcating pulmonary
i)ronchi, the movement of the diaphragm, and the un-
steady light left something to be desired. I therefore
resorted to photography by the Roentgen rays. Hav-
ing arranged my light and table so that the light and
the patient would always be at the same distance from
each other and in the same line, I took the photograph
of the heart (developing the plate and reproducing it
on paper in the usual manner) before and after the
resistance exercises, and thus proved that tlie heart
undergoes change in shape and diminution in size,
the greatest difference in cardiac diameter before and
after e.xercises being equivalent in one case to more
than two centimetres.
In sijeaking of this subject, whether as the result of
baths or exercises, it must not be presumed that the
diminution in size or change in shaj^e of the heart is
a continuous one. Nor is the change in shape uni-
form in all directions. In different cases various
portions of the heart, one or both auricles, one or both
ventricles, in var)'ing combination and extent, change
their form. .\s to size, what has just been said of the
change in shape will indicate the exjiected diminution
in size in different directions. To presume, however,
that each day's gain is permanent, would be to expect
the impossible. The reco\ery of the heart during a
certain day is lost in a measure by the following day,
and in this manner of successive daily diminution, with
p.irtial loss of the ground gained, we gradually succeed
in attaining to that diminished size whicli in the
given case represents the heart in the condition of
most perfect muscular compensation.
Upon applying the s])hygmomanometer, sphygmo-
graph, etc., and taking measurements before and after
exercises, just as in the case of baths, allowing of
course a sufficient interval of time to ])ermit the imme-
diate effects of the exercise to pass off, the pulse trace,
arterial pressure, and capillary pulse showed changes
similar to those following the bath, before referred to.
(It will be found in certain instances in which
marked dilatation complicates the case that during
liie period of dilatation the effect upon the arterial
pulse as recognized by the sphygmomanometer and
arteriometer is just the reverse.)
It has been a subject of physiological investigation
for many years to measure the increase in tissue meta-
morphosis following e\ery \ariety of motion with the
aid of the Mosso arm holder, and by its adjustment for
measuring the work done by the individual fingers of
the hand, with or without added weights to be lifted,
aided by the Zuntz-Ciippert analyzing apparatus for
the expired air, by which latter the increase of oxygen
absorbed and of carbonic acid exhaled is accurately
measured, the increase of tissue change is gauged.
Recently investigation made by Leber and Sluewe upon
the subject of tissue metabolism produced by massage
(carried up to twenty-eight minutes' duration) proved
that the increase of tissue change after massage did
not eqUal that of the simple movements of the un-
weighted fingers repeated for a few times only.
The importance of this investigation is readily seen
in its bearings upon the eft'ects produced by the move-
ments referr'ed to, and particularly upon the point that
I cannot repeat too often, to wit: that we siiould not
hurry to get to the greater movements, since the smaller
ones give us results.
In seeking for a physiological explanation of the
effects of exercise we are again met by difficulties.
It cannot be denied that the local circulation in the
different parts of the body brought into movement, is
influenced materially, and that the relief of local con-
gestion, whether cutaneous or visceral, and the result-
ing equalization of the volume of blood in its direct
and indirect effects upon the heart and viscera are of
importance. But the nervous system plays a most
important role in controlling the function of the heart
and blood-vessels. The condition described by Jacob,
of Cudowa, under the name of angiospastic cardiac
dilatation, is a forcible reminder of the vast e.xtent of
reflex influence between the nervous and circulatory
systems. But it is a well-established fact that the
refle.xes play an important role between one portion of
the body and another. Considering that the heart is
supplied with depressor as well as accelerator nerve
fibres, and that its functional activity is thus controlled
and kept within its bearable muscular limits, and the
relations of the \asomotor system to the blood-vessels
at large, we must be prepared to accept that the physi-
ological action of exercises is the result of reflex
action to some extent, be this small or large.
Combined Treatment — While at Bad Nauheim the
majority of patients received no medicinal treatment
aside from the baths and exercises, in general prac-
tice it is strongly to be recommended to omit no ordi-
nary means of medication, or any therapeutic measure
by which the patients mav be benefited. To every
physician who adopts this method of treatment oppor-
tunities will come by which he can put the baths or
exercises to the test by themsehes. It can never be
expected, however, that artificial baths will equal those
of Bad Nauheim. Such, however, are the good results
obtained by ]ihysicians in city practice that the pro-
fession need not hesitate in undertaking them. Pre-
vious study and preparation are, however, essential to
the successful carrying out of the treatment and in
order to prevent experimentation upon the patient.
Dietetics. — The theories of Oertel have not main-
tained themselves as to his antifat treatment. It is
well of course to limit the amount of liquids taken at
meals, and even an excessive amount between meals.
All spirituous liquids should be avoided, save when
the haliit of life permits of a small quantity of diluted
light wine (light Moselle or clarett. Aerated waters
should be used with care and no cold fluids of any
kinds taken. .-Vs to solid food, the avoidance of ex-
cess of starches, sugars, and fat is urgent, but to recom-
mend the suppression of carbohydrates is to leave the
system in a materially weakened condition and with-
out its main .source of muscular energy.
Indications and Contraindications. — Indications:
Generally speaking all circulatory disturbances, all
diseases of the heart with or without valvular disease,
and particularly with loss of compensation, angina pec-
toris (bath should always be first employed). Graves'
disease, hamophilia, and Barlow's disease. The .so-
called disease of puberty or adolescence with or without
cardiac murmur, congenital cardiac disease. Ordinary
complications, such as oedema, anasarca, hydrothorax,
hydropericardium, and moderate chronic renal con-
gestion, do not contraindicate the above treatment.
December 12, 1896]
^II-I)ir.\I. RKCORD.
851
Contraindications: Heart disease witli serious
complications, such as pulmonary infarctions and
with excessive debility, particularly if the circum-
stances of the patient do not guarantee that the treat-
ment can be carefully carried out; arterio-sclerosis in
its advanced stages ; aneurism of the aorta of the
second and third degree; acute and chronic Bright's
disease (more particularly the atrophic form).
The best results are obtained in that large group of
cases of weakened heart, of overstrained heart, or
irritable heart dependent upon or consequent upon
nervous or physical strain or infectious disease, irre-
spective of the presence of degenerative change in the
arteries of the heart muscle, or in the muscle itself.
Second to this we have a group of cases with rela-
tive insufficiency, in which the murmur of insufficiency
(most often aortic) disappears as the result of treat-
ment. These cases are often complicated with other
cardiac lesions. In the third series, we find the large
group of cardiac valvular cases with loss of compen-
sation. Of these there is an untold number, in which,
after all medicinal help at the hands of the most
skilled physicians in the world had failed, the above
treatment has restored the patient to such a degree of
health as to enable him to continue in his vocation
for a long number of years.
The improvement and relief in conditions of angina
pectoris, and in the other conditions referred to, place
this treatment, especially when in the hands of a pru-
dent doctor to whom all the resources of his art are
familiar, among the very first of remedies.
In noting the effects upon the patient, it is impor-
tant to bear in mind that the addition of this physical
means to our armamentaria for the treatment of cardiac
disease means much for our patients, their comfort,
and their longevity. In the first place, a considerable
number of patients are enabled to go through the winter
without treatment of any kind, and they return the fol-
lowing summer only because they wish to prolong the
good effects. Secondly, in many cases in which digi-
talis and other cardiac stimulants have lost their
effect, after a few baths or e.xercises, the heart muscle
seems to be brought within the limits of action of
these drugs and they then have a better etl'ect than
ever. Similarly, by being able to avoid digitalis and
the like drugs for a time, we have these remedies as
reserves for times of greatest need.
Relapses occur during the treatment at Nauheim as
well as they are likely to occur under other conditions.
At such times baths or e.xercises, or both, are stopped
for one or more days, as may be necessary, and, if need
be, drugs are administered. Usually, however, the
patient soon rallies and ultimately secures the desired
result. To expect marked improvement in every case
would be, however, too optimistic by far.
It is nine years since first I visited Bad Nauheim,
repeating this visit ever}' year since, and I have seen
an almost innumerable number of patients who, prior
to their attempting this treatment, had been given up
as hopeless. During these years, thanxs to the cour-
tesy of Dr. Theodore Schott, I have closely investi-
gated 120 cases, following the patients almost daily
at the bath and exercises, and examining them in the
manner above referred to. Of these 120 cases 24 had
come for the first time, 45 for the second time, 18 for
the third time, 9 for the fourth time, 7 for the fifth
time, 5 for the sixth time, 6 for the seventh time, 5 for
the eighth time, and i for the eleventh time. Thus
96 of the 120 had been there two and more times, 51
three and more times, ^^ four and more times, 24 five
and more, 17 six and more, 1 1 seven and more, 6 eight
times and more, and i each year for eleven years.
Such an experience as this, and that of an increas-
ing number of F.uro]5ean physicians, particularly of
Great Britain (the recent reports of Sir C'.rainger Stew-
art, liroadbent, Bowles, Lauder Brunton, Sir Francis
Cruise, of Dublin, supported by 2'/it- Lancet commis-
sion report, made by Dr. Alexander Morison, of Lon-
don, and personally expressed views of such men as
Baldwin, of Florence, and a host of others), settled the
question, which has often arisen before, as to the per-
manency of the effects of the treatment, in the decided
affirmative.
Prior to asking your attention to a few histories of
cases, I must reaffirm that careful study and prepara-
tion is necessary before a physician can hope to use
so potent a remedy successfully. Nor is a prudent
equipoise to be omitted in order to avoid the overdoing.
For even in the hands of the expert, I have seen over-
bathing with its consequent bad effects, and overexer-
cising which no number of wonder-exciting diagrams
of the heart's diminution (?) in size could free from
unhappy or fruitless result. Finally, it must not be
supposed that every variety of so-called medical gym-
nastics, now so popular in orthopjedy, is in any way
suited for the treatment of cardiac cases.
Cases. — Cases I. and 11. — As an illustration of
cases of relative aortic insufficiency, which was com-
plicated w ith aortic stenosis in one case and in both
with myocarditis, I quote the cases of t^vo locomoti\e
stokers, who had been obliged to give up work on ac-
count of dyspnoea, vertigo, and the usual symptoms of
loss of compensation. In both, aortic regurgitant
murmurs were clearly recognizable at the outset.
These murmurs grew feebler as the heart grew stronger
and more rhythmical in action, and finally disap-
peared. Both men were restored to a fair degree of
robust health.
I note here that the restoration of compensation in
a laborer does not mean that he can return to his
former laborious work, such as blacksmithing. stoking,
etc. Such men must seek work less fatiguing, and, if
this can be secured for them, the compensation may
be maintained so long as their hygienic surroundings
and food continue proper.
Case III. — Judge F. S , native of Wiesbaden,
sixty years old, who first came to Bad Nauheim in
1886. He had suffered with dyspnoea, vertigo, inabil-
ity to work, oidema, ascites, and had tried the Oertel
cure, with bad results. He was so despondent of re-
covery that he was about to resign his judgeship. In
a few weeks his improvement encouraged him to hope;
he continued in his recover}-, and retained his position
for eight years, resigning on account of age. His
heart was so dilated in 1886 that no murmur could be
heard; later, aortic murmurs were recognizable, and
persist to this day. The patient made his eleventh
visit to Bad Nauheim this summer, is now nearly sev-
enty-one years old, and has passed all these years
without medication in- the winter (save for a trifling
cold at times), and enjoys excellent health.
Case IV. — General X , fifty years old, native of
Russia, who came to Bad Nauheim in the summer of
1895. He had lost his health in consequence of in-
fluenza. Finally, dyspntea and general weakness,
combined with attacks of angina, com]x;lled him to
give up military work. He was examined by the med-
ical experts of Europe, who all recognized well-marked
cardiac dilatation and, later, aortic regurgitation. In
six weeks' time the patient walked four miles and over
a steep hill without dyspncea, cardiac palpitation, or
any detectable murmur being distinguishable by the
closest investigation. Patient did well till the spring
of 1896, and in the summer of 1896 returned for sec-
ond treatment, and made a nice recovery. The pa-
tient's habits of smoking and self-indulgence, which
he will not give up, have something to do with the re-
sult not being even better.
Ca.se V. — .Attorney X — — , forty years old, a Ger-
man, who, in consequence of repeated rheumatic at-
852
MEDICAL RECORD.
[December 12, 1896
tacks, was left with aortic stenosis and regurgitation
and mitral regurgitation, came to Xauheim in 1886.
All his disabilities, including ctdema, disappeared.
Barring an attack of rheumatism in 1888, he has re-
quired no medical treatment since, except his annual
monthly pilgrimage to Nauheim and taking bath and
exercise treatment. During the past four years he has
worked long and hard throughout the winter, without
discomfort or complaint. His heart is perfectly com-
pensated; the murmurs are still present.
Case VI. — Merchant X , a Russian, fifty years
old, came to Nauheim anasarcous, with hydrothorax
and hydropericardium, dyspnaa, vertigo, angina, etc.
The patient, on arrival, was seen by Sir Grainger
Stewart, McGregor, Robertson, Holman, and others;
and the diagnosis of myocarditis with extreme dilata-
tion and, after urinary examination, chronic conges-
tion of the kidneys was made. Such was the recovery
of this patient (despite two relapses), that after six
weeks he was examined by Dr. R. L. Bowles, of Lon-
don, with me, who found his heart in excellent com-
pensation. In the summer of 1896 the patient re-
turned, having had a good winter, and an examination
by Dr. Alexander Morison, of London, showed the size
of the heart exactly the same as it had been found by
Bowles and myself in September, 1895.
Case VII. — Lady, forty years old, English, with old
history of atheromatous arteries and myocarditis.
Patient had been told by a most conservative and
able physician that she would be confined to her room
and chair for tlie rest of her days. The heart was di-
lated, arhythmical, and intermittent. .Vfter a course
of treatment, which was carried out a second time in
the same season (summer, 1896), the patient walked
ten miles daily without fatigue.
Case VIII. — .\ngina pectoris. An Englishman,
forty-eight years of age, who had suffered from numer-
ous daily attacks, brought on by any exertion, and last-
ing years, was so completely relieved that he was able
to return to his home in India and continue at work
two years without renewing treatment. The diagnosis
in this case was moderate arterio-sclerosis and myo-
carditis.
Case IX. — Physician, forty-three years old, with
aortic stenosis and moderate arterio-sclerosis, had
suffered with frequent daily attacks of angina; was
relieved after the second week of treatment, and re-
ported himself well six months later.
Case X. — Englishman, forty-three years old, iiad
literally lived u|)on nitroglycerin for years; was never
free from attacks of angina or precordial pain. Diag-
nosis, aortic stenosis and insufficiency, mild arterio-
sclerosis. This patient had several attacks during
the first week of treatment, when they ceased; and
<luring the succeeding winter he reported himself still
well.
All of these three cases of angina were treated with
baths and exercises.
Casks XL and XII. refer to two girls, one ten and
tlie other eight years of age, both with congenital car-
diac disease. Having watched both children for four
or five years, it is wonderful to note the improvement
in both cases. In comparing these children with oth-
ers suffering from patent foramen ovale, it cannot be
denied that the treatment has markedly ameliorated
the condition and materially aided the development of
both children.
Cases of exophthalmic goitre and numerous other
cases coming under the category referred to as amena-
ble to this form of treatment will be mentioned in
subsequent publications upon the individual disorders.
A Good Local Anaesthetic for spraying abscesses
before lancing is made with half a drachm of chloro-
form in an ounce of ether. — The ^ledical Sitmniary.
AX.ENHA IX CARDIAC DISEASE.
liY .VNDREW H. SMITH, M.D.,
EMERITUS PROFESSOR OP MEDICINE, NEW YORK POST-CRADrATE .MEDICAL
school; physician to the PRESBYTERIAN HOSPITAL.
When we consider that the three most striking phe-
nomena of organic cardiac disease, dyspnoea on exer-
tion, oedema of the extremities, and the presence of a
heart-murmur, are also prominent features of pro-
nounced anamia, it is evident that when the two con-
ditions occur together there is room for nice discrimi-
nation in assigning to each its share in the result.
Unless we are on our guard, the tendency is to over-
look the functional trouble and to attribute an undue
importance to the organic lesion. No one in first
approaching a supposed heart case fails to consider
whether the affection is not purely functional, but,
when once the diagnosis of organic disease is fixed,
we are prone thereafter to attribute whatever we ob-
serve to this cause, and not fidly to take into account
the infiuence of blood changes, which are certain
sooner or later to contribute more or less to the clini-
cal aspect of the case.
This is, however, a grave error, for it may lead, on
the one hand, to neglect of measures by which the
condition of the blood and therefore of the patient
might be improved, and, on the other, to a false esti-
mate of the degree in which compensation is insuffi-
cient, thus urging to ill-timed efforts to correct the
supposed defect. If there is any one point especially
important in the management of cardiac disease, it is
to appreciate accurately the result of nature's effort to
meet tiie increased tax upon the heart muscle by ade-
quate hypertrophy. So long as this compensation is
maintained it is unnecessary and unwise to resort to
medication designed to get more work out of the dis-
abled organ. We should reserve such measures for
the time, only too sure to arrive, when there will be
evidence that the ventricle is no longer equal to the
task imposed upon it. Chief among these signs will
be dyspnoea and adema of the extremities. But if
the dyspnaa and icdema are in part the result of an
impoverished condition of the blood, and we do not
appreciate this fact, we shall be pushing digitalis and
its congeners when we ought to be giving our princi-
pal attention to the production of belter blood.
The occasions on which this discrimination is
called for are numerous, from the fact that organic
cardiac disease almost inevitably sooner or later leads
to digestive disturbances that in tiieir turn become
causes of anaemia. The circulation in the chylopoi-
etic viscera being deranged by the impaired action of
the heart, the functions of digestion and absorption
are not properly performed, and we have insufficient
nutrition and consecutive anamia as the result. It
follows that in a large proportion of case.s, as .soon as
compensation becomes defective, anamic are associ-
ated with the organic phenomena.
In view also of the origin of so large a proportion
of cases of cardiac valvular disease, it is to be remem-
bered that the poison of rheumatism tends in a re-
markable degree to impoverish the blood, and that the
use of .salicylic acid or its compounds contributes also
to this result. Tlierefore, unless special care has been
taken to obviate this tendency, we are likely, in a case
of heart disease with a rheumatic basis, to have a con-
dition of ana-mi a from tlie very first, as a legacy from
the rheumatic attack.
Ana-mia may also be the direct result of organic
disease. Incompetency of the aortic valve induces
this condition by lessening the supply of blood to the
arterial system. To a patient suffering from organic
cardiac disease the addition of anamia is a compli-
cation of serious import. .As already stated, so far as
the anamia is consequent upon the previously existing
December 12, 1896]
MEDICAL RECORD.
853
coiwiition of the heart, it is not lii<ely to be developed
until compensation begins to fail. Coming at this
juncture, it adds much to the gravity of the case. The
tissues, already beginning to feel the lack of a sufficient
quantity of blood, suffer now in addition from deteri-
oration in the quality of the Huid supplied. This ex-
tends to the heart muscle itself, and, at a time when
more is required of it, it is less able to meet the de-
mand. The organ, that already was overworked, is
now underfed. This in turn lessens still further the
vigor of the circulation, and a vicious circle is estab-
lished. L'nless the resources of art are sufficient to
restore compensation on the one hand, and to bring
about a better condition of the blood on the other, the
downward progress is necessarily rapid.
If this be the case when the antemia is secondary,
it is more emphatically true when cardiac disease
attacks a subject who is already anamic. Compensa-
tion in these cases is maintained with difficulty and
the response to treatment is imperfect. The tendency
is to rapid development of digestive troubles, general
anasarca, pulmonary oidema, and all the evils attend-
ant upon cardiac insufficiency. In fact we have the
condition to begin with, which in secondary cases be-
longs to the later stages of the cardiac disease.
The most obvious symptom of ana:mia is pallor, but
this may be obscured or masked by the dusky hue
which often accompanies organic cardiac disease.
When there is no tendency to cyanosis, the pallor has
the same value as a sign of impoverished blood that
it would have in the absence of a cardiac lesion.
Stephen Mackenzie suggests that an idea as to the de-
gree of anitmia can be formed by observing the nail
beds. " So long as any pink color can be seen, it may
be assumed that there is a proportion of at least fifty
per cent, of red corpuscles. When the pink color
entirely disappears from the nail bed the corpuscles
will be found below fifty per cent" (Sansom).
In estimating to what extent thinness of blood is a
factor in these mixed cases, we have to consider that
the hajmic murmurs may be obscured or entirely con-
cealed by the organic. Thus, when a blood murmur
would be heard at the apex in the absence of an ana-
tomical change in the mitral valve, it would be wholly
obscured if there was incompetency of the valve due
to organic lesion.
As hasmic murmurs are always systolic, the question
would not arise in the case of a diastolic bruit. The
problem, then, is practically confined to cases in which
a systolic murmur is found in a locality in which a
previous organic lesion has not been demonstrated.
In such a case we shall be required to determine
whether we have to do with a functional or an organic
condition.
So far as the mere auscultatory signs go, they may
be very inconclusive. While the inorganic murmurs
are as a rule softer, less harsh, less grating than those
of organic origin, it is not safe always to depend upon
this quality. A blood murmur may have enough of
harshness to be identical in this respect with a rather
soft organic sound, and a sound that is unquestion-
ably organic may be so soft as to pass for a strong
bruit of ha-mic origin.
Fortunately we are aided materially by the location
of the sound. Organic dist-ase of the pulmonary ori-
fice is extremely rare, while this is the most frequent
seat of aneemic murmurs. Sansom found that fifty-
seven per cent, of all his cases presented the maxi-
mum intensity in the pulmonary area. If, then, a soft
systolic murmur appears in this locality, we can be
almost certain that it is functional. This conviction
will be strengthened if we find that on changing the
position of the patient from the standing or sitting
posture to the recumbent the intensity of the murmur
is decidedlv increased, since in organic murmurs in
this situation the horizontal position adds compara-
tively little to the strength of the bruit, while in ana-
mic murmurs the increase is very marked. In the
aortic area the vast preponderance of the murmurs are
organic. A functional bruit, according to Sansom,
occurs here only once for four and one- half times that
it is heard in the corresponding area at the left of the
sternum.
Hffimic murmurs occur very rarely in the mitral
region. They are soft in character, but, contrary to
the general opinion, they conform to the organic mur-
murs in a large proportion of cases, in this, that they
are propagated toward the left and are heard at the
back. Indeed, it seems probable that these murmurs
are caused by a veritable though transient incompe-
tency of the valve, resulting from defective muscular
action. Certain it is that murmurs occur that resem-
ble in everything except harshness the sounds accom-
panying organic mitral insufficiency, and yet at the
autopsy the valve is found to be normal. But in these
ca.ses we do not have the displaced apex beat, nor the
forcible impulse that usually goes with organic insuffi-
ciency of the mitral valve.
Anemic murmurs are extremely rare in the tricuspid
area. Sometimes, however, they extend downward
from the pulmonary area so as almost to include the
region in question. But in these cases the intensity-
will be found to be greater as the stethoscope is
moved upward, thus indicating their true origin. Ac-
centuation of the pulmonary second sound, if not
referable to obstruction in the lesser circulation, is
an indication of ana-mia. Apparently the thinner the
blood, the more readily and forcibly it is thrown back
against the valve cusps. This, however, is to be care-
fully distinguished from the accentuation of the aortic-
valve sound, so often present in reno-cardiac con-
ditions, and which may be heard with considerable
distinctness over a wide area, including the location
of the pulmonary valve.
Leaving the cardiac region, we find evidence of the
existence of anamia afforded by murmurs in the great
vessels of the neck. These are of two kinds, the in-
terrupted arterial bruit synchronous with the cardiac
systole, and the continuous hum produced in the veins.
In pronounced anaemia, if we place the stethoscope
above the clavicle and just outside the sterno-mastoid
muscle, we shall generally, though not always, perceive
a murmur with each ventricular systole. This sound,
though not rough or grating, is more decided than the
blood murmur heard in the pulmonary-valve region.
It has more of a whizzing character. It may be heard
for some distance in the course of the subclavian ar-
teries and along the carotids. This murmur may be
present when there is no bruit in the pulmonary area,
and on the other hand it may be absent when the pul-
monary murmur is pronounced.
The other sound heard in the neck is the venous
hum, the bruit dc diahle. This is a continuous sound
produced in the great veins, as is proved by the fact
that pressure on the vein above the stethoscope causes
it to cease. It may or may not coexist with the arte-
rial murmur. It is intensified by turning the head
toward the opposite side, thus putting the vessel and
the overlying tissues on the stretch. It is also made
louder by anything that quickens the current of blood
through the veins, such as exercise, mental excite-
ment, etc. It is more distinct in the upright than in
the recumbent posture, and during inspiration than
during expiration.
This venous hum, however, is not in every case an
evidence of anainia. It is found in a considerable
proportion of perfectly healthy persons, especially
females. Still it is more common in subjects whose
blood is thin, and in such cases it disappears as the
quality of the blood improves. Its value, therefore.
854
MEDICAL RECORD.
[December 12, 1896
as corroborative evidence of anamia is considerable,
and in a doubtful case its presence inclines to the
conclusion that a cardiac murmur is functional rather
than organic.
Pulsation in the veins of the neck, if tricuspid re-
gurgitation can be excluded, may be taken to indicate
poverty of the blood.
The dyspnoea of anamia may be very marked, but
it scarcely reaches the degree which is often observed
in organic valvular disease. Orthopncea is rare.
The shortness of breath is scarcely felt when the pa-
tient is at rest, but it is easily excited by any exertion.
In these combined cases, there is, of course, no way
of distinguishing the dyspncea of organic origin from
that of functional derangement. We can only judge,
perhaps, that the degree is greater than the valvular
lesion present would seem to warrant, and thus infer
that thinness of blood is adding to the effect of ana-
tomical changes.
tEdema of purely cardiac origin is apt first to show
itself in the feet and legs; that of anamia is more
generally diffused. If, therefore, we have an cedema
confined for a while to the lower extremities and sub-
sequently without any notable change in the cardiac
signs there is superadded a more general puffiness,
we may believe that poverty of the blood is becoming
a factor in the production of the effusion, especially if
other indications point in the same direction.
If, as is so often the case, there is nephritis as a
complication, this also will have to be taken into ac-
count in our estimate of the resulting aggregate of
uedenia.
There remains to be considered the most conclusive
and most precise evidence of the hamic condition,
viz., that afforded by direct examination of the blood
itself. This should never be omitted if we wish to man-
age the case with a full appreciation of all that can
be ascertained in regard to it. By means familiar to
all, it is easy to determine with approximate accuracy
the number of blood cells to the cubic millimetre and
also the relative percentage of hamoglobin which the
blood contains. This puts us at once into a position
to judge of the need of treatment designed to improve
the quality of the blood, and subsequently affords a
measure of the success of our efforts in this direction.
These examinations should be repeated at short inter-
vals, so that if one remedy does not give satisfactor)-
result, another may be employed.
The treatment of anamia associated with cardiac
disease is not essentially different from that of the
condition when occurring alone. If it has preceded
the cardiac affection, its cause must be searched for
and if possible removed. Chalybeates,etc., will then
lie in order, and just in projKjrtion as they are suc-
cessful in improving the quality of the blood they
will oppose the tendency to early failure of compen-
sation. In any case, when this failure begins to be
manifest, cardiac tonics and stimulants will be re-
quired, and, if successful, they in turn will act as
blood-making agents, by promoting a better circula-
tion in the tissues concerned in that process.
The necessity for relief of the blood condition is
often so urgent that the most prompt and efficient
means must be selected. Nothing else has in my ex-
perience met this indication so satisfactorily as ene-
mata of defibrinated blood. This .substance seems to
be taken up by the rectum almost unchanged, the
absorption often being so perfect that the dejection
on the following morning will show scarcely a trace
of blood. From its use I have seen remarkable, in-
deed marvellous benefit, and I should employ it in any
case in which prompt results were especially demanded.
From one to two ounces of blood diluted with an
equal bulk of warm water may>be injected twice a
day, or more frequently. The rectum should be
cleansed with a simple enema every alternate day
while the treatment is continued.
Of course this method does not exclude the simul-
taneous use of remedies by the stomach, and the pref-
erence of each practitioner will suggest the drugs to
be employed.
In conclusion, what I wish especially to insist upon
is that, not- only in advanced cases, but even in the
earliest stages of heart disease, the evidences of ana-
mia should be sought for, and as soon as they are
recognized, appropriate treatment should be instituted
and persisted in, so long as the condition remains. I
am satisfied that bv pursuing this course, very many
patients may be carried along for an almost indefinite
time, who would otherwise offer but comparatively lit-
tle resistance to the combined effects of anamia and
cardiac insufficiencv.
^roQrcsa of Ijtlcdical Science.
Cocaine Poisoning. — Dr. W'einrich discusses cocaine
poisoning originating from the urinarj' passages. The
symptoms are very variable, but they are mostly refer-
able to the nervous system. Cocaine must, therefore,
be used with caution in neurotic individuals. The
symptoms may consist of stupor, vertigo, headache,
and these may end in collap.se with severe precordial
anxiety. Clonic and tonic spasms are noted, which
may produce sleeplessness and restlessness in .sonie
people and unconsciousness in others. Mental excite-
ment and a mild degree of mental aberration may be
observed. Paralysis, tremor, slight loss of co-ordina-
tion may also be among the motor symptoms. If re-
spiratory difficulty, cyanosis, loss of consciousness su-
pervene, the prognosis becomes very serious. 'l"he
unfavorable action of cocaine on the heart rarely be-
comes threatening, the respiratory symptoms being the
most significant. .V feeling of suffocation with irregu-
lar stertorous breathing may arise, and eventually
Cheyne-Stokes breathing. Death may result from
respiratory paralysis. Idiosyncrasy to cocaine is
sometimes very marked, so that the size of the dose
maybe almost without perceptible influence on the in-
toxication svmptoms produced. The author records
two cases of cocaine poisoning, the first he had seen
among several thousand of bladder cases which had
been cocainized. In comparing experiments on ani-
mals with observations on man, it is proved that
cocaine can be absorbed from the bladder, but the
absorption is so slight as to be practically without
significance. With increased dexterity in the use of
the cystoscope, pierhaps weaker solutions of cocaine
can be employed or no local anasthetic used at all.
Cardiac and vascular di-seases, pernicious anamia,
are contraindications to its use. The horizontal po-
sition should be adopted when it is used. Chloroform
may be given when spasms arise, but the chief remedy
against cocaine poisoning is artificial respiration. The
proposal of Gauchier to add nitroglycerin (coc. mur.,
Merck, 0.2; aq. dest., 10; sol. nitroglyc, i per cent.,
gtt. X.) is worth bearing in mind. — Bfiliiier klinisilie
Wochenschrift.
The Secretion of the Skunk — \x\ article on this
subject has been published in \\\e. Journal of Experi-
mental Medkinc, by Dr. Thomas H. .\ldrich. He finds
that the offensive secretion is discharged from two
oval pouches, about one inch long, situated on the
sides of the rectum close to the anus, by two ducts
which terminate at the top of little papilla just inside
the sphincter ani. The wall of the pouches consists
of a fibrous investment, a muscular coat of striped
fibres, a submucous coat, and a mucous membrane;
December 12, 1896]
MEDICAL RECORD.
855
die masses of glands are situated in the subnnicuus
layer. The glands are tubular and lined by cubical
epithelium. They present strong analogies to the
sudoriparous glands. The disgusting odor of the se-
cretion is so intense that one of Dr. Aldrich's prede-
cessors having collected a little for examination, the
whole college of the Johns Hopkins University rose
in revolt, and he had to get rid of his material. ])r.
Aldrich was more fortunate and was permitted to pur-
sue his examination without interruption. The tluid
secretion is clear, limpid, and golden yellow or amber
colored, having a characteristic penetrating and most
powerful odor; its specific gravity is 0.939; it remains
fluid at — 12" C. ; and its reaction is neutral. The va-
por is highly inflammable and burns with a luminous
flame, giving off sulphur dioxide. It is readily solu-
ble in alcohol, ether, and chloroform. A fifty-per-
cent, solution of sodium or potassium hydroxide dis-
solves the fluid partially, the odor almost disappearing,
but returning on the addition of sulphuric acid. Its
reactions justify the assumption that one or more
mercaptans or thio-alcohols are present. It contains
about thirty per cent, of sulphur. Experiment showed
that when so far diluted that the air inhaled contained
only one-sixty-nine-billionth in each cubic centi-
metre, it was still perceptible to the smell. It is a
powerful ana;sthetic. When inhaled without the ad-
mixture of a large amount of air, the victim loses con-
sciousness, the temperature falls, the pulse slackens,
and if the inhalation were prolonged fatal results
would probably ensue. Introduced into the conjunc
tival sac, it produces intense pain and sets up acute
inflammation. The fumes of this liquid are overpow-
eringly pungent and extremely irritating to the glottis.
The Forms of Diabetes. — Dr. George Harley gives
the following classification in The Lancet : i. Hepatic
diabetes — including the gouty variety. 2. Cerebral
diabetes — including all cases of saccharine urine aris-
ing from nerve derangements. 3. Pancreatic diabetes
— the most deadly form of the disease. 4. Hereditary
diabetes— a form by no means uncommon, and one,
too, in which both brothers and sisters may labor under
the disease without either their maternal or paternal
parent having been affected by diabetes, though more
distant members of the family may have suffered from
it. 5. Food diabetes — including all forms of sac-
charine urine arising from the ingestion of unwhole-
some substances. Dr. Harley recommends, in addi-
tion to diet and opium or codeine, croton chloral,
strychnine, phosphoric acid for thirst, and an absolute
prohibition of alcohol.
Movable Kidney. — According to Dr. Franks, the
symptoms presented by movable kidney come so fre-
quently under the notice of the physician that he must
be able to recognize it. This is the author's defini-
tion of the condition : " Suppose we get a patient lying
in the dorsal position. Standing on the right side, I
pass the four fingers of my left hand underneath the
hollow of the loin just beneath the twelfth rib. The
thumb in front encircles the abdomen just below the
costal arch, but without exercising any pressure. I
then direct the patient to draw a full breath. Imme-
diately before expiration begins I press my thumb up-
ward below the costal arch, and let it sink as deejily
as possible, following the liver as it recedes during
expiration, while the fingers behind press the loin for-
ward; if now with my right hand I can feel the kid-
ney lying entirely below the grasp of my left hand, I
call that a right kidney patiiologically movable. If
the right hand presses on the tumor so felt, while the
left hand relaxes its grasp gradually, the tumor can be
felt to slip between the fingers of the left hand and to
disappear from our ken — upward into the position
normally occupied by the kidney. This sensation is,
I believe, pathognomonic of a movable kidney. A
kidney which can be felt to descend so that its lower
half can be felt, but which moves back on expiration,
is a kidney physiologically movable." The kidney is
normally wedged in its place and kept there by the
pressure of the viscera acting upon it from above and
below, but when the balance between these forces is
lost the position of the kidney may be altered. This is
especially liable to occur after parturition. Descent
of the right kidney is liable to cause gastric crises.
The best treatment is nephrorrhaphy or stitching the
kidney in the loin. Mr. Bland Sutton has seen jaini-
dice result from dragging down of the viscera by a mo\ -
able right kidney. — The Birtiiinghiim Medical Review.
Resection of Nearly Eleven Feet of Small Intes-
tine in a Boy Eight Years Old.— Dr. Kuggi has re-
ported the case of a boy who was struck on the ab-
domen by the car of a large swing, and thrown into
the water about forty feet distant. For two weeks he
had some tenderness in the abdomen, but no other
symptoms. He then showed signs of obstruction.
The abdomen was opened, and a loop of intestine was
found constricted by a band of omentum. He im-
proved for a time, but signs of obstruction returned in
more pronounced form, and the wound was reopened.
The intestine was found stenosed at the point where
the contricting band had been divided. This was
freed, and for a time the boy again had relief, but
complained, as he had before the first operation, most
bitterly of hunger, crying night and day in spite of
tlie fact that large quantities of food were given, in ad-
dition to rectal feeding. Obstruction again returning,
it was decided to again open the abdomen. A large
mass of intestine was found adherent to the abdominal
wall. On attempting to free this, it was discovered
that a large extent of bowel had been stripped of its
mesentery. Dr. Ruggi determined to resect these por-
tions, and removed successively ten feet nine inches.
The lowest incision was six inches from the ileo-cacal
valve. The ends were brought together by silk su-
tures. In a few days the boy was again crying for food.
Gradually, however, the hunger lessened, and in five
weeks he was discharged cured. At the time of re-
port, fifteen monlns later, he was in perfect health. —
The Canadian JVactitioner.
Symptoms of Incipient Exophthalmic Goitre.— It
is important to be able to distinguish this disease from
the first, instead of waiting for the exophthalmos and
goitre to appear. Principal among the early signs by
which it may be recognized is a series of ocular trou-
bles, a lack of synergic action in the lid and'brow when
the globe is turned abruptlv upward, incomplete clos-
ure of the palpebral fissure, pulsation in the lids, mus-
cular paralyses, and sometimes diplopia or photopho-
bia. There are also disturbances in the nervous
system, besides a general irritability; there are often
cramps, neuralgias, hyperasthesias, insomnia, choreic
movements, and sensations of excessive heat. The
tremor, which is rarely absent from the first, has a spe-
cific character in its rapid vibrations. If there are no
accompanying symptoms of hysteria, this tremor is of
great diagnostic value. The general symptoms that
mav occur are numerous and various, from dyspepsia,
bulimia, gastric and diarrlut-ic crises, to genital trou-
bles and ff-dema resembling myxadema. Other dis-
turbances indicate the ]5artici|)ation of the medulla
oblongata, suffering from lack of the normal secretions
of the thyroid gland, polyuria, albuminuria, and dysp-
n(ca. Pregnancy is one of the mo.st important predis-
posing causes of this disease, and it may also appear
as a complication of neurasthenia, chorea, epilepsy,
paralysis agitans, syringomyelia, general paralysis, and
various psychoses, especially tabes and hysteria. —
Neiue de Medecine el de Chiniixie.
8s6
MEDICAL RECORD.
[December 12, 1896
Appendicitis and Perityphlitis. — In a paper upon
this subject, in the Albany Medical Anuals for Novem-
ber, Dr. Seth M. Mereness draws the following con-
clusions: From the statistics of the last decade, and
particularly of Fitz and Porter, it may be concluded
that an operation is necessar\- in at least one-half of
all cases, and that the mortality, even when an early
operation is performed, will be from twelve to fifteen
per cent. There is probably no other disease on tlie
border line between medicine and surgery that requires
such thorough individualization, and for this reason
no definite rules can be adhered to; but, in general, it
maybe said that an operation should be advised: i.
In all cases in which a purulent collection is known to
have been formed in the pericaical tissues. 2. When
a purulent collection cannot be demonstrated, but
when signs of perforation of the appendi.x e.\ist. 3.
In all cases in which there is a reasonable doubt as to
perforation of the appendi.x or pericacal suppuration,
but in which symptoms of general peritonitis are pres-
ent. 4. When after a reasonable time the patient
does not improve under medical treatment, or in conse-
quence of relapses life is rendered unbearable and the
patient's vocation cannot be followed. On the other
hand, operation is rarely necessary and should not be
undertaken: i. In all cases of simple, acute, or chronic
catarrhal appendicitis. 2. While the symptoms indi-
cate a purulent inflammation of the appendicular mu-
cous membrane, but when ]x;rforation has not occurred
and the presence of a marked resistance over the ca^cal
region shows the peritonitis to be localized. 3. In all
cases in which ix;rforation has occurred and has caused
a diffuse septic peritonitis. This latter generalization
is contrary to the famous ma.xim of Lawson Tait, never
to let a patient die from peritonitis without an opera-
tion. The fact is, however, that practically all cases
of well-marked septic peritonitis are fatal under any
plan of treatment, l)e it medical or surgical, as Son-
nenberg admits when he says: •" Absolut schlecht bleibt
die Prognose bei ausgesprochener, allgemeiner, septi-
scher Peritonitis. Auch die letzten sechs Falle sind
alle todlich verlaufen.''
Vaginal Hysterectomy. — Dr. M. J. Boeckel, in a
discussion in tiic recent congress of F'rench surgeons,
advanced the following propositions: i. Pefore the
menopause vaginal hysterectomy should not be prac-
tised in genital prolapse, excepting (<?) when plastic
operations previously tried have failed; (/') when the
duration of the prolapse and its volume lead to predic-
tion of certain failure by the employment of autoplas-
tic methods alone; (<) wiien tiie reduction cannot be
maintained by reason of uterine hypertrophy; ((/)
when the prolapse, as it were strangulated, cannot be
reduced. 2. Vaginal hysterectomy should always be
followed by immediate colpoperineorrhaphy. J'his
should be performed with a free hand. Success is as-
sured only on this condition. 3. These operations
combined give excellent results, and better than those
of simple autoplasty. 4. The mortality is low, even
nil, for the author's personal cases, he having operated
eight times with eight successes. 5. After the meno-
pause, vaginal hysterectomy, other things being equal,
presents no contraindications. .Advanced age of the
patient even will not deter us at the present day. In
the cases related women were operated on who were
sixty years of age and over, and in one instance the
limit was advanced to the age of eighty. — Gaz. Hcbd.
Indications for Suspensio Uteri — Dr. Augustin
H. Coelct {yortli Carolina Medical Journal, November
5, 1896) writes that the recent controversy over the
dilTerent operations for rectification of retroflexions of
the uterus has been productive of some good, as it has
brought out the contraindications for some and the
absolute futilitv of others. Vaginal fixation deser\-es
only condemnation. .Alexander's operation for short-
ening the round ligaments is appropriate when the
retroflexed organ is freely movable and the adnexa are
not diseased. In this condition another more simple
procedure will accomplish as much in a much shorter
time and with less inconvenience to the patient. This
procedure aims at a cure of the metritis and endome-
tritis, the maintaining cause of the displacement in a
majority of ca.ses in which the organ is movable. This
places shortening of the round ligaments in the cate-
gory of unnecessary- operations, though there may be
certain cases in which it is appropriate and even nec-
essary. Ventral suspension should be reserved for
those cases in which the organ is bound down by
adhesions, the adnexa are irreparably diseased and
require removal, and the retroflexed organ, though
movable, is prolapsed, and for prolapsus without re-
troflexion.
Typho - Malarial Fever. — Dr. Gordon ( Virginia
Alcdical Scmi-Monthly) discusses what typho-mala-
rial fever is and concludes that: i. \\'ithout ex-
tended bacteriological investigation it cannot be abso-
lutely denied that there is a typho-malarial fever,
answering to the usual descriptions and resulting from
the co-operation or antagonism of two distinct germs.
2. On the other hand, it is thoroughly illogical to con-
clude that there is such a disease until the necessary
conditions for its existence have been demonstrated.
3. Atypical typhoid fever is a very common disease,
whose symptomatology, in numerous instances, cannot
be differentiated from that of typho-malarial. It fol-
lows, therefore, that the two di.seases, indistinguisha-
ble from each other throughout, have different causes.
This is opposed to reason and the lessons drawn from
clinical observation. 4. If the cause of only one case
of disease on either side of the argument can be estab-
lished, and if this cause be a typhoid infection, are we
not justified in attributing the vast majority of all
cases to the typhoid poison? 5. The appropriate use
of quinine cures malarial poisoning with promptness
and certainty, as a rule, and leaves us to determine
the nature of diseases \\hich it does not control. 6.
Neglected cases of true malarial infection may, in
rare instances, fail to yield at once to quinine, and
lead to the suspicion of a typhoid element: but such
cases are not and cannot be called typho-malarial
fever, and a failure to resort to microscopic examina-
tion of the blood does not sanction a misnomer.
Woman's Inferior Sensitiveness to Pain. — Dr.
Ottolenghi (Ccntralbl.J. A'ivt'. u. J'syc/i., No. 7) reports-
the tests made with Edelmann's faradimeter of the sen-
sitiveness to pain and the endurance of pain in six
hundred and eighty-two women. He finds that women
are less sensitive to pain than men, and that this sen-
sitiveness is less in early life, increases to the twenty-
fourth year, and decreases after that. The higher
classes are most sensitive and the degenerate least.
He found the latter class very obtuse to the sensation of
pain. Endurance of pain varies between much broader
limits in women than in men, reaching a maximum far
beyond the masculine limit, possibly due to the
"greater suggestibility" of the female sex. General
sensibility reaches the highest point in the nineteenth
year. He concludes that sensitiveness to pain stands
in close relation to the " psyche," while ''general sen-
sibility" depends upon the peripheral nen-es. He
considers woman's comparative insensibility to pain
as a sign of her inferiority to man, as the uncivilized
and degenerates are least sensitive. He attempts to
prove a connection between this characteristic and her
longevitv.
December 12, 1896]
MEDICAL RECORD.
857
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 43, 45, & 47 East Tenth Street.
New York, December 12, 1896.
THE NEEDS OF THE MEDICAL SERVICE
OF THE NAVY.
The annual report of Surgeon-General Trj'on of the
navy is of more than usual interest to the members of
the medical profession, not only as physicians, sur-
geons, and sanitarians, but also as citizens. Those of
us who have noted the increasing influence of our
country and the growth of our force afloat have doubt-
less often considered that the efficiency of the new-
navy depends upon more than ships, guns, and men
with the technical knowledge necessary for handling
engines of war, however essential all these things may
be. No one can fail to recall how useless the Ameri-
can squadron would have been at Rio, a year or two
ago, had yellow fever, then prevailing on shore and in-
vading the ships of all other countries, been able to
evade the measures of safety so skilfully adopted for
our own vessels. The medical department of every
military or naval organization has an importance the
world over that is rapidly increasing with the advance
in knowledge. That this department in our navy
should be deficient in any essential is a reproach to
our sagacity as a nation and an obstacle to the ad-
vance of the humanitarian element of our civilization.
The report of the surgeon-general shows a knowl-
edge of the needs of his department that has been de-
rived from careful study stimulated by a desire for
efficiency in caring for the sick and wounded of the
navy under any emergency in peace or war. He states
with much earnestness that the navy is without a hos-
pital corps, and that unless such an organization be
authorized by Congress no definite results can be ob-
tained in the attempt to solve the most important
problems relating to methods of handling the wounded
in battle on board modern ships of war or of properly
meeting many emergencies arising in times of peace.
It appears that the subordinates of medical officers in
the navy, with the exception of apothecaries, are with-
out previous training, even the nurses on our ships
being simply detailed from time to time for that ser-
vice, but enlisted for other purposes. Such a state of
affairs should not be allowed to continue. The effi-
ciency of our costly machines of war as well as consid-
erations of humanity demand a change, and Congress
should act promptly in a matter of such moment.
That such corps exist in the medical departments of
the navies of all important powers is a standing re-
proach to our American civilization.
The outline of a bill for a well-equipped and thor-
oughly organized hospital corps appears in this re-
port. We hope it will receive immediate attention,
and that the navy will not long appear at a great dis-
advantage in this respect when compared not only
with our army but with the militia of the different
States. Surely at the present day no naval hospital
should be without a corps of well-trained nurses, and
no naval ship should be allowed to go into commis-
sion without a requisite number of trained nurses on
board.
The subject of a hospital corps is considered by the
surgeon -general in relation also to that of ambulance
ships. He makes a strong plea for such ships, believ-
ing that after battle some asylum for the immediate
reception of the wounded should be at hand, and that
only ambulance or hospital ships of special construc-
tion can answer this purpose. The whole question of
rendering proper assistance to the wounded or drown-
ing in naval warfare, irrespective of nationalities, is
of such interest and importance that it well deserves
the most serious attention and careful consideration.
Another weakness in the medical department of the
navy appears to be the number of vacancies in the
medical corps. It seems that during each year there
is a large number of applicants for information in
regard to appointment as assistant surgeon, but that
few avail themselves of the opportunities to appear for
examination. At the date of this report there were
ten vacancies in this small corps in the grade of as-
sistant surgeon, and it is stated that the department is
embarrassed by not having a sufficient number of
medical officers to fill important stations ashore and
afloat. We believe that the medical corps of the navy
has not had its complement since the war, and that this
state of affairs will continue until there is some favor-
able legislation for junior medical officers. The cor-
responding corps in the army has no difficulty in this
respect, and it is remarkable that the same corps in the
navy should have its efficiency seriously impaired be-
cause it is not allowed by Congress to offer at least
equal advantages. This subject is one of national
importance as it relates to the efficiency of our na-
tional defences, and no influence within or without the
navy should be allowed to delay suitable congressional
action.
Dr. Tryon's administration of his department as
surgeon-general of the navy has shown a most praise-
worthy progressiveness, that will leave its mark on the
naval service for very many years. This is apparent
in his report in various directions, among which may
be cited the establishing of a course of instruction for
junior medical officers, preliminary to their entering
upon active ser\'ice, the introduction of electric lights
in naval hospitals, their equipment with aseptic operat-
ing-rooms and furniture and with bacteriological and
chemical laboratories, and the adoption of disinfect-
ing plants of modern make. Improved outfits of
microscopes and accessories have been added to the
supplies of hospitals, ships, and navy yards, thus
completing a supply table which we believe has been
858
MEDICAL RECORD.
[December 12, 1896
made in the last year or two superior to that of any
naval medical department in the world, especially in
surgical instruments and appliances. An improved
swinging cot of unique design has been adopted for
sick-bays, and a method of transporting wounded on
ships of suitable construction has been introduced
which is extremely simple and, it is stated, very eflfect-
ive. By this method an injured man is moved along
the deck of any ship of favorable design, lashed in a
hammock, including the mattress, and is lowered
through hatches by the use of a stretcher bar of spe-
cial construction.
The improved method of gathering statistics re-
cently adopted, the results appearing in this report
for the first time, is very noticeable. The new no-
menclature of diseases is adapted to the requirements
of the naval service, but in view of the difficulties
experienced in all directions in securing a suitable
classification it is worthy of general attention. Much
valuable information is conveyed by tables well ar-
ranged and apparently selected with great care. It
appears that the death rate was 6.82 per thousand of
strength, and that during the year there were no cases
of yellow fever and but one of small-pox and two of
cholera.
Appended to the report are a number of interesting
articles by members of the medical corps and a good
index follows, completing a volume of about two hun-
dred and fifty pages.
We congratulate Surgeon-General Tryon upon his
administration of affairs and his comprehensive grasp
of the needs of his department in relation to the gen-
eral efficiency of the naval service.
those not classified by the health authorities as such;
for instance, the numerous skin affections so prevalent
in the schools, and other maladies propagated indi-
rectly through water-closet seats, drinking-cups, books,
slates, and the like.
CONTAGION IN SCHOOLS.
The health department of this city, being very properly
convinced that the greatest source of transmission of
infectious and contagious disease among children is
through contact with each other in school, proposes to
take radical measures for the mitigation if not sup-
pression of this obvious danger. Appropriations are
asked for paying a corps of physicians, at a low rate
of course, whose duty it shall be to inspect the schools
regularly and inform themselves directly and indirectly
on all points connected with possible disease dissemi-
nation. How competent men can be obtained at $30
per month can best be determined by officials who are
notoriously indifferent to the real value of such ser-
vices. Such, it strikes us, is a way of proving how
not to do a good thing. This, however, is merely a
remark in passing and especially in connection with a
reasonably fat salary offered to a chief inspector, whose
duties could be performed by the sanitary inspector or
his ambitious and not overworked assistant.
Still, the proposed school inspection is a most excel-
lent thing and it is to be sincerely hoped that it can be
properly carried out. Not only should the public
schools be under such a jurisdiction of the health board,
but every parochial and private institution as well.
We would extend the functions of such inspection to
include that of infectious disease of every sort, evexi
THE PHYSICIAN OF THE NEAR FUTURE.
Unwilling to combine in any manner with his fellow-
workers for his own protection, giving the best of his
early energy to work in institutions which take the
very bread from his mouth by treating and caring for
those who are not poor, his work competed with on
every hand by an ever- increasing host of special fads
and frauds, what will be the doctor's source of income
in the near fuutre unless a change is worked?
A crusade, organized to reclaim the holy shrines in
Palestine, incidentally booms the sale of Jerusalem
drops and other remedies supposed to originate with
the Franciscan friars. The Kneipp curists do not walk
long in dewy grass before the discovery is made that
Kneipp remedies for all known ills should be placed
on sale in every city of the world.
Park commissioners are asked to extend the courte-
sies of the grass to the early morning sockless peram-
bulator with the sole object of advertising the Kneipp
company's wares.
Faith, hope, and charity healers, mind, brain, and
thought curers, hypnotic, hydropathic, magnetic, elec-
tric, eclectic, spiritualistic, human, and divine work-
ers of miraculous cures increase and flourish. The
reputable physician walks to his dispensary class and
treats many who should be going to his own or to his
brother's office, and who will to-morrow run off to "a
divine healer" and leave a bank bill on his table in re-
turn for the benefit they hope will come from the laying
on of hands. There are many things the self-respecting
physician cannot fight against, but how some men can
put up with the indignities placed upon them by hos-
pital authorities and continue to respect themselves is
more than we can explain.
MUSIC AND NOISY NUISANCE.
Every one who lives in the close quarters of a noisy
cit}' is interested in settling the difference between
music and noisy nuisance. He may feel it, but it is
not polite to say it. If he does both, there is danger
that he may be open to the charge of want of culture
and taste. This is the strong side of the music nui-
sance, and generally some professional artist has to sit
in judgment on disputed proprieties. A sewer inspector
in this city has material difterences on this point with
a neighboring music teacher. In times gone by they
were very neighborly, l)ut subsequently their partitions
were not sufficiently iniiDcrvious or strong to keep
them at the required distance from each other. There
was no question about the noise in the business of
pupil's straining for high notes, but it was not music
to the over particular and unappreciative neighbor.
Not caring to endure the infliction, he trusted to a
well-known and oft-tried remedy of counter-irritation.
At given signals of distress well-paid organ grinders
December 12, 1896]
MEDICAL RECORD.
859
and hurdy-gurdy performers were posted on the side-
walk as an improvised chorus. The rebuke was pro-
nounced, emphatic, and overwhelming. In the mean
while the suffering inspector kept the best time he
could with an accompanying hammer tattoo on the
partition. Then it became a question as to which of
the contestants should have the privilege of creating
the most noise, and an attempt was made to right the
matter in a criminal court. The point was such a
delicate one that the responsibility of its settlement
was referred to civil authorities.
In the testimony it was asserted by the inspector
that " every time the pupils sang, the putty in his
window sashes cracked." This is probably an exag-
geration of metaphorical license in his effort to differ-
entiate between a subjective sensation and an object-
ive fact. The comparison with " the howls of suffering
dogs" perhaps comes nearer the mark. The organ
grinder understa ids this when a stray dog is within
earshot. When the Italian band was told to " move
on," the members smilingly ground their teeth and
their organs simultaneously. Thus there was no com-
mon ground upon which a general shut up could be
adjudicated. As the fight is still on, the situation is
an amusingly serious one, for the exasperated neigh-
bors are willing to admit that so far the sewer in-
spector has the most emphatic side of the argument.
If we could collect all the amateur horn blowers, the
practising squealers, the exasperating piano thumpers,
and harbor them in an isolated district, they might
fight out the noise nuisance very effectually without
harming innocent and forced listeners.
Vaccine Virus in Liquid Form. — Formerly the
vaccine virus employed by the health department of
New York was the serum which issued from the base of
a vaccine pock, dried on quills or ivory points. To
determine the most valuable part of a vaccine vesicle,
the following experiment was made : A typical vesicle
was chosen, and the crust, the underlying pulp and
base, and the serum exuding after the former were
removed, were collected separately. Each was mixed
with glycerin in the proportion of sixty per cent, vac-
cine matter and forty per cent, glycerin, then thor-
oughly comminuted in a mortar, and the products
were used in the multiple vaccination of children.
The pulp showed by far the best, the crust the next,
and the serum the poorest results, as determined by
the percentage of successful vaccinations. Other sim-
ilar experiments confirmed these results, and it was
concluded that the largest proportion of the active
virus is contained in the pulp. Therefore the virus
now issued is in the form of a glycerinated vaccine
pulp. Before using the virus derived from an animal,
first, the animal from which it was obtained is sent to
autopsy and the organs are examined for any evidences
of disease; second, two samples of the virus are given,
one to the bacteriologist and the other to the medical
tester of virus, and no virus is issued unless the re-
ports of the pathologist, bacteriologist, and clinical
tester are all satisfactory. The clinical test consists
in the inoculation of the virus after scarification in
three places on each of five children who have never
been previously vaccinated. There is tluis a case test
of five and an insertion test of fifteen points. The
results from the new method with this rigid system of
tests are shown in the records of the last three months.
Since July i, 1896, there have been vaccinated in the
routine way thirty calves from which virus has been
collected and tested as above described. All this
virus gave one hundred per cent, case and one hundred
per cent, insertion success at the original test, and the
same percentages of success at the last re-test made
about October i, 1896. There can therefore be no
doubt that the durability of the virus is assured for at
least three months from the date of collection. In all
the primary vaccinations made during September and
October by the department vaccinators in which the
results are known, more than seven hundred in num-
ber, there was not a single failure. The virus is a
syrupy, opaque, brown emulsion of uniform consist-
ency. It is put up in capillary tubes containing each
enough for a single vaccination, and in vials of two
sizes, one containing one-fifth of a cubic centimetre
for ten vaccinations, and the other containing one
cubic centimetre for fifty vaccinations. In using the
new virus the skin is scarified in the usual way, and a
drop of the liquid virus (discharged from a capillary
tube by blowing out the contents with a rubber tube
furnished for the purpose) is then thoroughly rubbed
into the scarified area with a slip of wood, which ac-
companies each tube. The new virus, like the other
products of the health department laboratories, is fur-
nished free to all public institutions in the city on
application. It is also supplied to physicians at a
moderate price.
The Late Dr. Samuel Sexton. — At the meeting of
the Practitioners' Society of New York, held Decem-
ber 5, 1896, the following preamble and resolutions
were adopted :
" Whereas, It becomes our painful duty to announce
the death of Dr. Samuel Sexton, one of the founders of
this society, therefore be it
" Resolved, That the Practitioners' Society desires
to place on record its due appreciation of his long and
valuable services in his chosen line of work, his
praiseworthy contributions to the literature of his spe-
cialty, his persistent and untiring advocacy of new
methods of treatment, and of his laudable endeavors
to broaden the domain of aural surgery by the patient
test of varied operative procedures and the careful
study of pathological conditions.
" Resolved, That the society has suffered a serious
loss in being deprived of his wise counsels, his ma-
tured judgment, and of his high example of profes-
sional rectitude.
'^Resolved, That his successful career will stimulate
his professional associates to endeavor to follow his
example in courtesy, loyalty, and unselfish work.
"George F. Shr.\dv,
"Charles L. Dana,
"Francis P. Kinnicutt."
86o
MEDICAL RECORD.
[December 12, 1896
Hotel Accommodations in Los Angeles. — A corre-
spondent writes that the disadvantage under which
Los Angeles, Cal., has labored, of having no hotel in
which a semi-invalid could be housed with comfort, is
soon to be removed. There is now in course of erec-
tion a large hotel having many sunny rooms and pro-
vided with all the conveniences which the modern
tourist or health seeker demands.
"Acromegaly." — The author of this paper, pub-
lished in the issue of November 28th, is Dr. H. H.
Vinke, not Dinke as printed.
Philadelphia Hospital. — The Association of Ex-
resident and Resident Physicians of the Philadelphia
Hospital held its annual dinner at the Hotel Bellevue,
on the evening of December ist. Some sixty members
were present, and toasts were responded to by Drs.
Horatio C. Wood, Francis M. Perkins, James C.
Bloomfield, David Kiesman, and Daniel McCarthy.
" Medico-Surgical Bulletin."— Dr.Egbert H. Gran-
din has retired from the associate editorship of the
American Aledico- Surgical Bullet in.
Dr. Lightner Witmer, professor of experimental
psychology in the University of Pennsylvania, has
been appointed psychologist to the Pennsylvania In-
stitute for Feeble-Minded Children at Elwyn.
Vital Statistics of Philadelphia.— For the week
ending November 28th, there occurred in the city of
Philadelphia, 389 deaths, 15 more than during the
preceding week, and 28 less than during the corre-
sponding week of the previous year. Of this number,
118 were in children under the age of five years.
The individual causes of the largest number of deaths
were: Pulmonary tuberculosis, 52; pneumonia, 46:
diphtheria, 24; heart disease, 21. There were re-
ported to the board of health during the week, 133
cases of diphtheria, 77 cases of typhoid fever, and 31
cases of scarlet fever.
Obituary Notes. — Dr. John Ellis died at his
home in this city on December 3d from pneumonia.
He was bom in Ashfield, Mass., in 18 15, and was
graduated in medicine from the Pittsfield Medical
College in 1842. He practised for a while in Michi-
gan, later became a convert to homoeopathy, and finally
abandoned medicine to engage in the refining of pe-
troleum.— Dr. William H. Woodruff died on De-
cember I St, at the age of sixty-five years. He was a
graduate of the All^any Medical College in 1854, and
had practised since that time in Pine Bush, Orange
County, N. Y., where he died. He left a widow and
four children. — Dr. Henry G. D.'Wis died recently
at his home in Everett, Mass. He w-as born in Maine
in 1807, and was graduated from the Yale Medical
School in 1839. After practising in Massachusetts
for a number of years he came to New York, where he
was the pioneer in orthopedic surger)'. He devised a
number of ingenious forms of apparatus for the cor-
rection of deformity, among others the hip splint.
He also wrote several monographs on orthopaedics. —
Dr. Guido Furman died on December 2d at his
home in this city. He was born in Nassau, Germany,
in 1831, and was graduated from the medical depart-
ment of the New York University in 1856. All his
professional life was passed in this city. He was a
member of the Medical Association of the County of
New York, of the Academy of Medicine, and of the
New York Pathological Society. — Dr. E.mil Wolff,
professor of chemistry, died at Stuttgart, Germany, on
December 7th. He studied medicine and natural
science, but early turned his attention to agricultural
chemistry, of which he became perhaps the greatest
exponent of his time. — Dr. Pincknf.v Webster Ells-
worth, of Hartford, Conn., died in that city on No-
vember 29th, of cerebral hemorrhage. He was bom in
Hartford in 18 14, and was educated at Yale College.
He was graduated in medicine from the College of
Physicians and Surgeons in this city in 1839. At the
beginning of the civil war he was appointed surgeon
of the Connecticut brigade of volunteers, and he par-
ticipated in the first battle of Bull Run. He was one
of the organizers of the Hartford Medical Society, a
member of the Connecticut Medical Society, and an
honorary member of the New York State Medical So-
ciety. Dr. Ellsworth's mother was the eldest daughter
of Noah Webster, the lexicographer, and he was a
grandson of Chief-Justice Oliver Ellsworth of the
United States Supreme Court. — Dr. C. S. Fi.ovd, of
Austin, Pa., was killed on November 26th by falling
down the stairs of a hotel at Coudersport.
Insane Prisoners. — It was developed in a recent
court proceeding in Philadelphia that many inmates
of the f^astern penitentiary in that city are insane,
and are without the attention which should be given
to insane people, despite the fact that Pennsylvania
has a law providing for the removal of insane con-
victs from the prisons to the a.sylums. It is asserted
that the enforced idleness of the prisoners has much
to do with this increase of mental disorder among
them.
Cremation in Canada. — It is proposed to establish
a crematory in connection with the Mount Royal
Cemetery in Montreal, but the measure has not yet
been decided upon by the directors, and vigorous op-
position to it is expected from the conservative mem-
bers of the board.
Koch on the Rinderpest. — Dr. Koch and Dr.
Kohlstock are on their way to South Africa to inves-
tigate, at the request of the Cape government, the
outbreak of rinderpest. They will establish their
laboratory at Cape Town.
The Trinidad Leper Asylum -The report of the
Trinidad Leper Asylum issued by the medical officer,
Mr. R. H. E. Knaggs, for the year 1895, shows that
there were two hundred and nine persons in the asy-
lum at the end of the year and that there had been
fort)'-seven deaths during the year, and fifteen patients
discharged; two of these latter were sent to prison,
one to the lunatic asylum, and one left for India.
The Anglo-American Continental Medical Society
held its annual meeting in Paris on November nth.
Seventeen new members were elected.
December 12, 1896]
MEDICAL RECORD.
861
A Congress of French Alienists and Neurologists
will be held at Toulouse in 1897, under the presi-
dency of Dr. Ritti, editor of tiie Annahs Afeifho-Psy-
chologiqiics.
Pathological Socie y of Philadelphia. — At a stated
meeting of tlie Pathological Society of Philadelphia
on November 12th Dr. Joseph McFarland exhibited a
portion of small intestine displaying an ulcer of un-
certain origin resulting in perforation and peritonitis.
Dr. Joseph Sailer exhibited a heart whose aortic valve
was formed of two cups only, and two other hearts
whose pulmonary valves were each constituted of four
leaflets; he also showed a renal tumor, probably sar-
comatous, and an abnormally lobulated spleen from a
colored person. Dr. D. Riesman exhibited two speci-
mens of carcinoma of the oesophagus, a tuberculous
tumor of the larynx, and lungs presenting miliary
tuberculosis in conjunction with a caseous mesenteric
gland. Dr. H. W. Cattell and J. D. Steele exhibited
a specimen of aneurism of the sinus of ^'alsalva. Dr.
W. S. Newcomet presented tuberculous ulcers of the
intestine, with a vermiform appendix only three-
eighths of an inch long. Dr. S. M. Hamill exhibited
a dilated stomach due to pyloric obstruction, result-
ing, it was supposed, from an ulcer in the duodenum.
The following card specimens were exhibited: Dr. A.
W. Booth, a renal cyst; Dr. A. Stengel, probable sar-
coma of the retroperitoneal glands with metastasis,
especially in the spleen; Dr D. Riesman, anomalous
distribution of the coronary arteries and apparently
supernumerary spleen.
A Worthy Celebration. — The British Medical Jour-
nal announces that the lord mayor elect. Alderman
Faudel Phillips, proposes to signalize his mayoralty
and commemorate the sixtieth anniversary of the
Queen's reign by raising a national subscription to
free the public hospitals from debt. It is estimated
that the amount required will be from ^800,000 to
^1,000,000.
Leprosy Congress. — An invitation has been ex-
tended by Drs. Ehlers, of Copenhagen ; Hansen, of
Bergen ; Koch and Lassar, of Berlin, to convene in the
last-named city during the month of October, 1897.
Atlanta's Health Inspector has declared war
against the city well. There has been of late much
fever in the city, and its prevalence is accounted for by
the drinking of unwholesome well water. The hydrant
supply is said to be abundant and pure.
The Woman's Health Protective Association has
started in upon a praiseworthy attempt to improve the
hygience of the bakery. Many of the underground
shops in this city are foul. Of the fifty-two hundred
and seven bakers investigated thirteen hundred and
seventy-five were on the sick list. Most of them suf-
fered with inflammation or congestion of the lungs,
and there were quite a number of tuberculosis cases
and also some cases of diseases arising from personal
uncleanness or immorality. — The Sanitarian.
Tight Lacing was given as the cause of death in an
inquest held within the past fortnight in London.
Abundant testimony pointed to the custom as having
been the undoubted cause of death.
New York Otological Society for 1896-97 The
following officers were elected at the annual meet-
ing held November 24, 1896: President, Dr. Gor-
ham Bacon; Vice-President, C. J. Kipp; Secretary and
Treasurer, H. A. Alderton.
Bacteriologists to the Pennsylvania State Board
of Health.— Dr. W. M. L. Coplin, of Philadelphia,
has been appointed bacteriologist to the Pennsylvania
State board of health, and Dr. Richard Slee, of Swift-
water, Dr. Nelson F. Davis, of Bucknell University,
and Dr. Robert L. Pitfield, of Germantown, assistant
bacteriologists.
Philadelphia Neurological Society. — At a meeting
of the Philadelphia Neurological Society on Novem-
ber 23d, Dr. C. W. Burr reported a case of mind blind-
ness and touch amnesia.
Philadelphia County Medical Society. — At a
meeting of the Philadelphia County Medical Society
on November 25th a paper entitled "Eight Primary
Movements in the Treatment of Cur\ature of the
Spine,'" read at the preceding meeting by Dr. J. T.
Rugh, was discussed by Drs. De Forest Willard, H.
Augustus Wilson, James K. Young, J. Packard Mann,
Bertha Lewis, Walin, and Benjamin Lee. By in-
vitation of the directors Dr. A. O. J. Kelly read a
paper entitled "The Neuron, with Exhibition of Speci-
mens and Diagrammatic Representation of its Mor-
phological Characteristics," which was discussed by
Drs. Charles K. Mills, F. X. Dercum, and J. K. Mitchell.
Royal University of Ireland. — Dr. More Madden
has had conferred upon him the degree of M.A.O.
(master of obstetric art) honoris causa. Dr. Madden
has long been known as a writer and teacher and this
new honor only adds to the many which have preceded.
Pharmacists are not held in high esteem by Dr.
Schweninger, Bismarck's physician. He says the
physician who places himself at their service and aids
them to lay up a fortune at the expense of humanity
dishonors his calling.
The American Laryngological, Rhinological, and
Otological Society. — The western section of the
American Laryngological, Rhinological, and Otologi-
cal Society will hold its meeting in Kansas City, Feb-
ruary 2 and 3, 1897.
An IneflScient Army. — Venereal diseases keep over
three thousand soldiers from performing duty in the
English army in India, according to the recent report
of the sanitary commissioner to that government. In
1894 sixty-two thousand admissions for venereal dis-
ease occurred, or 5.342 total admissions for each one
thousand of strength of the whole English army.
Thus a small army in itself is constantly incapacitated
by diseases which for the most part are preventable.
Philadelphia Semi-Centennial Meeting of the
American Medical Association, to be held June i,
2, 3, and 4, 1897. In view of the fact that the next
meeting will be the semi-centennial gathering, and
862
MEDICAL RECORD.
[December 12, 1896
that it will occur in a great medical centre and near
the other great cities of the Eastern coast, the com-
mittee of arrangements for this meeting has already
made provision for the accommodation and entertain
ment of the delegates, by the engagement of the Acad-
emy of Music, Horticultural Hall, the South Broad
Street Theatre, and the large meeting-rooms in tlie
Hotel Walton and Hotel Stenton. As these large
buildings are all within a short distance of the great
railroad depots in the centre of the city and are all
situated within one block on both sides of Broad
Street, every department of the meeting will be con-
veniently arranged. At the last meeting of the asso-
ciation it was voted to devote the first evening of the
meeting, Tuesday, June 1 st, to dinners of the various
sections. The officers of the sections desiring to give
such a dinner will please communicate with Dr. G. E.
de Schweinitz, chairman of the subconnnittee on
accommodation, 1,401 Locust Street, as early as pos-
sible, in order that dining-rooms may be engaged or
other entertainment provided. As it is expected that
fully three thousand physicians will be present, the
committee suggests that application for accommoda-
tions be made as early as possible. It is hoped that
every member of the association will make a special
effort to attend. Further circulars of information will
be issued by the committee from time to time. Indi-
viduals and firms desiring space for exhibition in the
exhibition hall, which will be in the same block as
the various meeting halls, will please apply promptly
to the chairman of the subcommittee on exhibits, Dr.
Edward Jackson, 1,633 Locust Street, Philadelphia.
H. A. H.ARE, M.D.,
Ch.-\irm.\n of ihk Committkk of Arranokments.
Typhoid Antitoxin It is announced that an effi-
cacious and reliable antitoxin for typhoid fever has
been elaborated in (Germany by Pfeiffer. An account
of the mode of preparation and the report of a series
of experiments will soon be ]Hiblished.
Health Inspectors for Schools. — The board of
health of this city proposes, if it can secure the neces-
sary appropriation, to appoint medical examiners for
all the schools — public, private, and parochial — in
New York, with a view to prevent the spread of con-
tagious diseases, especially diphtheria and scarlet fe-
ver, among children. It is the opinion of the medical
officers of the board that the greatest source of trans-
mission of infectious and contagious diseases among
children in this city is through their contact with one
another in schools. It is also believed tliat a material
reduction in the number of cases of sickness and
death from contagious diseases can be secured by a
daily inspection of the pupils of each school by a med-
ical inspector, and by a.scertaining whether children
absent from school are sick with contagious or infec-
tious disease. It is proposed to appoint one hundred
and fifty medical inspectors, to serve for ten months
each year, at a salary of S30 per month, and one chief
inspector at a salary of $2,500 per annum.
The Relationship of the Testicles and Prostate
Gland. — The following is an instructive case in this
regard, which was published by Dr. John R. Gibson,
in The Laturt : A man, aged between fifty and sixty
years, afflicted with enlarged prostate gland and re-
quiring the use of the catheter before any urine could
be drawn off. recently became afflicted with acute or-
chitis of one testicle, the orchitis being probably
caused by the irritation of the catheter, as great diflfi-
culty was experienced in passing it. Almost imme-
diately after the onset of the orchitis, he could pass
urine more or less freely, an act he had not performed
for over a year, and all the bladder symptoms under-
wer.t great improvement.
Dr. Jameson, who was sentenced to Holloway Jail
for unethical conduct in South Africa, has been re-
leased on account of serious illness, and is now in a
private hospital in one of the suburbs of London.
St. Luke's Hospital. — The annual report of this
hospital has just been issued. It states that the
greater part of the ground formerly occupied by the
hospital, on Fifth Avenue, has been sold, and that the
corporation is now free from debt. The number of
patients treated during the year was 1,439, ^^ whom
663 were in the medical and 776 in the surgical wards.
The expenses for the year were Si 09,744.47. An ap-
peal is made for funds to endow a pathological labo-
ratory and to erect a pavilion for consumptives.
The Louisiana State Board of Health announces
that it will supply antitoxin gratis to the poor who are
suffering from diphtheria.
Wholesale Poisoning. —At a silver wedding anni-
versary banquet in Hollidaysburg, Pa., recently, sixty
of the guests were made seriously ill by some poison-
ous material in the food.
Surgeons Wanted. — A dispatch fom Madrid states
that General Weyler has telegraphed that one hundred
army surgeons are urgently needed in Cuba. The
work of getting surgeons for the Cuban service is more
difficult than that of raising raw recruits. The gov-
ernment has been forced to extend the maximum of age
for admission into the army sanitary corps, the appli-
cants above the age established by law to be assigned
for service in Cuba.
Bogus Wines in Germany Commenting upon the
enormous exports from Germany to the United States
of artificially prepared wines and inferior spirits and
beers, the Berlin Ncucste KaihruiiUii says that, since
the passage of the wine act by the Reichstag, in April,
1892, in regard to the adulteration of wines and alco-
holic beverages, immense quantities of liquors have
been brought into the market under the name of wines,
at such low prices as to prove it impossible that they
could have been prepared in accordance with the law.
Cholera in Southern Russia. — The Russian au-
thorities have apparently come to the conclusion that
cholera is now endemic in South Russia, for perma-
nent cholera barracks are being erected at Odessa, Se-
i)astopol. Novo RossiisV, Batum, Kertch, Poti, Berdi-
ansk, and many other places, which will be ready for
occupation by next spring.
December 12, 1896J
MEDICAL RECORD.
86:
"ocictij Reports.
NEW YORK ACADEMY OF MEDICIM
Sf<i/t(i J/<i///ix, Dtwmbcr
l8<p6.
Joseph D. Bryan r, M.D., President, in the Chair.
Resignations. — The Secretary read some corre-
spondence from Dr. George L. Peabody, stating that
he was to remain abroad for some time, on account of
ill health, and therefore tendered his resignation as
trustee. It was accepted with regrets.
Dr. A. Jacobi's resignation as chairman of the board
of trustees was read. The President spoke of Dr.
Jacobi's long and valuable services to the academy,
and said no explanation had been received for his res-
ignation. Replying to Dr. J. P. Tuttle's inquirv'
whether a motion was in order, authorizing the presi-
dent to appoint a committee of one to wait on Dr. Ja-
cobi and learn whether his resignation was unaltera-
ble, he said it certainly was; and, on adoption of the
motion, appointed Dr. Tuttle on the committee.
Ernst Krackowitzer Library Fund. — A communi-
cation in the form of an affidavit was received from
Dr. Jacobi, stating that, inasmuch as the Ernst Krac-
kowitzer prize fund had not been competed for, but had
been accumulating since it was founded, he would re-
quest, as the only surviving member for its administra-
tion, that it be converted into an Ernst Krackowitzer
library fund. The matter was referred to the trustees
of the academy, with power.
Nominations. — Dr. Bryant was renominated for
Presiikiit, but declined, saying that he thought, unless
a special contingency arose, the honor of one term of
two 3'ears was enough. Dr. E. G. Janeway was then
nominated, and on motion the nomination for President
was declared closed. For Vice-President, Drs. Arpad
G. Gerster and Everett Herrick; for Trustee, long
term, Dr. Bryant; short term. Dr. F. R. Sturgis: for
Committee on Library, Drs. C". H. Knight and Achilles
Rose ; for Committee on Admission, Drs. Dessau, Ew-
ing, Satterthwaite, Brill.
The Management of Pneumonia Patients. — Dr.
Si-MON Barlch, in presenting this paper, said his rea-
son for doing so was the continued high mortality from
pneumonia and the desire to give a resume of his e.x-
perience in country and city practice for a third of a
century, together with what he thought was the man-
agement most likely to save life at the present time.
The teaching of the schools and the practice in the
army at the commencement of the civil war was clearly
antiphlogistic, including bloodletting and purging.
Seeing a vigorous young soldier practically recover
from an attack of pneumonia and also from a relapse,
then to die of exhaustion attributable to such heroic
treatment (directed by another physician), he was
himself deterred thereafter from imitating the e.xam-
ple. Afterward, it became almost the universal prac-
tice to combat heart failure by such drugs as digitalis
and strophanthus; and, finally, the temperature re-
ceived chief attention, leading to the employment of
the coal-tar series of antipyretics. The view was that
pneumonia was a local disease, and it was only re-
cently coming to be regarded as a constitutional affec-
tion with a local e.xpression in the lung, just as in ty-
phoid fever there was local manifestation in the
intestine. At this point Dr. Baruch pointed out anal-
ogous conditions relating to typhoid and pneumonia,
and their bearing upon treatment, particularly hydro-
therapy. Both diseases were due to germ infection,
the micro-organisms entering the mouth, and going in
one instance to the intestine, in the other to the lungs:
but in both running a definite life course, during which
they produced constitutional symptoms, which ceased
with the death of the micro-organisms, although local
lesions might still remain. In pneumonia, however,
the diplococci had a life history of only about a third
duration of the Eberth bacilli, and they were more
likely to reach the meninges and other structures, as
well as the lungs, adding further symptoms to those
depending upon toxin circulating in the blood. But
the chief blow in both diseases was upon the nervous
system. It was not until he had learned the true
principle of the Brand method in typhoid fever that
he had come to feel a sense of security in treating this
disease, and he suggested that in hydrotherapy would
be found a like positive treatment for pneumonia.
The following was, in brief. Dr. Baruch's manage-
ment of pneumonia patients: Complete rest of body
and mind. Thorough ventilation of the sick-room.
Diet restricted to milk and farinaceous broth, four to
six ounces every two hours. Plenty of water. Since
pneumonia was a disease of short duration, he did not
believe in " stuffing" the patients. Alcohol was not
necessary, as a rule. He used few medicinal agents,
but gave a good dose of calomel at the outset, not re-
peating it. Its effect was twofold: Placed dry upon
the tongue, it destroyed the diplococci in the mouth;
it removed the ptomains which might have lodged in
the gastro-intestinal canal. Further, it probably was
of benefit in indirectly relieving the engorged lung
by acting upon the portal circulation. The patient
was directed to rinse the mouth frequently with chlo-
rate of potassium. Strychnine was used hypodermi-
cally for the heart.
The author then spoke of hydrotherapy, dwelling
upon its importance and explaining its mode of action.
With children, the tub bath could be readily applied;
but for adults he preferred the wet compress, because
it was much less disturbing. \\'hen tubbing was used
for children, one could begin with a temperature of
95° F., and reduce it according to the case. It should
be continued a shorter time than in typhoid fever, say
ten minutes, and repeated in three or four hours.
The cold compress used for adults covered the back
and front of the chest, was wrung out of water at 60^
F., and was repeated every half-hour or hour, accord-
ing to the case. A higher temperature than 60° V.
might be used if there was much jactitation and exci-
tability. If there was delirium with depression, the
compress could be preceded by dashing on of cold
water. The author attributed much of the benefit to
the tonic effect of the cold compresses upon the ner-
vous centres, and to relieving the heart by dilating
the surface capillaries. It also acted by reducing the
temperature and increasing elimination, whereby the
toxins were cast out of the circulation. The action
was very different from that of warm poultices. Un-
der special conditions, oiled silk was placed over the
flannel coverings, which converted the compress into a
poultice. Only about forty per cent, of the cases
treated in this manner liad terminated by crisis; the
remainder by lysis, or gradual clearing up of the phys-
ical and subjective symptoms.
Dr. Baruch said he had not lost a case of uncompli-
cated croupous pneumonia in private practice since he
had adopted the cold compress and general manage-
ment outlined in his paper. It was more difficult to
judge of the method by hospital practice, where one
seldom saw the patient in the early stage of pneumo-
nia. The method of applving the cold compresses
must be as exact as that of drug administration. 'I'he
general statement to use cold water might mean, in the
summer, water at 75" F. : and in the winter, below 45"
F. — certainly a great difference.
Cold Bath in Thirty-Six Cases of Pneumonia. —
Dr. Charles B. Folso.m, of Boston, expressed the
strong conviction that pneumonia should be treated by
864
MEDICAL RECORD.
[December 12, 1896
boards of health and by the public as an infectious
disease. He then related his experience with cold
baths, and said it had been limited to thirty-si.x cases
in the Boston City Hospital. It was given very
nearly as in typhoid fever, only not quite so long and
the temperature was not quite so low. Three classes of
cases were excluded : i.The moribund and those not
likely to live more than a day or so after admittance
to the hospital; 2, cases in which the temperature did
not rise above 102.5° ^■'< 3> cases of simple, mild, un-
complicated pneumonia, involving perhaps one lobe,
in young people who were likely to get well without
much interference on the part of the physician. Of
the 36 patients, 28 recovered, 8 died — a mortality rate
of 22.2 percent. During the last year, 355 cases of
croupous pneumonia had been treated without baths,
with 124 deaths — mortality of 34.9 per cent., which
was about their average mortality for all years. Of his
eight patients who died under the bath treatment, one
had typhoid fever and one kidney disease, and if these
two were excluded, it would leave a mortality rate of less
than 18 percent. Judging by this experience, Dr. Fol-
soni thought the bath treatment in pneumonia, as in ty-
phoid fever, gave a better chance of recovery, even in
seemingly desperate cases. It was clear to him that it
had done no harm, and he was well pleased with the re-
sults. The patients themselves felt comfortable under
the treatment, whereas in typhoid fever about one-third
of them disliked the baths. They were given plent}-
of fresh air and other treatment as indicated. In Bos-
ton they gave little medicine for pneumonia, except
when directly indicated, and this occurred less fre-
quently under the bath treatment. The baths acted
beneficially by moderating the fever, mitigating the
pain, lessening the cough, quieting restlessness and
delirium, relieving distress in breathing, and inducing
sleep.
Adapts the Treatment to the Case, Not the Case
to the Treatment. — Dr. E. G. Janeway opened his .
remarks with the statnient that pneumonia was a broad
subject. There was not only a toxic agent, not only
inflammation of the lung, but the indi\idual reaction
to these two things. In old people pneumonia might
attack one or botii lungs, prove fatal, and yet not be
attended by fever. There one could not employ the
cold bath nor the compress. Yet he dreaded the afe-
brile pneumonia of old people more than he dreaded
the highly febrile pneumonia of young people. In the
former all treatment had for its object to keep up the
strength of the patient.
In young people we saw pneumonia result in recovery
under almost any plan of treatment. One week he
saw four subjects, all of whom recoveredon the third
day; in each case the attending doctor had pursued a
different course of treatment, and with equally good re-
sults. If he had seen but one of the cases, the good
result might have been attributed to the treatment.
There was tri lobar pneumonia, in which a si/ie qua
7ion to recovery was o.xygen. There was cyanosis
throughout. We could not look upon pneumonia sim-
ply as a toxic disease. The lung was inllamed, the
breathing capacity was diminished, and to meet this
indication he regarded oxygen as the best agent.
Then we iiad to consider maintaining the heart's
strength. Different doctors had different ways for do-
ing this, some preferring digitalis, some strophanthus,
others sparteine, camphor, strychnine, nitroglycerin.
A good deal might be said about the size of the dose.
Nothing varied more than the dose of digitalis and
other heart tonics. He remembered a case of Dr.
Duncan's, in which the pulse was very bad at the out-
set of the pneumonia. Dr. Duncan gave a dose of a tea-
spoonful of tincture of digitalis and repeated it once;
the pulse improved, the patient recovered, no more
digitalis was required. The case showed that we had
to meet contingencies. He had seen some patients
treated with the cold compress as recommended by
Dr. Barucii, some treated w ith a wet flannel, some with
oiled silk o\er the chest. Of the different plans, he
thought the compress laid across the chest had acted
as well as any. For himself, he did not feel like ad-
hering to any iron rules, either as to external applica-
tions or internal medication. More important than
any plan was the individual under treatment.
Dr. Janeway was not one of those who decried the
coal-tar series of drugs. He had given patients a great
deal of comfort at times by their use. In one case,
in which the temi^erature rose to 106° F., cold com-
presses did not reduce it and the attendant restless-
ness, while phenacetin did. This experience was re-
peated twice in that case. The phenacetin reduced
tiie temperature and also induced sleep, as morphine
might; but it did not, like morphine, cause constipa-
tion, tympanites, and derangement of the liver. Dis-
couragement of the coal-tar series, on account of de-
pressing effects, came from Germany, where they gave
very large doses of everything. It was Dr. Janeway's
custom to give the smallest dose which would accom-
plish the purpose, and not to give the largest dose
which the patient could stand.
Abortion of Pneumonia. — Dr. Janeway thought it
was possible to abort pneumonia, but the opportunity
seldom presented itself when the physician was called
soon enough, and it was very difficult to prove that
without the physician's interference the patient would
have had pneumonia. The method which he thought
had aborted an attack in a few cases which he had
seen consisted in applying a hot footbath for half an
hour, hot drinks, sweet spirits of nitre, liquor ammonia;
acetatis, aconite, followed by large doses of quinine.
Dr. W. p. NoRTHRii' expressed interest in Dr. Jane-
way's remarks on the varieties of pneumonia, and said
that he had at one time seen a good many ca.ses of afe-
brile pneumonia in old people, and was willing to try
something new in the way of treatment, since under
the plan adopted all died. Regarding the abortion of
pneumonia, he thouglit he had accomplished that in
one case, that of a young man, by very hot water to the
feet, he'at to the side, and hot drinks. In all cases of
pneumonia he gave free ventilation and paid special
attention to the digestive tract. Flatulency, with
pressure against the diaphragm, was very oppressive
to a pneumonia patient. He gave cxygen, but it was
through the open window. He related several cases
illustrating the rapid improvement in the condition of
patients suffering with pneumonia when they were
given plenty of air by opening tlie window, and when
cold was applied by ice bag, or, better, by bath. What
we found especially good in the bath w-ere improvement
in the mental condition, quieting of the nervous cen-
tres, improvement of the pulse, depth of respiration,
sleep. He felt under great obligations to Dr. Baruch
for what he had done for New York in the way of hy-
drotherapy.
Dr. .'\i.fred Mevkr said he had had no experience
with the bath treatment, but had employed such reme-
dial agents as seemed appropriate to individual cases.
He had not a long list of cases, but his assistant at
Mt. Sinai had tabulated twelve treated on the plan
named, with only two deaths, a mortality rate of about
sixteen per cent.
Dr. Baruch said, in some closing remarks, that he
had not met with afebrile pneumonia in the aged, but
he had seen high temperature pnevmionia in the aged
which had been treated with cold compresses. He
could not accept the view, prevalent among the pro-
fession, that oxygen was of use in the dyspna-a of
pneumonia, as it had been shown to be against the law
of the diffusion of gases. He believed in Dr. Nor-
thrup's way of giving oxygen, namely, by way of the
December 12, 1896]
MEDICAL RECORD.
865
window. Regarding digitalis, he did not doubt that
it was a splendid heart tonic in the early stage of pneu-
monia, but in the later stages it caused the weakened
organ to struggle tremendously against contracted pe-
ripheral vessels. Indeed, it did harm in the later
stages by contracting the peripheral vessels. Regard-
ing cold compresses, he repeated that everything de-
pended upon how they were applied.
SECTION OX GENER.VL MEDICINE.
Stated Meeting, November ij, i8g6.
Reynold W. Wilcox, M.L)., Ch.\irnl^x.
Anaemia in Relation to Cardiac Disease. — Dr. An-
drew H. Smith read the paper (see p. 852).
Dr. Beverley Robinson opened the discussion.
He thought all must have at times met with difficulty
in determining to what extent a patient was suffering
from simple ana;mia, or anamia depending upon heart
disease, or whether certain physical signs were depen-
dent upon the latter or were anamic in origin. These
difficulties applied more particularly to women and
children. For instance, a patient appeared in whom
we appreciated a blowing murmur at the ape.x of the
heart; there were pallor and oppression of breathing.
It was difficult to say at the moment whether such a
patient had cardiac disease. Examination of the
blood was probably- the chief test, and if it were found
to show only from fifty to seventy per cent, of hanioglo-
bin, relative increase of the white cells, and some
change in the red cells, of course we would feel that
anaemia was a very important factor. But those were
not the cases in which there was most difficulty. It
was rather those in which there was but slight change
in the blood and there were certain signs of cardiac
disease. Modern authors had dwelt less upon the re-
lation of cardiac trouble to ana-mia than some who
had written a number of years ago, and he might men-
tion Stokes, in particular, as one who recognized the
difficulty of diagnosis and the importance ot making
it. The best advice which he could give was to be judi-
cious in doubtful cases. It might be that the cardiac
murmur and symptoms of anamia would disappear
under tonic and hygienic measures. As to iron, while
we all had some preparation which we were more
likely to give than others, he did not think the organic
salts possessed any special advantage over the inor-
ganic salts of iron. There were manganese, digitalis,
strophanthus, nitroglycerin, etc. He knew clinically
that in a good many cases iron acted better when oxy-
gen was also administered artificially. One of the
best tonics, when properly used, was sulphur baths,
either artificially prepared or at springs. He be-
lieved a good deal of the benefit obtained at Bad
Nauheim and the Schott treatment, on which Dr.
Heineman had recently read a paper before the acad-
emy, was due to relief of anamia and not to the effect
upon what he believed to be irreparable cardiac le-
sions. But it was not necessary to go abroad for the
treatment or to get the information.
Functional Cardiac Murmurs.— Dr. Willlam H.
Tho.mson' said he had been rather disappointed to hear
anaemic cardiac murmurs referred to almost to the
exclusion of functional murmurs. The latter were
extremely interesting to him, and he was sure that in
many cases they were the most important ones which
came before the hospital physician and the insurance
examiner. Functional murmurs included much more
than anamic murmurs. He had known of more than
one man being rejected for insurance because of a
murmur taken to be a cardiac regurgitant, but which
Dr. Thomson believed was only functional : yet there
was no anaemia. He was sure there were some strange
murmurs which were affected by the respiration and
which were certainly functional. All functional mur-
murs were systolic. A diastolic niurnuir could not be
functional, neither could a presystolic munnur. A
systolic ha-mic murmur, as in chlorosis, was heard
loudest at the second interspace to the left of the ster-
num, and while it was frequently transmitted down to
the apex, where one heard mitral organic murmurs, yet
it was never so loud there, nor was it transmitted to
the left, but rather to the right. He did not doubt
that Dr. Smith had, as he had stated, occasionally
heard a ha-mic murmur in the axilla to the left: but
Dr. Thomson personally had never had such experi-
ence. When in doubt whether a murmur was func-
tional or organic, the examiner should have the
patient lie down, and if it were functional it would
be diminished. Further, if it were functional, it
would totally disappear while the patient took a
long breath and held it. If the murmur were due to
a lesion of the mitral valve, it would not diminish on
lying down, nor disappear on holding the breath.
Then there was a difference in the character of the
sound. It was not whizzing, buzzing, or booming, as
in functional murmurs. The functional murmur di-
minished also on quieting the patient, who, when he
came in for examination, was likely to be much ex-
cited, anxious, and to have a rapid pulse. He be-
lieved such functional murmurs to be due largelv to
the muscular element of a rapidly acting, irritated
heart in nervous persons.
There was another kind of functional murmur which
was very puzzling indeed. It was heard during cer-
tain acts of respiration, but was particularly apt to be
heard during inspiration and then to disappear. It oc-
curred at the mitral area and was not transmitted at
all. This was one of the most peculiar of murmurs,
for he had heard it nearly as far to the right as the
nipple, and again on the left side, away from the area
of the heart, very nearly at the posterior axillary line.
He did not know how it was produced, but evidently
it was through the lung. A murmur which was heard
at a distance from any of the areas of the heart could
be put down as functional.
The question of anamia was a large one, and he
would say but a few words on it. He fully agreed
with Dr. Smith, that anamia in relation to the heart
was very important. He believed, also, that it bore
a causative relation in many instances to organic
trouble in the heart; that there were cases of heart
disease which were produced by anamia in the first
instance. Throughout the whole animal kingdom
muscular power was in direct proportion to respira-
tion. Muscular weakness tended to produce anamia.
The muscle cell had to breathe more than any other
cell, more even than the ner\e cell, for it had two func-
tions to perform — to produce muscular contraction and
to make heat. The most marked cases of fatty heart
found at the autopsy table were in pernicious anamia.
There was a softened heart in chlorosis, and in anamia
connected with muscular debility we found a weak
heart. Many cases of cardiac disease had dated from
a muscle disease, like rheumatic fever.
Dr. Thomson would take issue with any one who
would give iron simply because there was anamia.
In all febrile anamias it did mischief. Doctors were
very apt to give it in the anamia of acute articular
rheumatism, and the result was much harm, for it in-
creased temperature. I*^ was so in phthisis. It would
be far better to give cod-liver oil.
Anaemic Murmurs Not Always Systolic. — Dr.
Frank. W. Jaik^dn said the point in the paper which
struck him as most important was the fact that anamia
might be primary, although associated with heart dis-
ease. We were too apt to think it must necessarily
be secondarv to the heart disease. It would be much
866
MEDICAL RECORD.
[December 12, 1896
better in the cases named to direct treatment to the
anamia and let the heart alone. The opinion gener-
ally prevailed that all ansemic murmurs were systolic,
and the same opinion had been expressed to-night, but
in reality one who examined many and all kinds of
hearts found now and then an exception to that rule.
Last year a German author had published three cases
of accidental murmurs, and, death having taken place
from some other cause, the heart was examined and
found to be absolutely normal. Dr. Jackson had him-
self found a presystolic murmur in several ana-mic
persons, which disappeared when they regained their
normal health. Regarding the influence of the recum-
bent posture on ana-mic murmurs, he had seen some
cases in which it made no difference. He used the
hajmoglobinometer, and if the percentage of h.tmoglo-
bin fell below seventy-five there was good reason to
suppose that the murmur was anaemic, if there was no
definite evidence of organic disease. As Dr. Thom-
son had said, a large number of murmurs were func-
tional, some were intermittent; at times the diagnosis
of their nature was easy, at others very difiicult.
Dr. LEON.'\RD\VEiiK.Rhad observed, in a small num-
ber of cases of progressive disease of the coronary
arteries, more or less rapidly developing anamia, in
conjunction with general disturbance of nutrition con-
nected with disturbance of nutrition of the cardiac
muscle. The anaemia was one of the signs and con-
sequences of cardiac degeneration, from blocking up
of the coronary arteries in the course of the cirrhotic
change in their walls. A second point was the devel-
opment of anajmia from aortic regurgitation. He had
seen several such cases in which the anaemia, deijend-
ing upon mechanical causes, preceded other constitu-
tional symptoms. .\ third point was that he had seen
several cases of diffuse disease of the cardiac muscle
and disturbed heart action, without there being any
valvular disease — a condition which might occur in
gout or old syphilis, causing disturbance of the gen-
eral health, with more or less profound ana-mia.
Lastly, while anaemia might give rise to fatty degener-
ation of the heart, yet there were cases in which fatty
degeneration began in a previously dilated heart and
caused secondary ana-mia.
Dr. Heine.man thought it was about time the pro-
fession abandoned the method which was prevalent
when he was a student, of basing a diagnosis of car-
diac disease on a few data. The murmur was always
the least important thing; the pulse next; then the
size of the heart in a moderate number of cases. But,
on the whole, the diagnosis was made in a perfunctory
way, and when we came to difficult cases we found
our methods failed us. If the ana-mia, the sphygmo-
graphic tracings, and all known facts were taken into
consideration, he thought there would be much less
doubt than existed in many instances to-day. It was
especially important to bear in mind that the intensity
of the murmur bore no relation to the extent of the le-
sion. Regarding baths, he did not agree with Dr.
Robinson that we could well judge of a health resort
without going there. For instance, he had had no
idea of the Hot .Springs until lie visited them. As to
cardiac disease and anaemia in cases treated at Had
Nauheim, the ana-mia was the smallest factor. The
ana-mia had improved, but it was the smallest part of
the benefit.
Dr. a. H. Smith closed the discussion. He had
heard the murmur to which Dr. Thomson alluded, on
the right side, perhaps about the fourth interspace, not
connected with ana-mia, but rather with muscular
prostration. It disappeared with the disappearance of
the muscular disturbance or restoration of the capil-
lary circulation in the muscles. He had occasionally
heard the harsh sounds at a distance from the heart,
present during inspiration, absent during expiration.
He was also unable to explain them. He agreed with
Dr. Thomson regarding iron in fever, that it ought not
then to be administered. Regarding Dr. Jackson's
remarks on having occasionally heard diastolic or
presystolic ana-mic murmurs. Dr. Smith did not be-
lieve much in such murmurs. They were systolic, or
he might say that the explanation of presystolic mur-
murs was that in nine-tenths of the cases the valves
did not close on the instant.
Original Contribution to the Anatomy of the
Blood Supply of the Heart : Its Bearing upon An-
gina Pectoris Treated by Physical Methods. — Dr.
H. Newi'on Heine.man read a paper with this title.
It was based upon some pathological and histological
investigations, begun in Paris, in 1895, and finished
in June, 1896, and also upon some clinical facts. .As
was well known, it had been disputed for many years
whether the coronary arteries on the two sides finally
anastomosed. There had been a good deal of accepted
anatomy in this connection, but very little proven
anatomy. His experiments had been on the hearts of
various animals, as turtles, rabbits, etc.; and on the
human heart, obtained as soon as possible after death.
Injections were made with gelatin and Prussian blue.
Carmine stain was not suitable, because it injected the
surrounding tissue. The facts brought out were that
the blood supply of the heart was principally capil-
lary, but what was rather unusual was that in the
heart the capillaries came oft" directly from the large
branches, so that one saw a trunk and suddenly on all
sides numerous capillary vessels, and very soon ve-
nous capillaries and large veins. Further, here and
there the capillaries were seen to form what appeared
like little reservoirs, the object of which was, no
doubt, to receive the blood in systole when contraction
of the heart drove it from the vessels. The muscle
shortened, and these reservoirs were between the mus-
cular fibres. The two coronaries did anastomose, but
it was not through large branches, but through the cap-
illaries. Regarding angina pectoris, he preferred the
term stenocardia, and would include under this head
all degrees of cardiac pain. F.ven microscopically we
could not always recognize changes in the heart at
post-mortem. Consideration of the blood supply of
the heart made it evident that even moderate changes
in the large branches must make a great difference in
the capillary circulation. The prognosis would de-
pend upon the question of cardiac lesion, the condi-
tion of the blood supply of the heart, and the severity
of the attacks. Cases which showed themselves amen-
able to treatment offered a better prognosis. The au-
thor mentioned the various symptoms sometimes con-
nected with those referable to the heart, and the
nimierous exciting causes, many of which seemed to
act retlexly.
The Treatment of Stenocardia. — The point which
the author wished to make with reference to treatment
was — after having determined as far as possible the
condition of tiie heart, of the arteries, and of the spleen
and liver — to relieve the heart by lessening the circu-
latory resistance in the organ, and then to strengthen
the cardiac muscle. The jrotent factors were to un-
load the congestion of the liver and spleen by calomel
and salines, and strengthen the heart by saline baths
and resistance exercises — a course of treatment which
he had described before the academy in his paper on
the baths at Had Nauheim combined with the Schott
physical treatment. But one could not make much
headway if he resorted to the baths and exercise alone,
and failed to relieve the engorged viscera. In addi-
tion to the.se measures, one found aid in such remedies
as strychnine, nitrites, etc. Attention must also be
given the diet.
Dr. F. W. Jackson expressed his agreement with
the author, that we ought not to make the minute divi-
December 12, 1896]
MEDICAL RECORD.
867
siou of cases of angina pectoris wliicli it iiad been the
custom to do. He also agreed witli tlie choice of
name, preferring that of stenocardia. He did not,
however, think we could exclude the possibility of
some cases being only pseudo-angina. In other words,
he thought there might be a cardiac pain which was
not true angina.
Treats the Circulation Rather than the Heart.
— Dr. C'h.aki.ks l',. (JriMr.v expected anaemia to occur
sooner or later in all cardiac cases. It preceded
dilatation. This malnutrition might be slight at first,
but should be combated, which he did by giving
tonics, especially iron; and if the patient was unable
to assimilate this, he made it possible by differential
breathing. The important thing was to increase the
capillary circulation, instead of giving drugs intended
alone to increase the heart beat.
MKDKAL
SOCIETY OF THE
NEW YORK.
COUNTY OF
AJ/i>i/ni<-(f Annual and Statiul Alcctings, No'cembcr
23, i8g6.
E. D. Fisher, M.D., afterward L. C. Gray, M.D.,
IN THE Chair.
The Medical Directory. — Dr. Daniel Lewis, editor
of the medical directory published under the auspices
of the society, presented his report. The first edition,
nine years ago, was very small compared with the
present volume, and, of course, contained much less
information. At present the addresses were given of
nearly eleven thousand physicians, including those in
the States of New York, New Jersey, and Connecticut,
and in the volume of five hundred pages was much
information useful to the profession. The next vol-
ume would contain one hundred additional pages.
The expenditures for the last volume had been $3,72 i ;
the income, $3,980.
Advertisements in the Directory. — Dr. A. Y.
REin wished to be informed as to what could be done
regarding such advertisements in the medical direc-
tory which members would not be willing to endorse
individually as physicians, but which apparently had
the endorsement of the county society because printed
in this book.
After some discussion, whicii took place in executive
session. Dr. Reid offered a resolution which received
the approval of Dr. Lewis and the society, providing
for the statement in the preface that the society did
not hold itself responsible for anything contained in
the advertisements.
Address of the Retiring President. — Dr. E. D.
Fisher, in retiring from the presidency, cast a brief
retrospect over the work of the year. It had not been
characterized by any departure from the usual course
of scientific advancement. The question of the or-
ganization of hospital boards had arisen, and could
safely be left to the sober common sense of the pro-
fession. The various standing committees had done
efficient work. The committee on hygiene in particu-
lar had had under consideration some important ques-
tions relating to the public health and well-being.
Among these was the proper care of the poor, the
founding of public baths and of convenient lavatories.
Dr. Fisher had himself given some study to the sys-
tem of lavatories in London and other European cities,
and hoped to see something done in New York for the
sake of the public health and to do away with the
necessity for entering saloons or hotels.
Address of the President-Elect Dr. Landon Car-
ter Gray, in his address, said : " When I look over
the long list of presidents of this society, and perceive
such nanies as Hosack, Cock, the two Rogers, Dela-
field, iSulkley, Taylor, Finnell, Hubbard, Peasley, tiie
two Elliotts, Jacobi, Sands, Peters, iiumstead, Purdy,
Sturgis, Webster, Vander Poel, Lewis, Grandin, and
Fisher, I cannot but feel that I have received a great
honor in being chosen as a successor to these gentle-
men.
" In the great changes that have taken place in this
city between 1806, when this body first came into
existence and the population was about 90,000, and
the present year, during which it is estimated that the
dwellers within our corporate limits number 1,85 1,060,
medical societies have multiplied, not only for scien-
tific but also for social, topographical, and collegiate
reasons, and the County Society no longer occupies
the same relative position that it did for years after
its foundation ; and this has too often caused those
not familiar with its work to overlook the fact that it
is possessed of great powers, which would make medi-
cal men instinctively turn to it in time of war or epi-
demic. It has at the present time a membership of
fourteen hundred and eighty-four. It is the official, or
authorized, or representative society of the medical
profession in the county of New York; while through
its delegates, who can become members of the State
Society by the simple process of attending for two
successive years, it has an intimate affiliation with
the larger organization, and, by this intermediary,
with every medical society in the State. It has three
standing committees of great importance, hy means
of the one upon ethics it regulates the professional
conduct of its members with an authority that very
few men would care to dispute. ]!y its committee on
hygiene it keeps a watch upon the public health ; and
the committee upon prize essays gives an opportunity
for generous recognition to many a struggling man of
talent. It has a large and active comitia minora act-
ing as councillors to the president. It has a salaried
counsel of the law, standing ready to protect the inter-
ests of the profession against imposture and injudi-
cious legislation. It is in the metropolis, and its
incentives, its opportunities, and its dignity are those
of the greatest city of the country, so that what it does
(provided it be worthy of notice) is known of all men
throughout the broad American nation of physicians.
I do not need to remind you of how effectively these
powers have been used in the past, and are being em-
ployed in the present, for the historian of the battles
that have here been fought and won for a higher
standard in medicine would need more than an even-
ing to chronicle these achievements.
" It would seem, from what information is at my dis-
posal, that the members of this society are not aware
of the fact that section 41 of the consolidation act,
chapter 410, laws of 1892, disqualifies a physician
from being the president of the municipal board of
health in these words:
"' The head of the health department shall be called
the board of health. Said board shall consist of the
president of the board of police, the health officer of
the port, and two officers, one of whom shall have been
a practising physician for not less than five years pre-
ceding his appointment. The commissioner of health,
who is not a physician, shall be the president of the
board, and shall be so designated in his appointment.
The commissioners of health shall, unless sooner re-
moved, resi^ectively hold their offices for six years and
until their successors shall be respectively appointed
and have qualified.'
'■ I am told that this clause was copied from the char-
ter of 1873, but I am at a loss to understand the reason
for disqualification of physicians for an office which
one would think peculiarly required medical skill and
experience.
•• lint I wouKl like to ask your especial attention to
868
MEDICAL RECORD.
[December 12, 1S96
the abuses of medical charity— a subject which has
been so often discussed and rediscussed that our souls
have become weary, and I should hesitate to allude to
it but for the seeming opportunity now offered to us
in the power recently given to the Stale board of
charities to revoke the charter of any institution
proven to dispense medical ciiarily improperly. This
clause was introduced into the new constitution by
Mr. Tunis G. Bergen, president of the State board of
charities, to whom the profession should be under a
lasting debt of gratitude; and I never fully appreci-
ated what this gentleman has attempted to do for us
until I obtained accurate figures upon the subject,
through the kindness of our distinguished colleague,
Dr. Steplien Smith, who is a most energetic member
of the same board. From these statistics it would
seem that the county of New York has, at the present
time, 26 hospitals and 1 14 dispensaries. In the for-
mer, during the year 1895, 75,368 patients have been
treated free, and in the latter 661,803, making a total
of 737,171. Just stop for a moment to think of it,
gentlemen, that 737,171 patients have been treated
gratuitously in the last year in this city, of which tiie
population is only 1,851,060. In other words, the
proportion of such free patients to the whole commu-
nity is 39 per cent. There have been 92,529 free
visits of patients to hospitals in 1895, and 1,387,-
170 free \isits of patients to dispensaries. (Jut of
1,104,381 prescriptions that have been dispensed,
there is no means of knowing e.xactly how many have
been without charge, because 52 of the dispensaries
have made no report to the State board of charities,
while of the 62 that have reported, 16 make no charge
for their medicines, and 46 make nominal charges of
from five to fifty cents, or nothing w'hen the patients
are unable to pay. Oi these i 14 dispensaries, 60 take
certain precautions to weed out the unworthy, such as
making inquiries, questioning the patients, judging
by their appearance, and by the statements of phy-
sicians sending them, while the remaining 54 eitlier
make no inquiries or have made no report. In at-
tendance upon tiiese 1 14 dispensaries are 949 medical
men, wiiich is 27 per cent, of all the physicians in the
city, who number 3,430. Efforts were made to ascer-
tain iiow many of these patients were non-residents,
but the answers were usually very indefinite; one in-
stitution stating ' very few, if any,' others ' from one
to ten per cent.,' while 10 had treated 2,124. ihe
foregoing summaiy does not include institutions under
the charge of the local commissioners of charity, one
of whom, Mr. John P. Faure, lias kindly informed me
that tliere are 8 city hospitals, containing 7,089 pa-
tients, and that the out-patient branch has treated 49.-
620 patients during the year ending June 30th, 1895.
-Although it is probable that these cases are really
worthy of charity, yet, in strict logic, the figures should
be added to those given above, which would swell the
total of patients treated in this city in one year to
793,880.
"These statistics confirm the rumors that have been
rife among us for many years, such as that the presi-
dent of one of the largest municipal railroad corpora-
tions was discovered to be a regular attendant at one
of the dispensaries; that patients come occasionally
to the clinics in carriages; that practices can almost
always be obtained from certain clinics in a large
dispensary, such as those of general medicine or gyne-
cology; that the neighborhood of large dispensaries is
bare of physicians' residences; that patients come to
town from distant cities with a physician, occasionally
with a relative, put up at a hotel, seek a clinic for
medical advice, and, when told in one dispensary that
they are not fit objects of charity, speed away in hot
indignation to another; that patients are frequently
sent to a clinic with a letter from the attending phy-
sician containing a modest request for diagnosis, prog-
nosis, and treatment, inquiry eliciting that their
intention is to go back to this gentleman's office and
pay him for treatment; that patients in the country
towns for miles around New Vork are quite appreci-
ative of the excellencies of our city dispensaries for
different diseases; and that patients constantly go to
dispensaries in order to ascertain the best physician
for their particular disease. 'J"he reasons for this
enormous increase in our charity work is plain to any
one who has witnessed the development of our hos-
pitals and dispensaries of late years. The public
must be appealed to for money ; the larger the num-
ber of patients, the more need shown for money; and
no effective general regulations being strongly en-
forced, the growth of the abuse has been so stupendous
that all methods of restriction liave proved utterly in-
effectual. The intentions ha\e been altruistic in the
extreme, on the part of both lay and medical members
of hospital boards; indeed it is questionable whether
any one has known the full extent of the evil.
"It will not be denied for one moment that a cer-
tain, nay, a liberal amount of ciiarity work is a neces-
sity to the medical profession, distinguishing it in this
respect from all others. The lawyer, for instance, the
engineer, the minister, the arciiitect, the ////tw/Av//-, the
journalist, can each perfect himself in the art of his
calling without proffering his services gratuitously,
but the physician must study types of disease only to
be adequately observed in such large numbers of hu-
man beings as are incidental either to a large practice
or to hospitals and dispensaries — indeed, it may be
doubted whether the fullest practice, in the harvest
time of a successful piiysician's life, will offer him
such opportunities for familiarizing himself with mal-
adies as do our hospitals and disi5ensaries. It must
be remembered, too, that relatively few men obtain
great practices, and that they can hold them only by
means of the knowledge of ailments acquired in the
previous years of attendance upon hospitals and dis-
pensaries, so that these institutions are the training-
schools of our profession, inestimable to the men
whom they bring into contact with each otiier in their
varyingly eager and mutually stimulating jjursiiit of
the same ideal, aided by the assistants, the instru-
ments, the nurses, tiie housing, and the organization
of such corporations. Then the thousands of students
who come to this city must be taught, and this cannot
be done without the clinical material of hospitals and
dispensaries. Any unwise restraint would therefore
imperil the existence of New York as the medical
centre of the country, and no man in his senses would
dream of such restriction. But sucii manifestly indis-
criminate charity does not seem necessary to these
purposes. It is trite to say that no suffering person
should fail to receive the medical aid that may be
needed in the emergencies of life, but in this city
there really does not seem to be much likelihood of
such a grievance when 949 physicians, out of a total
of 3,430, treated 737,171 patients in one year, made
1,479,699 free visits, and wrote 1,104,381 prescrip-
tions, besides paying due attention to tlie other duties
incidental to attendance upon 26 hospitals and 114
dis|3ensaries.
" In our medical profession there are gentlemen who
have been so favored by fortune that it has not been
their lot to come in contact with the seamy side of
practice; there are others to whom fame has brought
its attendant success; and there are still others whose
special branches obviate the necessity of practice. To
these medical men this statement of facts may seem
exaggerated, but the great body of practitioners and
those who are broad-minded enough to realize this
grave violation of the first principles of a wholesome
political economy will feel, as I do, that prompt and
December 12, 1896]
MEDICAL RECORD.
869
just measures should be taken to regulate our medical
charities. For my part, I have a most thorough ap-
preciation of the needs of those upon whom we should
bestow charity, but my sympathy is broad enough to
embrace the medical as well as the lay poor. I should
therefore recommend to this society that a special
committee be appointed to obtain such facts about
this subject as may be necessar\- to just conclusions,
and that the results of this investigation be submitted
to the entire society for such action as it may think
proper. I would suggest that this committee consist
of eleven members, namely, the chairman, five mem-
bers to represent respectively the five medical schools,
and the other five on behalf of the profession in gen-
eral."
Committees. — The President appointed the fol-
lowing committees: On ethics, A. M. Jacobus, chair-
man, James P. Tuttle, John Beach Knapp, Henry S.
Stearns, William S. Dennett; on hygiene, \\. H.
Katzenbach, chairman, Egbert Le Fevre, Charles
North Dowd, J. Harvie Dew, Robert C. Myles; on
prize essays, William Stevens, D. Hryson Delavan,
John E. Weeks; on auditing, V. P. Gibney, George
Woolsey.
Notes on Appendicitis and Exhibition of Type
Specimens. — Dr. Robert T. Morris read the paper.
The specimens, arranged in rows in bottles on a card-
board, began with a normal appendix, which he ex-
plained was obtained post mortem. Next was an
appendix in a state of acute exudative appendicitis,
with desquamation of the mucosa and compression
anaimia of the coats. The specimens then succes-
sively led up to the more chronic pathological changes.
They showed how some cases might cure themselves,
at least for that attack.
In order to estimate the number of cases of appen-
dicitis occurring annually in the United States he had
asked eight physicians who were in the habit of diag-
nosticating the disease the number of cases they had
encountered for the year ending Julv i, 1896. The
number would have to be much greater in order to
form a reliable opinion, but the following estimates
were thought to be quite within the bonds of truth :
twenty-five per cent, of cases of appendicitis not
treated surgically finally proved fatal of that disease,
but not necessarily in the first attack: a liberal esti-
mate of his own death rate from surgical treatment
gave only two per cent. ; the number of physicians in
the United States was probably about one hundred and
three thousand, each of whom saw probabl)- two cases
of appendicitis annually, giving a total number of cases
for a year of two hundred and six thousand. If this
number were treated not surgically, the total number
of deaths would be over fifty thousand.
Regarding the origin of appendicitis, it was fre-
quently due to trauma inflicted by the right psoas
muscle. This occurred oftener in man than in wo-
man, because, as pointed out by Dr. Robinson, of Chi-
cago, the appendix in the latter more frequently hung
in the pelvis out of the way of trauma by the psoas.
But whatever the cause of the trauma, the appendix
frequently contained a faecal concretion and infectious
bacilli ready to attack the mucosa as soon as this was
injured. The form of the tube was such that it did
not allow the lymphoid tissue to swell equally: the
inner layers of the tube suffered from compression
anemia and became a prey to bacteria.
The diagnosis was objective and subjective. Dr.
Morris placed stress upon the value of palpation when
the appendix was not in a state of acute inflammation,
for by palpation the condition of the organ could be
recognized, whether healthy or diseased. In acute
inflammation there was a board-like condition of the
belly, which was a valuable differential sign from sal-
pingitis. Xo doubt catarrhal appendicitis might exist
with catarrh of the colon and cacum, but in all cases
in which the diagnosis of appendicitis was made
the case had passed beyond the catarrhal stage.
Years ago he had laid down the rule to operate in
all cases in which the diagnosis of appendicitis was
well established, during or after the attack, for it was
impossible to say what patients would not die under
medicinal treatment, or how soon a fatal attack would
occur if the patient recovered from the first. His
statement on this point had led to his having been
misrepresented, as he had been on other points, but
surgeons, nevertheless, had come to adopt the propo-
sitions which a few years ago they had combated.
He had been represented as even removing the normal
appendix in case the abdomen were opened for some
other purpose, while in fact he was opposed to such
practice. He had also been misrepresented with re-
gard to the inch-and-a-half incision. He did not
recommend it to those in whose hands the patient's
life would not be safe without an opening six inches
long. Gauze should be avoided if possible, for it
tended to the development of ileus. Iodoform gauze
was not an infrequent cause of some seemingly un-
accountable rise of temperature and wandering in
mind.
The paper was discussed by Dr. McEnroe, who
spoke of medicinal treatment, including opium: by
Dr. B. S. Talmev, who thought it was not twentv-five
per cent, of all cases of appendicitis which resulted
fatally, but rather of the operative cases: by Dr. Sav-
IDGE, who thought those who spoke of medical treat-
ment versus surgical had done so without discrimina-
tion ; by Drs. Cole and Collyer, both of whom
approved of the position taken by the author. Dr.
Cole would attach more importance to the pulse
and also to the temperature than was done in the
paper.
Dr. Morris concluded his reply with the statement
that those who were not willing to turn cases over to
the surgeon, but preferred to turn them over to the
bacteria, must allow the decision to be made upon the
pathological condition. There were some surgeons
more dangerous than some bacteria, and some bacteria
more dangerous than some surgeons.
Committee on the Abuse of Medical Charity
Dr. Burtexshaw, in accord with the suggestion con-
tained in the president's inaugural address, moved
that a committee of eleven members be appointed to
report on the abuse of medical charity. The motion
was adopted. The committee will be composed of the
president as chairman, and of five members to repre-
sent the medical colleges and five to represent the
general profession.
Committee on Legislation. — On motion of Dr.
Frank \'an Fleet the president was authorized to
appoint a committee on legislation, to act with the
committee of the State Medical Society, and see that
no bills pass the legislature detrimental to public
health. It was because nobody was present to oppose
it that the chiropodists had secured the passage of a
bill permitting them to practise minor surgery on the
feet. No doubt the opticians would try again this
winter to have their bill passed.
A Humiliating Law. — Dr. D. R. Si. John Roosa
moved that the comitia minora be requested to draft a
bill, and have it presented in the legislature, for the
abolition of that clause in the present law which pro-
hibited a physician from being president of the board
of health. Adopted.
Tight Lacing, according to Einhorn, is accountable
for the large proportion of ptosis of the stomach and
intestines with movable kidney found in the female
subject.
870
MEDICAL RECORD.
[December 12, 1896
SOUTHERN SURGICAL AND GYNECOLOGI-
CAL ASSOCIATION.
Ninth Annual Meeting, Held in Nash'illc, Tenn.,
November jo, ll, and 12, l8g6.
E. S. Lewis, M.D., of New Orleans, La.,
President.
First Day — Morning Session.
The association met at the Nicholson House, and was
called to order by the president at lo a.m.
Address of Welcome. — This was delivered by the
Hon. John ISf.i.l Keebi.e, of Nashville, and was re-
sponded to by President Lewis.
Vaginal versus Abdominal Section for Pus in
the Pelvis. — This paper was read by Dr. VV. D.
Hagoard, Jr., of Nashville, in which the author re-
counted the transitional periods in the treatment of
pus in the pelvis — vaginal puncture, superseded by
abdominal section and removal of pyosalpin.x, total
uterine castration per vaginam by the French and
through the abdomen by the American school. These
operations had given way to modern vaginal section
and evacuation and drainage of all pus pockets. The
abdominal route affords visual inspection of the field.
The attack on morbid masses could be made with
safety to visceral integrity. If pus accumulations
were multiple, rupture and peritoneal soiling were in-
evitable; that is the supreme disadvantage of abdom-
inal incision. The author had often seen the pelvis
deluged with pus with impunity. He had also seen
patients die within twelve hours from fulminant sep-
sis from peritoneal contamination. The writer re-
ferred to a mortality of 18.5 per cent, in a series of
collected cases of laparotomy for pus, done in five
metropolitan iiospitals in the last year, and asked.
What must it be in the '" unheard-from precincts," and
in the hands of the great unwashed.' The abdominal
method offered the best approach in tuberculous inflam-
mation of tiie ovaries and tubes and in small unilat-
eral pus tubes. I'he author referred to the advantages
of exploring the pelvis for retro-uterine tumors and
disease of adne.xa by vaginal section.
The geography of pus in tiie ]3elvis in most cases
made vaginal incision extraperitoneal, a minor pro-
cedure giving major results — no shock, no risk, no
disturbance in convalescence. In prolonged sepsis
from large abscesses, posterior section and drainage
were a life-saving procedure. The special indica-
tions were in (1) early cases of acute suppurating sal-
pingitis; (2) incipient post-puerperal peritonitis; (3)
large pyosalpinx and true pelvic abscess. The first
group included early gonorrhct-al and abortion cases.
In puerperal ca.ses, incipient peritonitis and puddles
of pus in Douglas' space imperatively demanded in-
cision. Should simple pus-letting in any of these
cases not effect a cure, subsequent operation for re-
moval of the relics of previous ravages can be done
without the dangers incurred in the presence of pus.
The field of vaginal section is to prevent suppuration
in early cases, to anticipate it in puerperal cases, and
to save life in desperate cases. Its application to the
pelvic inflammatory processes and to pus in the pelvis
was one of the greatest surgical triumplis of the age.
Discussion Dr. Joseph Taber Johnson, of Wash-
ington, D. C, said that while the vaginal method had
a great many points in its favor and was being re-
sorted to more and more in cases of large pus collec-
tions in the pelvis, yet those who had been familiar
for a considerable time with the abdominal route could
operate more conveniently and de.xterously by this
method and with greater safety to the patient than by
the vaginal method. He could not agree with the
speaker that the vaginal operation may be done with-
out any risk to the patient. Sometimes in operating
through the vagina for the purpose of removing the
uterus and its adnexa, or for large pus collections high
up in the pelvis, where it was necessary to manipulate
the parts a good deal and to do a thorough enucle-
ation, the surgeon was likely to tear the intestine, the
bladder, the ureter, or rupture a large vessel which
was out of sight. In such cases the abdominal was
much safer than the vaginal route.
Dr. Charles P. Noble, of Philadelphia, did not
feel that either the abdominal or the vaginal method
possessed all the advantages, but if restricted to one
or the other he should prefer the abdominal rather
than the vaginal route. An objection formerly urged
against the abdominal route was the large percentage
of hernias which followed this method. Only a week
since he had tabulated the operations he had done in
four years, which amounted to 397 abdominal cases,
in w hich he had used the buriecl suture in closing the
abdominal wound. In this number 7 of the wounds
suppurated, while 390 healed by primary union. Of
the 7 which suppurated, i had a hernia. Of the 390
cases, I had a large umbilical hernia. Aside from
these two cases, he had not had any hernias in his
operative work for the last four years when the buried
suture was used. If the patient was in a condition to
permit the surgeon to do ideal work, he thought the
question of hernia was such an insignificant one that
it might be left out of consideration.
Dr. Howard A. Kelly, of Baltimore, said that,
whenever possible, pus in the pelvis should be treated
by vaginal puncture or section posterior to the cervix,
without sacrificing any of the uterine appendages. A
large percentage of the cases thus treated would have
no future discomforts. Illustrative cases were cited.
One of the principal arguments advanced by advocates
of the vaginal route in removing the uterus, tubes, and
ovaries was the excellent drainage that could be se-
cured by this method. In Dr. Kelly's opinion it was
unnecessary to take out the uterus to get drainage.
Dr. L. S. McMurtrv, of Louisville, said a deep
impression had been made upon the profession in the
last two years by the vaginal method of operating for
pus in the pelvis. This procedure, however, was by
no means a new one. liattey, in his original opera-
tions upon the ovaries, attacked the pelvic organs
through the vault of the vagina. The method of at-
tacking accumulations of pus in the pelvis by vaginal
puncture and drainage was the universal practice of
abdominal surgeons for a long time. The sacrifice of
the uterus in the majority of cases of suppurative pel-
vic inflammation was unnecessary. Surgery should
be confined witiiin the limits of removing only such
diseased tissue or organs as were necessary for the
complete cure and restoration of the patient.
Dr. J. Weslev Bov6e, of Washington, D. C, ob-
jected to anterior colpotomy in dealing with pus cases
unless the accumulation of pus was on top and in front
of the bladder. He thought these cases could not be
drained through the anterior vaginal route, and the
pus could not be reached in many cases. He believed
it was not necessary to remove the uterus at the same
time pus tubes were taken out. He did not want to be
understood as being opposed to the vaginal route in
very urgent cases.
Dr. R. B. Maury, of Memphis, had, during the last
two years, made it his duty thoroughly to study the
subject of vaginal hysterectomy, as he had done quite
a number of these operations without any mortality,
without any accident, and without unj^leasant result.
But he would not undertake to say that we ought to
substitute it for laparotomv. Both abdominal and
vaginal hysterectomy were operative measures that sur-
geons must avail tiiemselves of according to the cir-
cumstances of the case. Dr. Maury then cited the
December 12, 1896]
MEDICAL RECORD.
871
histories of two cases that lie had treated within the
last thirty days, which beautifully illustrated the ad-
vantages of the two methods.
Dr. W. E. B. Davis, of J^irmingham, Ala., said the
practise of incising pelvic abscesses was so old that it
hardly required discussion, but the method of attack-
ing pus tubes by vaginal section was comparatively
recent. Unquestionably vaginal incision for pus con-
dined to the tubes and ovaries would save these impor-
iant organs in a good proportion of cases. In all cases
of large pus collections in the pelvis, nothing more
should be done than to incise the abscess and drain,
and then later on the surgeon should be prepared to
■do an abdominal section, if necessary, but he thought
the surgeon would rarely have occasion to do this.
Total ablation of the uterus and its adnexa was un-
necessary in the many instances in which it was prac-
tised by some surgeons.
Cholelithiasis. — A paper on this subject was con-
tributed by Dr. A. M. Cartledge, of Louisville, in
which the author reported several interesting cases.
He dwelt upon cholecystostomy and cholecystenteros-
tomy, pointing out the indications for each operation.
He considered cholecystostomy as the only operation
that was applicable to the cases cited. In his opinion
there were no cases that primarily demanded chole-
•cystenterostomy.
Dr. James McFadden Gastox, of Atlanta, agreed
■with the essayist that in ordinary cases of gall stones
in the gall bladder with obstruction of the cystic duct,
the simplest procedure was to lay open the abdominal
wall, attach the gall bladder to the incision, and re-
move the gall stones. But in a large proportion of
cases of complete obstruction he doubted whether there
would be restoration of bile through the cystic duct
into the gall bladder. With reference to the compara-
tive value of cholecystostomy and cholecystenleros-
tomy, the two operations were applicable to entirely
different conditions. No one would operate and e.\-
pect benefit from a cholecystostomy except to establish
drainage for the bile in a case of permanent occlusion
of the common duct, and this was the only condition
in which the advocates of cholecystenterostomy had
ever claimed anything for it.
Dr. John D. S. Davis, of Birmingham, emphasized
the point that patients frequently had gall stones with-
out the manifestation of symptoms, particularly the
symptom jaundice. He did not believe that it was
ever wise to resort to cholecystenterostomy as a pri-
mary procedure. The surgeon should first resort to
drainage, and then, if rela.xation did not take place
and the flow of bile was not effected, a cholecystente-
rostomy should be done.
Dr. Geurge Ben Johnston, of Richmond, Va.,
spoke of the diagnosis of gall stones. He was con-
vinced that if examinations of suspected cases of gall
stones were as careful and minute as they should be,
surgeons would frequently find them. It had been his
experience that enlargement of the gall bladder did
not always occur when a gall stone existed, but that a
condition which simulated enlargement of the gall
bladder frequently did exist, this condition being due
to the presence of numerous dense adhesions found in
the neighborhood of the gall bladder, gluing it to
every tissue with which it came in contact. One
thing which struck him as very singular in connection
with the presence of gall stones was that the size of
the stone or stones seemed to make no difference in
the production of symptoms. In regard to hemor-
rhage, it was generally admitted that incases in which
cholamia was profound, they were the ones in which
we were to expect hemorrhage, and by no known
method could this hemorrhage be successfully con-
trolled. The cholamic condition seemed to invite a
fatal hemorrhage. The experience of operators in
this field of surgery was that when cholaemia was
profound, hemorrhage of a fatal character was to be
expected. He considered cholecystostomy a proper
procedure in all cases, except in those in which the
obstruction was in the common duct and could not be
relieved.
Dr. W. E. B. Davis said surgery of the gall bladder
for the removal of gall stones had given brilliant re-
sults, but there were still questions in regard to op-
erative procedures on the ducts that were not as yet
definitely settled. He did not believe the essavist
referred to cholecystostomy as being the choice of
operation in cases in which the obstruction of the duct
could not be removed; that he must have had in mind
the procedure advocated by Murphy of resorting to
this operation in a case of gall stone in the gall blad-
der when there was no obstruction in the duct.
Murphy resorted to cholecystenterostomy instead of
cholecystostomy, and he thought the essayist did not
intend to convey the idea that he would not do a cho-
lecystenterostomy when the obstruction in the duct
could not be removed. Chola;mic cases were bad to
operate upon. Perhaps in not more than five or six
per cent, of the cases was the obstruction found in the
common duct. Some years ago the author made ex-
periments which conclusively showed that the surgeon
could incise the duct and drain with gauze without
peritonitis following. A paper on this subject was
read by him before the American Medical Association
in 1892, since which time he had done further experi-
mental work in which sutures were not used after the
stone was removed from the duct, and while several of
the subjects were at the time very nearly dead from
profound cholaemia and eventually did die, yet in the
cases in which this method was resorted to the abdomi-
nal cavity was walled off and peritonitis did not result.
Dr. George A. Ba.xfer, of Chattanooga, directed
attention to the frequency of gall stones unattended
with the ordinary symptom of colic, and cited an
illustrative case in which there were found post-mor-
tem three large stones in the gall bladder.
Dr. F. W. McRae, of Atlanta, reported a case in
which there were repeated attacks of colic with pro-
found cholaemia. An operation was undertaken with
the idea that the obstruction was in the common duct,
and that there were stones in the gall bladder. On
opening the abdomen in the presence of several phy-
sicians, the liver was found much enlarged and reach-
ing almost to the umbilicus. Instead of finding the
gall bladder enlarged, he found a fibrous cord not
larger than his index finger. The common duct from
disuse was reduced to a mere cord. A calculus was
found in the hepatic duct extending up into the trans-
verse fissure of the liver. He did not know what to
do for a case like this, and after consultation with
his colleagues closed the abdomen. The patient died
five days later from exhaustion. If anything could be
done for such patients he would like to know it.
First Dtix — Afternoon Session.
Mental Complications Following Surgical Ope-
rations— Dr. John T. Wilson, of Sherman, Tex.,
read this paper. He said the subject of mental dis-
orders produced by or following surgical operations
had not been discussed to any great extent, and until
within the past two years only a passing notice had
been given to it. It was a strange fact that while sur-
gical operations would sometimes cause serious men-
tal disturbances, on the other hand those same opera-
tions would sometimes cure them. Especially was this
the case with some melancholiacs. Many females
laboring under attacks of melancholia caused by some
disease of the genital apparatus had been cured when
relieved of the physical defects by operation ; others
8-2
MEDICAL RECORD.
[December T2, 1896
had been much improved, and yet some had received
no benefit. The question might very properly be
asked why a surgical operation should produce an at-
tack of insanity. This could no more be answered in
every case satisfactorily than could the question why
some persons became insane from the many other
causes to which insanity was attributed, for in most
cases the mental complications were a surprise and no
good reason could be given why they should follow.
In others, however, a logical explanation might be had.
If tiie patient was a high-strung, nervous individual,
easily excited, unable to bear pain, the great and in-
creasing dread of the anaesthetic, the operation, or both,
would so affect him that he would lose control of the
will power and the explosion would come after the
operation and reaction from the anaesthetic. In many
of these cases, probably a majority, there was a he-
reditary taint or a strong neurotic tendency.
The author quoted Mairet, who thinks (1) that it is
in those individuals who are predisposed by heredity
or other grave causes — alcoholism, infectious dis-
eases, etc., that surgical operations give rise to insan-
ity; (2) in the constituent elements of an operation
that may act on the brain the two most important
ones are the anesthetic and the degree of surgical
traumatism, with its after-effects, of which disturbed
nutrition plays a very important part; (3) when pre-
disposition also is considerable, the anaesthetic alone
may produce insanity, or it may result even after
minor operations. It is, of course, necessary to take
into consideration the mental state of the patient prior
to the operation, especially in those graver ones in
which frequently questions of life or death are invohed.
Discussion. — Dr. E. .S. Lewis, of New Orleans, re-
lated the case of a woman, forty years of age, very
hysterical, upon whom he had operated for laceration
of the perineum. She had manifested no evidences
of insanity prior to operative interference, but during
convalescence the hysterical manifestations increased
and were associated with delusions. Her condition
became so serious that on different occasions she
threatened to commit suicide. She was transferred to
an insane asylum, and after a thorough examination
by the physician in charge an unfavorable prognosis
was given. Investigation of the family history showed
traces of insanit)".
In another case, that of a woman sixty years of age,
he removed a very large adherent ovarian tumor, the op-
eration being attended with considerable shock. For
a few days subsequently the patient did well, but she
later became perfectly insane. These were the only
two cases he vividly remembered, although he had
seen after operations cases of temporary insanity
which had passed off in the course of a few months.
Dr. W. E. Parker, of New Orleans, had seen in
men two or three cases of insanity following surgical
operations, but had never been able to trace any his-
tory of the disease in the family. The insanity oc-
curred in alcoholics. Two of the men were either
cocaine or morphine habitues. In the management
of such cases the ijarticular drug to which the patient
was addicted should still be continued in very small
doses, being cut off graduallv, for the reason that great
prostration often followed the sudden interdiction of a
habit that had been continued for many years.
Dr. R. B. Rhett, of Charleston, S. C, had met
with three cases of postoperative mental aberration,
two of which occurred in old women after removal of
the breast for cancer. A third case occurred in a
young woman who had had puerperal insanitv prior to
operation. In two cases the insanity lasted for three
days, in the other for three weeks.
Dr. \. M. C.ARTi.EDCK, of Louisville, said the ques-
tion of postoperative insanity led us to discriminate
as to the probable etiology in many of the cases. He
thought the author of the paper had in mind to deaf
with those cases of postoperative insanity that were
functional in character, rather than those in which
patients suffered from the mental impression produced
by the operation in general. He was quite sure most
of the cases, except those characterized by hereditary-
tendencies and traits, could be traced to some organic
lesions. The history of the case should always be
thoroughly investigated. He had encountered what
he considered pure postoperative insanity in only twO'
cases.
Dr. John D. S. D.avis considered the subject of in-
terest from a medico-legal standpoint. No surgeon
was absolutely free from such mental complications
occurring in his operative work. He had encountered
four cases. In the case of a certain young man there
was no history of insanity, but an analysis of the urine
before operation showed a great many casts and a
slight trace of albumin. Operative interference was
followed by acute mania, which lasted seven days, then
disappeared, and the patient recovered. He would
like the essayist, in closing, to touch upon the respon-
sibility of the surgeon in this class of cases.
Dr. Joseph Taher Johnson said that in talking
with Drs. Kelly and Noble, he learned that the latter
had met with eight cases of insanity following peri-
neal operations. He asked the essayist to state wheth-
er operations upon the jierineum were more frequently
followed by insanity than others.
Dr. Wilson in summing up said he had seen a
number of cases of various forms of insanity follow-
ing surgical operations, but did not think the disease
occurred more frequently after perineal operations and
operations upon the genitalia than upon any other part
of the body. In reply to Dr. Davis' question, he did
not think the physician was any more responsible for
the death of a patient from insanity following an oper-
ation than he was for death following any other opera-
tion. He had never heard of a suit for malpractice
being brought against the practitioner for a case of
mental derangement following a surgical operation.
Splitting the Capsule for the Relief of Nephral-
gia.— Dr. Okor<;k ]'>es Johnston, of Richmond, \'a.,
read a paper with this heading, in which he drew the
following conclusions: (i) Nephralgia is not always
associated with a demonstrable lesion. (2) V\"hen
other evidences of kidney disease are wanting, the
pain is due to a too tight capsule. (3) Nephralgia
may and frequently does simulate symptoms of gross
tissue changes or mechanical irritation. (4) When
severe and persi.stent pain in the kidney exists without
other evidences of renal disease, exjjloratorv operation
is indicated. (5) When inspection, palpation, and
needle puncture fail to disclose a condition sufficient
to account for the ])ain, the capsule should be freely
opened.
Uretero-Ureteral Anastomosis. — Dr. J. Weslev
B()\iK, of Washington, D. C, read a paper on this
subject and reported an intere.sting case. The author
dwelt at length upon the literature of the subject,
quoting from the contributions to the surgery of the
ureters by Van Hook, Fenger, Kelly, and t'abol in
this country, and the classical works of Glantenay.
Liaudet, TutFier, and others in Europe. He drew the
following conclusions: (1) Uretero-ureteral anasto-
mosis is a perfectly feasible procedure. (2) Uretero-
ureteral anastomosis, whenever possible, is far pref-
erable to any other form of ureteral grafting, to I
nephrectomy, and to ligation of the ureter. (3) It
should be done preferably by lateral implantation or
by oblique end-to-end anastomosis, though the trans-
verse end-to-end, or the end-in-end methods may be
safely emploved. (4) Con.strictions of the calibre of
the ureter do not usually follow attempts at suturing
in ciosure of complete transverse section of the duct.
December 12, 1896]
MEDICAL RECORD.
87-
•(5) Nephrectomy for transverse injuries of the ureter,
per sc\ is an unjustifiable operation. (6) Simple liga-
tion of the ureter to produce extinction of the function
of the kidney is too uncertain to justify its practice.
(7) Drainage is not necessary if the wound be per-
fectly closed and the tissues are aseptic.
Dr. Howard A. Kelly was very much interested
in this subject and said every abdominal surgeon
should be familiar with uretero-cystotomy or uretero-
ureteral anastomosis, because in doing abdominal
operations the surgeon was liable at anytime to injure
the ureter, when he would be confronted with the
necessity of doing something to repair it. Dr. Kelly
then pointed out the various ways in which the ureter
might be cut during operations and described the
method he pursued in repairing such injuries.
Dr. Ch.\rles p. Noble cited a case of neglected
extra-uterine pregnancy complicated with an intra-
ligamentous ovarian tumor. In operating, the intes-
tines were apparently adherent over a mass of blood
and a large fleshy adhesion ran upon it. To save
time this was clamped, cut through, and the pelvis
cleaned out. It was necessary to do a hysterectomy
in order to get anything to tie, as the anatomical land-
marks were obliterated on both sides of the pelvis.
Furthermore, the broad ligaments did not come down
in the usual way. When the operation was completed
the patient was in collapse, and it was found that
what was supposed to be a tieshy adliesion was really
the ureter and thickened peritoneum. The ureter was
cut off almost up to the kidney itself. The lower part
of the ureter was taken out with the mass of blood,
there being only the upper three or four inches of the
ureter left. Dr. Noble thought that if any attempt
had been made to prolong the operation with the pa-
tient in collapse death would have resulted. Although
the remainder of the ureter was short, it was dragged
up into the upper end of the abdominal incision. It
was impossible to do a uretero-ureteral anastomosis,
likewise to switch the ureter into the bladder, because
it did not reach anywhere near the brim of the pelvis,
much less the bladder, and there was nothing else to
do but to remove the kidney, which Dr. Noble did,
and the patient recovered.
The Treatment of Pregnancy and Labor Compli-
cated by Fibroid Tumors of the Uterus. — Dr.
Henry D. Fry, of Washington, D. C, read this
paper. He advanced two propositions : First, that
the production of abortion is unjustifiable. Second,
that labors presenting serious difficulty to delivery are
best treated by abdominal section and removal of the
child and tumor. By maintaining this position the
interests of the mother are not relegated to second
place. While saving the life of many infants, the
maternal mortality will also be diminished. After
making a few brief remarks on the natural history of
fibroid tumors complicating the pregnant state and
reporting a few cases that had come under his care,
he considered the treatment.
Dr. .\. J. CoLEY, of Alexander City, Ala., reported
a case of cyst on the right side with a left uterine
tumor, low down, involving the body of the uterus,
which was firmly fi.xed in the pelvis and complicated
pregnancy. The woman, forty years of age, suffered
so much pain that it was thought advisable to resort
to hysterectomy, but it was not insisted on. The wo-
man had been married a little over a year. She was
closely watched, and, as pregnancy and labor advanced,
the tumor was pushed above the brim of the pelvis.
The woman was subsequently delivered naturally of a
child, and is now attending to her household affairs.
Dr. Coley counseled against operative interference in
many of these cases.
Dr. R. R. Ki.me, of Atlanta, had encountered a case
some two years ago of a debilitated patient with evi-
dences of infection before labor. In introducing the
hand a tumor was felt in the posterior uterine seg-
ment, crowding the cer\ix apparently above the sym-
physis pubis, and it looked as if the patient could not
be delivered. However, by waiting and placing the
patient in the exaggerated Sims position and elevat-
ing the growth, delivery of the child was effected.
Dr. Howard A. Kelly agreed with the conclusions
of the essayist. There was a tendency on the part of
the profession to interfere too much in cases of preg-
nancy complicated by fibroid tumors of the uterus.
He had been called in consultation to see a number
of such cases, but the indications were not such in
some of them as to warrant the induction of premature
labor. In many instances a consultation had been the
means of postponing operative interference. \\'hen
fibroid tumors complicating pregnancy were situated
in the upper part of the uterine body, unless large and
multiple, they were comparatively unimportant. If
situated in the lower part of the uterus, and it was found
as pregnancy advances that they could be pushed up,
this should be done in order that labor might proceed
naturally. On three occasions he had opened the ab-
domen and had done a myomectomy for tumors compli-
cating pregnancy, the woman subsequently going to
full term and being delivered normally.
Dr. W. D. Haggard, Sr., of Nashville, mentioned
a case of uterine fibroid complicating pregnancy
which came under his observation a few years ago.
Hysterectomy was advised by the consultants but not
resorted to. The woman was subsequently delivered
of a child, and the tumor six months later had entirely
disappeared. Dr. Haggard reported another similar
case.
Dr. James A. Goggans, of Alexander City, Ala.,
had observed during the last twenty years a number
of cases of pregnancy complicated by uterine tumors.
He had seen the case referred to by Dr. Coley. He
thought it was unwise in a great many cases to resort
to hysterectomy, believing that the tumors could be
pushed up and delivery effected without surgical in-
terference.
Dr. James McFadde.n Gaston cited a case of der-
moid tumor which complicated pregnancy. The ob-
struction was so great that it was utterly impracticable
to undertake to deliver the woman by forceps, and it
was concluded to lessen the obstruction by aspirating
the tumor. This was done, and a little more than one
quart of grumous material was drawn off, after which
the woman was delivered with forceps of a dead child.
Dr. Gaston believed that the woman would ha\e to be
subjected to a radical operation for the removal of the
dermoid before perfect relief was afforded.
Dr. George A. Baxter referred to the danger of
post-partum hemorrhage in cases of fibroids compli-
cating pregnancy and related an interesting case. The
fibroid tumor interfered with the natural contraction
of the uterine fibres, and on this account it was ex-
ceedingly difficult to arrest hemorrhage. This was a
complication which endangered the life of the woman.
Dr. E. S. Lewis said it often fell to the lot of
some physicians to meet with a series of anomalous
cases, such as those that had been reported by the
essayist, while other physicians with probably quite
as large experience would pass through life without
meeting some of the complications that had been men-
tioned. During an experience extending over thirty-
four years he had never met with a fibroid tumor
which justified interference before labor, that is, a
fibroid occupying the lower segment of the uterus and
impinging upon the pelvic -cavity. Within the past
year he had delivered two women having large
fibroids.
In one case in which pregnancy super\-ened, after sus-
pension of menstruation for two months he was unable
874
MEDICAL RECORD.
[December 12, 1896
for several months to determine the existence of preg-
nancy. The uterus then reached above the umbilicus,
but the woman was found pregnant and was delivered
at full term with forceps, but with no extraordinary
difficulty. The other woman had an abdominal tumor
the size of a six months' foetus. Although she had
been married a number of years, she was about forty
wlien she became pregnant. The tumor occupied the
upper portion of the body of the uterus, but she was
delivered without the use of instruments. He could
conceive that in a case of fibroid situated in the broad
ligaments or occupying the lower segment of the
uterus, seriously impinging upon the cavity of the
uterus, hysterectomy would be inevitable, but it had
been his fortune to escape such cases.
Dr. Fry, in closing, was glad to note that the gen-
eral trend of the discussion was favorable to conser-
vative work in the treatment of pregnancy complicated
by fibroid tumors of the uterus, and of permitting wo-
men to go to full term and trying to deliver them
naturally. Some of the cases in the paper, which he
did not read, exemplified the wonderful resources of
nature in overcoming uterine obstructions. Post-par-
tum hemorrhage was one of the serious complications
of labor under these circumstances and was common.
If the placenta was attached to the fibroid tumor hem-
orrhage was free. If it was found necessary to operate,
Cesarean section ought not to be resorted to, as the
mortalit)' following this procedure was fully as high
as eighty-four per cent. The best thing to do was to
resort to hysterectomy, either the complete or supra-
vaginal method.
©otrtespondcucc.
OUR LONDON LETTER.
(From our Special Correspondent. )
PERICARDITIS — FRACTURED RIBS IX OLD AGE — HER-
NIA— CLUBBING OF FINGERS GASTRO-ENTEROSTO.MY
CURIOUS DEFORMITY OF JAW FRAGILITAS OS-
SIU.M — TUMOR OF SACRUM — GENERAL MEDICAL COUN-
CIL— ANNUAL MEETING OF COLLEGE OF SURGEONS —
DR. CULLINGWORTH's DEFENCE.
Lo.sDON, November 20, 1896.
Some very interesting cases were related at the last
meeting of the Clinical Society. Thus, Mr. H. Besham
Robinson described a case of suppurative pericarditis
treated by resection of the sixth rib and drainage, in a
lad aged sixteen years. The lung was fi.xed by recent
adhesions. All fibrinous coagula as far as possible were
cleared out from the cavit)- by the finger, and over two
quarts of pus were evacuated, but irrigation was de-
cided against, owing to his feeble condition. A large
drainage tube was introduced into the pericardium
and was stitched to the margin of the wound. His
recovery was uninterrupted but protracted, and the
tube was removed on the sixty-first day after the oper-
ation, the wound soon healing, and the patient, al-
though not taking verj- strong exercise, can walk ten
miles. There are very slight enlargement of the super-
ficial cardiac area upward and no retraction of the
spaces with the systole. Very few such cases have
been recorded during the larger part of a century, less
than a dozen, but they show a large proportion of suc-
cesses (five out of eight).
Mr. R. H. Mills-Roberts related a case of an old
man, aged sevent)'-three, who was knocked down by a
falling rock and crushed by two boulders, between
which he was jammed by the rock which fell on
him. On admission he was nearly moribund; he ral-
lied, but on the si.xth day he developed pneumonia.
He again got better and steadily improved for si.x:
weeks, when he had a fit and died suddenly, appar-
ently of syncope. Post-mortem revealed, on the left
side, comminuted fracture of the sternal end of the
clavicle; fracture of all the ribs, including the first; the
second, third, fourth, fifth, sixth, seventh, and eighth
ribs were broken at angles, and the second, third, and
eighth at the sternal end. The ninth, tenth, eleventh,
and twelfth each had a single anterior fracture ex-
tending through the inner plate only. On the right
side there was single fracture of the third rib at the
sternal end ; of the fourth, fifth, sixth, seventh, two
fractures, sternal end and angles; of eighth and ninth,
single fracture. The right kidney showed a blood
calculus in the lower part. All other organs were
normal. There appeared to be very little lung injury.
Mr. \V. G. Spencer described two cases of a rare form
of inguinal hernia, each presenting three peculiarities,,
viz. : absence of an internal ring, the deep epigastric
artery lying across the front of the hernia, and close
above the pubic spine an extraperitoneal protrusiorv
of a bladder pouch, closely adherent to the sac.
Dr. Samuel West related two cases of ''clubbing of
the fingers developing within a fortnight and four
weeks," respectively ; (i) In a gentleman, aged thirty-
six years, with right-sided empyema between the base
of lung and the diaphragm. The patient recovered of
the empyema, and by the end of three months the
clubbing had completely vanished. (2) In a healthy
woman, aged fifty years, who came under treatment
because she had taken ammonia by mistake and had
a troublesome gastritis in consequence. Her fingers
were extremely clubbed, and had become so four
weeks before without apparent cause, while she was in
perfectly good health. Her attention was first drawn-
to their condition by her gloves ceasing to fit her.
This seems a unique case.
Mr. Richman Godlee remarked that however chronic
the clubbing might be, it cleared up if the disease
calising it were cured. He remarked that the nose
often suffered as well as the fingers etc., but this was-
apt to escape notice, as there was no orthodox type of
human nose. He had a little child under his care in
whom only one finger was clubbed, and there was
nothing wrong with the bones. Well-marked club-
bing might certainly occur without any disease to ac-
count for it, though perhaps it was more frequently met
with in association with bronchiectasis than any other
disease.
.\t the clinical evening of the Medical Society Mr.
Lockwood showed a successful case of gastro-enteros-
tomy performed on an elderly man for cancerous ob-
struction of the pylorus. He insisted on the impor-
tance of furnishing the artificial opening with a
complete lining of mucous membrane, thus rendering
it less liable to subsequent contraction. Mr. Battle
had had a somewhat similar case of rapid onset in a
young man, aged thirty, in whom, at the operation
performed within six weeks of the onset of the symp-
toms, extensive secondar)' growths were found. He
used Senn's bone plates reinforced by a Lembert
suture, and the patient promptly recovered from the
operation with relief of all his urgent symptoms. Mr.
G. R. Turner showed a lad with a curious bilateral
deformity of the lower jaw, which the mother believed
to be congenital, but which the father stated had com-
menced after an attack of measles at two years of age.
There was no ankylosis of the temporo-maxillary ar-
ticulation, but the vertical ramus of the jaw projected
lower than the horizontal so that there was consider-
able prominence at the angle. The lad could open
his mouth only a little way and was unable to protrude
his tongue. Mr. Bruce Clarke said he had never seen
this deformity in the bilateral form, as in this instance,
but had iiad a unilateral case, in which it was neces-
December 12, 1896]
MEDICAL RFXORD.
875
saiy to perform tracheotomy to prevent asphyxia caused
by the tongue falling back into the throat.
Dr. F. de Haviland Hall showed a young man who
had developed progressive enlargement of the cervical
and supraclavicular glands, followed by the develop-
ment of a mass of enlarged glands over the upper part
of the sternum. The enlargement decreased for a time
under large doses of arsenic, but there was a marked
pigmentation, probably due to the drug. There was
now dulness all over the left lung behind, and he
raised the question how much of this was due to en-
larged glands and how much to pleuritic effusion.
Dr. Outterson Wood pointed out that arsenical pig-
mentation displayed a curious tendency to ,vary in
intensity from day to day without obvious cause.
Mr. Clinton Dent showed a very remarkable and
pronounced case of fragilitas ossiuni in a man, aged
twenty-nine years, whose stature did not exceed thirty-
six inches. He had in all sustained twenty-seven
fractures, principally of the limbs, but his intelligence
was unaffected. He had been brought up on his
mother's milk exclusively until four years of age.
Mr. Dent showed some very interesting skiagraphs of
die bones. The first fracture (of the femur) occurred
when the child was four months old.
Mr. Goodsall showed a large pelvic tumor which had
grown from the sacrum. He removed the tumor, tak-
ing away at the same time the lower portion of the
sacrum to which it was attached, .and the result was
most satisfactory.
The General Medical Council meets next week,
when the fate of the ])ublin Apothecaries' Hall will
again be in the balance. Meantime the electioneering
for seats in the council is being energetically carried
on.
The annual meeting of fellows and members of the
College of Surgeons took place yesterday; Mr. Mac-
namara, vice-president, presiding in place of Sir W.
MacCormack (president), whose progress toward re-
covery is still slow. In the report submitted the fi-
nances are stated to be satisfactory. A resolution was
passed after full discussion in favor of voting money
toward the effort of Mr. Anderson to appeal to the
House of Lords for the restitution of his rights as a
fellow and member, of which he has been deprived by
judge-made law. You will remember his gallant de-
fence against the oppression he suffered at Tobago and
that a British jury decided in his favor, but that deci-
sion was overruled by the court. The council opposed
the resolution, as a grant of the kind would probably
injure the cause they are supporting — to be exempt from
certain taxes, on the ground that they are only a scien-
tific body. Nevertheless, the resolution was carried
by forty-seven to two.
Another resolution was carried, requesting the coun-
cil of the college to instruct their representative on
the General Medical Council to forward in every way
feasible the principle that the representatives of the
licensing bodies should effectively represent the hold-
ers of all their diplomas. Corporation reform is in
the air and must come, in spite of the opposition of
the few in possession.
Dr. Cullingworth, of St. Thomas', has successfully
defended the action brought against him by a woman
on whom he performed double ovariotomy. She al-
leged she consented to have only one ovary removed,
but he said he could undertake to operate only on the
understanding that it must be left to his judgment to
do the best he could for her. He has vindicated his
procedure, the jury adding to their verdict that the
action ought never to have been brought. But no
doubt he has been put to great expense and endured
some four years of worry. It seems as if operators
would be well advised to insist on consent in writing.
Sir S. Wells and Dr. Bedford f'enwick were called for
the plaintiff', but their evidence, founded on notes of
the case, did her no good, and it is a pity they should
have appeared and so illustrated the prejudice as to
doctors disagreeing. It is very hard on Dr. Culling-
worth, after a successful gratuitous operation, to have
to defend his conduct in court. He will certainly lose
a considerable sum, as there are numerous items in
costs which do not pass the tax master. Drs. Her-
man and Galabin, as well as Mr. Lawson Tait, agreed
that it was necessary to remove the second ovary.
Professional responsibilities are heavy enough with-
out the terrible risks of lawsuits to decide whether a
patient has consented to a procedure which may prove
necessary in the course of an operation.
THE CURE OF SEASICKNESS.
To THK Editor of the Medical Record.
Sir: Notwithstanding the large circulation of the
Medical Record in Europe, I did not until quite re-
cently have an opportunity of reading Dr. Rockwell's
article on seasickness published in the spring or early
summer. The doctor was kind enough to mention my
work on the subject, but was also frank enough to in-
timate that he did not believe in the results I obtained
by my method of treatment of seasickness.
Since my chief desire is that the sea-going public
may benefit by my former researches in that direction,
I beg that you will here permit me to reaffirm the ex-
actitude of my statements as to results in treatment.
I also might venture to observe that a physician who
has barely crossed the ocean and back, with all the
upholstered comfort of a first-class passenger, is hardly
in a position to pass judgment upon the work of an-
other man who, as a regularly appointed ship's phy-
sician, has travelled his sixty thousand miles in all
latitudes and has as conscientiously treated his sea-
sick emigrants as he has the first-cabin passengers.
In the eighty-seven written clinical records upon which
I based my conclusions as to the efficacy of my mode
of treatment, there were no flights of the imagination,
but only carefully considered facts. Other phy-
sicians have tried my method with marked success,
although the writer of the above-mentioned article in
the Medical Record may never have heard of them.
The doctor is without doubt a first-rate authority on
electro-therapeutics, and also able to fill four columns
of the Medical Record on the well-known properties
of the bromides in seasickness, but that hardly quali-
fies him to characterize as "mistaken" a fellow-prac-
titioner who has had a comparatively large experience
in the matter. I am not disparaging the mode of
treatment by bromidization as a means of prophylaxis,
for I dwell upon it sufficiently in my own treatise on
seasickness, but I simply claim that the results ob-
tained by my method are fully as favorable as stated,
and that that treatment will reach desperate cases
which other means fail even to alleviate.
W. W. Skinner, M.D.
LiCERNE, November 16, iSgC*.
THE JUDGING OF COMPARATIVE RESULTS
IN THE SURGICAL ARENA.
To THE Editoi; oi" the Medical Record.
Sir : With all the presumption of the ancient shep-
herd boy going out to meet the giant with pebble and
sling, with not the remotest idea of criticising the
surgery of any person or institution, with neither
standing nor right to pose as champion of Roosevelt
Hospital — the writer ventures comment on some recent
surgical statistics given to the profession.
Dr. Gaillard Thomas, in an address at the Woman's
876
MEDICAL RECORD.
[December 12, 1896
Hogpital, drew comparisons between several city hos-
pitals as follows:
Abdominal Sections done in 1894, at
Roosevelt Hospital
New York Hospital
New York Cancer Hospital. . .
Mount Sinai Hospital
Woman's Hospital
Number , Re- I
of Cases, covered. ,
66
67
104
55
153
"'"'• I of Deaths.
50
52
86
46
130
16
15
18
9
23
24.24
22.37
17.3
16.36
15.03
Dr. Morris, in a recent paper, cited a series of loo
cases of appendicitis in which he had operated, with
a mortality of two per cent.
Pe'an, of Paris, recently reported 584 cases of vagi-
nal section (non-suppurative), with a mortality of less
than two per cent. ; and 816 suppurative cases of vagi-
nal section, with a mortality of less than five per cent.
Jacobs, of Brussels, reports 403 cases of vaginal
section, with less than three per cent, mortality.
These statistics, without analysis or qualification,
prove logically that surgery in the Woman's Hospital
is almost doubly as successful as in Roosevelt Hospi-
tal. Those of Morris, when compared with surgeons
who have a ten or a twenty per cent, mortality, prove
logically that he is five or ten times more skilful than
they, and is justified in deducing that it is all a matter
of " individual art," and that " some surgeons are more
dangerous than some bacteria." The figures of Pean
and Jacobs prove logically that they have five or ten
times more " individual art" than the principal sur-
geons at New York hospitals.
But does anybody who knows the whole ground be-
lieve these logical deductions? Such unqualified sta-
tistics are, to the unthinking, a standing criticism
upon more conservative men in the profession.
Suppose that surgeons with fancy statistics meet a
dozen desperate cases in their respective lines, each
with one bare operative chance for life in a hundred.
Would these gentlemen have regard for their statistics
and refuse the patient the one poor chance by opera-
tion? Or would they rule out from their statistics
these " practically moribund cases" ? In either event,
while the operators themselves may be soberness and
truth itself, their figures are vainglorious cheats as a
test of comparative skill.
As low mortalities cannot be had from desperate
cases, we must seek another standard to test a sur-
geon's worth, namely, the character of his cases. The
conservative man who operates only on grave cases,
will necessarily have a shorter list and a larger mor-
tality than another who operates on everything com-
ing into his hands. Life-saving is a higher ambition
than record-making. And low mortalities mean many
easy cases to help the average up — cases that the con-
servative man would not subject to risk of operation.
Eugene Coleman Savidge, M.D.
66 West Fiftieth Street, New York.
An Exception. — In an examination of sanitary in-
spectors one candidate answered the question relating
to the wilful exposure of a person suffering from an
infectious disease: "He must not ride in any public
conveyance, excepting a hearse, without first inform-
ing the driver." — The Medical Times and Hospital
Gazette.
Eye Strain. — The long continuance of eye troubles
may be the unsuspected source of insomnia, vertigo,
nausea, and general failure of health. In many cases
the eye trouble becomes suddenly mischievous, owing
to some failure of the general health, or to increased
sensitiveness of the brain from moral or mental causes.
— The Medical Times and Hospital Gazette.
Vertical ^tcms.
Contagious Diseases — Weekly Statement — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending December 5, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis
Measles
Diphtheria
Small-po.K
Cases.
Deaths.
136
45
98
3
86
263
85
14
5
3
3
35
o
A New Use for Patent-Medicine Literature. — It
is a favorite axiom of the optimists that everything has
its uses, but it has remained for the New Mexico
territorial board of health to find a use for the patent-
medicine almanac. In a recently issued circular on
the prevention of consumption, among other things, it
is advised that "every person so affected should spit
into some receptacle and should see that the sputum
is soon destroyed by fire. About the house there is
no better way than to spit between the leaves of patent-
medicine almanacs — to be had freely at all drug stores
— and after a half dozen or more spittings burn the
book."^ — Journal oj the American Medical Association.
Sixpence for medicine and attendance was the
charge of a lady doctor in Fulham, England.
Oxytoxins — The subject of the oxytoxins is one
that will require long-continued experiment upon ani-
mals and cultures before we shall know its limitations.
For the present, liowever, it would be unwise to ex-
pect miraculous cures of patients in the last stages of
consumption. — Hirschfklder.
Pate' de Foie Gras. — Instances of illness following
the free use of this delicious product of the fatted
goose may have at times a raison d'etre in the fact that
some goose farmers have been found to possess a
secret of securing enormous livers in their stuffed
fowls by administering the acid oxalate of potassium,
a powerful poison.
The Night Lunch Wagon Mr. John F. Hurley,
president of the water board, of Salem, Mass., who
has been indefatigable in promoting a good water
supply, has now called attention to a matter which
aft'ects the public health in a different degree. Dis-
claiming any intention of needlessly interfering with
any person's means of livelihood, he has protested
against the licensing of night lunch wagons, on ac-
count of the liability of the spread of disease by this
means. These wagons are familiar sights in the
cities and larger towms. Either they are driven about
the streets or they occupy a stand, night after night.
Mr. Hurley has interested himself to inquire into their
operation and finds that when ready for customers the
water supply of a wagon consists of about two gallons
of water in a bucket. During the nijjht several hun-
dred cups of coffee and mugs of milk are sold and
emptied into mouths many of which are dirty and dis-
eased, some foully so. The cleansing of the mug or
cups consists of a rinsing in the bucket of water and
a wipe with a towel that does dut)' for the entire
night. We must agree with Mr. Hurley that prob-
ably no better method of spreading disease can be
found than the practices he describes, and the subject
is one which should receive the attention of the board
of health in the cities where such a menace to public
health exists. — The Engineering Record, October 24th.
Medical Record
A iVeekly jfournal of Medicine and Surgery
Vol. 50, No. 25.
Whole No. 1363.
New York, December 19, 1896.
$5.00 Per Annum.
Single Copies, loc.
(Ovigimtl lii'ticlcs.
OBSERVATIONS ON VESICAL STONE AND
PROSTATIC DISORDERS, BEING THE BRAD-
SHAW LECTURE DELIVERED BEFORE THE
ROYAL COLLEGE OF SURGEONS OF ENG-
LAND ON DECEMBER g, 1896.
By REGINALD HARRISON, I-.R.C.S.,
MEMBER OF COUN'CIL ; EX-VICE-PRESIDENT, AND FORMERLY HUNTERIAN PRO-
FESSOR OF PATHOLOGV AND SURGERY, KOVAL COLLEGE OF SURGEONS ;
PRESIDENT OF THE MEDICAL SOCIETY OF LONDON,
We are met by reason of the beneficence of the widow
of the late Dr. William Woods Bradshaw, a physician
who practised first at Andover and subsequently at
Reading, and who was a fellow of this college, for the
purpose of endeavoring to promote in one direction or
another the scientific objects for which this college
was originally founded, I shall best mark our re-
spect to the memory of the founder of this lectureship,
and my appreciation of the honor conferred upon me,
by at once proceeding to attempt to discharge the duty
I have thus undertaken.
If, for any purpose, we look at the surgery of to-day,
as exemplified, for instance, by the work of many of
those who either have been, or are, associated with
this college, and compare it with what existed at the
commencement of this century, or even later, it is im-
possible not to recognize the marvellous progress that
has been made all along the line. Though in some
directions it may be more apparent or practical than
in others, yet it is at once obvious that it is the out-
come of the development of principles which are appli-
cable not merely to subdivisions artificially arranged
for convenience of study or of practice, but to the
whole field over which the science and art of surgery
may be said to range.
It will be my endeavor in noticing certain ad\'ances
that have taken place in work which circumstances
have brought more immediately under mv notice, to
give prominence to some aspects of a large and an
important subject which appear to deserve further
consideration and expansion. In this way I venture
to hope I shall best fulfil the objects entertained by
the beneficent founder of this lectureship.
In bringing under your attention some points con-
nected with the surgery of the urinary organs it is im-
possible to refrain from noticing the important changes
that have taken place in the operative treatment of
the afi^ections of these parts within the recollection of
most of us present on this occasion. Lateral lithot-
omy has practically disappeared from the scene ; supra-
pubic and perineal cystotomy, more especially in their
application to calculus, have undergone important
inodifications and have been revived ; the older methods
of removing stone from the bladder by crushing have
been supplanted by Bigelow's process of litholapaxy,
and the surgery of the kidney, with the various meth-
ods this includes, now occupies a permanent and
prominent position in our text-books. Nor is it im-
probable that the range of renal surgery may not be
still further extended with advantage. The outcome
of these changes in and additions to our methods of
dealing with urine stones alone represents a saving of
life and suft'ering which it would be diflicult, if not
impossible, to estimate by figures.
The almost entire disappearance of lateral cystot-
omy, using this term in its more extended application
to various affections and injuries of the urinary appa-
ratus, is. a turn of afi^airs which I venture to think
cannot be viewed entirely with satisfaction. Some of
us may remember how marvellously this operation was
utilized by the late Sir \\'illiam F'ergusson for the
rapid and successful removal of certain forms of stone
from the bladder. It was in this theatre and before a
distinguished audience of the kind gathered here to-
day that he referred to this process in terms of eulogy
as "the master handiwork of surgery."
In thus dissenting from the tendency existing at the
present day to relegate lateral cystotomy to the surgi-
cal shelf, the suggestion comes to me in a measure
from reading some remarks in a review relative to cer-
tain observations of which I liappened to be the author,
in which I was rather severely taken to task for being
so old-fashioned or so eccentric as to reproduce for the
use of my readers, at the close of the nineteenth cen-
tury, a somewhat carefully prepared description of this
operation. It seemed to me that such a criticism was
a little premature, for, though the use of this operation
in stone cases was daily becoming more restricted by
reason of the substitution of other methods, the fact
that lateral cystotomy possessed essentials in treatment
peculiar to itself must forever command for it a place
in the records of operative surgery.
By what other means that have yet been devised,
may I ask, can a surgeon, by an opening from the
perineum in the male, secure the removal of a stone,
the incontinent and dependent drainage of a diseased
bladder, without the use of apparatus, together with
the necessary infliction of a wound on the prostate
which, there are reasons for thinking, has not unfre-
quently been the means of arresting its growth, if not
of inducing its atrophy when enlarged? Nor can it be
doubted for the reasons just assigned that in certain
forms of injury involving the neck of the bladder,
complicated as this sometimes is with fracture of the
bones constituting the pelvic arch, as in instances of
extraperitoneal rupture of tiie bladder, an incision as
for lateral cystotomy has frequently been the means,
by at once establishing free and untrammelled drain-
age for the urine, of alone l^ringing about a successful
termination to the case. F'or reasons such as these, I
should be sorry to think that the mode of performing
lateral lithotomy has either ceased to be taught in our
schools or to be tested by our examiners.
Lateral cystotomy has to a large extent been dis-
placed by the revival of the suprapubic or high opera-
tion on somewhat altered lines, and with this substitu-
tion I am not disposed to find fault. By this method
an easy access to tlie bladder for the purposes of
exploration and drainage not requiring a dependent
opening, for the removal of growths from the interior
of this viscus as well as pendulous excrescences from
the prostate, is provided. In the case of small stones,
both in the adult and the child, its substitution for
crushing, in uncomplicated cases, is often unneces-
sary, while in the instance of very large calculi, though
8-8
MEDICAL RFXORD.
[December 19, 1896
no other course may he open to the surgeon, the risk
to life, it must be remembered, is considerable.
Time, however, will not permit me to tra\erse opin-
ions and practices relative to an operation which has
undoubtedly justified its revival and has proved of
much service in connection with the general surgery
of the bladder. Its selection relative to the treatment
of stone will be found mainly to turn on individual
experience, rather than upon those hard and fast lines
which lecturers are sometimes disposed to lay down.
Turning to the crushing operation for stone, as now
generally practised on the lines laid down by Bigelow
in 1878, we shall find much connected with it of in-
terest to di.scuss without encroaching upon historical
and personal controversy. There can be no doubt
w hatever that the anticipation expressed by the author
of the term " litholapa.xy" as to the crushing and evac-
uation of stone from the bladder by an uninterrupted
and completed process, with hardly any reference to
its size or constitution, being followed by a largely
diminished mortality has been more than realized.
In connection with ISigelow's method of operating I
may perhaps be excused in saying what pleasure it
afforded me in being present at the Massachusetts
(ieneral Hospital and witnessing some of the cases
wiiich formed the earliest portion of the important
series that Bigelow subsequently published ' in illustra-
tion of his work. The instrument I am showing you
is one of his original evacuators with the catheters,
which I brought over with me from Boston in 1878
and subsequently used.
I do not, howe\er, think it would be right in thus
referring to the greatly diminished mortality that has
followed successive improvements in the crushing
operation for stone, or by whatever name we may call
the proceeding, were I to omit to refer to the impetus
given to this direction of work by Civiale and Guyon
in France, and by Sir Henry Thompson in this coun-
try. By the latter the museum of this college has
been greatly enriched by his gift of a collection of
calculi which is unique in its extent and clinical his-
tory, while our librar)- and our literature have largely
profited by his pen.
I must, however, turn, as I have already indicated,
to another aspect of my subject. In his Hunterian
lectures delivered before this college in 1886, Mr.
("adge observed that, "although the immediate and
direct mortality of lithotrity is small, the recurrence
of stone is lamentably frequent." In illustration of
this statement he referred to figures which indicated
this as then amounting to about one in seven. It
must, however, be remembered that this calculation
was based to a considerable extent upon cases operated
upon by the processes of crushing, with very imperfect
means of artificially evacuating the fragments from the
bladder which preceded Bigelow's time.
.\ decade has now elapsed since this criticism was
offered, and, without troubling you with figures which
might be open to objection for this purpose if not
drawn from sources in actual parallelism with those
which formed the basis for the conclusion Mr. Cadge
arrived at, there can be no doubt that within this pe-
riod, and directly arising out of the further development
and more general adoption of Bigelow's work, the
liability to recurrence after these o(3erations has
greatly diminished.
Improvements in the construction of lithotrites or
breaking machines, so far as relate both to trituration
and speed, the more general substitution of fenestrated
for smooth-bladed instruments, the use of evacuating
cannula- permitting of the more ready withdrawal and
escape of the broken-up fragments from the bladder,
and the employment of aspirators or wash bottles more
capable of sluicing the bladder and any irregular
' ■• Litholapaxy." Wm. Wood & Co., New Vork, 1S7S.
pouches it might possess, are the means which have
chieriy contributed toward this end.
It would be an interesting study, and not without
some prospect of promoting further developments in
this direction, to trace, if occasion permitted, the va-
rious advances that have been made from time to time
in the construction of the mechanical appliances used
in crushing and evacuating stone in the bladder. I
am disposed to think, however, in the further ap-
plication of chemistry and physics in this direction
(I refer more particularly to the extension of such in-
vestigations as Rainey's, "On Molecular Coalescence
Relative to the Formation of Calculi") to all forms
and positions of urine stones that further improve-
ments in practice will eventually come.
Reverting to stone recurrences, it must still be rec-
ognized that even with the best appliances and skill
they not unfrequently occur, and it is to such in-
stances, in relation more particularly to some recent
investigations in collateral directions, I would desire
now to direct your attention for a few moments.
If we analyze the causes of stone relapses after
crushing oixrations, there can he no doubt that a fail-
ure to remove all the fragments from the bladder in
the first instance is by far the most frequent one. It
is in reference to this very important matter that li-
thotomy, however performed, irrespective of the ques-
tion of mortality, shows to an advantage, and at the
same time suggests an explanation why this distinc-
tion should exist. This is a point wliich I think re-
quires further analysis and consideration.
I'he general experience of crushing operations as
now, and for some years past, almost universally prac-
tised under the name of " litholapaxy," in this coun-
try at all events, seems to indicate sufficiently clearly
that the liability to recurrence after this operation
increases considerably as age advances. Recurrences
before sixty years of age are rare and are usually
traceable to .some exceptional circumstance, such as
urethral stricture, or obstruction attended with pouch-
ing or trabeculation of the bladder. Hence we may
conclude that hypertrophy of the prostate and the
structural complication arising out of this in conjunc-
tion w ith atony or imperfect powers of urine expulsion
are frequent concomitants, in by far the larger propor-
tion of stone relapses after lithotrity. This is the
view which I believe now finds general acceptance.
This explanation of course applies only to those
instances of recurrence in which the calculus is mainly
phosphatic and of vesical origin, in contradistinction
to those in which a fresh descent from the kidney takes
place, and accidental arrest and growth in the bladder
secondarily ensue. Instances are occasionally met with
in which the operation of crushing has been followed
within a few days by an attack of renal colic. Here
a diathetic stone is either spontaneously expelled in
the course of normal micturition, or, being too large to
get over the bar caused by an enlarged prostate, re-
quires pulverizing with the lithotrite before its evacu-
ation can be effected. In cases in which persons have
been in the habit of passing renal calculi for years, it
is frequently found when the prostatic age is reached
that the ureters, no doubt much dilated by previous at-
tacks, allow stones of considerable size to descend into
the bladder, comparatively painlessly, which are subse-
quently trapped by the enlarged prostate. Otherwise
they niight, as previously, have been spontaneeously
voided. Recalling, however, the ordinary circum-
stances under which stone recurrences after lithot-
rity most frequently occur, I am brought to consider,
not the necessity for imposing other restrictions upon
the employment of an operation by means of which so
much has been achieved at so small a risk to life, but
how far progressive surgery permits us to remove or
mitigate complications in structural defects which
December 19, 1896]
MEDICAL RECORD.
879
tend to provide mechanical difficulties, sometimes in-
superable, in the way of complete evacuation of the
fragments, and subsequently furnish favorable con-
ditions for repeating the process of stone making when
once the nucleus is there.
We may therefore proceed to inquire: (i) What
means have we, if any, of diminishing the enlarged
prostate? (2) To what e.\tent are they applicable
to cases complicated with recurring vesical stone?
(3) What alternative measures have we for litholapaxy
under exceptional circumstances of this nature? If
the question were put to a student under examination.
What surgical measures have been followed by atrophy
or shrinkage of the hypertrophied prostate ? I think he
would be justified in replying somewhat in this way:
It has followed cases of simple incision into the
prostatic ring, as in the second stage of lateral lithot-
omy. It has supervened upon puncture of the bladder
through the enlarged prostate with retention oi' the
cannula for some weeks.'
Shrinkage of the enlarged prostate has followed
upon double and single castration and upon double
and single vasectomy or division of the vas deferens.
This answer would of course not be regarded as in-
cluding cases of partial or complete removal of the
prostate gland, now known under the name of prosta-
tectomies.
The second question which necessarily arises out
of the preceding statement, namely, How far are these
several methods of inducing shrinkage applicable to
cases of hypertrophied prostate complicated with re-
curring vesical stone? is not so easily or so briefly
answered, and will, for the latter purpose, require
some expansion.
Prostatic incision, or puncture as first referred to,
apart from the limited nature of the observations of
cases in which atrophy seems to have followed it, would
hardly be applicable in cases otherwise suited for
lithotrity. I will, therefore, without further comment,
pass on to notice the adoption of castration and vasec-
tomy in resjject to the question now under review.
Reference to these proceedings opens up a subject
which, so far as it relates to the practice of surgery, is
new, though from an anatomical and physiological
aspect it has previously received some attention, w hich
must not be entirely overlooked. John Hunter" ap-
l^ears to have experimented on animals in reference
to this point, and more recently Griffiths' has added
importantly to these researches. Decimus Hodgson,*
of Glasgow, remarked in 1856, ''in persons who have
been castrated the prostate dwindles down almost to a
rudimentary condition.'"
The inference, however, that what is true relative
to the normal state of these parts also applies in vary-
ing degrees to the hypertrophied prostate does not
appear to have been utilized systematically for practi-
cal purposes, until Dr. \\'illiam White, of Philadel-
phia, drew attention to it in 1893.* Since this paper
appeared, the operation of castration and other pro-
ceedings arising out of the same train of thought rela-
tive to the enlarged prostate have been somewhat
extensively employed, and to some of the results
obtained and the considerations suggested I purpose
now referring.
From the records of this operation, now covering
several hundred cases, which from time to time
have been drawn up by various surgeons, I do not
think there can be any doubt in arriving at the con-
clusion that in a certain proportion of cases castration
has undoubtedly been proved to have been speedily
' "Surgical Disorders of the I'rinary (.)rgans," by Reginald
Harrison, 4th ed.. p. 2-0.
• Works edited by I'almer.
" [ourn. Anat. and Pliys. , vols, xxiii. and .x.xiv.
' " On the Prostate ('.land," Glasgow, i8;6.
' Trans. Am. Surg. Ass., 1893 and 1895.
followed by shrinkage of the prostate and abatement
of the symptoms attending this condition.
Taking one of the most recent communications on
the subject, of which Dr. Cabot,' of Boston, is the
author, and which includes about one hundred well-
authenticated cases in illustration, on reading it I was
struck not so much with the somewhat high death rate
as with the uncertainty as to the kind of result, phys-
ical as well as mental, the surgeon is likely to expect.
Will the patient recover completely or imperfectly
when the risk of the operation is passed, whatever this
may be? is a question which naturally arises and is
apparently at the present stage not very easy to an-
swer. In the expression of opinion by Dr. Cabot that
castration seems especially efficacious in cases of large
tense prostates, when the obstruction is due to the
pressure of the lateral lobes upon the urethra, and is
of but little use in cases of myomatous and fibrous
glands, he is warranted, I consider, by the records to
which I have referred.
I have hitherto been addressing myself more partic-
ularly to the application of castration to prostatic
hypertrophy generally. Scattered, however, through
the cases which have been recorded are some few in
which it has been utilized with advantage for recur-
rence of stone after crushing operations, when this
complication was prominent. I cannot quote a case
of my own in illustration, as I have not had occasion
to resort to it under these circumstances, but I am ac-
quainted with one in which it well served this purpose.
It was that of a male, seventy years of age, who
after lithotrity had stone recurrence on three occa-
sions, at intervals of a year or so. The fourth time of
relapse the urine and bladder were in so foul a state
from cystitis and great enlargement of the prostate
that a suprapubic cystotomy was performed, by means
of which another phosphatic stone was removed and
the bladder was drained for some time. The patient,
however, was intolerant of all the methods that were
tried with the object of keeping the wound open bv
various drainage appliances, and eventualh' it closed
before the latter process was completed. This was
followed by a speedy return of all the symptoms of
cystitis and the commencing formation of more phos-
phates. To meet this condition the bladder was again
cleared by means of the lithotrite and the aspirator,
and double castration was performed. The relief was
now complete and is, I Iselieve, permanent, as the
patient has been free of his stone and of his symptoms
for nearly two years, and has no need of either his
catheter or his irrigator.
It is under circumstances such as these that castra-
tion may occasionally find a place in the treatment of
recurring stone complicated with enlargement of the
prostate. In selecting it, however, apart from other
considerations, the surgeon must be reasonably clear
in his opinion that the case is not one either of en-
cysted or pouched stone, otherwise, as castration
affords no opportunity of making either a digital or
ocular examination of the interior of the bladder, a
suprapubic prostatectomy would, in the face of these
presumed complications, be preferable.
After reading Dr. White's first paper, to which I
have already referred, I took an early opportunitv of
raising the question as to whether somewhat similar
results, so far as the enlarged prostate was concerned,
could not be induced by dividing either one or both
of the excretory ducts of the testicle. I based my sug-
gestion partly on a case" in which some years previ-
ously, under somewhat exceptional circumstances,
which I narrated, I had casually, though at the urgent
desire of a patient, divided the vasa, with good results
after a considerable inter\al of time. Further I drew
' .\merican Surgical .Association. .May, 1896.
' Brit. Med. Joum., .September 23, 1S93.
88o
MEDICAL RECORD.
[December 19, 1896
attention, in connection witli the subject of injuries to
the vas deferens, to certain cases recorded by Hilton
and Birkett,' in which atrophy of the corresponding
testis was proved to have followed the accidental divi-
sion of this tube either by section or laceration. My
contention was that if division of a vas brought about
atrophy of the corresponding testis, it was logical to
conclude that atropiiy of the prostate would follow to
a like e.xtent — that is to say, the division of one vas
would be followed by unilateral atrophy, first of the
testis and afterward of half of the prostate — whereas,
if both vasa were divided, both testes and the whole
of the prostate would subsequently undergo shrinkage.
I think I may claim that this has now been proved to
be the case.
It must, however, be stated that one of the objec-
tions I have put forward against castration applies, as
matters at present stand, with equal force to vasec-
tomy. I refer of course to the uncertainty that exists
as to what kind of results will be obtained.
In the course of a discussion that recently took
place" in reference to the treatment of prostatic hyper-
trophy by these means, I took the opportunity of say-
ing that from some e.xperience of my own the results
of vasectomy depended very much on attention to
certain details connected with the operation, which I
ventured to enumerate and which I will briefly repeat.
In the first place, 1 do not think it is well to operate
on both vasa at the same time, as any risk connected
with the proceeding is increased, and mental effects
of a serious nature may follow, such as have been
observed after castration. I have not met with an in-
stance in which any ill effects resulted when a sufficient
interval was allowed to elapse between the two opera-
tions. I think the interval should be not less than a
month. I have seen instances in which the relief fol-
lowing the division of one tube was so sufficient as to
render division of the opposite one unnecessary. In
some of my cases I found that after one vas had been
divided the prostatic symptoms subsided at once, and
then, after an interval of three weeks or so, began to
reappear coincidently with some hypertrophy of the
testicle of the opposite side, where the tube had not
)'et been divided. The second operation was then pro-
ceeded with, and it was in the group of cases in which
this incident was observed that I obtained the most
satisfactory results.
It must, however, be remembered, as I have endeav-
ored to put it, that in bringing about prostatic atrophy
by section of the ducts it is through the medium of a
double process, or rather by the induction of an
atrophy by an atrophy. Hence the etlects of vasec-
tomy upon the prostate are longer delayed and more
gradual than when the testes are primarily removed.
In some of my cases of double vasectomy it was ob-
.served — though in all instances the effects were prop-
erly explained to the patients beforehand— that the
division of these ducts was not immediately followed
by cessation of se.xual desire and power, and months
sometimes elapsed before these sensations finally
ceased and atrophy of the testes was marked. I am not
aware, however, of an instance in which these effects,
though delayed, were not finally attained. Though
vasectomy must be regarded as a slower process than
castration, relative to prostatic changes, in this, I be-
lieve, lies its comparative safety and advantage.
In the next place a portion of the vas must be re-
sected and not merely ligatured. I'avone," who has
recently reported twenty-eight cases out of thirty-four in
which the patients were either cured or improved after
vasectomy, advises that in addition to excision the
ends of the canal should be twisted, so as to insure
' Holmes' " System of .Surgery." ist ed., vol. ii., p.
■' Brit. Med. Journ.. October lo, 1896.
'II Policlinico, Xo. 15, 1896.
139-
complete closure. The possibility of the restoration
of the occluded vas when a ligature only has been
used has been illustrated by Dr. Bransford Lewis.'
Here, on the return of prostatic .symptoms, it was
found that the continuity of the duct had been re-
established after the ligature had come away.
The simplest way of performing the operation seems
to consist in exposing the vas by a short linear inci-
sion over it, and protruding it between the finger and
thumb. -Vn aneurism needle is then slipped under
the isolated duct, by means of which a loop about an
inch in length is withdrawn. The latter is then in-
cluded in a silk ligature, when the free portion is
removed by scissors. The small wound usually heals
quickly. Apart, how-ever, from some failures arising
from want of attention in operating to details such as
these, there appear to be other reasons requiring con-
sideration, and which apply with equal force both to
castration and to vasectomy. I have already stated that
when the prostate lias passed into a fibrotic condition,
or when the obstructing third lobe represents in struc-
ture a fibrous tumor, the prospects following either
operation on the sexual apparatus are unpromising.
Here McGill's operation is usually indicated. There
are, however, other conditions of the prostate which
must be taken into our reckoning.
I am inclined to believe that if the consideration
and discussion of these two operations relative to pros-
tatic hypertrophy did no more than lead us to recon-
sider many jicints connected with the pathology of
this part much will have been accomplished. I have
long thought that slowly progressive carcinoma of the
prostate, resembling in some features the more ordi-
nary forms of hypertrophy, is far more common than
is generally believed to be the case. My attention
was first called to this matter in 1886, when I recorded
a case' which I will briefly refer to.
It was that of a man, aged fifty-nine years, whom as
a private patient I had the opportunity of watching
for two years, up to the time of his death. In the
first instance he suffered from some irritability of the
bladder which he could not completely empty. He
was losing flesh, becoming pale, and, though the men-
tal faculties remained vigorous to the last, he con-
stantly complained of pain in the loins, nates, and
thighs. In the course of a few weeks he became en-
tirely dependent upon the catheter. His prostate, as
felt from the rectum, was hard, nodular, and almost
insensitive to the touch, though it was not much en-
larged, nor were any neighboring glands foimd to be
involved. As his general health slowly declined,
minute petechial spots apjjeared on various parts of
his body, and his feebleness gradually increased.
Occasionally he passed a small quantity of blood
with his urine. He appeared to die of exhaustion,
the result of prolonged bl< od vitiation. .After death
his prostate was examinea by Mr. F. Paul, who re-
ported it to i)e an unmistakable example of carcinoma.
There was no evidence to show that this was other
than the primary disease. I remember Mr. Paul re-
marking to nie at the time that the precise nature of
the disease would probably have been undiscovered
had it not been carefully looked for, as there was ap-
parently to the naked eye but little to distinguish the
specimen from one of ordinary hypertrophy. I have
since met with many instances of this kind in practice
and have been able occasionally to confirm the diag-
nosis by patliological examination.
Clinically this group of slowly progressive carcino-
mata may be distinguished by the following indica-
tions: In the first place, they are generally met witli
in persons who are rather under what I would speak
of as the prostatic age, that is to say, they chiefly occur
' Journ. Cut. and Gen.-Urin. Diseases, New York, 1896.
' Op. cit. , p. 509.
December 19, 1896]
MEDICAL RECORD.
881
in males of fifty-five years or therealiouts. \\'hen felt
from the rectum the gland is found unusually hard,
bossy, and rather insensitive to the touch. They sel-
dom bleed much or ulcerate, unless damaged by a
catheter or sound. Though the use of the former is
generally required more or less constantly before the
case terminates, there is seldom either sudden or com-
plete retention, or even distention of the bladder.
Reflected pain in various parts, such as the thighs,
nates, and rectum, is often complained of, in addition
to much painful irritability of the bladder. Death is
usually caused by blood vitiation and exhaustion, with
well-marked signs of what we used to speak of as a
cachexia.
I have referred to fibrous and carcinomatous pros-
tates for the purpose of remarking that for such
growths as these neither castration nor vasectomy is
at all likely to be of any avail. Together they repre-
sent a by no means uncommon condition of this part,
and their treatment must be conducted on the princi-
ples which are applicable generally to growths in\'olv-
ing the interior and neck of the bladder. In going
over the recorded cases of castration and vasectomy, it
is not difficult in reading between the lines to see that
among them are included instances of the two con-
ditions to which I have just referred and in which ex-
perience shows that no good was likely to accrue from
what was done. These we must endeavor to exclude,
and then I think we shall find that division of the
vasa deferentia will be found an efficient means for
curing or relieving advanced forms of prostatic hyper-
trophy, without incurring the additional risk, not to
mention other drawbacks, which naturally attend such
an operation as castration.
I must not here forget to mention that I have in
three instances employed division of the vasa in re-
curring stone with cystitis due to much enlargement
of the prostate, with great and, I believe, permanent
advantage, .\part from the non-recurrence of the
stone after fair intervals of trial, a general improve-
ment in the function of micturition has been main-
tained, and this is in correspondence with what other
surgeons have illustrated in the records to which I
have referred.
It will of course be understood that the expedients
I have drawn attention to as worthy of consideration
are applicable only to grave varieties of prostatic dis-
ease, whether complicating vesical stone or not. When
we consider how considerable a number of well-
matured brains carry on long and useful lives with
advantage to those belonging to them, as well as to
the community at large, and who are more or less de-
pendent upon the aid a catheter affords, it is unneces-
sary to say that such measures as those I have been
discussing can apply in any degree only to the excep-
tions and not to the rules. The latter are already, I
believe, adequately provided for, while in the interests
of the former all proved methods, either of cure or
relief, must receive, as they always have done, our
careful and unbiassed consideration.
I will now pass on to offer some remarks in refer-
ence to perineal lithotrity. Among the variations that
stone cases present a small proportion will be met
with in which, by reason of the condition of the blad-
der and the urinary apparatus generally, the ordinary
operation of crushing is not applicable. In these cases
not only must the stone be removed but provision
made for the drainage of the bladder; and for the lat-
ter purpose lithotrity in no way adequately provides.
When the stone is large, and I am speaking now of
calculi between two and three ounces in weight, and the
prostate and bladder are more or less involved in sup-
puration and chronic inflammation, various substitute
proceedings are adopted which have to be considered.
Suprapubic cystotomy under these circumstances is
attended with a high rate of mortality. Guyon and
others have estimated it in males of advanced age,
who are generally the subjects of these complications,
at somewhere about fifty per cent., and my own im-
pression is that this is about the case.
Such a mortality as this takes us back to some of
the worst days of lithotomy and contrasts unfavorably
with other forms of suprapubic cystotomy, as, for in-
stance, when applied to younger persons, and even
with suprapubic prostatectomy, which Mr. Mayo Rob-
son' has shown to be a much less risky proceeding.
It is now some years ago since I had this point under
careful consideration in connection with one or two
cases of septicaemia after lithotrity, arising under the
conditions I have just referred to.
On reviewing the various operations employed for
removing stone from the bladder, other than by crush-
ing alone, it appeared that there was much in Dol-
beau's' method of perineal lithotrity to recommend it.
The objections against it chiefly centred in the em-
plovment of forcible dilatation of the prostatic urethra
and the neck of the bladder, and in the instruments
used in crushing and evacuating the stone fragments.
Further, no provision appears to have been made by
Dolbeau for draining the bladder systematically, after
the stone had thus been withdrawn. These objections,
however, seemed to be capable of removal, and I pro-
ceeded to practise this operation from time to time, as
suitable cases presented, in the following manner:
In the first place an ordinary boutonniere or median
perineal cystotomy is practised on a grooved staff
sufficient to admit the introduction of the finger into
the bladder, as for digital exploration. This repre-
sents all the dilatation of the prostate or neck of the
bladder that is attempted. The next step is to with-
draw the index finger and substitute a pair of crushing
forceps specially made for this purpose, though in
other respects resembling an ordinary pair of lithot-
omy forceps, either straight or curved. These have
been constructed for me bv Messrs. Krohne and Sese-
niann, and by Messrs. Tiemann, of New York. They
are made in different sizes, the most powerful having a
screw at the handle by which the full crushing power
is brought into play. In circumference the combined
blades correspond in size with an average index finger,
and contain well within cover a strong cutting rib run-
ning down the centre of each, by which the fragmen-
tation of the stone or stones is chiefly accomplished.
By means of these forceps the stone is sufficiently
reduced in size to be either easily withdrawn in
fragments from the bladder by these instruments or to
be sluiced out with a cannula and an ordinary wash
bottle as used for litholapaxy. Straight cannula- will
be found the most convenient for this purpose.
After the stone has been withdrawn and the bladder
and prostate have been carefully examined, either with
the sound or with the finger, the drainage tube is intro-
duced and retained for as long as is necessary, in ac-
cordance with the nature of the case. Here is a speci-
men of the hardest kind of urate stone, the fragments
weighing over three ounces, which was broken up and
withdrawn in this way in something like five minutes,
a process which would have occupied an hour or more
had it been expedient to substitute lithotrity. I also
removed with my finger quite easily a grape-like third
lobe which was in my way. The patient made a rapid
and complete recovery. I show this specimen merely as
illustrating what these forceps are capable cf effecting
and what may be withdrawn through a wound only suf-
ficient in extent to admit the introduction of an index
finger. I have in one or two in.stances tried a short
lithotrite, such as Surgeon-Major Keith has described,
passed into the bladder through the perineal wound,
' Mrit. Med. Journ., April 2S, 1804.
' "De la Lithotritie I'erineale," Paris, 1S72.
882
^lEDICAL RECORD.
[December 19, 1S96
instead of crushing forceps, but find the latter more
effective and convenient for use in this position.
I have selected this method in fifteen instances out
of considerably over three hundred cases of lithotrity
and have so far had no deaths or recurrences of stone
following it. The chief points in its favor are these:
( I ) It enables the operator to crush and evacuate
large stones in a short space of time. (2) It is at-
tended with a very small risk to life as compared with
other operations, such as lateral or suprapubic lithot-
omy, and is well adapted to old and feeble subjects
when for any reason crushing is inadmissible. (3)
It permits the operator to wash out the bladder and
any pouches connected with it more effectually than by
the urethra, as the route is shorter and the evacuating
catheters employed are of much larger calibre. (4)
The surgeon can usually ascertain, either by explora-
tion with the finger or by the introduction of forceps
into the bladder, that the viscus is cleared of all de-
bris. (5) It enables the surgeon to deal with certain
forms of prostatic outgrowth and obstruction compli-
cated witii atony of the bladder in such a way as to
secure not only the removal of the stone but the re-
storation of the function of micturition. (6) By the
subsequent introduction and temporary retention of a
soft-rubber drainage tube states of cystitis due to the
retention of urine in pouches and depressions in the
bladder wall are either entirely cured or are perma-
nently improved. To lock up unhealthy ammoniacal
urine in a bladder that cannot properly empty itself
after a lithotrity is to court the formation or recur-
rence of a phosphatic stone. Hence it is well suited
to some cases of recurrent calculus. I have never
known the wound to remain unhealed except in those
instances in which, for some reason or other, it has
been desired to construct a low-level uretiira. It is
well adapted for some ca.ses of stone in the bladder
complicated with stricture in the deep urethra, as it en-
ables the surgeon to deal w ith both at the same time.
In a recent paper by Mr. Herbert Milton, of Cairo,'
I see that the operation of perineal lithotrity figures
prominently and successfully among the two hundred
cases of stone he records. He has employed it, much
on the same lines as I have described, in twenty-one
instances with one death. Though speaking of Bige-
low's operation as the more brilliant of the two, he
evidently has reason to regard perineal lithotrity, as
now revived, as the more generally useful. .\ speci-
men made by Messrs. IJown, of London, of tlie break-
ing forceps Mr. Milton employs is submitted for
inspection. Taking Mr. Milton's twenty-one cases
and fifteen of my own, we ha\ e a total of thirty-six
with one death, which, considering the size of many of
the stones and the complications that were present,
gives, I think, a very satisfactory result and one that
will compare favorably with those obtained from other
operations, either crushing or cutting used in the treat-
ment of stone. I have a growing impression that in
countries where by reason of the great age that is often
attained by persons suffering from stone in the blad-
der, and where the opportunities for practising litho-
lapaxy are not very frequent, perineal lithotrity will
be more generally utilized.
Before leaving subjects connected with the treat-
ment of vesical stone by crushing, I would briefly
allude to a change in practice for the better, which is
a direct outcome of the excellent work in the applica-
tion of this operation to male children. I refer more
particularly to the successful employment of litho-
lapaxy in this direction by our distinguished fellow.
Dr. Keegan, work which has been importantly supple-
mented by my colleague, 1 )r. Freyer.
Sudden retention of urine in young males is most
frequently caused, as we are all aware, by the impac-
' Lancet, .\pril and .May, 1S96.
tion of a small stone in the urethra. Such an incident,
apart from the extreme urgency of the symptoms thus
produced, has not unfrequently led to ulceration of
the urethra and serious, if not fatal, extravasation of
urine into the neighboring tissues. In fact, it may be
stated with liardly an exception that it is under these
circumstances alone such a calamity is met with in
these young subjects. In earlier days when the cath-
eter detected that a stone was thus impacted, the prac-
tice universally was either to cut down and remove the
calculus from the position it occupied in the urethra,
or if possible to push it back into the bladder and
then to extract it by some form of lithotomy or cutting
operation. Though either proceeding was usually
successful, it entailed an operation which necessarily
required a period of convalescence to follow. .Among
some of my earliest lithotomies in male children were
cases occurring under these circimistances. In illus-
tration of the importance of this change in practice I
may be permitted to mention very brielly the particu-
lars of a recent case. It was that of a boy, aged four
years, whom I saw, with urgent retention of urine due to
the lodgment of a stone in the urethra just behind the
scrotum. I pushed the stone back into the bladder
and the retention was at once relieved. On the fol-
lowing morning I had the child placed under an anes-
thetic and crushed the stone. .As I foimd at the
moment I had not an evacuating catheter sufticiently
small to enter the bladder witliout more force than
was desirable. I contented myself in more completely
pulverizing the calculus with the lithotrite than I
should otherwise have thought necessary to do. The
debris was discharged in the natural course of mic-
turition and the patient was practically well without
anv delay, as the urine was never even tinged with
blood. Sir William Roberts was kind enough to
examine the fragments of the calculus and reported
that it consisted of uric acid with a coating of oxalates
and weighed a little over five grains. A short time
ago the patient would undoubtedly ha\e been sub-
mitted to a cutting operation. I may incidentally
mention that I reported ' a very similar case, in which
I practised lithotrity in a male child, aged eleven years,
in 188 1, and 1 have since from time to time success-
fully adopted this proceeding. I believe this was one
of the first recorded examples in so young a subject,
a circumstance I had forgotten until recently reminded
of it by iJjy friend. Dr. Keegan, and some small litho-
trites were then made for me by Messrs. Weiss.
In bringing my observations to a conclusion I shall
ask your indulgence for a few moments while I engage
in some speculations in contradistinction to the sub-
ject matter I have hitiierio \entured to bring under
your notice, in the belief that it has been sufiiciently
demonstrated to warrant me in doing so. I refer
to the application of the Roentgen or .r-rays to this
branch of surgery. I feel. that I am justified in doing
so, partly for the reason that if these anticipations
eventually fail to be realized, they may still possibly
serve to indicate in wliat directions assistance from
collateral science is required and may be expected,
and partly because Sir Joseph Lister, the distinguished
president of the British Association, in his recent ad-
dress in Liverpool, emphasized the belief that in the
near future surgen,- had much to gain by this method
of investigation. As to the truth of the latter state-
ment there can be no doubt.
To what extent this means may be utilized in mat-
ters which have occupied a considerable portion of
this lecture has yet to be demonstrated. In its appli-
cation to the diagnosis of calculus situated within any
portion of the male or female urinary apparatus from
the kidney downward, I am not aware that it has been
sufficiently successful in indicating either the form or
' '■ Surgical Disorders of the Urinary Organs," 4th ed.
December 19, 1896]
MEDICAL RECORD.
88:
the position of the stone. From some experiments
made chieriy outside the human body (I refer to such
as those of M. D'Arsonval,' in Paris, and of Mr. Henry
Morris" and others) it is quite possible by the shadow.s
thus cast to distinguish various kinds of calculi. At
present I do not think more than this can be said or
has been sufficiently demonstrated. Though I have
had several patients skiagraphed, I have not yet suc-
ceeded in obtaining results which were of help to me
in making a diagnosis independently of such means
as we are in the habit of using.
In thus referring to this method of investigation it
is with the hope that in its further development and
application it will among other aids enable us to dis-
pense with the use of the sound as a means of diag-
nosing stone in the bladder. I cannot call to mind
an instance in the child, woman, or young male adult,
extending up to what I could call middle age, who was
ever seriously damaged by the judicious use of this
instrument, but in males of a more advanced age, in
whom the prostate was large and access to the interior
of the bladder by means of a rigid instrument by no
means easy, we have seen, when a stone had been dis-
covered as well as when one had not, serious and even
fatal consequences ensue. A cystitis, for instance,
has thus been aroused, with considerable general dis-
turbance which has sometimes taken a long time to
overcome, not to say anything of being the means of
postponing a necessary operation indefinitely, by
reason of the acute septic conditions under which it
would otherwise have been undertaken.
Nor is this all. How few surgeons, in whatever
degree they may be engaged in work of this kind, can
feel that the skilful employment of the steel sound is
an absolute guarantee against the possibility of a
stone escaping their vigilance. When we look at the
shape the diseased bladder and prostate often assume,
it is astonishing to me that this somewhat primitive
mode of examination so rarely fails us. But it is in
just this particular class of cases that we rely upon it
most, and as to which our disappointment is the
keenest if it falls short of our expectation, whatever
the explanation may be.
Under these circumstances I have for some time
past been in the habit of including under one process,
with great advantage, the administration of an ana;s-
thetic, the use of the soimd for the first exploration of
the bladder, and the immediate removal of the stone,
by crushing if practicable, if one is discovered. Just
as in earlier years a preliminary paracentesis of an
ovarian tumor was often found to be an unfavorable
antecedent to an ovariotomy, so may the passing and
use of a sound be a preface, which we would avoid, to
the subsequent removal of the stone, however this may
be effected. No more desirable object can be wished
for in connection witli the practical use of these rays
than their application in determining the presence,
position, and constitution of the various stony concre-
tions that have their habitat in the human urinary
organs.
I have every confidence in expressing the belief that
the time is not far distant when, under the circum-
stances I have mentioned, these Roentgen rays will
enable us to .see the stone instead of feeling it, just as
in a recorded case' in whicii a Murphy's button, lost
in a remote corner of the intestines, was found in this
wav by my old friend and colleague, Mr. .Mitchell
Banks.
Infantile Colic. — Tincture of lobelia, one drop in
an ounce of water. Dose, one-half teaspoonful warmed.
— Cal. Med. Journal.
' Bull, de r.-\cad. de Med., Paris, June 2, 1S96.
* Lancet, November 14, 1896.
2 Brit. .Med. Journ., October 24, 1S96.
CLEANSING AND CLEANLINESS IN AB-
DOMINAL SURGEONS' OPERATIONS.
1!y I,.\\VS0N T.\IT, M.D. Neo Euor. Honoris C.ms.i,
M.D. St. Louis, LL.D. Albany, etc
A FKW days ago I read the detailed description of an
operation for the removal of a bullet lodged in the
brain, the operation being done by one of our best-
known European surgeons and a pronounced follower
of the school of Lister. He first removed the dressing
and exposed the scalp, which looked like a huge bil-
liard ball, excepting for one ominous black spot where
the bullet had bored its unkindly way. Then he took
a scalpel which was dripping with antiseptic, a pre-
caution which had not been taken with the foregoing
bullet, and deftly incised the scalp. Almost all the
time an assistant allowed a fine stream of warm water
— sterilized by being boiled and allowed to cool to a
safe temperature — to play from an irrigator upon the
field of the operation. 'J'hen instrument after instru-
ment was used, all evidently the subject of fear, for
they all dripped with antiseptic, though the track of
the wound and the locus of the infected bullet were left
to the prey of the germs which had been carried theie,
and had been working about for forty-eight hours be-
fore the operation. The operator had not read Mr.
Leedham Grei\e's interesting papers on how difficult
if not impossible it is to sterilize the hands of the oper-
ator, for he consistently made no attempt in the direc-
tion, and yet he closed the wound with a parcel of cot-
ton wool feebly impregnated with corrosive sublimate.
He then addressed his surroundings on the marvellous
results obtained in modern times by antiseptic surgery.
In the museum of the Royal College of Surgeons is a
large iron bar, technically known as a jumper, which
went, under the inffuence of a charge of gunpowder,
from below the chin of the user and straight upward
through the head and out at the vertex, carrying into
the wound a lot of germs and leaving them there. No
sterilized water was used about the superficial wound,
and no corrosive sublimate was then employed, about
the end of last century; yet the patient got well and
remained so for years. The museums of this country
and of others literally swarm with ancient specimens,
which prove the receipt of serious cerebral injury with
complete and permanent recovery, so that the belief,
now seemingly established in the minds of surgeons
for the present moment, that a stream of sterilized wa-
ter and a few grains of corrosive sublimate in the
superficial dressings give any greater security for re-
covery, has no foundation in fact and is a mere tem-
porary mental aberration.
Some few months ago I read a paper by the same
surgeon as I have already quoted, on the subject of
the influence of germs; and, in the short space of a
column and a half of an ordinary medical journal he
used in thirteen instances such phrases as: "It is now
fully established," "It is beyond dispute," "It must
be universally acknowledged," "Smith has proved,"
" Jones' remarkable observations have established,"
and " A complete result of Robinson's original re-
searches we must believe;" though in not a single in-
stance would I, for one, admit anything of any one of
the single assertions. It happens that those indicated
as Smith, Jones, and Rol^inson are three frequent con-
tributors of papers on the aiiplicalion of the ever-ad-
vancing, ever-developing, ever-changing, and never-
ending conclusions of the bacteriologists to the
practical work of the surgeon ; and such men, always
anxious for second-hand novelties, forget in one week
what they said the week before. In their writings it
is an easy matter to picture in detail the extraordinary
phases of the evojution of the practice and principle
of Listerism, though it is only fair to say that I use
Lister's name here with this qualification, that he,
884
MEDICAL RECORD.
[December ig, 1896
while the originator and still the chief advocate of the
doctrines so various and so varying, is not responsible
for more than about half the nonsense which has grown
round the original antiseptic religion. There have
been a large number of surgical " Pauls,'' who have
freely disseminated ix;rple.\ing epistles to the various
surgical churches of the world, and thereby much and
very acrimonious differences have arisen.
The antiseptic generation has now sped its cycle
from 1866 to 1896, and we have come back to the fig-
ure of the clock at which we started. The lime ex-
actly embraces my own surgical life. In Glasgow and
Edinburgh I saw patients die of the same terrible in-
fliction, no matter what had happened to them. I saw
removal of breasts end with a fatality which seemed
to rival that of amputation at the middle of the thigh,
and yet in my own practice during the cycle, out of
many hundreds of cases of removal of breasts — how
many I could not venture to guess — I think it pretty
certain that the mortality has been a long way under
five per cent., and probably not been one per cent. In
fact, I can call to mind only two fatal cases. The
crowded wards, the deficient ventilation, the one saluc-
ing-dish and the one sponge in each ward, the want
of ordinary lavatory cleanliness were the causes of the
terrible results. The carbolic oil, the putty, and the
lac plaster may have had some countervailing influ-
ence under the circumstances of these horrible old
pest houses, but in practice outside such influences
they were useless. These details, together with others
which ended finally in the harmonious logic of the
spray, marked the first epoch of the antiseptic cycle,
a time during which it was devoutly believed that
every germ was potent for evil and every resting spore
was a surgical pest. Every germ, every spore, every
scrap of harmless dust must, therefore, be submitted
to a process of destruction by some potent chemical
agent. This chemical agent was constantly changed.
As soon as one was contrived, adopted, beloved, and
trusted, it was found by some new observers to be
wanting when weighed in the clinical balance. The
chemical manufacturers were nearly wild, and many of
them were ruined by the continual changes, and the
antiseptic market rate for years was something more
variable than that of African gold shares.
When the spray was introduced, I was led, by cir-
cumstances altogether outside my own conviction, to
range myself once more as a follower of the chemical
antiseptic school, though I did not for a moment forget
or neglect my old methods. I performed a hundred
consecutive ovariotomies with a full and complete
adoption of all tlie antiseptic precautions of the Liste-
rian school of the period, and I published a paper in
the Transactions of the Royal Medical and Chirurgi-
cal Society, contrasting the details of that series with
those of a consecutive hundred in immediate opposi-
tion to them (and the contrast was not in favor of the
antiseptic practice).
By this time I had become thoroughly ix.-rsuaded
as to tiie future progress of the antiseptic doctrines
and practice, and I expressed my prophecy in what I
called an experiment, though it was more of the nature
of a satire.
I went through all the ceremonious observances with
gradually diluted solutions, until I used nothing but
boiled water, and then that was dispensed with. Fi-
nally, I used only ordinary tap water, and then I gave
up the spray. This is precisely what has hajipened all
round. The poisonous solutions were weakened bit
by bit; the spray was abandoned, with an expression
of shame that it had ever been introduced: rigorous
hunting for germs was slackened, and the antiseptic
belief so modified, that it was at last accepted that
not every germ was hurtful, but only such as might
vet be identified.
But, on the other side, we found the cubic space
allowed to each patient rapidly increased; new hospi-
tals were built, and, above all, the segregation of sur-
gical patients was enormously advanced by the erec-
tion of cottage hospitals all over the country. For
my own part, between 1878 and 1880, I secured an
accommodation of about forty beds, for the occu-
pants of which had each a separate room; in fact,
practically they may be said to have all had separate
rooms. The efi'ect was at once apparent, for my mor-
tality went down from about thirty per cent, to less
than five; and I had long runs of fifty, sixty, eighty,
and once as far as one hundred and forty-six consecu-
tive operations, without a death. Even hysterectomy,
the most obstinate of all abdominal o];erations in
yielding satisfactory results, has, within the last ten
years, given me runs of thirty, forty, and even forty-
five consecutive successes. What are the explanations
of all this? The answer is, that though I cannot pro-
duce anything from which I can "absolutely prove"
or "make it apparent beyond doubt,'' or anything of
the cocksure order, yet I can give basic conclusions
whicii will be with difficulty upset; and those who ne-
glect them will have to bear serious responsibility in
the criticism of the future.
The first conclusion at which I arrived concerning
abdominal operations was, and it remains the strong-
est now, that the more the patients submitted to Ihem
are separated the better. For this purpose and for
the greater part of my practice I adopted, as I have
said, a room for each patient. Sometimes with a press
of work I was tempted to " pack," as we used to call it
— that is, put two patients in one room, after the first
six or seven days; but I had so frequently to regret
this that I ultimately abandoned it.
I am quite sure that there is much truth in one con-
clusion I have often advanced, that time has much to
do with what will happen in the septic infection of an
abdominal section. The fourth night is the tritical
night w ilh all save hysterectomies, and with them that
period is not to be so definitely fixed. If an ovariot-
omy is all right on the fifth morning, the chances of
the patient going wrong are small indeed. But if you
"pack" them, they will have hamatoceles, stitch ab-
scesses, pulmonary complications, mumps, and all
sorts of secondary troubles, in a proportion far greater
than if you keep them absolutely one in each room.
These complications do not aflfect the mortality much,
but they jirolong the convalescence in a fashion of the
most annoying kind. This has been still more im-
pressed on me during the last three years, in which I
have far more widely adopted the plan of operating in
the houses of the patients, and leaving the subsequent
treatment of them to their private medical attendants.
This is now possible, seeing. that I sedulously avoid
anything in the shape of gratuitous work, whereas for
more than twenty years I did not get payment of any
kind for more than one-fourth of my clientele, and not
more than costs out of pocket for one-tenth of them. I
am now, therefore, working solely in a class among whom
it is possible to have all that is requisite in the way
of accommodation in the houses of the patients, and
after the operation is over I am seldom required to see
the patients again, recoveries are so little interrupted.
All this experience points out to me the extreme im-
portance of segregation, and the uniform results of
the work at the Sparkhill Hospital, not in the hands
of one man but in the hands of all to whom it has
been intrusted, prove this, as far as proof in surgery
can go: for there segregation is carried out almost as
completely as it can be carried out in the best houses,
while the perfection of the sanitary arrangements pro-
vided by the committee of management is almost ab-
surd in its completeness of detail.
All this, and the necessitv for it, were enforced on
December 19, 1896]
MEDICAL RECORD.
885
my mind coincident witli tlie complete banisliment of
any fear of germs, either wholesale or individual,
though there still remained with me the wholesome
dread of certain specific poisons, the nature of which
I do not know — and 1 think 1 may safely say that
their nature is equally unknown to everybody else.
First of all of these, as deadly beyond all things
known to me, is the poison begot in the peritoneum
and uterus of the puerperal woman, and in some sub-
jects who have died after abdominal sections.
This brings me to speak of the third ]5hase of the
slowly developing Listerism or antiseptic doctrines of
surgery, when it had begun to call itself " aseptic,"
and to adopt some of the minor doctrines and prac-
tices which I ha\e been preaching and practising
since 1881. All that I have been saying up to now
leads me to that condition which, after segregation,
constitutes my second general condition essential for
success in abdominal surgery, and going a long way
to explain our modern success — I mean cleanliness.
Cleanliness in surgery may be divided into general
and specific. General cleanliness, such as close at-
tention to cleaning wards and all in them, the clean-
liness of all linen bedclothing, etc., and the personal
cleanliness of the surgeon and the members of his
staff, are matters I need not waste time over. The
details of specific cleanliness are matters much more
in need of discussion.
For a long time in the earlier part of my practice, I
allowed all properly introduced and qualified practi-
tioners to visit it, and they came in great numbers,
chiefly from America. But I soon had to stop this
kind of hospitality and to limit admission to such as
came as serious-minded students, prepared to see and
understand what they saw. The reason for this was
simple. The "globe-trotter" came and saw one or two
operations, and departed without understanding any-
thing he had seen; and, if he published, he perversely
misrepresented the facts. To this misrepresentation
are due two misstatements, which e\en now appear at
intervals in the medical journals of the continent and
America. The first is that I really am a devoted dis-
ciple of the chemical-germ-destroyer school, but that
I have some substance in use which I will not dis-
close. The second is that my secret is '■ water steri-
lized by boiling;" and this ridiculous blunder recurred
only a few months ago at one of the great congresses
of America, and, strange to say, from the mouth of one
of my old pupils, ])r. Ricketts, of Cincinnati, who
spent six months with me.
It is now fourteen years since I have used sterilized
water for any purpose save to raise common tap water
to the temperature required, so that the mi.xture would
be probably five parts common tap or well water, and
one part water which had been boiled and possibly
sterilized. The mi.xture would have a temperature of
about 102' F., for my hands will not stand much more
with comfort. I have yet to learn that such a mixture
deserves the term of " sterilized."
My attention to specific cleanliness is as close as
can be given. It may be divided between the instru-
ments and hands of the operator and the abdomen of
the patient.
I hail with great satisfaction all the wonderful in-
ventions and devices of the modern operating-theatre
for securing general cleanliness, for that cleanliness
can be secured only by the work of women, and
women in themselves have not the slightest idea of
cleanliness save on the surface, and unless they belong
to the really well-educated classes. This is a fact
which no one knows so well as he who has gone
through the filthy drudgery of a gynecological out-
patient department, where fifteen out of sixteen of the
patients have lice or fleas upon them, and often both.
This is the material from which the great bulk o{ the
so-called trained nurses are obtained, and with their
training, unless most especially well looked after, they
alter their habits only in the sense of the smart cap
and an attractive uniform. They remain as dirty as
ever, and it is therefore necessary to give them sheh'es
and boxes of plate glass.
All instruments with sliding tubes, screw, or Clen-
don joints ought to be abandoned; every joint should
be capable of being unsiiipped, and after every opera-
tion every instrument used should be scrubbed with
raw turpentine and a brush, and then well washed with
soap and water. If this is done, simple immersion in
cold tap water at the next operation is all that is
wanted. Sponges — ah ! they want a paper to them-
selves. They are and ought to be the terror of the
operating surgeons, and I cannot stay now to say what
I have to say about them, sa\e that new sponges are
bad, old sponges dangerous, and that none of them
should ever be boiled. The Americans will have it
that I boil my sponges; but I never did such a thing
but once, and that ruined the lot.
Now I come to the real subject matter of my paper
— the cleanliness or cleansing of the patients.
I see that a number of superstitious observances on
this subject are still recommended, such as the appli-
cation of an antiseptic pad to the abdominal wall for
twenty-four hours before the operation.
I have never employed any such plans, being quite
content with a soap-and-water washing of the skin to
remove the dead fat and epithelium with which women
are always coated, and generally thickly. If there
were any real poison in the skin, no antiseptic pad
would remove it in twenty-four hours. The real poi-
sons known to me as absolute realities, such as those
which I have spoken of as occurring in puerperal peri-
tonitis, cannot be removed by any known germicide
from the hands of tlie surgeon infected by them. Mr.
Leedham G reives' experiments seem to show that it is
impossible to cleanse the hands from the ordinary
spores of decomposition, and yet we know that no-
where is epithelium reproduced and shed at so rapid a
rate as it is on the hand. My knowledge of the terri-
bly infective power of the puerperal poison, from my
own experience and that of others, has been so em-
phatic and the lessons so disastrous, that I am per-
suaded that the poison, whate\er it be, permeates at
least the whole epithelial layer and cannot be got rid
of save by efllux of time and skin, and that it is not
safe for any one so infected to operate till at least a
fortnight or three weeks have elapsed. Have there
not been lessons enough in the same direction by the
spread of puerperal fever from tlie hands of the ac-
coucheur ?
I am not alarmed by the conclusion to which Mr.
Leedham Greives' observations point, for I do not fear
tiie ordinary germ poison at all. But still, I take the
precaution of keeping my nails short and clean, and
washing my hands in raw turpentine the last thing be-
fore performing any operation, and then washing off
the turpentine by ordinary soap and water. My rea-
son for this may be seen in the simple experiment of
washing the hands three or four times in the ordinary
way, and then in perfectly fresh water repeating the
process with the previous employment of turpentine.
After this last water has stood for a few minutes, there
will be seen on its surface evidence of dirt of a very
convincing kind. That dirt must be either in the
clear turpentine or it must be a layer of dirt removed
from the hands by the turpentine, after having resisted
the previous efforts with soap only. The latter con-
clusion is that af cepted by me, and it accounts for my
using turpentine on the patient's skin and my own, as
well as on the hands of my assistant, in the rare cases
in which I need one.
The final cleansing, and I think bv far the most im-
886
MEDICAL RECORD.
[December 19, 1896
portant of the lot, is the cleansing of the abdominal
cavity during and after operations.
All the other details of every operation performed
by me are conducted, as I have said, by the use of
plain cold water, taken immediately from the tap or
well and raised when necessary to the desired temper-
ature by the addition of the water from the kettle or
ixiiler; nothing whatever is added to that water for
instruments or sponges.
.V careful search through the records of abdominal
operations, particularly those for the removal of ova-
rian and other tumors, has not revealed any but the
slightest and most casual allusions to any cleansing
process, till we come to the work of Charles Clay and
Baker Browne, who freely mopped out the pelvic cavity
with sponges through their large incisions. One of
the most interesting recitals, for many reasons, is that
(jf the first ovariotomy of which we have any record,
that by Houston, of Glasgow, when he removed the
glairy contents and cystic fragments of a ruptured and
half-digested tumor with gelatinous contents. He
makes no allusion of any kind to a process of cleans-
ing, and yet it is certain that the contents of this rup-
tured cyst must have spread themselves throughout the
peritoneal cavity and have coated every viscus con-
tained within it, as I have seen on many occasions.
In my earlier e.\;jerience I thought such a case was
that of all otiiers which required a full peritoneal toi-
lette, and it was to one sucii in the year 1875 that 1
owed the initiation of the process of washing as largely
a substitute for, and certainly a great addition to, the
process of sponging. Now I am quite sure that this
is not the case, and for the reason that the gelatinous
cyst contents are not dead material, but endowed with
just that degree of vitality as to be able to resist the
germs of decomposition unless overdosed with them,
just as Lister's blood clot did. In a properly aseptic
operation, therefore, as Houston's must have been, the
peritoneum will absorb wiiat is left with perfect safety,
and here it is that sponging is most especially danger-
ous and washing particularly safe. The moment a
sponge touches such material, the surface of its frame-
work is clogged and it will not absorb, while the gluey
material is readily soluble in warm water. In the
same way, coagulated blood is not dead so long as it
is safely locked up in living tissue and protected by
it from tire access of the germs of decomposition, when
it speedily dies, decompo.ses, and becomes a source of
danger. Clot adherent in layers becomes slowly or-
ganized, and after a period of weeks or months comes
to ha\e a system of full nutrition, progressing in this
direction till removed or so altered as to be recognized
with difficulty from original tissue. This is fully
proved by the history of clot layers in cases of recur-
rent hemorrhage in ruptured ectopic pregnancies, and
ill the process of cure of aneurism by arrest of the cur-
rent through the sac. Bearing the fact in mind, tliere-
fore, that the displaced substances we have to deal
with in cleansing the abdomen have different degrees
of vitality, and therefore different degrees of resisting
power, it will help us much in deciding not only how-
much cleansing is required, but as to the particular
method in which the process should be carried out.
These, at least, are the principles on which I have
worked for over twenty years, and there has not yet
been heard any utterance of weight against the almost
uniformly admitted fact that my methods of cleansing
have not only materially assisted the surgeon in his
work, but that they have greatly diminished its mor-
tality.
My early publications on this subject were met with
claims for priority by others, as by Keith, who did not,
however, advance any evidence on the subject, nor did
others. But it would not matter if it were the fact, as
it very likely is, that some one else or many others
had poured out a jug of water into the peritoneal cav-
ity before 1875: but certainly no one made any at-
tempt to systematize the processes of peritoneal cleans-
ing until I did so, or to show how best it could be done
and which methods to choose under particular circum-
stances. All this I reviewed in a paper published in
the British Gynecological Journal \x\ August, 1887, and
therefore I" need not repeat it here.
First of all, let me say that if an operation, such as
the removal of an ovarian tumor, has been conducted
so well and so fortunately that nothing has entered the
peritoneal cavity, the wound ought to be closed at
once without sponge or anything else entering it. If,
on the contrary, a mess has been made inside, it must
be cleansed out ; and the question is to decide on the
best method, and the weight of argument should al-
ways be against the use of sponges — they are so inhe-
rently dangerous, yet their use is often essential.
Thus, in separating adhesions of the omentum to a
tumor, nothing displays the ability and dexterity of a
surgeon so much as the rapid folding up of a dry
sponge in the damaged apron. Or, if the adhesion of
the appendages to the pelvic wall bleed freely, the pel-
vis must be packed, and the packing will probably re-
move much dirt with it. Until two years ago, I al-
ways used sponges for this purpose, and would often
have six or eight sponges squeezed tight down in the
peh is. Now, I use iodoform gauze for this purpose.
\\'ho it was who led us into this important aehance, I
do not know; but it is one of real value, for iodoform
gauze stops oozing from parietal and visceral surfaces
in a way that nothing el.se will do, save perchloride of
iron. If, however, a ligature has cut through a rotten
parietal, or a vessel has escaped the forceps and liga-
ture and cannot be found, these washings out with a
stream of clean water will speedily display the source
of the bleeding and enable the vessel to be secured.
I do not combine the two processes if I can help it,
for they do not generally aitl one another.
As 1 take it that pus is a substance already dead
and generally decomposing — as Miller very character-
istically detined it from his common-sense surgical
pathology, '" effete matter, a foreign body" — I take the
utmost care to cleanse it all away, or anything which
from my view more or less imitates it, such as loose
blood clot and blood in solution. The method to be
employed in this case is the continuous stream. The
handiest method to serve this purpose is simply to re-
\erse a stream of common tepid water through one of
my ovariotomy trocars, and I use a large or small one
according to whether I wish to dislodge and wash out
loose clots by means of a large volume of water issu-
ing from a large tube: or, on the other hand, if I want
to wash carefully every inch of the peritoneal surface,
I use a small tube with a gently flowing .stream. If
the tubes are not handy — and in our worst emergen-
cies, like ruptural ])regnancy, they may not be — a very
efficient sul)stitute is to open the wound as widely as
possible, pull up the parietals, and to pour in with
cautious violence one or more jugfuls of tepid water,
insert the right hand into the abdomen, and with the
left close the wound round the wrist as closely as pos-
sible. The process of washing may then be carried
out as fully as is considered desirable.
If a tube of my kind can be obtained, it is better to
use it, for it can be carried into every one of the com-
ple.v interstices of the peritoneum, and the washing
be thereby made most thoroughly. But let me caution
the inexperienced operator against using a double tube
for entrance and exit, as has recently been recom-
mended in The Lancet. This is no new proposal, and
when such is used the stream does not get spread but
returns at once, short-circuited, as the electricians say,
and without doing much cleansing. Care must be
used to have the temperature of the water streams not
December 19, 1896]
MEDICAL RECORD.
SS7
lower than 100 F., and not higher than 103' F., and
it must be borne in mind that few women, and none
whatever of the nurse type, have any sense of temper-
ature in their hands. To them, "blood heat" may be
anything between 75" and 120 F.
The further or secondary cleansing of the perito-
neum is secured by the use of the drainage tube, to be
considered at length in another chapter. So far as I
have gone I have laid down the lines on which have
been developed the wholesome and aseptic surgery of
the peritoneum, a system which I have been advocat-
ing for over twenty years, for which persistence my
reward is now coming, in seeing that it is being ac-
cepted all over the world, and mv former opponents of
the antiseptic school are finding shelter under its roof
from their former extravagances.
A FURTHER STUDY OF THE BIOLOGY OF
THE GONOCOCCUS (NEISSER), WITH
CONTRIBUTIONS TO THE TECHNIQUE:
A PAPER BASED ON THE MORPHOLOGI-
CAL AND BIOLOGICAL EXAMINATION OF
EXUDATES IN CASES OF CHRONIC URE-
THRITIS.*
I!v HENRV IIEIMAX, .M.D.,
NEW VCIKK,
ATTENDING PHYSICIAN TO THE OfTDOOK CHILDREN DEPARTMENT OF MOUNT
SINAI HOSPITAL.
In Studying the biology of the gonococcus in the ex-
periments noted in my first paper,' entitled "A Clin-
ical and Bacteriological Study of the Gonococcus
(Neisser)," etc., New York Mkdic.\l Record, Jime
22, 1895, I employed for the gonococcus cultivations
chest serum plus agar,f believing this to be the best
medium. At that time I stated that a sterilized plati-
num loop was passed into the urethra and some secre-
tion withdrawn. This method was tedious and trou-
blesome, inasmuch as either the infected subject had to
be brought to a laboratory or else the culture medium
had to be brought to the patient. A second difficulty
encountered was that the quantity of pus w ithdrawn by
means of the sterilized loop was scantv. In order to
obviate these disadvantages, I decided to employ for
the collection of the secretion tubes available for the
centrifuge. It is important to state at the outset that
in no case did I first cleanse the genitals. The pa-
tient was instructed to pass his urine into a sterilized
tube. This was then placed in a centrifuge, ;J; where
it was whirled for three minutes. On decanting the
resulting supernatant fluid, it was found that a com-
* This paper was based on experiments conducted in the bacte-
rial laboratory-, department of pathology of the College of Physi-
cians and Surgeons, Columbia University, New York.
f This culture medium consists of a 2 per cent, agar plus i
percent, of peptone plus 0.5 per cent, of salt. Of this mixture
two parts were added to one part of chest serum (pleuritic effu-
sion) fractionally sterilized between 65' C. and 70' C. Chest
serum of neutral reaction is desirable. In case the chest serum
should be strongly alkaline, it is desirable to treat the 2 per cent,
nutrient agar in such a manner that it will remain slightly acid,
so that on the addition of the alkaline serum the medium will
give a neutral reaction.
X The centrifuge employed in my experiments is my own modi-
fication of the Litten apparatus. The improvement consists in
the employment of eight Edison I.alande cells with a special motor
derised by the Edison Manufacturing Company. This improved
centrifuge gives a speed of 1,500 revolutions per minute and is so
constructed that the h^^matocrit (Richards Ot Co.) can be attached
so as to give the re(|uired 6,000 revolutions per miniite. The
battery operating this improved centrifuge can be advantageously
employed as a galvano-cauterj-. and can also furnish an incandes-
cent light of six-candle power. This centrifuge possesses the
further advantage that the street wire can be tapped, by interpos-
ing a rheostat This combination centrifuge can be purchased
from the Edison Manufacturing Company, no East Twenty-
third Street. The accompanying print demonstrates the motor
and tube carrier of the apparatus; the semilunar-shaped tubes are
employed to reduce the weight of the disc.
plete sedimentation of the pus was obtained, a layer
from one-half to one centimetre in height resulting.
This sediment was then planted by means of a steri-
lized platinum loop on chest-serum agar plates (Pe-
tri's), as a surface culture. In this manner I was
enabled to procure an almost pure culture of the gono-
coccus. This method I employed in twenty-two cases
of acute gonorrhcea in the male, obtaining positive re-
sults in all. One of these cases, it is interesting to
note, was that of a boy two years old. Cover-glass ex-
aminations and cultures in this particular case gave
positive results. The " centrifuged" sediment, if I may
be permitted to coin a new word, was found to be acid
in reaction, while the pus which was obtained by means
of the platinum loop from the urethra was found to be
neutral or else alkaline. In this connection I would
like to cite eight cases of colpitis gonorrhceica of chil-
dren, from each of whom, without cleansing the geni-
tals, some vaginal pus was placed by means of a plati-
num loop into the tube accompanying the centrifuge.
This tube was then
placed in a test tube
containing some ster-
ilized water. This
procedure was adopted
to prevent the pus
from drving, a diffi-
culty always encoun-
tered when swabs were
used. Preserved in
this manner, it will be
found that even in
twenty-four hours at
room temperature, a
positive result can be obtained in cultivating the gono-
coccus on chest-serum agar plates. For the purpose
of ascertaining how the " centrifuged" sediment of the
urine of acute gonorrhctal urethritis in the male be-
haved when planted on media unfavorable to the
growth of the gonococcus, I planted some of this sedi-
ment on gelatin and some on agar plates, and for
control purposes on chest-serum agar plates. The re-
sult was as follows: Nutrient agar plates, kept at body
temperature, showed a considerable growth of bacteria,
especially a diplococcus, which did not thrive so well
on chest-serum agar plates, while on the gelatin plates
the growth was still less than on agar plates.
Media Employed for the Cultivation of the Gono-
coccus.— Of the various media employed in my e.x-
periments, I found that the gonococcus would not
grow when planted on the coagulated (by heat) chest
serum, I also found that when I employed a culture
medium composed of one part of non-sterilized chest
serum and two parts of a two-per-cent. prepared nutri-
ent agar, which had been previouslv boiled, filtered,
and sterilized for one-half hour on two consecutive
days in a steam sterilizer, and which medium, while
still hot, was poured directlv on plates for streak cul-
tures, gonococci did not grow. I then attempted to
plant the gonococcus according to the method em-
ployed by Pfeiffer" in the case of the influenza bacil-
lus. That is, a drop of blood is taken from the finger
and smeared on the surface of a nutrient-agar tube.
Upon such a smear a pure culture of the gonococcus
was planted, with positive results. For further control
purposes I transplanted this gonococcus from this same
smear on a chest-serum agar * plate after the third
day, and obtained typical colonies. Another series
of my experiments was based on the method described
by Hammer,' of Heidelberg. The medium employed
by him consisted of one part of sterilized urine, con-
taining 1.5 per cent, of albumin plus two parts of
nutrient or glycerin agar. This medium, Hammer
* To Drs, Alex. Lambert, James Ewing, and F. S. Mandel-
baum I am indebted for the chest serum.
888
MEDICAL RFXORD.
[December 19, 1896
claims, gave him good results. His method is theo-
retically correct, because urine containing albumin
in large quantities contains also a large proportion
of serum albumin, paraglobulin, albumose, and pep-
tones. I am of the opinion that liquid albumin or
its allied products are essential for the successful cul-
tivation of the gonococcus. I followed Hammer's
technique in all its details, except that I employed
urine containing one per cent, of albumin by Ksch-
bach's test tube, and for control purposes gonorrhceal
pus was planted on chest-serum agar plates. My ex-
periments showed a comparatively small growth of
gonococci on albuminous urine plus glycerin agar, but
an abundant growth on chest-serum agar plates; while,
on planting the pure cultures on tubes containing al-
buminous urine plus glycerin agar, I also obtained a
relatively small growth of the gonococcus. It is w^orth
noticing that Hammer does not mention the degree of
reaction of his medium. The albuminous urine in my
experiments was neutralized by adding i c.c. of a so-
lution of sodium hydrate to 100 c.c. of urine. My
experiments, in common with those of Hammer, gave
negative results on the acid albuminous urine plus
agar. Anotlier medium was then tried, \iz., a steril-
ized liquid hydrocele fluid plus tw^o per cent, of nu-
trient agar for the planting of gonorrhceal pus from
the male urethra, and for control purposes chest-serum
agar, with the following result: Hydrocele fluid plus
agar gave nearly as good a result as the chest-serum
on the plate and test-tube cultures. I then tried still
another medium, prepared as follows: 500 grams of
finely chopped meat were mixed with 1,000 c.c. of
water; this mixture was jjlaced for twenty-four hours
in a refrigerator and then strained througli cheesecloth.
The resulting meat infusion was acid, reacting 0.42
per cent, to phenol-phthalein. Some was made neutral,
and to a portion of this latter was added 0.5 per cent,
of sodium chloride. A portion of this neutral meat
infusion was then treated by the addition of i per
cent, of peptone and 0.5 per cent, of sodium chloride.
These media were placed in a refrigerator for twenty-
four hours, then filled into test tubes for fractional
sterilization at low temperatures, the low temperature
being applied to retain the albuminous matter in solu-
tion. After the first sterilization at 65 C. for one
hour, I noticed a considerable amount of coagulated
material, consisting of, as was afterward ascertained,
muscle proteids. This latter, according to Hallibur-
ton, is composed of mu.sculin, coagulable at 47' C;
myoglobulin, coagluable at 63° C. ; myoalbumo.se, a
substance obtained from tlie coagulum and itself not
coagulable.
A second precipitation followed the; further sterili-
zation of the meat infusion. .\t the completion of the
sterilization, 1 utilized the lic|uid porti(m with one or
two per cent, of nutrient agar, in the proportion of one
to three. Planting gonorrhceal pus on Petri plates
containing this last-described medium, a negative re-
sult followed. This failure might be attributed to the
small amount of albumin contained in the meat infu-
sion, as compared with tlie greater amount of albumin
present in the various kinds of serum which are in
use for the cultivation of the gonococcus. For exam-
ple, according to Hammersten,' blood serum contains
8.2 per cent, of solids, of which 6.9 per cent, is albumi-
nous. The rest of the plasma ingredients amounts to i .3
per cent., of which 0.84 ]x;r cent, consists of inorganic
substances. He also .states that the albuminous in-
gredients of animal-blood serum consist mainly of
globulin and a small proportion of serum albumin.
Pure serum albumin, he states, coagulates at 50" C,
but in combination with salt solution at between 72°
and 75° C. It is a well-known clinical observation
that with the increase of the pleuritic effusion the
sodium chloride in urine gradually diminishes. This
accounts for the fact that the pleuritic effusion lie-
comes rich in sodium chloride. My experience has
been that chest serum (pleuritic effusion) gelatinizes
at 75'' C. and coagulates at between 80" and 82' C.
I found the reaction of sheep and chest serum neutral.
The yellow color of blood serum is attributed to the
jjresence of a soluble coloring matter, termed lipochrom
(Hammersten), which precipitates in the presence of
amyl alcohol. Hammersten also found soaps — leci-
thin-cholesterin, glucose-sodium-chloride — in predom-
inance in blood serum. Bunge (Neumeister) furnishes
the following table of an analysis of horse, cattle,
and pig .serum : Potassium, 0.026 : sodium, 0.435 ; ^^^'
cium, 0.013; magnesium, 0.004; chlorides, 0.369;
phosphoric acid, 0.022. Total, 0.869 and sodium
chloride in solution.
The medium to which I gave preference is sterilized
liquid chest serum — i part (pleuritic effusion) plus 2
per cent, of agar plus 1 percent, of peptone plus 0.5 per
cent, of salt, 2 parts. This is readily obtainable, and
upon it the gonococcus grows, according to my experi-
ments, better than on any other medium. My first ex-
periments with chest-serum sterilizations were faulty,
as many of my plates became contaminated. I attrib-
uted this to the fact tiiat sterilization for one hour at
65 C. for six consecutive days, and then placing the
serum in the incubator for control for forty-eight
hours, are not sufficient to render the serum entirely
sterile. I therefore continued the fractional steriliza-
tion for three days longer at 65° C, after having kept
the serum at room temperature for three days.
Liquid Media Employed for Gonococcus Cultiva-
tion It is a well-known fact that up to the present
time no liquid medium has been foimd in which the
gonococcus thrives. Hearing this point in mind, 1 en-
deavored to find a liquid medium adapted to this jnn-
pose. After much experimentation, my efforts were
rewarded in finding three media which gave positive
results, namely: Liquid chest serum, sterilized at 65'
("., plus fermentation broth;* secondly, sterilized
liquid chest serum plus Dunham's peptone solution;
thirdly, sterilized liquid chest serum plus nutrient
broth. That is to say, on planting the gonococcus on
fluid chest serum, on fermentation broth, on Dunham's
]3eptone solution, or on nutrient broth alone, it does
not thrive; but on adding an equal part of chest serum
to any of the other media we get positive results.
Knowing that the gonococcus thrives upon sterilized
liquid chest serum plus one or two per cent, of nutrient
agar, and believing that the agar does not furnish the
lirincijial nutriment, I utilized the three above-de-
scribed media in equal parts, and carefully mixed them
to avoid further .sterilization. I'pon these media I
then planted a second generation of a pure culture of
the gonococcus from a chest-serum agar tube, placing
the liquid media at body temperature. Examining the
iiciuid chest-serum plus fermentation - broth tube
twenty-five days later, I found a few gonococci in
cover glass preparations. At the same time I planted
a portion of the above liquid medium for control pur-
po.ses on chest-serum agar j^lates, and obtained a pure
culture of the gonococcus. On repeating the experi-
ments on the twenty-ninth day, I found no gonococci
on cover-glass preparations, but obtained a pure culture
on chest-serum agar plates. On the fifty-first day I
was still able to grow the gonococcus contained in tlie
liquid medium on chest-serum agar plates. How
*'riieobald Smith, in " Wilder Quarter-Century Book," 1S93:
"Tlie bouillon wa.s prepared by digesting fresh beef in water
at 60° C. for several hours, then tiltering and adding 0.25 per cent,
of peptone, 0.5 per cent, of sodium chloride, and about 3 c.c. of a
normal solution of sodium carbonate for every 100 c.c. of the
fluid. This sutriccs to make it feebly alkaline. To this peptone
bouillon 2 per cent, of one or the other of the three sugars men-
tioned was added and the resulting fluid sterilized in the fermen-
tation tubes."
December 19, 1896]
MEDICAL RPICORD.
889
mucli longer the gonococcus would retain its vitality
in the liquid chest serum plus fermentation broth, 1
am unprepared to state at present, as my experiments
in this direction are still unfinished. Fifty-one days
is, therefore, the oldest gonococcus culture known to
me. When the gonococcus was first cultivated by
Bumm,^ in 1885, on solidified placental blood serum, it
was necessary to transplant it every sixth or seventh
day, owing to the readiness with which it dried. Since
then. Finger" was able to demonstrate the fact that the
gonococcus could live as long as four weeks upon a
sealed beef-serum agar tube. From the liquid chest
serum plus nutrient broth containing the gonococcus I
repeatedly planted on chest-serum agar plates, finding
on the forty-second day that I was still able to grow
the gonococcus. In the Dunham's solution the gono-
coccus was still found on the seventeenth day, when
planted on chest-serum agar plates.
Experiments to Determine the Longevity of Gono-
cocci with Gonorrhoea! Pus Kept Either at Body
or Room Temperature. — Gonorrhoeal pus for this
purpose was obtained from gonorrhoeal urine for the
centrifuge. The clear urine, having been decanted,
was then placed in the tubes of the centrifuge, and
then reposited within a larger test tube which con-
tained a small amount of sterilized water. Some of
these tubes were placed at body and some at room
temperature. The result of the immediate examina-
tion of the gonorrhceal pus intended to be kept at
body temperature was positive botii in cover-glass prep-
arations and on chest-serum agar plates. After twenty-
four hours at body temperature, I was able to find only
few gonococci in cover-glass preparations and very
many on cultures. Some of the gonorrhoeal pus re-
acted acid and some neutral. Some of the tubes con-
taining gonorrhceal pus, kept under the same condition
at room temperature, showed gonococci in the first ex-
amination in cover-glass preparations and on chest-
serum agar plates. After they had been kept for
twenty-four hours at room temperature, I was able to
demonstrate the gonococcus on both cover glasses and
plates, obtaining the same results after forty-eight
hours. In gonorrhceal urine kept twenty-four hours at
room temperature, I also found gonococci both in cover
glasses and on chest-serum agar plates.
I now smeared gonorrhceal pus on sterilized linen,
which was stored in a test tube, and after three hours
planted the pus directly from the linen on the agar
plates, and made cover-glass preparations. This ex-
periment gave a positive result, but on planting the
material directly from the linen after twenty-four hours
I could no longer grow the gonococcus, while the pus
cells on cover glass appeared to be undergoing decom-
position. Some of this pus-smeared linen was exam-
ined by me sixty-six days after its preparation, when I
was still able to demonstrate the gonococcus with
cover glasses. The pus was obtained from the linen
in the following simple manner: A drop of sterilized
water was placed by means of the platinum hook on
the linen, and a cover glass was smeared directly over
the moistened surface. Wocholtz and Nowak' found
that gonococci, w hen dried, lose their power of grow th.
They report results similar to those obtained by me
from dried spots of gonorrhceal pus. A. Haberda" re-
ported that he found gonococci on linen several weeks
after besmearing the fabric. He did not, however,
make culture experiments.
On one occasion I just smeared gonorrheal pus upon
the inner side of a sterilized test tube, and as late as
fifty-seven days after I was able to demontrate the gon-
ococcus morphologically. Some of the dried jjus from
the above tubes was planted after twenty-nine days on
chest-serum agar plates, with negative results: but I
found gonococci in cover-glass preparations. In all
instances of my own. Gram's method was employed.
Relative Growth of Other Pathogenic Bacteria
on Chest-Serum Agar Plates.-- In my experiments to
determine the relative growth of some of the other
pathogenic bacteria on chest-serum agar, I planted,
among others, the staphylococcus pyogenes aureus, the
streptococcus pyogenes, and for control the staphylo-
coccus pyogenes aureus on nutrient agar, and found
that the staphylococcus throve better on nutrient agar
than upon chest-serum agar. The streptococcus pyo-
genes grows nearly as rapidly upon chest-serum agar
as the gonococcus does. This is an observation of
importance, for the reason that it demonstrates that a
mixed infection might occur. But granted, still it
would be possible to demonstrate the gonococcus with
chest-serum agar plates in cases of mixed infection,
e.g., when both streptococci and staphylococci are
present. In this connection it is proper to allude to
the observations of \\'elch," of Baltimore, who at the
meeting of the Association of American Physicians,
1895, was the first on record to demonstrate the gono-
coccus in cover glass and culture medium from the
blood of a living person. Welch's report was based
on a case of endocarditis with general septicaemia fol-
lowing gonorrhoea. Even with this complex of patho-
logical processes the only pathogenic bacteria he
found was the gonococcus.
Morphological and Biological Examinations of
Chronic Urethritis Exudates. — In reviewing the lit-
erature of chronic urethritis, I find that much has
been written upon every phase of the subject except
upon the bacteriology ; especially upon the examina-
tion of gonorrhceal threads with culture medium has
little been published. It is on this account that my
efforts were mainly directed toward the well-known
" Tripperfaden.'" Those who study these threads with
the microscope are familiar with the fact that the old
method of collecting them is both tedious and uncer-
tain. It occurred to me to avail myself of the centri-
fuge, for I remembered how useful and successful this
apparatus proved to be in collecting urinary sedi-
ments. This apparatus was therefore employed in all
my experiments for the collection of gonorrhctal
threads, and I believe my experiments are the first on
record in which the centrifuge was employed in con-
nection with culture media. My method of procuring
the urine in chronic urethritis is to allow the patient
to void his urine into two sterilized centrifugal tubes.
The first tube will contain threads of the anterior
urethra; the second tube will be likely to contain se-
cretion from the posterior urethra and from the pros-
tate gland, if, while urinating, the patient's prostate be
pressed upon with the finger. Tubes containing such
urine are placed in the centrifuge and whirled for
three minutes at twelve hundred revolutions per min-
ute; the threads are thrown down. The centrifugal
action to which the pus cells are incidentally sub-
jected seems to have no effect upon the bacteria. The
"centrifuged" sediment will be found to contain other
bacteria, epithelial cells, and at times spermatozoa.
Normal urine on being "centrifuged" at this velocity
will be found at times slightly turbid at the bottom of
the tube. This turbidity will be found on microscopi-
cal examination to consist of pithelial cells, a few
leucocytes, and some bacteria. \ point of practical
importance developed by this procedure is the fact
that the urine, after having been whirled, will contain
a large amount of mucus. This fact would seem to
point to the presence of a catarrhal urethritis. The
literature of chronic urethritis deals solely with cover-
glass preparations. This is probably attriliutable to
the fact that suitable culture media were difiicult to
procure.
In my former paper, I stated that if I had to ex-
amine chronic urethritis cases with cover-glass prepa-
rations, I should require three examinations of the
Sgo
MEDICAL RECORD.
[December ig, 189b
gonorrhoeal. threads at different intervals. To-day,
with my additional experiments, I am led to modify
the above statement, in that we should only employ
culture media (surface culture) in connection with the
cover-glass examinations. I am also forced to dis-
continue the use of the ordinarj' staining solutions of
the gonococcus, such as methyl blue or the solution
recommended by me in my fonner paper, namely, a
two-per-cent. alcoholic methyl-violet solution for dif-
ferential diagnostic purposes. I look upon the decol-
orization by Gram's method as the only reliable cri-
terion, so far as known, for the gonococcus, and it is
of material help also in determining whether a culture
is or is not that of the gonococcus. The examination
of gonorrhcEal threads with cover glass by Gram's
method is a very tedious affair, as in every instance I
examined no less than three, and at times as many as
ten cover-glass preparations. It would require many
hours upon each and every specimen, especially if
gonococci are present in very small number, before a
reliable and conscientious opinion could be rendered.
If, after all, a negative opinion is ventured, we still
are under the necessity of proving that the threads
which we tished out for the cover-glass examination
were free from gonococci, while the remaining ones
might contain them. It is a well-admitted fact that
the culture medium is more sensitive for bacteria
than is the cover glass, and this holds true for the
gonococcus, for we are able to plant each and every
thread of the sediment in the centrifugal tube. Fiir-
bringer'" in his work mentions the fact that in certain
cases the absence of the gonococcus in many exami-
nations of cover-glass preparations is not a positive
proof that th ,■ gonococcus is not present, and to illus-
trate this unreliability he quotes Oberlaender's lan-
guage: "Verlorene Liebesmiihe," "Love's labor lost."
I have been able to confirm the correctness of the
above allusion, for on one occasion, in examining
threads, when I could not demonstrate the gonococcus
in cover-glass preparations I succeeded in growing
it on chest-serum agar plates, while in all instances
in which 1 found the gonococcus in threads in cover-
glass preparations I invariably succeeded in growing
it on chest serum agar plates. The results of other
observers in chronic urethritis are open to the objec-
tion that Gram's method was employed only in doubt-
ful cases.
I append here the tabulated results of my investi-
gations. They include examinations of gonorrhceal
threads with cover glass alone, from chronic ure-
thritis varying in duration from seven weeks to eight
years (Table I.). Of these 34 cases 7 positive and
27 negative results were obtained — a percentage of
20.55 of positive results. Table II. covers examina-
tions of gonorrhceal threads in 6 1 cases of chronic
urethritis with cover glass and culture medium. In
these 61 cases, 13 positive results were obtained with
cover glass and 48 negative results — 21.31 percentage
of positive results. The same cases examined with
culture media gave 14 positive results and 47 negati\e
results, a percentage of 22.95 ^^ positive results.
In regard to the question of infection in chronic
gonorrhoea, I am inclined to believe that chronic gon-
orrhoea can cause only an acute gonorrhoea in another
person. This belief is confirmed by Finger and
Wertheim" by inoculation experiments. Of course
we cannot always trace the method of gonorrhttal
infection in the male urethra, nor even account for it.
This latter observation holds true for acute gonor-
rhceal colpitis cases in which coitus can be excluded,
although the infection is gonorrhoeal. I cannot be-
lieve with certain observers that diplococci may be
present in the male urethra or in the vuUo-vaginal
tract, which under certain peculiar conditions can be-
come virulent and thus produce a true gonorrhoea.
Of course I do not denv that there mav not be some
T.VBLE I.— MICROSCOPICAL KXAMINATIOX OF CHRONIC UKKTHkiriS WITH COVER (.LASS HV MEANS
OF THE CENTRIFUGE.
Duration of Disea-**.
Condition of Urine.
Gonococci Fot^jo.
Number
of Cases.
Pcrccnuge.
kcmarks.
of Infection.
Positive.
Negativt.
7 weeks.
8 ■•
2 months.
2
3
3
3
4
4
6
6
6
8
I year.
I year 2 months.
1 " 6 "
2 years.
2
2
2
3 "
3 "
3 ■• •
8 "
Clear, threads.
few threads.
" threads.
Cloudy.
Clear, threads.
Cloudy.
Clear, threads.
(1 11
Present.
Present.
Present.
Present.
1
I
I
I
I
I
I
1 I
1 I
1
After injecting .\g. No.
• •
Second
First
Second
First
..
First
First .
3-
First
"
• >
First
Second
First
Second . . .
First
7
27
34
20.55
December 19, 1896]
^lEDICAL RECORD.
891
TABLE II.— EXAMINATION OF GONORRHCEAL THREADS OF CHRONIC URETHRITIS CASES WITH
COVER GLASS AND CULTURE MEDIA BV MEANS OF THE CKNTKIFUGE.
Number
of
Infection.
iFirst.
-Second.
First.
Second.
First.
Tenth (2)
Third.
First.
Second.
First.
Duration
of Disease.
5 weeks.
6 ■■
6
6 "
10 '
3 months.
3
3
3
3
3
3
4
4
4
4
4
4
4
5
5
5
5
6
9
10
year.
Condition of Urine.
Cover Glass.
1 Positive.
" 6mos.
2 years.
Clear, threads.
" no threads.
" threads.
Cloudy.
Clear, threads.
Cloudy.
Clear, threads.
Cloudy.
Clear, few threads,
threads.
' ' number of threads
Cloudy.
Clear, threads.
" few threads.
Cloudy.
Clear, few threads,
threads.
few threads,
threads.
few threads,
threads,
few threads,
number of threads
" threads.
I'rostatic secretion.
Clear, threads.
few threads.
threads.
few threads.
threads.
few threads.
Cloudy.
Clear, few threads.
Present.
Present.
Present.
Present.
Present.
Present.
Present.
Present.
Neg-
ative.
Present.
13 48
CuLTfRES.
Present.
Present.
Present.
Present.
t Present
Present.
Present.
Present.
I'resent.
Neg-
ative.
47
Number
of
Cases.
Percentage.
61
Covei
Glass,
21.31
Cul-
ture.
RemarlwS.
Spermatazoa.
22.95
After injection of Ag. No. 3.
Found gonococci after 48
hours.
Gonorrhoeal cystitis.
Urine blue, after methyl
blue.
Found spermatozoa.
micro-organism, not as yet isolated, which might pro-
duce a urethritis or vaginitis, but it is not a gonor-
rhoeal type of intlammation. Welander'^ has shown
as far back as 1884 that on injecting vaginal pus free
from gonococci into the male urethra no urethritis fol-
lowed, and in three cases in which vaginal pus con-
taining gonococci was injected virulent forms of
gonorrhcea followed. Zweifel " inoculated lochial se-
cretions free from gonococci into the conjunctiva of
the new-born with negative results. Bumm injected
secretions from the cervi.x uteri free from gonorrhoeal
elements into the male urethra with negative results.
.Sanger" as far back as 1884 suggested that gonococci
may be present in the secretions of the urethra which
may assume an amorphous or a granular form. This
characteristic was noted by Teuton'-' and termed the
"involution" or "degenerated" type of gonococcus,
which may be present in the pus cells and be unrecog-
nizable under the microscope with the usual stains.
I was able to demonstrate by experiments w'ith gon-
ococcus cultures that were from seven to fifty-one days
old that a cover-glass preparation showed nothing but
an amorphous and granular mass. But on transplant-
ing such amorphous material I obtained in from twenty-
four to forty-eight hours a characlerLstic colony of the
gonococcus which morphologically was typical. Even
892
MEDICAL RECORD.
[December ig, 1896
with a culture fifty-one days old, experiments prove
that gonococci may be present in gonorrhttal threads,
and yet may not be recognizable in cover-glass prepa-
ration but only in cultures. I endorse the experiments
of Wertheim, who believes that the gonococcus does
not lose its virulence in the urethra, but that the
mucous membrane which it infests becomes tolerant
to this particular gonococcus. A patient who had a
gonorrhcea of two years' standing was inoculated by
Wertheim with a pure culture of gonococcus obtained
from the patient's urethra seven times, with negative
results. The same culture was then inoculated into
another urethra, with the result that a typical gonor-
rhcea followed. Wertheim therefore concluded that a
spontaneous cure for gonorrhoea is the general rule.
A male with chronic gonorrhoea will cause an acute
gonorrhoea in a person with whom he cohabits, and
the same is true of the female. The probability there-
fore points to the fact that an acute exacerbation in a
case of chronic gonorrhrea is produced in such a way.
Another advantage of culture examinations over cover-
glass preparations is that with the former we are able
to demonstrate the viability of the gonococcus. I am
well aware how difficult it is to determine the pres-
ence of gonococci in chronic gonorrhcea of adult fe-
males. In children with chronic colpitis I found a
diplococcus smaller than the gonococcus, which decol-
orizes by Gram's method and has a dift'erent appear-
ance in culture. Bumm in 1885 said that the time is
not far distant when the term " latent gonorrhcea" will
be dropped by those studying the etiological factors
of gonorrhoea with culture media.
The following are the results of the examination of
gonorrhoea! threads of chronic urethritis with cover-
glass preparations of other observers. Goll,'° accord-
ing to his elaborate article, examined 1,046 cases of
chronic urethritis var)-ing in duration between four
weeks to six years or more, finding gonococci in 178
cases, the remainder giving negative result. Neisser,''
out of 143 cases varying in duration between two
months and eight years, found gonococcus in 80 cases.
Weinrich,'" out of 25 similar cases, obtained 2 posi-
tive results. E. Noeggerath," in 1887, deplored the
fact that on account of the lack of culture media for
the gonococcus we cannot always demonstrate them.
Brose,'° in 1893, stated that the culture medium is the
only reliable agent for the detection of the gonococcus.
This latter statement is certainly applicable to chronic
urethritis of the male.. Neisser,"' in 1893, stated that
in chronic urethritis with slight discharge the exami-
nation with a culture medium for gonococci will re-
place the cover glass. Lundstrom"' examined 50 cases
of acute chronic urethritis, finding gonococcus in cases
of two years' duration. Gabriel '' examined the secre-
tions of 100 chronic urethritis cases, without finding
the gonococcus in any. Kaeufer" examined 50 cases
of chronic urethritis, finding in 15 cases no bacteria,
in 7 cases gonococci, in 10 cases bacilli and other
cocci, and in 18 various forms of cocci. It is interest-
ing in connection with the results of the last writer
to allude to the fact that his cover-glass prepara-
tions were stained with solution of the aniline dyes
and only in doubtful cases was Gram's method ap-
plied.
Clinical Division of Urethral Threads. — Furhrin-
ger"'' speaks of two varieties of gonorrliceal threads:
firstly, a muco-gelatinous, about one centimetre in
length (this variety occurred in most of my cases');
secondly, a brittle, yellowish, short thread, slightly
tenacious and easily scattered when shaken. Taylor"
describes four varieties of gonorrhoeal threads — the
purulent, the gelatinous, a variety consisting of pus,
mucus, and epithelium, and, last, the epithelial. For
clinical purposes this last division of threads is quite
valuable.
In conclusion I will submit the following proposi-
tions as a summary of my experiments :
I. I believe that in the examination of secretions
from urethritis the employment of the centrifuge not
only is the most convenient method but also gives the
best and most reliable results.
II. The- medium employed by Hammer, consisting
of albuminous urine plus glycerin agar, does not give
so good results as chest-serum agar, as far as my ex-
periments have shown.
III. Fractional sterilization of serum should be con-
tinued longer than six days, and after an interval of
two or three days it should be sterilized again on three
consecutive days.
IV. I recommend fermentation broth plus liquid
chest serum, Dunham's peptone solution plus liquid
chest serum, nutrient broth plus liquid chest serum, as
liquid media for the gonococcus.
V. In the fermentation broth plus licjuid chest
serum I was able to cultivate the gonococcus after
fifty-one days, at which time i discontinued my exper-
iments.
VI. Gonorrhoeal pus submitted to the centrifuge and
kept moist at room temperature contained living gono-
cocci after forty -eight hours, as proven by culture.
VII. In gonorrhoeal pus which had been smeared
on linen the gonococcus was demonstrated morpho-
logically by Gram's method after forty-nine days in
cover glass, at which time my experiments were dis-
continued.
VIII. The gonococcus was demonstrated after
twenty-nine clays in cover-glass preparation made
from pus which had been dried on glass.
IX. In chronic urethritis, culture media alone are
to be recommended for the detection of the gonococcus.
X. In 34 examinations of gonorrhoeal threads with
cover-glass alone, by Gram's method, 7 cases showed
the gonococcus.
XI. Of 61 cases of gonorrhoeal threads examined
with cover-glass and culture media, 13 gave positive
results with cover-glass and 14 with culture media.
XII. For the collection of the .secretions and threads
for planting, at least two sjjecimens of urine must be
obtained; first that which washes out the urethra; sec-
ond, that which contains threads of the posterior ure-
thra and secretion expressed from the prostate.
XIII. I beliexe that a urethra may contain gono-
cocci which lie dormant and maybe innocuous in that
person for vears, but which may at any time excite an
acute gonorrhcea in another person.
Xm K. — I cannot conclude this article without expressing my
sincerest thanks to Drs. J. R, Hayden and II. Goldenberg, of
this city, for material furnished by them from their clinic. To
Drs. Prudden and Cheeseman, of the College of Physicians
and Surgeons. I am indebted for many acts of courtesy in connec-
tion with the pursuit of my e.\perimcnts at the laboratory.
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MEDICAL RECORD.
893
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coccen bei chronischer Urethritis. Correspondenzblatt fur
Schweizer Aerzte, iSgi, vol. 21.
17. Neisser : Ueber die Ansteckungsfahigkeit der chronischen
Gonorrhoe. Breslauer arztl. Zeitschr. , 8 Jahrgang, No. 6.
18. Weinrich: Die bacteriologischen Untersuchungsmethoden
bei chronischer Gonorrhoe des Mannes. Inaug. Dissert., Berlin,
1894.
19. Noeggerath : Ueber latente und chronische Gonorrhoe
beim weiblichen Geschlecht. Deutsche med. Wochenschr. , 1S87,
S. 1,059.
20. Brose : Zur Aetiologie. Diagnose und Therapie der weib-
lichen Gonorrhoe. Zeitschrift fur GeburtshUlfe und Gynakolo-
gie, 1893, Band 26, S. 187.
21. Neisser: Welchen Werth hat die mikroskopische Gono-
kokkenuntersuchung ? Deutsche med. Wochenschr., 1S93, S. 694
and 722.
22. Lundstrom • Studies ofver Gonococcus Neisser, Helsing-
fors, 1885.
23. Gabriel: Zur Diagnose der chronischen Gonorrhoe. Deut-
sche med. Wochenschr., iSyo, No. 30, S. 657.
24. Kaeufer ■ Ueber die Beziehungen der Filamenta urethralia
zur chronischen GonoiThoe. Dermatologische Zeitschr.. Januar
1S96, Bd. 3, Heft I.
25. Furbinger : Untersuchungen liber die Natur, Herkunft
und klinische Bedeutung der Urethralfaden (sog. Tripperfaden).
26. Taylor : The Pathology and Treatment of Venereal Dis-
eases, 1895.
220 East One Hundred and Slvteenth Street.
progress of "^cdxcnl Jicicnce.
Forceps, Indications for Use. — Dr. A. D. Wil-
kinson [U'c-stcrn MeJiid! Review, Octoher 15th) sub-
mits tlie following propositions. The forceps are
indicated and should be employed : i. In all pelves
where the diameters are below the normal measure-
ments. 2. When the head is in an immovable posi-
tion, with chin fi.xed over the symphysis pubis. 3.
When the head is in the superior strait, with chin to
the front. 4. When the head is locked at the pubis,
but when flexion is imperfect and fixation of the fron-
tal part of vertex is the result. 5. When the face is
fixed anteriorly, with chin locked. 6. When the face
is fixed laterally. 7. In transverse and oblique posi-
tions of head. 8. When the head is laterally rotated
and deeply fixed in the pelvis. 9. In great narrow-
ness and rigidity of the soft parts, when the hand
cannot be introduced, or when the fingers soon become
exhausted on account of the constriction. 10. In too
large heads— as hydrocephalus. 11. In placenta pre-
via and eclampsia. 12. When the extractive methods
have been tried and proved insufficient. 13. When
the foetus is dead. 14. When the head has been torn
from its trunk.
Artificial Dilatation of the Cervix at Term or
During Labor. ~.\I. Fochier (La Scmai/u- AhJiaih;
April 15, 1896, p. 156) says: "Commencing dilatation
of the cervix is to be recognized by softening of the
cervix and the e.vtent to which the lower uterine seg-
ment is thinned. During labor, if the cervix is efiaced,
thinned, movable, and retracted a little, the head be-
ing fixed, by the application of the forceps dilatation
can be accomplished either suddenly or gradually, the
head in the latter case being allowed to retract with
the pains and the progress of dilatation watched. If
the head is not easily grasped by the forceps, version
may be performed by the introduction of two or more
fingers and bringing down a foot, thus furthering dila-
tation. In other cases, if these methods are unsatis-
factory, good results are obtained by the use of the
balloons of Champetier. Rigidity of the cervix due
to infection or eclampsia, as a rule, requires incision
or hysterotomy. Spasmodic rigidity of the cervix
indicates the employment of chloroform ansesthesia.
Roughly speaking, dilatation should not require more
than half an hour; but if the balloons of Champetier
are used, it may require two hours. No one method
accomplishes the three results desired — rapidity of
delivery, harmlessness, and good results."
The Treatment of Headache with Methylene
Blue — In a recent communication, Lewy (Bt-rliiu-r
klinische Wochenschrift, November 9, 1896, p. 996) re-
ports a series of cases of headache of varied origin,
in many of which relief was afforded by the adminis-
tration of methylene blue. The beneficial influence
appeared to be not merely temporary, but in many in-
stances of a curative character. The drug was given
in capsules, in doses of one and one-half grains, in
conjunction with an equal quantity of powdered nut-
meg, four times a day; and usually ten doses sufficed
to effect the desired result, although often less was
necessary. The urine became tinged with blue in the
course of half an hour after the first capsule was taken,
and continued so for from two to eight days. Upon
the basis of this experience, Lewy recommends methy-
lene blue in the treatment of angiospastic migraine,
the headache attending neurasthenia, and, above all,
in purely nervous headaches.
Successful Abdominal Nephrectomy for Rupture
of the Kidney. — At a recent meeting of the Clinical
Society of London, Wallis (Lancet, October 31, 1896,
p. 1,229) reported the case of a man, twenty -two years
old, who had fallen a distance of twelve feet from a
ladder upon a spiked railing. Though collapsed and
evidently in pain, consciousness was not lost. The
abdomen was rigid and rather distended. On exami-
nation it was found that one of the spikes — three
inches in length — had pierced the abdominal wall
nearly an inch below the tenth costal cartilage on the
right side. The opening in the skin ran downward
and inward, and the finger passed into the wound could
be pushed on into the abdominal cavity. Soon after
admission to the hospital, the patient passed a pint of
healthy pure blood by the urethra. He was at once
prepared for operation, and an incision made from the
lower end of the punctured wound downward to the
right semilunar line. A lacerated wound of the peri-
toneum came into view, through which the bruised in-
testines presented. The peritoneal wound was en-
larged and large masses of blood clot were turned out
of the abdomen. Sponges were inserted and the sides
of the abdominal wound held apart by two long silk
ligatures. The under surfaces of the liver and the gall
bladder were exposed and found intact. The intes-
tines in the track of the wound were bruised, and one
piece of small intestine presented a tear in the exter-
nal coats, through which the mucosa bulged. At the
bottom of the cavity the kidney could be felt, torn al-
most in two; blood welled up through the wound at a
great rate. The left kidney was found intact in its
normal situation. The peritoneum was now divided
along the outer edge of the ascending colon, and this
portion of the gut pushed in toward the middle line.
The left hand was passed in behind the colon, the
kidney rapidly freed and brought out of the wound.
The ureter was clamped, tied, and cut, the vessels were
treated in the same way, and the kidney was removed.
The deep muscles were considerably lacerated and
894
Medical record.
[December 19, 1896
bled freely. Sponges were temporarily inserted and
the abdominal caviiy was washed out with saline solu-
tion. The wound was packed with iodoform gauze in
strips and dressed with cyanide gauze, blue wool, and
bandao^ed. The patient was greatly collapsed after
the operation, but reacted well during the following
twenty-four hours. The wound healed without com-
plication, and the ultimate recovery was perfect. For
two days following the operation the urine contained
blood, and for twelve days albumin. The quantity of
urine passed in twenty-four hours averaged between
forty and fifty ounces. It was pointed out that in the
past, rupture of the kidney has been attended with a
mortality of thirty-five per cent.
Surgical Immunization Compared with Suscepti-
bility and Predisposition to Infection. — Dr. Gaston
(A/iiliama Medical and Surgiial Age, October, 1896)
thinks we may draw the following inferences: That
various agencies are at work, rendering the human
organism to a greater or less extent free from the inju-
rious impressions of surgical procedure. That local
and constitutional influences operate in conferring im-
munity, and that the environments of individuals, with
their habits of life, exert great control over the vital
powers. Shock may be averted by proper measures in
advance, and, in default of precautions, should be cor-
rected by vigorous means of treatment. Germicidal
solutions do not give immunity for normal structures,
and are admissible only in septic contamination of the
tissues. A preliminary examination of all the func-
tions of vital organs should precede surgical opera-
tions, and efficient correctives should be resorted to for
their derangements. The result depends largely on
proper means of preparation. It is not necessary that
the patient be placed in a hospital ; cleanliness, good
nursing, and the ordinary surroundings of the patient
may secure satisf actor)- results. A thorough compre-
hension of the reciprocal relations of immunity and
susceptibility should lead to the adoption of conserva-
tive measures in the practice of general surger)', and
the use of the most radical and aggressive measures
when indicated by the nature of the case. Appliances
which promote surgical immunization should be
adopted, and those means which lessen susceptibility
and predisposition to infection are warranted in all
cases of surgical interference. The author calls atten-
tion to the law of habit, as, for instance, in victims
to the use of opium, whose nerve centres are very ma-
terially aiTected by it. In such cases the habit must
be respected.
Successful Treatment of Suppurative Pericardi-
tis by Resection of the Sixth Rib and Drainage.
— At a recent meeting of the Clinical Society of Lon-
don, Robinson (British Medical Journal, November 21,
1896. p. 1,504) reported the case of a lad, si.xteen years
old, who developed right-sided diaphragmatic pleu-
risy, following a protracted bath in a swimming-pool.
On the fourth day there was some pain on the left side,
and the left wrist was swollen ; and on the sixth day
an unmistakable pericardial rub could be heard. Al-
though sodium salicylate was given, the temperature
failed to decline. In the third week the area of car-
diac percussion dulness was much increased, both up-
ward and laterally to the mid-axillary line, but there
was no dulness at the posterior aspect of the left chest.
The symptoms pointed to the presence of pus, either
in the pericardium or localized to the anterior and
lower portion of the left chest. .Aspiration in the fifth
interspace just behind the anterior axillary line re-
sulted in the evacuation of a small amount of pus.
Using the trocar puncture as a guide, the sixth rib
was on a subsequent occasion resected and the left
pleura opened, the left lung being found fixed by re-
cent adliesions. The bulging pericardium was incised,
and pus welled out freely on introduction of the finger ;
all fibrinous coagula were as far as possible cleared
out of the cavity. Over two quarts of pus were thus
evacuated. Irrigation was omitted, owing to the fee-
ble condition of the patient. A drainage tube was in-
troduced into the pericardium and stitched to the mar-
gin of the wound; Recovery was slow but uninter-
rupted, the tube being removed on the sixty-first day
and the wound healing soon afterward. There was at
no time any collection of pus in the left pleura. The
patient was able to walk great distances after conva-
lescence. There remained slight enlargement of the
area of cardiac dulness upward, but there was no re-
traction of the chest in systole.
Treatment of Ingrown Nail by Perchloride of
Iron. — The Gazelle Medicale de Liege, September 24,
1896, p. 644, publishes the following: " There are cases
of ingrown nails in which surgical treatment cannot
be employed. In these cases we may have recourse to
the method set forth by Dr. Reghi in the Gaz. d. Osped.
This treatment consists simply in a daily application
of a fifty-per-cent. solution of perchloride of iron.
Direct the patient to take daily foot baths, and when
this softens the skin and washes out the pus which has
formed, the side of the nail as well as the groove made
by the pressure of the nail should be stuffed with cot-
ton soaked in the perchloride solution. The same
operation is repeated twice daily, care being taken to
remove the blackened crust that forms. When this is
done, the toe is to be enveloped in a light dressing.
During the first few days the patient should remain in
bed. About the tenth day the granular mass disap-
pears, the cavity of the ulcer is cleansed and presents
a uniform surface, the end of the nail separates from
the skin, and in twenty days the patient is cured.
To avoid a relapse, it is necessary to separate the nail
from the skin with a little cotton steeped in perchlo-
ride solution."
Treatment of Mammary Tumors. — The Central-
hlatt fiir Chirnrgie, October 3, 1896, gives the follow-
ing: No affection has increased to such an extent in
this countr}\ Dr. Williams states that in England and
Wales in 1840 there were forty-five hundred ca.ses,
while in 1895 there were forty thousand. Should all
tumors be operated upon for fear that they may be-
come cancerous, or should they be left undisturbed in
women from twenty-five to thirty? Dr. Cow answers
these questions in the Revue de Therapie, No. 13, by
saying that every mammary tumor in liable to become
malignant in a proportion of from ten to fifty in one
hundred cases. Even with a proportion of one to one
hundred, he considers an operation indicated. Aside
from malignancy, he thinks there are other and suffi-
cient reasons to justify an operation — the care and the
pains, especially during menstruation, etc. A mild
operation puts an end to all these disturbances, if the
tumor is not diflfuse or malignant. He considers a
previous microscopical examination injurious, as it
may produce a rapid surrounding growth of the tumor,
or may open a passage for the introduction of cancer
cells leading to further infiltration. In actually ma-
lignant neoplasms, the pectoral muscle and glands, as
also the fat in the a.\illa, must be removed. He rec-
ommends to open and excavate the axillary cavity first,
thus avoiding infecting the depths of the opened mam-
mary tissue, and then remove the wliole in mass. This
method diminishes the hemorrhage, as all the blood-
vessels that supply the tissue are ligated. Patients
with generalized cancerous nodules should not be oper-
ated upon, except with the strict understanding that
it is only a palliative measure, as otherwise surgery is
brought into disrepute, and patients with operable tu-
mors are deterred from applying for relief in time.
December 19, 1896]
MEDICAL RECORD.
895
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO.. 43, 45, & 47 East Tenth Street.
New York, December 19, 1896.
ASEPTIC SURGICAL FEVER.
It has long been recognized by surgeons that opera-
tions and other forms of traumatism, such as subcu-
taneous incisions, simple fractures, luxations, and
contusions, unattended with suppuration or other
complication, may be followed by febrile reaction;
and various explanations have been offered to account
for this apparently paradoxic phenomenon. In open
wounds the possibility of infection cannot always be
excluded, despite the most rigid aseptic and antiseptic
precautions; and some have gone so far as to attribute
the febrile symptoms that appear under these circum-
stances to the presence of pathogenic micro-organisms
of attenuated virulence. Other investigators have
sought to place the responsibility for this reaction
upon the fibrin ferment set free as one of the results
of the traumatism. It has, however, been shown on
the one hand that the febrile state may be unattended
with the presence of fibrin ferment in the blood, and
on the other hand that fibrin ferment may be present
in the absence of febrile reaction. While traumatism
is often attended with a considerable degree of nervous
shock, the attendant febrile disturbance is not to be
attributed to this factor, for a variety of reasons. In
this connection it is to be borne in mind that general
infection may arise from a latent or unrecognized le-
sion, so that the diagnosis of aseptic surgical fever is
not to be made without the most rigid exclusion of all
ordinary causes of fever. Such evidence as exists
points to the fact that aseptic surgical fever is due to
the absorption of substances set free at the site of the
injury as a result of the traumatism.
From a careful analysis of the literature of the sub-
ject, in conjunction with a series of well-directed and
carefully conducted observations, Schnitzler and
Kwald ' have reached the conclusion that so-called
aseptic surgical fever is due to a combination of influ-
ences, and they adduce evidence to show that nucleins
and albumoses are set free through the agency of the
traumatism, and that these are, in part at least, to be
held accountable for the febrile reaction that takes
place in the absence of infection or other tangible-
cause. It has been claimed that the disintegration of
blood corpuscles is attended with the setting free of
albumin, and investigation has shown that the nuclei
of the leucocytes contain nucleohiston, whicli is ca-
' .-^rchiv fUr klinische Medicin, B. liii., II. 3, p. 530.
pable of causing multiple thrombi and breaks up in the
process of coagulation into histon and nuclein. As
the nucleins appear in the urine in the form of alloxur
bodies (including uric acid), the presence of these
substances in increased amount would indicate the
entrance of the former into the circulation. It has
further been shown that the presence of the nucleins
in the circulation is attended with leucocytosis. Now
Schnitzler and Ewald were able in both animals and
man to demonstrate the presence of an excess of alloxur
bodies in the urine following manipulative procedures
of such a character as gave rise to subcutaneous trau-
matism together with subsequent febrile disturbance,
in the absence of infection. They also found leuco-
cytosis under the same conditions. The inference
seems therefore fair that as a result of the traumatism
there are set free nucleins, which occasion the pres-
ence in the urine of an excess of alloxur bodies and
also the development of leucocytosis, and which fur-
ther may be viewed as one of the factors responsible
for the resulting fever.
Having advanced thus far in their investigation,
Ewald and Schnitzer proceeded a step farther and con-
finned the observations of previous investigators that
albumose could be found at the site of traumatisms
attended with extravasation of blood. It had already
been shown that both nucleins and albumoses are ca-
pable of causing death in animals when injected in
large amounts and of inducing febrile manifestations
when non-lethal doses are employed, and more espe-
cipally is this the case in tuberculous animals. In
the latter, in addition to the fever, evidences of local
reaction may be found after death about the tubercu-
lous foci comparable with those noticed after injec-
tions of tuberculin. Similar reactions were observed
in tuberculous animals subjected to sterile injuries,
while they failed to take place in control animals.
From this evidence one is forced to conclude that to
the albumoses set free at the site of aseptic trauma-
tisms must also be attributed a share in the etiology
of the fever that manifests itself. Accepting the fore-
going facts as established, we are furnished with an
explanation of the elevation of temperature often ob-
served in tuberculous patients following operative
interference of varied kind, and also perhaps of the
dissemination of the tuberculous process that some-
times takes place in the same way as such dissemina-
tion follows injections of tuberculin. The same
explanation may apply also to the recrudescence of
latent and the lighting up of unrecognized lesions of
other nature following operative measures at renwte
points.
SOME OF THE INFLUENCES OF X, SOLAR,
AND ELECTRIC RAYS UPON THE SKIN.
For some time newspaper accounts have told of re-
markable efiects whicli the rays from the Crookes
tubes have produced upon the skin of those exposed to
their influence. Reports of falling of the hair, dis-
coloration of the skin, and desquamation have reached
us from various sources. It has long been known that
certain of the sun's rays possess for particular indi-
896
MEDICAL RECORD.
[December 19, 1896
viduals the power of calling forth most distressing
cutaneous alterations, and experiments upon the sup-
posed power of red light over the efflorescences of
variola are still fresh in mind. Indeed, no longer ago
than December last the Gazette Mcdicale de Liege pre-
sented a lengthy resume of Dr. Finsen's modern and
scientific study of light in this connection, based upon
the empiricism of the middle ages, which led to the
custom of wrapping small-pox patients in red fabrics
and surrounding them with hangings of the same color.
After the successes reported by Lindholm and Svend-
sen from exclusion of the chemical rays in variola a
certain enthusiasm was created, which, extending over
Europe, reached us here, and a series of experiments
was carried out at some of the small-pox hospitals.
The success, however, was not pronounced. Instances
of dermatitis from the effect of light, aside from direct
sun action, in certain individuals of susceptible skin
are well known.
Dr. Graham, of Toronto, has reported two such
cases under the name of hydroa astivale.' The ma-
jority of writers attribute the cause of these distress-
ing eruptions to the action of the chemical rays of the
sun, and experiments would tend to show that the ultra-
violet rays act with great intensity in certain cases.
That the sun's action can be put to therapeutic uses
has been demonstrated by Rikli, and, to judge by the
following which this individual has secured in certain
German and Austrian quarters, the treatment carried
out at his institute in the mountains near Trieste
should have something to recommend it. Light is
here supposed to constitute the essential factor in the
cure, and hence the patients expose themselves to it in
a state of entire nudity. The sun baths are taken in
the open air, so that the body is subjected not only to
the direct action of the sun's rays but likewise inci-
dentally to the variations of atmospheric temperature.
The effects of electric light upon the skin have
been studied and present some features of interest in
this connection. In a paper read before the recent
meeting of the American Electro-Therapeutic Society,
Dr. Watson stated that in a large percentage of per-
sons whose naked bodies were exposed to the rays of
a number of incandescent lights in a room free per-
spiration would be induced before the temperature of
the room reached that of the normal body. This he
attributed to the chemic effect of the light. That cer-
tain eruptions are called forth by the action of bright
electric rays has been known for some time.
Passing now to the Roentgen rays and leaving aside
the questions which ha\e been raised as to their prob-
able value in the cure of disease, we find that they
exert a most pronounced effect upon healthy human
integument long exposed to their action.
In an instance related by Dr. Fuchs' so much pain
was experienced in the finger-joints of a hand exam-
ined for a lengthy period by the .r-rays that the test
had to be given up. The skin directly opposite the
cathode was colored brown; the hand became swollen
and gave the appearance of a frozen member. After
the lapse of a quarter-hour bulla formed, some being
'Trans. Amer. Derm, .^ssn., l8g6.
' Deutsch. med. Woch. No. 35.
of large size. The contents were similar to those in
blisters from burning.
This frozen appearance of exposed parts has been
noted in the ear of a man examined for several hours
at the University of Minnesota in order to locate a
bullet in the head. This patient, while experiencing
no pain or disagreeable sensation at the time, lost all
the hair from the one side of the scalp. Numerous
other instances of temporary hair loss have been
related.
Dr. Parker, of New Orleans, has called attention to
inflammation of the skin after long exposures, subsid-
ing, however, after a few hours.
In the British Medical Journal of November 7th
Dr. Drury reports that after an exposure lasting an
hour and a half the patient noticed a sunburn-like
condition of the skin over the abdomen, more intense
in the part which had been directly opposite the plati-
num plate in the tube. Upon the fourth day small
vesicles appeared, increasing in size and number,
bulla:: forming and rupturing, until upon the eigh-
teenth day after exposure a patch seven and a half by
eight and a fourth inches occupied the region. While
not painful, the discharging surface showed no ten-
dency to heal for ten days, when it began to cover
over slowly from the margins, as in a burn. Two
months later there was still an open wound three
by three and a half inches, despite attempts at skin
grafting. Cautery with silver nitrate produced no at-
tempts at granulation, and a month later the base of
the ulcer, which was covered with a thick false mem-
brane, was curetted under ether and the actual cau-
tery applied. Sixteen weeks after the exposure there
still existed an indolent ulcer, whose base was cov-
ered with an insensitive false membrane and which
showed no tendency to heal under any plan of treat-
ment. The patient was confined to his bed during
the greater portion of the time. The serious nature
of such an unfortunate outcome of a skiagraphic
SL'ance makes the matter one of interest and impor-
tance, and we would direct attention to a very similar
report of a case observed by Dr. Barrister of the
United States army. Such results should render
those who employ this most valuable aid to diag-
nosis cautious in the matter of prolonged exposure.
The patient who, while not securing the satisfac-
tion of seeing a skiagraph of his disordered interior,
has to undergo .several months of contemplation of a
disturbed e.xterior will not think well of the method
nor kindly of the operator. The suggestion of hair re-
moval in an intentional way, for cosmetic effect, .seems
not likely of successful application, since, so far as we
are aware, the hair grows again after a time in the
instances so far ob.served.
Fat Bivalves — A recent official medical report
published in London quotes with approval the words
of Professor Conn, that '" the public health is placed
in jeopardy when oyster dealers, for the sake of pro-
ducing plumpness, place oysters in the mouths of fresh-
water creeks in close proximity to sewers." — Post.
December ig, 1896]
MEDICAL RECORD.
897
INDIANA HEALTH BOARD RULES.
In "Health Circular No. 5,'' just issued by the In-
diana board of health, the following rule is the first of
a series governing the proper conduct of physicians.
" Rule i. — When visiting patients known to be sick
with small-pox, scarlet fever, diphtheria, or other con-
tagious or infectious disease, physicians shall clothe
themselves in a specially provided clean linen duster,
oil-cloth, or rubber coat, and a tight-fitting cap made
of silk, linen, oil-cloth, or rubber. The cap shall well
cover the hair. Before leaving the house, physicians
shall cleanse hands and face with antiseptic soap and
water, and use a disinfectant upon hands and face.
The coat, cap, antiseptic soap, bottle of disinfectant,
etc., shall be carried in a special glazed leather valise,
together with a pad of cotton, which is to be kept wet
with formaldehyde.* "
The asterisk calls attention to the fact that the outfit
can be obtained from the " -Clothing Store" in
Indianapolis. The rule is a most excellent one, and
but one it would be well to have adopted generally in
visiting small-pox, scarlatina, and diphtheria patients,
when it comes to extending the wearing of this cos-
tume to "crther contagious or infectious disease" the
burden placed upon the physician becomes onerous, no
matter how attractive the wearer may appear when
thus arrayed. Imagine for an instant the evening
mental and bodily state of a practitioner who starts
out in the morning clothed and in his right mind — of
course we assume that this is the way the Indianian
does start out.
His first call is upon his best-paying client. The
unfortunate lady has contracted pediculosis or scabies,
or possibly both, from the stable boy, who has the habit
of making a lounging-place of the victoria with its
lu.xurious cushions and robes.
According to rule, on goes the rubber coat and cap.
At the next call the disguise must again be extracted
from its glazed bag and donned before the gentleman
with gonococci concealed about his person can be ex-
amined. Then the little girl with pertussis next door
gets a chance to wonder at the strange appearance of
the doctor, and if he chooses the linen duster and cap
in which to visit the man down the street with secon-
daries it will be dollars to doughnuts that he will be
shot for a whitecap before he gets into the house.
If he escapes whole, the agility acquired during his
day's experience will lead him to abandon his profes-
sion for that of lightning-change artist in a continuous
performance, or it will drive him into a neighboring
State.
What the Indiana health board needs — and it must
be done quickly — is to issue "Circular No. 6," and
leave out the words " other contagious or infectious
diseases." It should also make provision for bald-
headed doctors. As the matter now stands, the cap
must be worn so as to cover the hair.
Jefferson Medical College. — Mr. William M. Sin-
gerly has been elected a trustee of Jefferson Medical
College to succeed the late Mr. Joseph B. Townsend.
COVERT PUFFING OF PROPRIETARY MED-
ICINES.
It is no secret that much of the pecuniary prosperity
of a medical journal depends upon well-filled adver-
tising pages. While the character of the advertise-
ments must depend upon the standing of the periodi-
cal, and thus carry with them a corresponding guaran-
tee of the value of the articles named, it is generally
conceded that the proper medium for such presenta-
tion to the readers is througii the pages specially set
apart for the purpose. All advertisers have then an
equal chance of presenting any special claims for pat-
ronage. It is perhaps a natural desire on their part
in some manner to obtain some sort of editorial
reference. As a consequence, it is sometimes pro-
posed, as a condition of contract with publishers, that
an occasional article on a special and well-advertised
drug or apparatus, or a covert notice of its value shall
accordingly appear in the reading-columns. We have
always maintained that such is a very reprehensible
practice and one calculated to thwart the higher
purposes of independent journalism. Readers natu-
rally e.xpect that an editor shall be perfectly sincere
in his efforts to enlighten them on all matters con-
nected with the earnest and honest pursuit of their
studies. His opinions must be necessarily untram-
melled by any pecuniary consideration, and be above
any suspicion of partiality either to advertisers or au-
thors. Hence he is often called upon to decline arti-
cles either designedly or innocently written which
extol the virtue of certain proprietary articles, in order
that his readers may not be deceived. As we know
from long experience that it is possible to be abso-
lutely consistent on this point, we are especially
pained to observe, in the reading-columns of one of
our much-esteemed contemporaries, a barefaced puff
of an advertised article in the same number, with the
signature of a reputable medical man, and with much
of the language of the advertisement in the body of
the so-called original article.
What possible benefit can be obtained from such
methods it is difficult to determine. They injure the
journal, its readers, and really the advertisers them-
selves. An article having such a transparent aim in
view is never of any value to the reader, and in the
end lowers the journal even as an advertising medium.
The subscribers, who really give the journal its value
as an advertising medium, have the right to demand
proper scientific reading in its columns. If such is
not given them, the true interest in the reading-col-
umns falls off. If the puffing notices are limited, gross
partiality is rightly charged by other advertisers; while
if all solicitors of such advertising are treated alike in
this particular, the journal inserting them must inevi-
tably degenerate to the level of an advertising trade
almanac, and no self-respecting medical man will read
the trash. The ordinary doctor patronizingly so-called
is never such a fool as many take him to be. He does
not subscribe to journals for the sake of reading puffs
of remarkable remedies, and is always ready to resent
such insults to his common sense by refusing to support
the journals which tolerate such doings. The best ad-
898
MEDICAL RECORD.
[December 19, 1896
vertisers appreciate this condition of patronage, and
are content to restrict themselves to the advertising
pages, trusting to the benefits of legitimate methods
for the sale of their wares and to the proper apprecia-
tion of straightforward methods in presenting their
claims for professional consideration.
.Advertising pages are as much an essential part
of a journal in respect to a doctor's needs as the read-
ing-matter; they both go to him at the same time,
both appeal to him legitimately along dififerent lines.
The different departments have their function and
place, and the integrity and worth of each are only
properly maintained by keeping one absolutely sepa-
rated from the other. Subscribers never complain of
this, and are always generous with fair-minded adver-
tisers accordingly; but they nevertheless hate to be
fooled, and rightly resent the covert persuasions of
the real fool at the other end, by refusing to read
what he has written or to believe what he has said.
Furthermore, and this is where some editors are short-
sighted, the readers come to look upon everj- article
published in journals which commit such blunders,
with a degree of suspicion which ultimately becomes
intolerable.
^cxns of the ScEcch.
Another Editorial Resignation from the "Bul-
letin."— Dr. Samuel Lloyd has severed his editorial
connection with the American Mcilico-Siogical Bulle-
tin.
A Deceptive Crank. — .\ man. aged sixty years, with
sandy hair and full beard shot with gray, visits doc-
tors at their offices and offers to engage them at an
extravagant salary to attend a millionaire abroad.
He is merely the victim of a delusion, says he is the
private secretary of the liberal patron, and the physi-
cian who cannot make a diagnosis at sight becomes
a victim to the same disease.
Department Store Dentists On \ovember 12th,
the superintendent and two employees in the dental
department of Siegel-Cooper Company were arrested
upon the complaint of the Dental Society of the State
of New York, the charge against each being that he
had practised dentistry in New York County without
registering therein according to law. .All of the ac-
cused waived examination and were held for trial at
special sessions, wherein several adjournments were
granted to them. Finally, on December 3d, all of
these cases were set down peremptorily for trial.
Counsel for two of the accused asked a further ad-
journment, upon the ground that the attorneys pre-
viously employed by them had abandoned their cases,
and that he had just been retained and wished to call
witnesses to prove his clients' innocence. The court
said that under the rules the adjournments could not
be granted against the opposition of the prosecution.
Counsel for the Dental Society then said that, although
the only defence to the charge of non-registration
would be the proof of registration, which, if it existed,
could be procured within ten minutes from the countv
clerk's office, he would nevertheless consent to an ad-
journment until the following day, upon the absolute
condition that the cases should be tried then. Upon
this understanding, Mr. Mingey, the counsel, accepted
the adjournment, and forthwith procured a stay of
proceedings and an order to show cause whv the cases
should not be transferred to general sessions. Upon
the following day the other defendant was then tried
and convicted — one judge, however, dissenting from
his colleague's opinion that the examination of a pa-
tient's mouth and subsequent advice as to the condi-
tion of the mouth and what was needed to be done
constituted " practice of dentistry,"' the dissenting
judge being of opinion that some mechanical or oper-
ative act should be performed.
Obituary Notes. — Dr. (,H.\Ki.ts N. Wodi.lev, of
Newburg, X. Y., died at his home in that city on
December iith, after a long illness. He was born in
.Southampton, L. I., in 1840, and was a graduate of
the Long Island Hospital Medical College in 1868.
He was for seven years a member of the Newburg
board of education and its president two years. — Dr.
Declat, of Paris, whose ardent advocacy of the heal-
ing virtues of carbolic acid did much to populari2e
the use of that remedy among the profession, died re-
cently at Nice. He always claimed for himself prior-
ity in the discovery with which Sir Joseph Lister's
name is associated, as well as in that of certain more
recently promulgated therai)eutic measures based upon
antiseptic or microbicide principles. — Dr, Leonarii
J. Sa.nford, of New Haven, Conn., one of the medical
faculty of Yale University, died at his home in that
city on December 12th. He was bom in New Haven
in 1833, and was graduated from the Jefferson Medical
College, Philadelphia, in 1854. He received the hon-
orary degree of \LA. from Yale in 1858, and was ap-
pointed professor of anatomy and physiology at the
.same university in 1863. Since that time he had lec-
tured regularly on these subjects and also upon hy-
giene in the medical and other departments of the
university. — Dr. C, E, Sec.er, of New Hackensack,
Dutchess County, N. Y., died at his home in that vil-
lage, after an illness of two weeks, of typhoid fever,
at the age of fifty-four years. He was healtli officer ot
the town in which he lived — Dr. Gf.hrce H. '1'avlor,
who devised a mechanical massage treatment, and who
wrote several medical works on the results of his ex-
periments, died on December 9th, at his residence.
No. 40 Central Park, South. He leaves a widow
and two children. — Dr. .Ai.krkd J. Martin died at
.Allentown, Pa., on December 8th, at the age of fifty-
nine years. He was graduated from the university ot
Pennsylvania in 1857. In 1878 he was elected mayor
of the city of .AUentown, and in 1880 senedasa presi-
dential elector. He was for twenty years prison physi-
cian and for a long time coroner's physician. He was
also a trustee and consulting physician to .St. Luke's
Hospital at South Bethlehem. — Dr. C. D. Keene died
at Homeville, L'pper Oxford, Pa., on December 8lh,
at the age of forty years.
December 19, 1896]
MEDICAL RECORD.
899
The Plague in India. — A telegram from liombay
states that the bubonic plague in that city is spread-
ing, and several Europeans have recentl}' bten at-
tacked. Two Englishmen died of the disease early in
December.
The Association of Assistant Physicians of Hospi-
tals for the Insane lield its fourth annual meeting on
December 3 and 4, 1896, at the Eastern Michigan Asy-
lum, Pontiac, Mich. A number of practical subjects
were discussed.
The Leprosy Congress A call, signed by Drs. E.
Ehlers, of Copenhagen, G. Armauer Hansen, of Ber-
gen, R. Koch and O. Lassar, of Berlin, has been is-
sued, inviting those interested in the repression of
leprosy to meet in Berlin in October, 1897. The
committee states, as its belief, that leprosy, which is
now slowly but steadily upon the increase, can be ar-
rested by proper and concerted measures; and it is to
discuss these measures and to devise some plan by
which they can be made effective that the congress is
called. It is unfortunate that the meeting is not to be
held immediately before or after the International
Congress at Moscow, instead of five or six weeks later.
It will be out of the question for many, from this side
of the water at least, to take part in the deliberations
of both meetings, unless, perchance, leprologists have
more leisure and more money than the majority of
their confreres.
No More Lodge Work. — The following praise-
worthy resolutions have been adopted and signed l)y
the physicians of Santa Clara County, Cal. :
" W/icreas, Rendering professional services at a
stipulated fee per capita per annum is derogatory to
the dignity of the medical profession, we, the under-
signed physicians and surgeons of Santa Clara Coun-
ty, Cal., enter into the following agreement:
'• First, we mutually, jointly, and individually pledge
our word of honor not to enter into any contract or
agreement, or renew any existing contract or agree-
ment, either written, verbal, or implied, to render
medical or surgical services to any lodge, society, as-
sociation, or organization.
" Second, we will not render medical or surgical
services to the members of the above-mentioned bod-
ies for less comioensation than we charge the general
public for similar services.
" Third, this agreement shall not be construed to
affect existing contracts between physicians and sur-
geons and the above-mentioned bodies.
" Fourth, these pledges shall take effect and be in
force for a term of three years from and after May 22,
1896.
"This agreement shall not apply to hospitals and
purely public charitable institutions."
Association of Military Surgeons of the United
States. — The following are the officers of this associ-
ation for 1896-97: President, iZom. Albert L. Gihon,
Medical Director, U. S. N. (retired). New York City;
First Vice-President, Brig.-Gen. Edward J. Forster, Sur-
geon-General, M. V. M. (deceased), Boston, Mass.;
Second Vice-President, Maj. John Van Rensselaer
Hoff, Surgeon, U. S. A., Fort Vancouver, Wash. ; Sec-
retary, Maj. Herman Burgin, Surgeon, P. N. G., Phila-
delphia, Pa.; Ircasiirer, Capt. James J. Erwin, Sur-
geon, O. N. G., Cleveland, i). ; Editor, Maj. Charles
C. Foster, Surgeon, M. V. M., Cambridge, Mass.
The seventh annual meeting of the a.ssociation will be
held at Columbus, O., May 25, 26, and 27, 1897.
The local committee of arrangements consists of Maj.
Henry M. W. Moore, Chairtnan, Assistant Surgeon, O.
N. G., Columbus, O. ; Capt. James E. Pilcher, Secre-
tary, Assistant Surgeon, U. S. A., Columbus Barracks,
Columbus, O.
Scarlatina is so prevalent in South Russia that it
is proposed that all educational establishments shall
be closed at once.
Military Surgery in Germany. — The medical ser-
vices of the German army and navy are to be separate
hereafter, and the privilege of changing from the army
to the navy, or vice versa, formerly enjoyed by the
members of either service has been abolished.
The Admission of Women to Universities in
Austria. — In the budget committee of the Austrian
Reichsrath on November 7th. the minister of instruc-
tion. Baron Gautsch, made a statement to the effect
that the government was preparing legal measures for
next year to admit women to all faculties of the uni-
versities, except that of theology, and also to grant to
the women who have obtained medical degrees at for-
eign universities the right of practising in Austria
after having undergone an examination. — British Aled-
ical Journal.
St. Christopher's Hospital for Babies On De-
cember I St there was opened at 283 Hicks Street, near
Joralemon, Brooklyn, Saint Christopher's, a hospital
for babies. Most physicians practising among the
poor have experienced the difficulty of getting hospi-
tal treatment for the very young, and it is to meet this
want that this hospital has been established. No
child suffering with a contagious disease can be re-
ceived, but all others, sick and destitute, will be taken
to the full capacity of the hospital. The hospital staff
is as follows: Consulting Surgeons, Dr. A. J. C. Skene,
Dr. William Maddren : Consulting Physician, Dr.
Charles Jewett; Consulting Neurologist, Dr. William
Browning; Consulting Laryngologist, Dr. William F.
Dudley; Consulting Ophthalmologist, Dr. William H.
Snyder; Visiting Pcediatrists, Dr. A\'illiam A. North-
ridge, Dr. John W. Parrish. On the advisory board
are Messrs. William G. Low, Edwin Packard, and
Francis H. Southwick, and Dr. Edward H. Squibb.
Visitors to the Moscow Congress The St. Peters-
burg correspondent of the British Medical Journal
writes that, in view of the fact that a large number of
visitors to next year's International Medical Congress
in Moscow is certain to take the opportunity of see-
ing St. Petersburg at the same time. Professor Peter-
sen, of the .\rmy Medical Academy, has undertaken
to form a local committee in that city, the purpose of
which shall be to enable the foreign visitors to see
what is worth seeing there (and there is very much
worth seeing) with the greatest ease and comfort A
goo
MEDICAL RECORD.
[December 19, 1896
similar committee has been formed in Brest-Litofsk, a
main junction on the line to Moscow, not with the
design of showing local objects of interest, but to sup-
ply information and perhaps also accommodation to
members of the congress who may break their journey
there.
Funny Lawmakers. — A bill has been introduced
in the Georgia legislature prohibiting the playing of
football in the State; also one prohibiting the sale of
cigarettes or cigarette paper. If the newspapers report
correctly, the same assemblage of Scions proposes to
make it a misdemeanor for women to wear bloomers,
divided skirts, or shirt waists.
Professor Roentgen was the recipient, on November
30th, of a medal awarded him by the Royal Society of
Great Britain, for his discovery of the x-rays. Pro-
fessor Moissan, of France, was similarly honored, for
his success in isolating the element fluorine.
Yellow Fever is epidemic in Port au Prince, Hayti,
and a strict quarantine is maintained against the place
by all the other West Indian ports. The Haytian au-
thorities claim that medical authorities differ as to
whether the disease is yellow fever or a pernicious
form of malarial fever.
The Morristown (N. J.) Memorial Hospital. — A
new building, a memorial gift of a friend, is to be
erected, at a cost of $38,000, on the grounds of this
hospital. The proposed building will be, it is hoped,
the central portion of a larger future hospital, to be
built in three sections, of which this is the first. It
will be about forty-five feet front, with a depth of
ninety-five feet, three stories and basement, of brick,
with trimmings of Indiana limestone, and fireproof.
It will be equipped with elevator, baths, toilet rooms,
steam laundry, etc.
Sunburn Effects from the Roentgen rays are due,
according to Tesla, to the ozone generated by the rays
in contact with the skin.
The Tri-State Medical Society of .Mabama, Geor-
gia, and Tennessee will hold its next annual meeting
in Nashville, on October 12, 1897.
Perfected .i-Rays .\ sixteen-inch spark in a
twenty-inch tube, giving an intensity two hundred per
cent, greater than that possible with the four-inch spark
in a twelve-inch tube, formerly used, is said to do the
work in thirty seconds and do away with long expo-
sures.
Jefferson Medical College. — There has been a strike
at the Jefferson. The students refused to attend lec-
tures on December ist. Dr. Keene had an audience
of one, to whom he lectured for the prescribed hour.
Dr. Chapman's solitary auditor was assailed with a
shower of eggs as he made his exit after the lecture.
Other demonstrations of a riotous nature were intended
as a protest against the rule which had been posted
three weeks ago, requiring all fees to be paid for the
first half-term on or before this date. Professor Hare
succeeded in gaining an audience in the evening, when
a lecture was delivered upon the rights of individuals.
The French Medical Press Association ate its
thirty-fourth dinnei in Paris on November gth. Pro-
fessor C'ornil presided.
The British Association for Child Study was re-
cently established at a meeting held in Newcastle-on-
Tyne, imder the presidency of Dr. Oliver.
A Medical Defence Society. — The editor of the
Lanat-Clinii calls for the foundation in Cincinnati of
a medico-legal society, which shall defray the ex-
penses of any of its members who may be sued for
malpractice. The suggestion is called forth by two
vexatious and iniquitous suits recently brought against
Cincinnati physicians, and also by the editor's per-
sonal annoyance in the matter of libel suits brought to
discourage him in his fight against quackery.
Brains for the Paris Faculty.— Dr. Luys, of the
Salpetritre Hospital, Paris, has presented the Faculty
of Medicine with his collection of twenty-two hundred
brains, carefully prepared and catalogued. The col-
lection is the result of thirty years' investigations,
and includes the brains of idiots, of blind persons, of
persons who had undergone amputations, and of those
who had suffered from various fonns of mental dis-
orders.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of tlie United States navy for the week ending
December 12, 1896: December gth. — Assistant Sur-
geon H. F. Parrish, resignation accepted from Janu-
ary I, 1897. December loth. — Surgeon E. H. Mar-
steller ordered to the Rnkij^/i : Surgeon H. G. Beyer
detached from the Raleigh, and ordered to the Nc7i'-
ark : Passed .Assistant Surgeon H. B. Fitts detached
from the Essex, ordered home, and placed on waiting
orders; Passed .Assistant Surgeon C. D. Brownell de-
tached from the Puget Sound naval station, and or-
dered to the fetre/, December i6th.
Dr. Jameson's Illness — We learn from the British
Meilical Joiinml tlie nature of the illness which has
necessitated the release of Dr. Jameson from prison
and his transfer to a private hospital near London.
The trouble was one of long standing, which had been
greatly aggravated by his enforced confinement. For
some time he had been suffering from hemorrhoids,
both internal and external. During his stay in Africa
he underwent two partial operations for their removal,
but since his arrival in F^ngland the condition had
become so much worse that further interference was
absolutely necessary. Recently a serious complica-
tion developed, in the form of a very painful fissure.
So great and so constant was the pain that sleep was
impossible. The operation was performed by Mr.
Herbert .-Mlingham. Dr. Jameson was thus in a low
state of health when the operation was undertaken,
and it is therefore not surprising to hear that he took
the anaesthetic badly. After the operation his condi-
tion did not improve so rapidly as might have been
wished. This was due to the restless condition of the
patient, the result of his confinement, combined with
the pain attending the dressing of the operation
wounds.
December 19, 1S96]
r^IEDICAL RECORD.
901
Functional Disorders of 'jhe Nervous System in
Women. By T. J. McGillicuddy, A.M., M.D.. Con-
sultiiii; Physician to the Italian Hospital ; Surgeon-in-Charge
of the New York .Mothers' Home Maternity Hospital, etc.
Illustrated by 45 Wood Engravings and 2 Chroniolitho-
graphic Plates. New York : William Wood and Com-
pany. 1 896.
\Vhile such great advances have been made in operative
gynecology, the diseases of womankind which are purely func-
tional and need not the surgeon's knife have been suniewhat
neglected, or at least have not received the attention which
their importance would seem to demand. The autlior of the
present work has attempted to draw attention to this class of
affections, and he modestly lays no claim to completeness in
his treatment of the subject. The work of three hundred
and si.xty-seven pages is written from the standpoint of the
general practitioner, and it is kept well before the reader
that many uterine disorders constitute but a small part of
general conditions which require treatment. The experience
and writings of other observers ha\'e been freely drawn upon
in illustration of practical points, and the histories of numer-
ous cases are given in a brief manner.
About eighty pages are devoted to therapeutics. In an
appendix is a series of illustrative charts devised by the au-
thor to make clear the various reflex neuroses. The volume
is neatly bound in conformity with the " Medical Practition-
ers' Library " series, to which it belongs.
Modern Greek M.\sterv; A Short Road to Ancient
Greek. By Thgm.\S L. Stedm.an, A.M., M.D. New-
York : Harper & Brothers. 1 896.
This work is intended as an aid to the acquirement of a
practical knowledge of modern Greek, and primarily for
those who cannot secure the services of a native Oeek
teacher. One of the aims which the author had in view in
the preparation of this work was to demonstrate the possi-
bility as well as the desirability of learning the ancient lan-
guage through the modern. The book will be welcomed,
however, not only by those who desire to study modern
Greek for philological purposes, but aiso by those who re-
gard this as the language best fitted to ser\-e as the common
tongue of scientific men of different nations. The method
employed by the author differs widely from the traditional
one. The teaching of grammar for grammar's sake has no
place here. The student is put at once in possession of liv-
ing Greek phrases, and insensibly acquires the ability to ex-
press his thought in this language without the intrusion of
English. An appendix contains a list of all the irregular
verbs and several specimens of Greek handwriting.
A H.\ndbook of P.^thological An.vi'Omv and Hi.s-
TOLOGV. With an Introductory Section on Post-mortem
Examinations and the Methods of Preserving and Exam-
ining Diseased Tissues. By Francis Dela field, iM.D.,
LL.D.. Professor of the Practice of Medicine, College of
Physicians and Surgeons, Columbia College, New ^■ork,
and T. Miichell Prudden, .M.D., Professor of Pa-
thology and Director of the Laboratories of Histology-, Pa-
thology, and Bacteriology, College of Physicians and
Surgeons, Columbia College, New York. Fifth Edition.
Illustrated by Three Hundred and .Sixty-five Wood En-
gravings; Printed in Black and Colors. New York : Wil-
liam Wood and Company. 1896.
The editions of this standard treatise on pathological anat-
omy follow each other in quite rapid succession, attesting not
only the numerous and rapid advances constantly being made
in the science of pathologj', but also the favor with which
this work is regarded by the medical profession. The plan
of this edition is the same as that of the previous ones, the
intention of the authors being " to give to sttidents and prac-
titioners of medicine, first, the knowledge necessary for the
making of autopsies, the preservation of tissues and their
preparation for microscopic study, and to outline the meth-
ods of study of pathogenic micro-organisms; second, to de-
scribe concisely, with such illustrations as seem necessary,
the lesions of the acute infectious diseases and, so far as
thev are known, the micro-organisms concerned in their cau-
sation, the various phases of degeneration and inflammation,
the character of tumors, the special lesions of different parts
of the body, of the general diseases, of poisoning, and of vio-
lent deaths." There is little to add to this description e.\-
cept to say that the promise has been more than realized in
the execution. This new edition contains many changes
which have been made in order to bring it thoroughly up to
date, and several new illustrations have been added. The
section on the blood has been rewritten by Dr. James Ewing.
SOUTHERN SURGICAL AND GYNECOLOGI-
CAL ASSOCIATION.
Ninth Annual Meeting, Held in Nashville, Tenn.,
November 10, 11, and 12, i8g6.
E. S. Lewis, M.D., of New Orleans, La.,
President.
Second Day — Alorning Session.
Uterine Drainage as a Factor in the Prevention
and Relief of Pelvic Inflammation Dr. R. R.
Ki-ME, of Atlanta, Ga., drew the following con-
clusions: (i) A uterine tampon is not a true drain
and even obstructs drainage in many cases. (2) Cap-
illary drainage is secured by carrying a strip of gauze
up into the uterine cavity, not packing it, and then it
drains for a few hours only. (3) Gauze cannot even
ac as a capillary drain when either end or centre is
coi ;tricted, or when coated with mucus. (4) Gauze
when saturated with serum, unless it contains an anti-
septic, forms a hotbed for germ development. (5)
Never tampon the uterus in puerperal septic infection,
except to check hemorrhage. (6) The good effect of
a gauze tampon in cases of endometritis and after
abortion is not due to drainage, but to its effects as a
tampon, i.e., checking hemorrhage, stimulating uterine
contractions, prolonging medication to the endome-
trium, and acting as a surgical dressing. (7) The
uterine drainage tube is the most essential factor in
the treatment of puerperal infection and the best
means of securing drainage when demanded in other
diseased conditions of the uterus. (8) It will save
more lives, prevent or relieve more pelvic complica-
tions than any other one factor at our command.
Gunshot 'Wounds of the Abdomen.— Dr. W. E.
Parker, of New C)rleans, read a paper on this sub-
ject, and reported thirteen cases with six recoveries.
In his paper he made the statement that he believed
that in the hands of men skilled in abdominal work
seventy-five per cent, of cases of wounds of the small
intestine should recover if they were seen early,
the prognosis being better in this class of cases than
in any other. He advised an early and rapid opera-
tion in all cases.
In conclusion he made the following general state-
ments : The diagnosis is generally easy, but when there
is doubt he would advise enlarging the wound or prob-
ing. In doubtful cases he is inclined to attach much
importance to pain referred to the umbilicus as a symp-
tom. He stated that he had never seen a case in which
this symptom was not present. There is frequently but
little shock when grave symptoms are present, and
when symptoms of it are present the trouble is gener-
ally hemorrhage and not shock. Senn's gas test was
not used in any of these cases, and he spoke of it as
being unnecessary in at least a majority of cases, un-
certain in the hands of those not skilled in its use,
and making it more difficult to replace the intestines
after sewing the wounds.
As to the technique he said that (i) unless the
wound is well to one side it is best to make a median
incision, and it should be long enough to enable the
operator to make a thorough examination of the ab-
902
MEDICAL RECORD.
[December 19, 1896
doininal contents. (2) The whole intestinal canal
should, as a rule, be examined. (3) All peritoneal
wounds should be sutured with silk Lembert sutures.
Intestinal wounds should, other things being equal, be
sewn in the long a.xis of the bowel. (4) If the liver
is wounded, better results are obtained from packing
than from suturing it. (5) If the kidney has been
wounded it is best to suture the peritoneal wound and
treat the kidney extraperitoneal ly if necessary. Of
course, he did not refer to those cases in which the
laceration and hemorrhage are so great that it is neces-
sary to remove the kidney at once. (6) Drainage, ex-
cept in late cases, is not necessary if all hemorrhage
has been stopped. (7) Cases in which the intestines
cannot be sutured without great risk of obstruction
should be resected. (S) While enough time should
be taken to do the work thoroughly, no time should be
wasted. (9) Unless the bullet can be felt, search
should not be made for it, as it causes unnecessary
delay. (10) The superficial wound should be closed
with silkworm gut or silver wire, and the author be-
lieves that a single suture should include the skin,
abdominal walls, and peritoneum.
Prognosis: (1) The sooner the patient is operated
upon the better the prognosis. (2) Tho.se cases that
have been reported in a series including all cases have
shown a mortality of about sixty-two per cent. The
prognosis is best in cases of wounds of the small in-
testine, and he believes that seventy-five per cent, of
the cases will recover if seen early. By early le
meant in the first two or three hours. (3) Every one
knows that alcoholics stood all surgical work badl\-,
and yet most of these patients have been drinking
before they come under care. The prognosis in
non-alcoholics will be better than in alcoholics. (4)
If the stomach and intestines are enijity the prognosis
is usually improved by this fact.
.After-treatment: While not favoring drugging these
patients, strychnine and other stimulants, he thought,
should be given hypodermatically if necessary. p:spe-
cially should strychnine and alcohol in .some form be
given to alcoholics. Much depends on starting these
patients well. If they are restless after the operation
or suffering, small doses of morphine should be given.
If the stomach is quiet and has not been injured,
small amounts of water and Ducro's elixir can safely
be given at the end of twenty-four hours and also small
quantities of milk or some light broth. If the stom-
ach has been injured, the feeding should be per rec-
tum. The diet should be liquid for at least two
weeks. If there is shock, with the clammy sweat
that is sometimes seen, atropine, one-sixtieth of a
grain, should be given every three hours as may be
necessary. When shall we give a purgative? This
is one of the most important questions that we shall be
called upon to decide. If we give a purgative too
soon our stitches may pull out, and if we wait adhe-
sions may form and give us trouble. The bowels of
these patients will usually act by themselves about the
end of the fifth or beginning of the sixth day. If
they do not, a mild purgative assisted by an enema
should be given about the end of the sixth day, or on
the morning of the seventh. As a rule, these patients
should be kept in bed for at least two and a half
weeks.
Discussion. — Dr. Ja.mes McFadden G.aston was
not able to corroborate, either from his reading or ex-
perience, the favorable percentage of recoveries which
the essayist had given in gunshot wounds of the abdo-
men. The fact that the Inillet entered the abdominal
cavity, if it did not wound the intestinal tract, was
not necessarily a very serious matter, althougii wound-
ing of the mesentery w ith hemorrhage was sufficient
reason for exploration. As to the Senn gas test for
determining perforation of the bowel, it was not used
by very many surgeons to-day. Dr. Gaston was very-
positive in his conviction of the propriety of laparot-
omy after gunshot wounds of the abdomen, and the
sooner the better.
Dk. \. P. D.\ndkid(;e, of Cincinnati, called attention
to the importance of making a distinction between
penetrating gunshot wounds and penetrating stab
wounds of the abdomen. The latter were much less-
dangerous. In fact, a \ery large proportion of these
cases, in which it seemed as though the intestines must
necessarily have been wounded, get well without op-
eration. In gunshot wounds, however, an exploration
should be made in every case in which there is rea-
sonable supposition that the abdominal cavity had been
entered. Gunshot wounds were much more .serious
than stab wounds. He could not agree with the es-
sayist as to the percentage of recoveries likely to take
place. Personally, he had never succeeded in saving
a case of gunshot wound of the intestine.
Dr. a. M. Cartledoe said that Dr. Parker's results
were the best he had seen mentioned in literature,
particularly in penetrating wounds involving the intes-
tines. Me had operated on five subjects with gunshot
wounds of the abdomen, three of them hopeless from
hemorrhage from the beginning, one dying within an
hour and a half from a short operation, simply from
the enormous amount of blood lost from a wound in
the mesenteric vessel. He had never sa\ ed a case of
gimshot wound with intestinal perforation.
Dr. a. V. L. Brokaw, of St. Louis, considered every
case of gunshot wound of the abdomen a law unto
itself, and that the surgeon had to meet the emergency
as it occurred. He agreed with the essayist that a
quick operation was absolutely necessary.
Dr. W. K. B. Davis emphasized the importance of
early operation and called attention to the almost
hopeless condition that was found if the surgeon oper-
ated after twenty-four or forty-eight hours. At the
Charleston meeting of the association he said he was
criticised for making the statement that at the end of
twenty-four or forty-eight hours usually a general peri-
tonitis would develop after a gunshot wound with in-
testinal perforation. If the surgeon had this condition
to contend with, an operation would ofler scarcely any
hope of recovery, unless done \ery early.
Dr. B. R. Rhkit happened to ha\e had three cases
of gunshot wounds of the abdomen during the past
year. In one case, that of a little boy, there were several
intestinal perforations. He was operated on, but died
within three hours thereafter. Case II. died eleven
hours after the closure of the perforations. Case III.
was that of a negro boy, who had six perforations. He
was oix_'rated on, the perforations were closed, and he
made a good recovery.
Dr. H. M. HiNiEK, of Union Springs, Ala., laid
stress on the importance of early operative interfer-
ence. He held that very few patients would recover
after twelve hours if not operated on, no matter how
expert the surgeon might be. He had operated on a
man, thirty-six hours after the receipt of the injury,
w ho had two perforations of the colon, the ileum being
just touched. The man died in three or four hours
thereafter of general peritonitis.
Dr. joH.v D. S. Davis did not believe it was possi-
ble to obtain in private practice seventy-five per cent.
of recoveries from early operations in injuries of the
small intestine. The patients saved by Dr. Parker
were operated on two hours after they were shot, hence
early operation was the keynote to success. While he
was not prepared to agree fully with Dr. Hunter that
none of the subjects could be saved after twelve hours,
still the majority of them would die if not operated
on within twelve hours. The most serious injuries to
the belly from gunshot wounds were seldom followed
by symptoms.
December 19, 1896]
mi:dical record.
903
Dr. F. W. McRae had seen and known of several
cases of penetrating wounds of the abdomen in At-
lanta, all of which had terminated fatally, with one
exception, and this patient was operated on by llie
late Dr. Armstrong, who found several perforations.
A foot and a half of the small intestine was resected
and the man recovered. The speaker would have
some hesitancy in opening the abdomen when there
was apt to be some medico-legal complication.
Dr. Howard A. Kei.i.v offered the following reso-
lution, which was unanimously adopted:
" A'c-si>/zYi/, That it is the sense of all the members of
the Southern Surgical and Gynecological Association
that in gunshot wounds penetrating the abdominal
cavity, the proper routine procedure is to make an
immediate exploratory incision."
Dr. P.\rk.er said, in closing, that the late Dr. Miles
in his first series of cases reported thirteen, the per-
centage of recovery being nearly forty. He had oper-
ated on probably twenty additional cases before his
death, and the percentage of recoveries was very much
better than in tlie first series. As to tlie medico-legal
aspects of this subject, all surgeons should advocate
the early opening of the abdomen, and, if some fel-
low practitioner should get into trouble as a result of
it, the profession should stand together and support
him.
The Evolution and Perfection of the Aseptic
Surgical Technique. — Dr. L. S. MuMiRrKv, of Louis-
ville, read a paper on " The Evolution and Perfection
of the Aseptic Surgical Technique." The author cited
cases in which surgeons of world-wide reputation had
infected their patients, through some imperfection in
the aseptic surgical technique, and said the subject
deserved much more study and attention at the hands
of operative surgeons than had heretofore been given
to it. So far as instruments, dressings, etc., were con-
cerned, surgeons had an absolute guarantee against
sepsis; but when it came to the operative field, the
hands of the operator and his assistants, they were re-
duced to mechanical and chemical methods of asep-
sis, which were certainly far less eflicacious and re-
liable than sterilization by heat. Everything that
comes in contact with the field of operation in the
form of instruments and dressings was exposed to heat
at a boiling temperature; hence the patient was safe
against septic infection from this source; but so much
could not be said for the hands of the surgeon and
those of his assistants nor of the field of operation.
Seauu/ Day — Afternoon Session.
The President's Address — This was delivered
by Dr. E. S. Lewi.s, of New Orleans, Reference was
made to the brilliant achievements of the masters of
the art of surgery who had passed away and of the
galaxy of shining lights who had followed after, who
had created an era in the medical history of this cen-
tur)- for all future time. How could we wonder that the
'•magnificent records obtained by exijerts have proved
alluring temptations to the inexperienced and am-
bitious," and led to abuses which have left a blot on
the fair page of abdominal surger)'. As a representa-
tive body of the surgeons and gynecologists of the
South, the society should condemn the reckless and
thoughtless plunging in this delicate and difficult
work, without knowledge, fitness, or preparation. The
statistics of the skilled, who had learned to minimize
risk and cope with difficulties, should not serve as an
argument with the inexperienced to secure subjects.
The responsibility of human life should not be ig-
nored in the craving and stniggle for notoriety or fame.
With regard to the relative merits of the abdominal
and vaginal operations for the removal of the ovaries
and tubes, or of the uterus with the appendages. Presi-
dent Tewis said that divergent opinions are entertained
and heated discussions have arisen. For the vaginal
method it is claimed less shock is produced, better
drainage is obtained, the abdominal walls are not
weakened, and the extirpation of the uterus removes a
menacing source of infection and of physical and ner-
vous disturbance. For the abdominal operation rapid-
ity of execution is contended, with increased security
to adjacent organs and facility of repair when injured,
as the structures are always in view. The removal of
the uterus is also condemned as complicating and un-
warrantable unless justified b\' the state of the organ.
In the modified vaginal method, as practised by Doyen
and others, the uterus is not necessarily sacrificed, nor
are a sound ovary and tube. It is in touch with the
conservative movement of the day, and is in marked
contrast w ith the ultra-radical operation of Pe'an.
Memorial Address on Dr. Paul F. Eve.— This
was delivered by Dr. Richard Douglass, of Nash-
ville, in which he said a retrospect of the lives of
great men inspired us with the spirit of emulation and
indicated to the ambitious mind the paths to fame.
Prof. Paul F. Eve had three distinguishing character-
istics— energy, consistency of purpose, and e.\treme
modesty, and upon them he built for himself an ever-
lasting reputation and secured an imperishable place
in the temple of fame. It is not alone as surgeon and
teaclier that his reputation rests. As a contributor to
current medical literature he was a conspicuous au-
thority. In military surgery he was without a peer.
His experience in Poland had engrafted a taste for
the work, which unfortunately in later years, as one of
the chief surgeons of the Confederacy, he had more
than ample opportunity to gratify. As the result of
his observation and work during the war of secession
he recorded many valuable facts which the surgeons
of to-day would do well to ponder. As a lithotomist
Dr. Eve was pre-eminent. Vi'hile his preference was
for the bilateral method, yet he was not wedded to it,
and appreciated the many advantages of the supra-
pubic oper,ition and often practised it, not, however,
with the same success that he achieved by perineal
section. Thoroughness characterized every undertak-
ing of his life. When the great and good life of Dr.
Eve came to an end, suddenly but peacefully on No-
vember 3, 1877, he had reached more than his three-
score years and ten, and, dying, left behind him a
name that was destined to live on in surgery through
many generations.
The Relations of the Tuberculous Diathesis to its
Local Manifestations.— A paper on •■Tiie Relations
of the Tuberculous Diathesis to its Local Manifesta-
tions" was read by Dr. J. McFadden Gastox, of At-
lanta, He said that in considering the various forms
in which tuberculosis shows itself in different struc-
tures, there must be an underlying element pervading
the whole organism, which results from a general de-
terioration of the secretions. Whether there is a pre-
disposition to the development of tuberculosis in
certain parts or organs in advance of any constitu-
tional disease or not, this change occurs in connection
with the general impairment of the vital forces which
characterizes the tuberculous diathesis. While most
recent authorities do not make a distinction between
scrofula and tuberculosis, there is a fundamental dif-
ference in their general and local development. We
have different characteristics of tuberculosis when it
involves separate organs and structures of the body
in a distinctly circumscribed form, or is defined as
miliary tubercle in different structures, and yet the
dyscrasia which marks the lymphatics under the des-
ignation of scrofula differs materially from any of the
varieties of tuberculosis heretofore recognized. Dr.
Gaston touched briefly on the causes of tuberculosis,
and reference was made to the papers that were pre-
904
MEDICAL REC(;RD.
[December 19, 1896
sented before the last meeting of the American Surgi-
cal Association on important tuberculous lesions. The
presence of a condition recognized as a tuberculous dia-
thesis corresponds in some respects with the cachexia
of carcinomatous tumors, and is held by many to be
hereditary. There has been quite a revolution in the
opinions of those best versed in the pathology of
tuberculosis as to the transmission of this disease from
parent to child, and also in regard to the communica-
bility from one individual to another by ordinary con-
tact in social relations. It is fair to conclude that
great caution should be observed in putting restraints
upon the marriage of those suffering w ith pulmonar)'
consumption, and the association of those laboring
under this disease should be limited as far as practi-
cable. Finally, the predisposition to tuberculosis
cannot be relieved by a surgical operation upon the
diseased structures, but must be corrected by remedial
agencies acting through the absorbent and secretory
organs.
Scconii Day — Evening; Session.
The Rational Treatment of the Diseased Appen-
dix by Operation -Dr. A. V. L. Hrok.\w, of St.
Louis, read a paper with this title. He said the ques-
tion had been vigorously discussed. Is appendicitis a
surgical disease at all times, or surgical only at times?
He wished to be put on record as favoring the first
proposition. He was aware that some ultra so-called
conservative practitioners claimed that the surgeon
who advocated the removal of the appendix in every
case when diseased was a dangerous faddist, an ex-
tremes! suffering from an inoculation of the bacillus
operativus. He earnestly advocated early operation as
soon as the diagnosis was made. He would always
oi^erate when there was even a slight chance of saving
a life, regardless of damage to statistics. Invariably
operation should be insisted upon in the recurrent
cases. With the knowledge of this dread disease
evolved from the mortuary chambers and the treacher-
ous clinical cour.se in a considerable percentage of
cases, why should the rational treatment of all cases
be other than by prompt surgery?
Report of Cases of Appendicitis. — Dk. Jamks \.
(Ioi;i;.\.\.s, of Alexander City, .Via., followed with a
paper on this subject. The fact that physicians gen-
erally took the stand tiiat operative interference in ap-
pendicitis was called for only in exceptional instances,
when the disease advanced to suppuration, gangrene,
and perforation, made the treatment of appendicitis a
never ceasing controversy ; hence h is e.xcuse for report-
ing a few illustrative cases that had come under his
observation, hoping thereby to add what he could to
harmonize the difference between the physician and
the surgeon on this, the most frequent and important
intra-abdominal lesion, in his opinion, of the present
day. The main point at issue between the physician
and the .surgeon in the treatment of appendicitis de-
pended much on a perfect diagnosis. This, too, ac-
counted in a measure for their differences of opinion
as to when the medical treatment should end and
when the surgical treatment should begin. .According
to his experience in the management of this affection,
there was only one cour.se to pursue, namely, to remove
the appendix just as soon as the diagnosis had been
made. Usually he deferred the operation until the
bowels had been evacuated by first administering a
few small doses of calomel, followed by a saline
purge.
Dr. Joseph T.aiser Johnson looked upon appendi-
citis as a surgical disease, and believed it .should be
so treated. He deprecated the use of opium and con-
sidered it the patient's greatest enemy, in that it masks
the symptoms and rendered diagnosis exceedingly diffi-
cult. If opium were not given in some cases a diag-
nosis could be easily made, surgical interference
resorted to, and the patient's life saved.
Dr. J.^.mes McFadden Gasion spoke of the impor-
tance of making a distinction between cases that have
foreign bodies in the appendix and those of a catar-
rhal nature leading to a general inllammatory con-
dition around the caput coli. Until we had inflam-
matory conditions which led to an exudate around the
caput coli, it was difficult to definitely determine the
exact condition which existed in supposed appendi-
citis. He was becoming more and more impressed
with the fact that there were cases of appendicitis that
were unattended with perforation, and that tliese were
curable without operative measures. An illustrative
case was cited.
Dr. F. W. McRae did not believe every case of ap-
pendicitis was a surgical one from the outset. A dis-
ease which showed so large a percentage of recoveries
was not always an operative one. Treves and other
English surgeons had shown that eighty per cent, of
patients with appendicitis got well witliout operation.
While demonstrator of anatomy he examined every
appendix which came upon the dissecting-table, kept
an accurate record of each case, and found that about
thirty-three and one-third per cent, showed evidences
of pre\ious inflammatory trouble around the appen-
dix. The individuals, most of them convicts, had died
of other diseases.
Dr. How\ard A. Keli.v favored early operation,
alluded to the difficulty sometimes of distinguishing
appendicitis from tubal and ovarian disease of the
right side, and related a case in point. In the case of
a woman with very high temperature and distended
belly he opened the abdomen, evacuated a quart of
pus, washed out, and found a gangrenous tube and
ovary, as w-ell as a gangrenous appendix. The patient
recovered nicely from the inunediate effects of the
operation, but died on the thirtieth day thereafter from
abscess of the liver.
Dr. Charles P. Noble said the safest general rule
was to operate as soon as a diagnosis of appendicitis
was made. It was impossible to differentiate the
patients who would recover from a primary attack from
those who would die.
Dr. M. C. -McGanxon, of Nashville, recalled one
case of appendicitis, that of a boy, in which the teni-
l^erature rose to 105" F. The patient was delirious.
The abdomen being opened the appendix was found
to be black but not perforated. It was easily remoxed,
and the boy made a prompt recovery. He believed
that in many ca.ses, if the piiysician should wait and
watch for distinct symptoms before operating, patients
would die.
Dr. a. J. Colev had met w ith six cases of appen-
dicitis, and made a strong argument in favor of early
operative interference.
Dr. a. .M. Cartledge said the diagnosis was the
only problem that practitioners were especially con-
cerned witii, together with tlie proper technique in the
execution of the operation. The more he operated, the
more he was inclined to believe we should operate on
every operable case as soon as the diagnosis had been
made. Mistakes were made by waiting and watching
for symptoms to manifest themselves. Very few, if
any, surgeons could tell when an appendix had rup-
tured.
Dr. George Hen Johnston said that for the sake
of statistics operations for appendicitis should be di-
vided into two classes. First, those which are per-
formed for recurrent attacks of the disea.se, and those
which are employed for the relief of the severer vari-
eties in which perforation has occurred, or will take
place when there is pus present. If the surgeon was
to operate upon recurrent cases, it was better for him
December, 19 i8g6]
MEDICAL RECORD.
905
to do so between the attacks, in order that he might
choose his time for operation. While there were cases
of the disease that recovered without treatment, the
best results were obtained by surgical interference.
Dr. N. p. Daxdridce said that with increasing ex-
perience he was more and more favorably disposed
toward early operation ; at the same time cases pre-
sented themselves in which he did not advise operative
measures. He believed that some of the desperately
bad cases were and could be saved by operation.
Dr. R. B. Rhett said he had operated twenty times
for this disease. He cited some interesting cases
illustrating the importance of early operation.
Dr. W. D. H.^gcako, Jr., called attention to the
method of Gerster to prevent contamination of the
peritoneal cavity in opening appendicular abscesses
that are not adherent to the abdominal wall or are not
walled off. It consists in introducing thick layers of
iodoform gauze through the abdominal incision and
packing it between the walls of the abdomen and the
abscess sac itself, so that in the subsequent steps of
enucleation there is no possibility of soiling the peri-
toneal cavitv.
Dr. D. Ford, of Augusta, Ga.. spoke in favor of
early operation, believing that if patients were not ope-
rated on, sooner or later perforation would occur, fol-
lowed by general peritonitis and death.
Dr. W. E. B. Davis thought there were few cases of
appendicitis that gave rise to general peritonitis in
which the surgeon was called and could do any good.
Frequently the surgeon was called too late. Even
though the family physician recognized the condition,
it was not an easy matter to persuade the patient to be
operated on within the first twenty-four hours, and
unless these cases were treated surgically within
twenty-four or thirty-six hours very few of them
could be saved. All cases of severe attacks of the
disease, in which pain was intense, if seen the first day
and consent was obtained, should be operated on. In
all cases in which there was a second attack, operative
measures should be resorted to.
Dr. George A. Baxter spoke of obliterating ap-
pendicitis and asked the essayists to gi\e their opinion
of it in their closing remarks.
Dr. Brokaw replied that obliterating appendicitis
was nothing more nor less than the relapsing form of
the disease, as a rule, or what had been termed "growl-
ing" appendicitis.
Dr. Goggan.s said, in closing, that he could no bet-
ter present his views on early operation than to sa\-,
that if he had the disease, or peritonitis supervening
upon it, he should demand operation. If he was so
low that he could not stand a general anaesthetic, he
would take a local one, and would ask the surgeon to
open his alxlonien and remove the appendix.
Compound Comminuted Fracture of the Wrist.
— Dr. H. M. Hunter, of Union Springs, Ala., re-
ported an interesting case of compound comminuted
fracture of the radius and ulna, near the wrist-joint.
He had been unable to find a similar case on record
in the literature of fractures. There were three points
with regard to this case. First, that he was unaware
of a similar fracture being reported; second, he had
never read nor heard of the method he had described
to reduce the fracture of the forearm. Third, he had
never seen nor read of such perfect results as were
obtained in this case, the wrist having perfect motion
and there being absolutely no interference with supina-
tion and pronation.
Dr. N. p. Dandridge, of Cincinnati, reported a
case of transperitoneal ligature of the external iliac
artery for inguinal aneurism, in which he removed
the aneurismal sac.
In the discussion. Dr. W. K. B. Davis also reported
a case of ligation of the common iliac for aneurism of
the external iliac, which was followed by an excellent
result.
Officers Elected. — The following officers were
elected: Prcsiiient, Dr. George Ben Johnston, of Rich-
mond, V'a. ; First Vkc-Ficsident, Dr. F. \\'. McRae, of
Atlanta, Ga. ; Second Vice-President, Dr. \\'. E. Parker,
of New Orleans, La. ; Secretary, Dr. W. E. B. Davis,
of Birmingham, Ala. ; Treasurer, Dr. A. M. Cartledge,
of Louisville, Ky.
Dr. E. S. Lewis, of New Orleans, was elected a
member of the judicial council, to supply the place of
Dr. Hunter McGuire, whose term had expired.
The association then adjourned to meet in St. Louis,
Mo., the second Tuesday in November, 1897.
OUR LONDON LETTER.
(From our Special Correspondent,)
meeting of medical council the elections — the
dublin hall case preliminary education, etc.
— the late dr. eraser, sir b. w. richardson —
surgeon-m.\jor foaker and surgeon-general
markey — operation on sir w. maccormack
abortion mongers.
London. NVivember 27, 181^6.
The General Medical Council met on Tuesday. It
seems a pity that the session began while the election
of the direct representatives is pending, as two of them
are not candidates for re-election, and other changes
are possible — in fact, generally anticipated. The sub-
ject of the election came up in the council, Dr. Glov-
er as a candidate asking to be furnished with a list of
recent registrations. We are flooded with election
circulars and postcards, and in some cases ladies have
been canvassing. Some vexation has been expressed
at this, but if all the arts of parliamentar)- electioneer-
ing are to be tolerated — and this seems to be the case
— why not this? \\'ith such an educated constituency,
I should have liked to see the addresses of all candi-
dates forwarded with the proxy papers, and the rest
left to the journals and the good sense of the voters.
But all the candidates are incurring heavy expenses,^
and in some cases the hat is alreadv going round for
their assistance.
The proceedings were once more opened with the
president's address. I should think Sir R. Quairk
must be getting tired of preparing these discourses,
which are of no practical use; and, as the time of the
council is estimated to cost a guinea a minute, some-
thing would be saved by dispensing with them. To
sketch out the course of business in this way in waste-
ful. The executive should furnish the agenda, and
the council go to work in a business-like fashion.
The Dublin Apothecaries' Hall case was taken up
on Wednesday and Thursday. The council refused to
appoint examiners, as requested by the hall, and that
body will now apply to the privy council. What
course "my lords'' will take remains to be seen.
They have expressed a willingness to assist the cor-
porations in obtaining new charters to enable them to
exercise discipline, after the manner of Cambridge
universities; but some of the bodies are by no means-
anxious to obtain such powers. Edinburgh University
has resolved to take no action in this direction, and
other "autiiorities" will follow the example, until the
profession insists or Parliament intervenes.
It was decided to improve the preliminary examina-
tions. This is to be done by pointing out deficiencies-
to certain bodies, whose examination-s are recognized.
At first it was proposed that the changes should come
into force in 1900, but an amendment to carry then\
9o6
MEDICAL RECORD.
[December 19, 1S96
out at once was adopted. It is a question whether this
system of recommendations is a good one, and there
are not wanting those who would like to see the list
of recognized preliminary examinations considerably
abridged.
The procedure in penal cases was discussed on a
proposal of the executive committee, which was re-
ferred back to that committee for further consideration.
Death continues his severe demands on our ranks.
Dr. Patrick Fraser died on November 12th, "full of
days," having been born in 1805. In younger days
he ser\-ed as surgeon in the Hagship under Admirals
-Sartorius and Xapier. In 1845 he became physician
to the London Hospital, and retained that office until
1866. During that period the Crimean war broke out,
and in 1854 Dr. Fraser and the late Mr. Wordsworth
offered their services to the government. The hospi-
tal authorities kept their appointments open for them.
How well I remember them both at that time, and the
esteem in which they were held was enhanced by their
patriotism. It is now some twenty years since Dr.
Fraser retired from practice altogether, and a genera-
tion has grown up to which his is a name in ancient
history. Those who knew him remember his sterling
character, his intelligence, kindness, and skill. You
may remember his book on " Wounds of the Chest."
Sir Benjamin Ward Richardson died early on Sat-
urday morning, after a very brief illness — so brief that,
although I knew him well, I did not hear of it until
Sunday morning. He was at a City meeting on
Wednesday. In the evening his son, going to his con-
sulting-room, found him on the couch in an imcon-
scious state from an apoplectic seizure. At first some
hope was entertained by the medical friends hastily
summoned, but he did not regain consciousness, and
on Saturday breathed his last. He leaves a widow and
two sons. He took the M.D. of St. Andrews in 1854,
in which year he gained the Fothergillian medal of
the Medical Society of London. He had been physi-
cian to the Metropolitan Dispensary and some other
institutions. He was elected F. R.C.F. in 1865, and
the following year ga\e the materia niedica lecture at
the college. One year more and he obtained the cov-
eted F.R.S. Other honors and distinctions fell to his
lot, and in 1893 he was made a knight. Sir B. Rich-
ardson took an interest in many branches of science
and medicine, as well as in numerous public questions.
His physiological researches are pretty well known;
some of them were outlived, so to say; others awaited
revision. His work on "Coagulation of the Blood" is
an example of how quickly in the.se times theories are
superseded. But Richardson was a practical physi-
cian, as evidenced by his " C'linical Essays," his
"Discourses on Practical Physic," and the ten vol-
umes of The Asdepiad. He was al.so an enthusi-
astic sanitarian. You will remember his"Hygeia, a
Model City," which appeared in 1875, and was much
talked of by the public, .\mong other works in this
branch were "National Health" (1889), and "Chad-
wick's Health of Nations" (18871. How great was
his activity and how widespread his interest may be
judged from his numerous contributions to various
journals and societies. He was also the author of
three plays, and in 1888 issued "The Son of a Star,"
a romance, though at that time he was engaged in the
temf)erance campaign, with which of late years he has
been so identified. That work may be dated from
1876, when he delivered the Cantor lectures of the
Society of Arts, taking as his subject. " Alcohol." For
some time previously he had been investigating the
properties of this substance, and I suspect some of the
temperance leaders heard a rumor of his results, and
used influence to get him appointed lecturer and to
induce him to take that opportunity of publishing his
researches. Be that as it may, the lectures proved to
be a valuable support, from the scientific aspect, to the
advocates of abstinence fronr alcoholic beverages.
Later on the author threw all the force of his energies
into this scale, and his loss to the temperance cause is
irreparable. He has been for several years physician
to the J'emperance Hospital, which has taken an im-
portant place among our charities. His adaptation of
the ether spray was the outcome of his researches on
ana:sthesia, and largely contributed to the success of
the testimonial of ^,1,000 and a microscope, presented
to him in 1868. Methylene bichloride as a general
anaesthetic was another outcome of his researches. He
designed the lethal chamber now in use for the pain-
less extinction of lost and starving dogs, etc. He was
also interested in an equal or greater degree in making
our slaughterhouses less terrible, by adopting painless
methods of killing. Cycling, too, attracted the early
attention of this versatile physician, and he became an
expert wheelman.
Surgeon-Major Foaker, who died on November
1 2th, in his eighty-sixth year, joined the army in 1838,
was in the principal battles of the Crimean war, and
retired in i860.
.Another distinguished army surgeon died last week,
suddenly, while still on active ser\ice, and fifty-nine
years old. This was Surgeon-Major-General Markey,
C.B. He joined the medical staff in 1859, and had
seen much service in India, .Afghanistan, and Fgypt.
Sir William MacCormack is better. A local em])y-
cma developed, which has been drained. The tem-
perature fell then and the appetite returned. I am
assured he is now doing well.
A criminal abortion case has excited .some attention.
A qualified doctor was tried for murder, with his as-
sistant. The jury found manslaughter. The doctor
was condemned to penal servitude for life; the assist-
ant gets off with five years.
OUR PARIS LETTER.
CFroin our .Special Correspondent.)
THE .SCHOOL OF THE SALPfiTRlkRE — CHARCOT AND
RAYMOND — RAYMOND AND CHARCOT ITS FOVNDKR
AND PROPAGATOR — ITS CHIEF TO-DAY — RAY.MOND's
LABORS — HIS GREAT AND VALUABLE WORK J VST
PUBLISHED — JEAN CHARCOT — VIOOUROUX — ELECTRO-
THERAPY, ETC.
Pahis, December i, 1896.
Two names are indelibly written in the history of the
Salpetriere; two names will shine forever over the
domain of neurology — Charcot and Raymond.
The old hospice situated in a remote quarter of
Paris at an angle of the Boulevard de I'Hopital, was
installed as early as the year 1653 in the buildings of
a small arsenal as an asylum for poor, aged, and in-
firm women. 'I'he name Salpetriere was given to it
perhaps for want of a better, perhaps because until
then the buildings had served for the manufacture of
saltpetre. In 1684 in the centre of the hospital was
constructed the workhou.se or prison for lost women.
It was, however, not until 179: that patients having
incurable mental affections, who had been up to that
time treated at the Hotel Dieu, were transported to
the Salpetriere. A few years later, in 1795, the work-
house or pri.son was abolished and given up to the
infirm, the building named Saint Vincent de I'aul
becoming an important service in the hospital. Other
buildings were added from time to time until the com-
pletion of the vast pile with its parks and gardens that
one now sees. The Salperiere of to-day, surrounded
on all sides by its high walls, the lofty dome of tlie
church towering majestically above its numerous and
immense buildings, the architecture of which belongs
December iq, 1896]
IMT'.niCAL RFXORD.
907
to different epochs, like old Gothic cathedrals or pal-
aces, gives one the impression of a smaller city within
the great one — a cit}- not devoted to pleasure but to
the care of the aged, the infirm, the insane, and those
suffering from every imaginable form and variety of
nervous disease.
Already in 1862 the population of this little city of
the diseased numbered five thousand souls, the total
number in iSg6 being about seven thousand. What
a field for neurological study and clinical work — the
largest and greatest in the world. It was Charcot
aided by Raymond who founded the school of the Sal-
petriere, properly and scientifically speaking. It is
left to Raymond, in every particular the equal of his
dead colleague and friend, to carry on the great work,
and the title of '"chef d'e'cole," left by his predecessor,
has fallen upon him who deserved it most. Professor
Raymond's Tuesday's and Friday's lessons or clinics,
which he began two years ago, are frequented by hun-
dreds of physicians and students from e\'erv quarter
of the globe, who come to familiarize themselves with
the diagnosis, prognosis, and treatment of diseases of
the nervous system. Professor Raymond's written
contributions to science have been many and valyable,
the most important of which, serving as a text-book
to students and works of reference to practitioners, is
■■ Diseases of the Nervous System," in two volumes,
the first being devoted to muscular atrophies and
amyotrophic diseases, the second to systematic scle-
roses of the spinal cord and a study of diseases of the
nervous system is Russia.
His last and greatest work has just appeared under
the title " Clinic of Diseases of the Nervous System."
These are the clinical lessons that Professor Raymond
lias held at the Salpetriere during the first of the two
years that are now expiring since his succession to
the chair of neuro-patholog}'. They were given in
the vast auditorium, fonning with the reception rooms
and eleetrical hall, of which more anon, an entire
building in the grounds of the .Salpetriere. This
auditorium cannot properly be called an amphitheatre,
being rather a hall or theatre, capable of seating and
accommodating many hundreds. At one end is an
elevated platform or stage and at the back of this is a
beautiful oil painting of colossal size in a handsome
gold frame, covering the whole end of the edifice,
painted by Robert Fleurv and representing Pinel break-
ing the irons from the wrists and ankles of the insane
as he renders to them liberty and daylight, in con-
formity to his famous words: "The insane are to be
treated, not punished" — an appropriate background
for the great work that is going on there year after
year without interruption. This picture was presented
to the Salpetriere by the government. It is here that
Professor Raymond demon.strates in the brilliant and
majestical style that characterizes him and lectures
upon the different cases of nervous disease that are
i^rought to him for diagnosis and treatment; some-
times there are several different types of a given path-
<jlogical process presented at the same se<riiiv, besides
in.iny and various others, so that he finds it no easy
task to get through with them all in the two hours
allotted to his clinical work. Professor Raymond is
a man above the medium height in stature, with a
broad expansive brow and quick intellectual eye; he
speaks smoothly and not too rapidly, but without a
hitch; never at loss for the right word, he has the
power of riveting the attention of his hearers from the
beginning to the end of his lessons. He confides to
others the care of taking down what he says. This
lias been admirably done by Drs. E. Ricklin and .\.
-S.jiiquer, who have done Professor Raymond and
themselves much credit in compiling and editing a
work that is destined to be the greatest epitome of
neurology, neuro-pathology, and neuro-therapeutics of
our time. We apply the word "destined" to what al-
ready really exists, simply because this is the first
series, 1894-95. Others are to follow.
The book in question is a handsome octavo, printed
on thick paper with large type, from the press of (>c-
tave Doin, Paris. The colored plates are by Jean
Charcot, .\fter the first chapter, which is devoted to
Professor Raymond's inaugural lesson, being reallv a
eulogium of the departed Charcot, follow in succes-
sion three others, headed '" The \\ork of a Man.'' In
these Charcot is considered as a physician, and, above
all, as a neuro-pathologist, with especial reference to
his study and researches on hysteria, hypnotism, and
treatment by metallo-therapy, suggestion, and transport.
"The Work of an Epoch" now claims the five suc-
ceeding chapters. This epoch is divided into four
periods, the first of which, beginning with Charles Bell
and his works in the year 1S14, sets forth the errone-
ous opinions of Walker, Kellingeri, and Valentin,
upon the res(x;ctive functions of the anterior and pos-
terior roots of the spinal cord. He pays en passant z.
tribute to Magendie, who in 1839 discovered the re-
current sensibility of the anterior roots, and continues
by referring briefly to the work of Stilling and Wag-
ner in 1842 to 1850, until which time it was thought
that the two varieties of nervous fibres, sensitive and
motor, ascended the entire length of the spinal cord
to unite and accord in the brain. In his recapitula-
tion of the anatomical and physiological discoveries
during the first half of this century, he dwells at some
length upon the rudimentary state of nervous pa-
thology during that period.
The end of the fourth period brings us down to the
present day. This period is marked by a revolution
in our conception of the fine structure of the nervous
system, which we owe to the perfections in histological
technique as it now exists.
Professor Raymond after demonstrating the ecto-
dermic origin of the neuroglia, passes on to the appli-
cation of new notions and ideas to nervous physiology
and pathological anatomy. He says : " The procedure
of Golgi furnishes us the means of studying the ex-
terior form of nervous units and their connections.
The theory of neurons is the most important result
that it has furnished up to the present time."
The procedure of Golgi he believes will shortly
elucidate many anatomo - pathological questions.
"Thus, the nitration of the peripheral nerves will
permit us to see much more distinctly the fibres with-
out myelin and to distinguish those fibres from empty-
sheaths. "
The remaining of the thirty-two sections are a
record of daily work done at the Salpetriere, embrac-
ing the study with cases of bilateral paralysis of the
deltoid muscle by elongation of the two circumflex
nerves — hemorrhagic compression and radicular pa-
ralyses of the brachial plexus, etc.
Considerable space is occupied by the lesions of
the Cauda equina, about the pathology of which com-
paratively little is known, being barely sketched, often
omitted altogether from classical books on nturology.
Two cases, both of women, are presented as different
types of disease of the cauda equina. The first type
begins with lancinating pains in the left leg and around
the waist, hypera;sthesia of the left thigh and gluteus,
cutaneous anajsthesia of the perineum, with hyper-
esthesia of the internal face of the left gluteus, and
of the external border of the corresponding foot: an-
esthesia of the mucous membranes of the urethra,
bladder, rectum, and left half of the vulva; vesico-
rectal troubles; disturbed motility of the left inferior
limb accompanied by atrophy of the same; stepping
and exaggeration of the patellar and plantar refle.xes,
with a sacral left unilateral eschar, these completing
the group of symptoms thus briefly summarized.
9o8
MEDICAL RECORD.
[December 19, 1896
The contrast with the second clinical type is highly
interesting. This begins with pains in the lower
limb on the right side, cutaneous hyperesthesia, in-
continence of the sphincters, anaesthesia of the peri-
neum, of the vulva, of the right gluteus, of the fibular
region, as well as of the internal border of the right
foot.
The differential diagnosis of cases of this nature
must be made from dorso-lumbar rheumatic arthritis,
lumbago, sciatica, and Pott's disease; also from the
cerebral, spinal, neuritic, and hysterical monoplegias.
The lessons on lateral amyotrophic sclerosis and
labio-glosso-laryngeal paralysis of bulbar and cerebral
origins are followed by practical essays on Jacksonian
epilepsy. The eminent author lays particular stress
on the chapters dealing with heredity in nervous dis-
ease; heredity and predisposition dominate nervous
pathology. Nervous heredity and its result, a state of
degenerescence, are prime factors in the etiology of
true psychoses and neuroses, such as hysteria, epi-
lepsy, e.xophthalmic goitre, Huntington's chorea, tics,
certain tremblings, Parkinson's disease, etc. Not the
least interesting are the closing chapters on the myo-
clonias and ambulatory deliria with fugues and hys-
terical somnambulism.
As regards the therapeutic side of this comprehen-
sive work, Professor Raymond seems to have in mind
in general two principal plans of treatment — the one
dealing with the symptomatic, the other with the
causal indications. Surgical intervention is at times
to be resorted to, for instance, in deformation of the
rachis with compression fracture and certain tumors —
trepannation for epilepsy, etc. In Jacksonian epilepsy
he counsels revulsives, preferably poiiitcs tA- feu (igui-
puncture) on the parietal region and the bromides.
He is a stanch advocate of electricity in all its forms,
a treatment indicated perhaps more frequentlyt han any
otiier in the different forms of paralyses. This is true
of the galvanic and faradic currents, static electricity
being more efficacious in hysteria and neurasthenia.
Injections of strj'chnine also find favor with him in
symptomatic paralysis of the bladder and large intes-
tine, but are administered always witli extreme pru-
dence.
.Antipyrin and the subcutaneous injection of mor-
phine are his typical mild and heroic calmatives in
pain. In many cases, of course, only palliative treat-
ment is advised. Hypnotism and suggestion are re-
served for iiysterical subjects.
Professor Raymond pays a well-merited compliment
to -American surgeons when he writes on page 112:
" The works of the American surgeons, to which I made
allusion a moment ago, had been worth to us docu-
ments of great value relative to traumatic neuritis."
We close the book fully convinced that this is the
first series of the greatest and most important work of
our day on diseases of the nervous system.
No physician passing through Paris should fail to
pay a visit to the Salpetriere; if he cannot attend
Raymond's clinic he can at least see the hospital, the
wards, ijuildings, etc., with the grounds, lawns, ilower
beds, squares, and streets. He will certainly find
there Dr. Jean Charcot, the efficient chief of clinic,
who has inherited his distinguished father's amiability
of temperament and will take great pleasure in show-
ing him what is most interesting in this neurological
world. He should not fail to see the electrical hall,
where every modern electric appliance is used in the
treatment of diseases of the nervous system. Patients
are treated here several days in the week. This de-
partment is under the direct charge of Professor
Vigourou.x, to whom it really owes its existence.
Professor Vigouroux has been for vears chief of the
electrical department of the Salpetriere and his writ-
ings on electricity and the treatment of neurasthenia
by Franklinism are classical te.xt-books. The two
static machines used are Wimshurst's and by connect-
ing the isolating benches together by means of small
chains eighteen patients are treated at once. This
hall is connected by a very short passageway with the
waiting-rooms and Professor Raymond's clinic. Be-
yond, a new electrical building has been erected within
the last year or two, under the direction of Dr. Huet,
and provided also with a \\imshurst static machine,
from which the current is given to twelve patients at
once, thus mailing a total of twenty-eight that can re-
ceive treatment every ten or fifteen minutes. The
new installation is also provided with apparatus for
giving complete faradic and gahanic baths.
Nor should the visitor omit spending a half-hour in
the museum of the Salpetriere. The collection of
casts of brains and the heads out of which they came
will alone repay him. Especially worthy of study are
the cerebral depressions. In the centre of the mu-
seum is a full-length figure in wa.\, representing a
case of ataxic atrophy, given by Charcot and illus-
trating the degree of muscular atrophy attained with
the ataxic dislocation of joints which characterize
tabes dorsalis when the disease has lasted many years.
.Another building is occupied by the pharmacy, one
of the largest and best appointed in Paris; still an-
other by the autopsy amphitheatre, and so on. But we
must stop. To do full justice to the subject a large
volume w'ould be necessary; but this sketch, brief as
it is, will give some idea of the great school of the
Salpetriere and of the work done by Charcot and by
its chief to-day, Raymond.
THE TREATMENT OF TYPHOID FEVER.
To THE F.OITOK OF THE MeUICAL RECOfCll.
Sir: I have read with much interest Dr. Nammack's
letter in your issue of November 28th, in reference to
the Woodbridge treatment of typhoid fever. It is a
very curious thing that one may read all sorts of re-
ports upon the results of this treatment — some highly
commendatory, others quite the reverse, and still
others which award to the treatment certain advantages
but denv tlie somewliat sweeping claims of Dr. W'ood-
liridge for it. What Dr. Nannnack says about tlie
ideal treatment of the poor man afflicted with typhoid
fever well expresses what many of us have long felt.
An easy and simple treatment, which can be carried
out without the expense for attendance and parapher-
nalia called for by the Brandt treatment, would be a
blessing of inestimable value to suft'ering humanity,
and one, let us hope, not unattainable. \\'hether a
serum treatment shall be found, as Dr. Namniack
seems to expect, seems quite problematical for several
reasons, which need not concern us here.
What has led me to take up your valuable space
with these few remarks are the enormous importance of
the subject and the belief tiiat after much deliberation
I can offer some suggestions in the treatment of t}'-
phoid wliich will prove of undoubted value. In the
present state of oiu" knowledge, the following plan
seems to be tlie most likely to give satisfactory' results
when for any reason the Brandt treatment may be in-
applicable. Just as soon as the patient comes under
observation and is found to have a continued fever
which cannot be controlled by quinine, whether the
serum-diagnosis test of Widal shall indicate t)'phoid
or not (and I am informed that the value of this te.st
is not as yet by any means determined), let him be
put upon small frequently-repeated doses of calomel,
and let these be continued until the constitutional
effects of the drug have manifested themselves — to
wit, the mercurial fetor in the breath, some spongi-
ness and swelling of the gums, and the characteristic
December 19, 1896]
MEDICAL RECORD.
909
stools. To accomplish this with one-twentieth-grain
doses of calomel every one-quarter to one-half hour
may take two, three, or four days, or perhaps longer,
since individuals differ so markedly in susceptibilty
to the action of the drug. In the mean time, let elimi-
nation and depuration be increased by copious
draughts of pure water. After the system has once
been brought under the influence of calomel, it seems
■quite probable that Dr. Delafield's suggestion (made
in the recent discussion of typhoid before the section
on general medicine in the New York Academy of
Medicine), that no mercurial will do any more good, is
a valuable and timely one, and that gentle catharsis
■can be better maintained by Epsom salts (or by other
salines or mineral waters).
I might suggest in passing that it seems probable
that the shortening of the mild cases of typhoid, which
Dr. Delafield noted among the thirty cases which he
had treated with the Woodbridge treatment, and which
he reported in the discussion just alluded to, was due
to the early use of calomel in these cases. It might
"be safe to go a step further, and claim that these cases
were mild because the use of calomel had made them
so, although, if such was Dr. Delafield's opinion, he
did not e.xpress it. So far as I know, no one has ever
maintained that calomel will abort ever}- case of ty-
phoid nor will quinine control every case of malaria.
Yet, from a-priori reasoning, it seems probable that a
drug with the eliminative and antiseptic action which
calomel institutes in the intestine may and in some
cases does sweep out from the intestinal tract the spe-
cific micro-organism whose presence and action there
is undoubtedly the cause of the group of lesions which
we know as tj-phoid fever. The assertions of Wunder-
lich and other eminent Germans (Ziemssen's Ency-
clopaedia, etc.) to this effect cannot in my opinion be
justly disregarded.
Following Dr. Delafield's suggestion, I would dis-
continue the calomel just as soon as the system has
been brought under its influence, and would maintain
gentle catharsis by Epsom or other salts or mineral
waters, aided by copious draughts of pure water, and
would put the patient upon the chlorine-water treat-
ment of Burney Yeo,' and keep him on that and on
liquid diet until convalescence is well established.
In all the recent discussions of the treatment of ty-
phoid fever which have met my eye, I cannot now re-
call a single allusion to tlie method so ably advocated
by the distinguished Englishman," who not only pre-
fers it to the Brandt treatment but claims for it a
much more favorable mortality rate.
Nor have I seen a recent paper upon this treatment
except one by Dr. Reynold Wilcox,' who reported the
successful use of chlorine-water treatment in a limited
number of desperate cases of typhoid, and who has re-
cently informed me that he is still in favor of the
method.
The treatment is mentioned without comment in All-
butt's " System of Medicine,'' and Wilson's " .\meri-
can Text-Book of Applied Therapeutics," 1896.
My own experience with it is limited to about a
•dozen patients, all of whom recovered except one hos-
pital patient, who was moribund when the treatment
was begun.
As to the Woodbridge treatment, like Dr. Nammack,
I hoped for great things from it, having convinced
myself, after having gone through an epidemic of sixty
cases while in the army, that the preliminary use of
calomel or other mercurial until the system shall be
mildly mercurialized, as directed by Dr. John Harley
(Reynold's " .System of Medicine"), does tend to abort
typhoid fever and does render its subsequent course
' See Amer. Journ. Med. Sci. , June. iS()4.
' Op. cit.
■■■ .Vmer. Journ. Med. Sci., Sepember, 1895.
milder and safer than when no mercurial is used.
Knowing this about the mercurial part of the treat-
ment, I had hoped that the so-called antiseptic and
eliminative treatment, which Dr. Woodbridge seeks to
carry out with his guaiacol, menthol, etc., would prove
equally efficacious: and that, in short, the ideal treat-
ment had at last been found. As the matter now
stands, it would seem to be our safest course to use
the combination which I have above outlined. We
shall thus combine valuable methods of treatment ad-
vocated by various authorities, of whom I might men-
tion Wunderlich, Harley, Delafield, Thistle, Burney
Yeo, Wilcox, Woodbridge, and a number of others.
I hope that I ha\e not made this letter too long. I
feel that Dr. Burney Yeo's chlorine-water treatment of
typhoid has not received the attention, in this country
at least, that its importance and, I might add, its
harmlessness and the ease with which it can be admin-
instered demand.
And I hope, further, that Dr. Nammack (if he has
not already tried it) will give this method a trial; and
if he does I believe that he will not despair of getting
hold of a treatment of typhoid which is admirably
adapted to the poor man's case, as it does not require
any expensive appliances nor a high degree of intelli-
gence in the nurse.
Richard C. Newton, M.D.
MoNTcLAlR, N. J., November 28, 1896.
THE INTUB.\TION TUBE AND ITS MODI-
FICATION.
To THE Editor of the Medical Record.
Sir: An article on intubation by Dr. Thomas T. Hil-
lis, which was published in the Medical Record of
November 28th, calls for a few remarks. The only
part of the article which I wish to criticise is that ad-
vocating the use of an intubation tube having an
appliance designed to facilitate extraction, to the ex-
clusion of all other considerations. This appliance,
which destroys the function of the epiglottis bv pre-
venting its closure during the act of swallowing, con-
sists of a semicircular wire which passes around and
is raised a little above the posterior portion of the
head of the tube; that portion of the latter correspond-
ing to the interarytenoid notch is scooped out, leaving
quite a little gutter for the entrance of food or vomited
matter, which the epiglottis cannot possibly prevent
because it is held up by this wire prop.
To exclude foreign material from the lower air
passages the entrance thereto is doubly guarded by
the epiglottis and the constrictor muscles of the lar-
ynx. Should the smallest particle of extraneous mat-
ter pass the first guard there is a violent contraction
of the second which tends to arrest its further prog-
ress. Now when we place a tube in the larynx we
destroy one of these guards and the whole duty of pro-
tecting this vital passage devolves upon the other, the
epiglottis. During the evolution of intubation, with
the single exception of devising a simple means of
making the tube self-retaining, the greatest amount of
experimentation was directed to overcoming the diffi-
culty of swallowing under these circumstances. These
experiments were continued long after the tubes were
in every other respect as perfect as they could be
made. It was soon demonstrated that no form of tube,
however small the head, would permit the larynx to
contract on itself as in the normal condition during
the act of swallowing, and all further experiments
were therefore directed to devising some means of aid-
ing the epiglottis to perform the double work now
impo.sed upon it. The best of the many devices tried
is that now in general use, in which the shoulder of
the tube is higher behind than in front, the object of
9IO
MEDICAL RECORD.
[December 19, 1896
this arrangement being to meet the epiglottis half
way, so to speak, thus utilizing to the greatest advan-
tage its intrinsic power of contraction as well as the
still greater power exerted by the base of the tongue,
as the latter is drawn backward while the larynx is
lifted upward and forward in the act of swallowing.
It is not claimed that liquids are thus completely
excluded because the syringe-like action of deglutition
forces some of them under the epiglottis, no matter
how closely it may cover the mouth of the tube. But
it is claimed that with rare exceptions the protection
against the admission of vomited matter is absolute
because there is no impediment to the escape of the
contents of the stomach from the pharjnx, such as
exists in swallowing. A properly constructed tube in
the larynx, therefore, does not contraindicate the use
of emetics if called for.
Those who advocate the employment of this easy-to-
get-out modification, if they think at all on the sub-
ject, must defend its use on the ground either that
the epiglottis plays no part whatever in excluding
food and the contents of the stomach from the air
passages, and consequently that there is no objection
to placing a prop under it, or that tiie entrance of
these substances does no harm.
Every one of the numerous modifications of the in-
tubation tubes that have from time to time appeared
has been simply a greater or less degree of mutilation
of the perfect instrument. No improvement has ever
been made and it requires no prophetic knowledge to
say that none ever will be made, except possibly in the
material of which the tubes are constructed. Let
those, therefore, who have inventive genius lying idle
and who will not seek other fields for its investment
try to discover some such material that will take the
place of metal, and if they fail no one will be injured
thereby. Intubation can never be made easy except
by a large amount of practice, and it is consequently
the operation of all others that should be confined to
to the hands of the few who have had or can have
such practice.
.\ score of intubationists in this citv, where thcv
are now numbered by hundreds, could do all the in-
tubations and do them skilfully, without much interfer-
ence with other work and with very little increase in
their incomes. Whatever be the motives that induce
so many to bungle this operation they are certainly
not mercenary, because diphtheria is essentially a dis-
ease of the poor, and, in the vast majority of cases, of
the very poor, so that comisensation bearing any rela-
tion to the nature of the work done is the rare excep-
tion. J. O'DWYER, M.D.
"MOUNTAIN' FEVER."
To THE Editor of the Medical Record.
Sir: In your issue of November 7th Dr. Newton, of
Montclair, N. J., is reported to have said before the
New York Academy of Medicine at its meeting on
October 20th, that '' in the army he had seen many
cases of so-called mountain fever, which autopsy
proved to be typhoid with intestinal lesion." To us
physicians practising in the mountainous regions of
\\'est Virginia anything in literature touching the
question of mountain fevers is of great interest. We
have a form of continued fever prevailing in this State
epidemically all the year around. Its symptoms col-
lectively form a picture not unlike that generally
called typhoid, as seen at the bedside, which of course
materially differs from that given in our text-books.
In quite a number of these cases, however, the diag-
nosis of t}'phoid can be made only by exclusion and
in .some it seems altogether unwarrantable. It is sur-
prising, however, to find what a great diversity of
opinion is held by local physicians as to the nature of
this affection. Thus you hear a good deal about re-
mittent fever, bilious fever, simple continued fever,
mountain fever, gastric fever, and " the" fever. The
absurd term " typhoid malaria" is still in common use
among physicians here, and has almost become a
household expression, to designate the severer forms
of this type of fever with perhaps a fatal outcome, in
spite of the fact that during the last war, when this
term was first coined, '" the mortality from typho-mala-
rial fever was very much less than from typhoid fever" '
and seems to have been applied to the milder forms of
enteric fever. The mortality from this fever was verv
great in former years but is now very small, probabl}-
not exceeding ten per cent., and no doubt due largelv
to the immigration of a better class of physicians
along with the general development of the country.
Aconite, quinine, and acetanilid have thus been re-
placed by care, judgment, and discretion. It thus
happens that autopsies are scarce and hence the inter-
est of Dr. Newton's remarks. I believe Dr. Newton
could write some very interesting pages if he chose to-
tell us of his experience with this "mountain fever,"
from a clinical or, what would be more interesting,
from a pathological point of view. Would not some-
body else volunteer?
WiLI.I.AM W. GOLDEX, M.D.,
Vice-President West Virginia Medical Society.
Elkins, W. Va.
A COMMENT ON DR. MORRIS' PAPER ON
APPENDICITIS, AS READ AT THE COUNTY
MEDICAL SOCIETY, NOVEMBER 23, 1896.
To the Editor of the Medical Record.
Sir: Dr. Morris said: " Between trusting appendicitis
cases to the surgeon or to the bacteria the decision
must be a histological one. Some surgeons are
more dangerous than some bacteria, and some bacteria
are more dangerous than other surgeons. . . . Dis-
cussion as to the treatment — medical or surgical — in
medical societies is farcical; it is a matter of individ-
ual art. . . . My statistics in the cited series of one
hundred cases show a mortality of two per cent." The
ergo is ob\ious. We all concede Dr. Morris' great
skill.
Dr. Morris said: "Medical treatment will show a
mortality of twenty-five per cent, in appendicitis. I
should not like such a mortality in my family, al-
though I could select families in which I would rather
have it than in my own." There is an ergo here to-
be obvious later.
Dr. Morris discussed a series of one hundred case.s
operated upon by him with two per cent, mortality.
It was conclusively proven that, on account of obstruc-
tion, abscesses, bands of adhesion, etc., the majority
of these one hundred patients would have died under
medical treatment. Where is the missing ergo.'
It is heie. The physicians who would have lost
twenty-five per cent, of their cases of appendicitis
under medical treatment managed, with great dis-
crimination, to get this twenty-five per cent, to Dr.
Morris' operating-table, thereby saving ninety-eight
per cent, of the otherwise lost quarter. There can be
no other explanation, considering the findings in the
series of cases.
This missing ergo seems to the writer the vital point
which the debaters miss, namely, how to weed out ac-
curately for the knife this imminent twenty-five per
cent. We hear of preconceived notions about operat-
ing as routine in all appendicitis cases, and about
operating as routine in no appendicitis cases, and we
can choo.se our consultant to suit our personal predi-
' Sternberg: "Reference Handbook of the Medical Sciences,'"
vol. iii., p. 94.
December 19, 1S96]
MEDICAL RECORD.
911
lection: but would not the welfare of the patient be
better conserved by a half-way meeting on this point
between physician and surtjeon?
The writer, in common doubtless with many other
practitioners, has cases of appendicitis under obser-
vation which seem safe in the medical seventy-five
per cent, category. He has had others which he has
put in some skilful surgeon's ninety-eight per cent.
Those in the seventy-five-per-cent. category have not
yet met the two-per-cent. surgical risk.
Eugene Coleman Savidge, M.D.
66 West Fiftieth Street.
"CATARRHAL SALPINGITIS."
To THE Editor of the Medical Record.
Sir: In your issue of November 21, 1896, Dr. Vine-
berg, of New York, has an article upon catarrhal sal-
pingitis, in which he reports several cases to illustrate
this condition. I fail to see that he proves Case III.
to be one of catarrhal salpingitis. Did the woman
li\e because of the operation or in spite of it? I saw-
nothing alarming in her condition was reported. If
she had received the same treatment before the opera-
tion as she did when her life was despaired of, would
she not have escaped both the operation and the pre-
mature birth of her child? What benefit did she
receive from the operation? Is it not a better illus-
tration of the mania for operating than of catarrhal
salpingitis? Adelaide Lambert, M.D.
263 Orange Strket, Nev\ Ha\ en, Co.nn.,
November 23, 1396.
A WOMAN
PHYSICIAN
ASIA.
IN TURKEY IN
To THE Editor of the Medic vl Record.
Sir: In your issue of October 17th, received here by
me yesterday, you copy a paragraph from The Hos-
l^ital, stating that the " sultan 'of Turkey has forbid-
den women physicians to attend upon his subjects."
Dr. Grace Kimball, who has been a physician four,
not fourteen years, at Van, to whom you refer, returned
to America to take the post of physician in a woman's
college in the East.
It is exactly three years ago to-day since I received
from the Imperial Council of Medicine at Constanti-
nople a diploma authorizing me to practise in all parts
of the Turkish empire — this after presentation of
my American diplomas and taking the usual "collo-
quium" examination required from all foreign appli-
cants. Ever since I have travelled in many parts of
the empire, never being required to show this diploma,
nor even being asked for my tezke're, or passport, by
any official except upon landing at seaport cities. I
have been able to render aid to every grade of the
official families, and have from every class in the em-
pire received only courtesy, appreciation, and grati-
tude. That I am the only woman who has the right
to practise in tiie empire is true, but throughout this
countiy many others without molestation are render-
ing valuable .services in caring for the sick and suffer-
ing-
The opportunities afforded are unlimited — skin dis-
eases among the Bedouin Arabs, malarial fever in the
valley of the Jordan, leprosy in certain villages, and
every variety of diseases of the eye in every place.
On one tour lasting three weeks I saw twenty-three
cataract patients ; at a place where I remained a few
days patients flocked from nineteen villages and I
had nineteen strabismus operations. I remain in each
l^lace from three to seven weeks, according to the needs
of the place and the number of operations to be per-
formed. I take a full supply of medical and surgical
supplies and appliances with me, and two Syrian as-
sistants share my labors.
Mary Pierson Eddv.
American Presbvtekian Mission, Sidon, Ssria.
I^acdicat Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending December 12, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis.
Measles
Diphtheria
Small-pox
Cases.
Deaths.
99
104
30
13
134
9
I
3
131
4
276
3S
0
0
A Step Lower. — St. Louis is the proud possessor
of two hospitals, each owned by a stock company and
run for the profits in the business. People are so-
licited to become members by paying fifty cents a
week, for which, in case of sickness, they receive hos-
pital care. This is the lowest stage yet reached by
the hospital abuse. — Cleieland Joiinial.
Ohio Doctors. — The Columbus Medical Jounial says
that, according to statistics there are 7,579 physicians
in the State of Ohio, of whom 4,030 belong to the
regular school, 1,199 ^""s eclectics, 678 homeopaths,
155 physio-medics, and 757 unclassified. It is esti-
mated that the new law regulating the practice of
medicine has driven out between 1,500 and 2,000
irregular practitioners from the State of Ohio, and it
is quite likely that others will find the climate en-
tirely too warm for comfort.
Precocious Mothers The American Journal of
Surgery aiul Gynecology notes that a girl ten years
and two months of age had been delivered of a
healthy child. In the Atlanta Aletlieal and Surgical
Journal of April, 1S96, Dr. T. J. Mitchell, of Locust
Grove, Ga., has an almost equally young mother, one
who at the age of thirteen years was already the
mother of three children. She first became a mother
at the age of eleven years, three months, and twenty-
three days, and gave birth to twins at the age of thir-
teen 3'ears, one month, and fifteen days.
The Nomenclature of the Brain show s how ideas
may influence language. Our anatomical fathers be-
lieved that in the encephalon the homologues of all
the parts of the body, both male and female, could be
found in miniature; and if you turn to your text-book
on anatomy to the description of the brain you will
find arms, brachia; legs, crura; knees, corpora genitu-
lata; breasts, corpora mammillaria; five stomachs, ven-
triculi, one of which was anciently called the womb,
utriculus; a vulva cerebri; buttock.s, nates; testicles,
testes; a penis, clava; a vulgar name for the pubic
hair, flocculus ; a veil, velum interpositum ; and a mar-
riage bed, thalamus. With all this procreative appa-
ratus before us, we are not surprised to find a union
(fornix) and numerous offspring, quadruplets (corpora
quadrigemina). — 7he Language of Aledieine, by F. R.
Campbell, A.M., M.D. (pp. 47-48).
Crotte's New Method of Treatment in Consump-
tion.— The French .Academy of Sciences has recently
appointed a committee — composed of M. Chauveau,
912
MEDICAL RECORD.
[December 19, 1896
the physiologist; M. d'Arsonval, biologist and elec-
trician,' and Professor Bouchard — to make a thorough
investigation of the alleged new cure for phthisis.
Dr. Crotte's patients have been poor persons whom he
has treated gratuitously, and it is said that he has
greatly improved the condition of six hundred con-
sumptives who had passed beyond the early stages of
the disease. The antiseptic known as formaldehyde
is inhaled in a gaseous form, and static electricity is
at the same time applied to the chest. Dr. Crotte's
theory is that the electricity opens the way for the
germ-killing antiseptic and permits it to reach the
bacilli in the cavities of lung tissue. This is not the
first time that attempts have been made to apply ger-
micides directly to the embedded bacilli of tuberculo-
sis, but it has been said that an application of suffi-
cient strength to kill the germs in the lungs would
also kill the patient. E.xperiments with injections of
carbolic acid have been made in this country and in
Japan.
Presenility. — An infant of eight months is reported
to have died in St. Louis, whose development, features,
and general appearance were those of old age. The
texture of the hair was coarse, like that of the adult,
and hair grew upon the face.
Reading-Matter at Advertising Rates — We re-
gret to see in a Western exchange the names of two
New York physicians of good standing attached to
reading-matter in the advertisement columns. 'J'hese
articles were evidently written in their original form
with proper intent and purpose. As they deal, how-
ever, in each instance with proprietary remedies, it has
evidently seemed to the advantage of the manufactur-
ing firms to reproduce them. They stand, however,
side by side with bold laudation of nostrums, and the
reflection is not creditable.
Sand Filters Allen Hazen {T/ic Sanitarian, No-
vember) concludes: " The city of Philadelphia is now
using water in a most wasteful and extravagant manner,
and immediate measures should be taken to check such
waste, and to reduce the consumption to a reasonable
amount. It is possible to construct sand filters similar
to those in use at London, Hamburg, and many other
European cities in connection with the existing pump-
ing stations, of sufficient capacity to furnish water for
all reasonable requirements, for the present population,
and for that which may be expected in the near future."
Laparotomy on a New-Born Infant — Dr. Mar-
jantschik reports the case of a full-term child, normal
in every respect except for an apple-shaped tumor in
the middle of the abdominal wall, extending from the
ensiform process to the navel. Operation was done
by Dr. Tschernow, about thirty hours after birth. The
tumor was found to contain part of the liver, omentum,
and intestines; these were carefully rejjlaced, the
edges of the abdominal wall freshened and then
brought together, the sutures passing through all the
tissues from peritoneum to skin. The infant died on
the fifth day after the operation, autopsy showing the
cause of death to be peritonitis and acute gastro-coli-
tis. The writer reviews the thirty-one cases previously
reported, in which seven of the patients died. He
concludes that operation should be done in all cases
if the child seems capable of life, and that it must be
undertaken as early as possible. The method of ope-
ration must depend upon the size of the defect in the
abdominal wall and the number of adhesions; but the
most correct method is laparotomy. — Centralhlatt Jiir
Gynakfllogic.
When May Gonorrhoeics Marry ?— Dr. Lowen-
hardt (/oiinial /it-s Connaissanccs Ali'ditalcs) gives the
following rules to be observed by physicians consulted
by blennorrhagics to gain medical consent to marry:
As the virulence of the urethral discharge depends
upon the presence of the gonococcus, the candidate
should be subjected to numerous bacteriological ex-
aminations, carried out separately on the secretion of
the anterior and posterior urethra. A slight secretion
is not sufficient, but the urethral mucosa must be irri-
tated in such manner as to place it in analogous con-
ditions to those (excess /'// Baccho ct Vencre) which
light up an indolent process. This result may be
obtained by injecting a few drops of a five-per-cent.
solution of silver nitrate into the urethra; if the dis-
charge thus set up contains no gonococci, but is en-
tirely made up of epitiielial cells, marriage can be
pemiitted. Another rather ]i(i])ular method of provok-
ing a urethral discharge in order to establish the verity
of a cure is to give an injection of 1 to 1000 bichloride
solution, and to instruct the patient to drink a quart
or more of beer. This would seem to be more heroic
tlian circumstances would warrant. The presence of
the numerous pus corpuscles necessitates renewed
examinations and energetic treatment of this pseudo-
gonorrhcea. In spite of failure to find gonococci after
repeated examinations, it is better to wait until the
discharge has ceased entirely, and to withhold consent
to marry until there can be no peradventure of conta-
gion. The extreme views of Noeggerath and Tail on
the incurability of gonorrhoea in the male are too
often and too clearly refuted by practical experience
to merit serious consideration. Latent gonorrhcea, in
tiie etymological restriction of the adjective to "lying
hidden," has no existence. If the disease exists, it can
always be discovered.
Specialism. — Wife: "Isn't that the celebrated der-
matologist. Dr. X — ■ — , who cured you?" Husband:
"No; I got his bill vesterdav. He's a skin special-
ist."
Time of Rupturing the Amniotic Sac in Labor. —
The Atlanta Mrdiial anil Sinxlial Joional gives the
following rules: i. In multipara-, ru])ture wlien the os
is fully dilated. 2. In primipara:-, delay until the soft
jiarts are also dilated. 3. In cases of face and breech
presentation, delay in rupturing the sac is best. 4.
When the pelvis is small and the foetus large, delay
rupturing. 5. In premature labor, with a dead fcetus,
rupture early. 6. Rupture the sac early when the
membranes are unusually thick, tough, and unyielding.
7. When speedy delivery is demanded, rupture early
and dilate with the fingers. 8. Ru])ture the sac when
an excessive amount of amniotic fluid retards labor.
9. \\'hen version is necessary, and can be accom-
plished by bimanual manipulation, perform this ojjer-
ation before rupturing. 10. Remember that a diy
labor is always to be deprecated; hence do not rup-
ture at all, unless for good reasons and the case de-
mands it.
While the Medical Record is pleased to receive all new publi-
cations which may he sent to it, and an acknowledgment will he
prom pit V made of their receipt under this heading, it must he 'Mth
the distinct understanding that its necessities are such that it can-
not Jie considered under ohligalion to notice or review any publica-
tion received hv it which in the judgment of its editoi will not he
of interest to its readers.
The Physician's Visiting List for 1897. P. Plakiston,
Son & Co., Philadelphia, Pa.
PRF.M.\TrRE Burial, and How It May Be Prevented.
By William Tebb and Col. Edward Perr}' Vollum, M.lJ. i2mo,
400 pages. Swan, Sonnenschein \ Co., London.
A MoNOGRArn OF Diseases of the Nose and Throat.
By C'.eorge H. Quay, M.D. i2mo, 214 pages. Illustrated.
Boericke & Tafel, Philadelphia, Pa. Price, §1.25.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 50, No. 26.
Whole No. 1364.
N-. r |-^ c o c $5-00 Per Annum.
Ew York, December 26, 1896. single Copies, loc.
©viginal |ivtidcs.
THE TREATMENT OF PUERPERAL
ECLAMPSIA.'
By J. CLIFTON EDGAR, M.D.,
ASSOCIATE PROFESSOR OF OBSTETRICS IN THE MEDICAL DEPARTMENT CF THE
UNIVERSITY OF THE CITY OF NEW YORK ; ATTENDING PHYSICIAN To THE
SOCIETY OF THE LYING-IN HOSPITAL, TO THE NEW ^ORK .MATERNITY
AND TO THE EMERGENCY HOSPIT.\LS; LECTURER AND E.KAMINER ON
OBSTETRICS I.V THE NEW YORK TR.AINING SCHOOL FOR NURSES.
It is necessary to preface our remarks upon the pre-
ventive and curative treatment of puerpeial eclampsia
Nvitii tlie statement that the real cause of the condition
in the human female is still an unknown quantity.
As far as we are aware, no new light has been thrown
upon the pathology and etiology of the condition.
That the pre-eclamptic condition and the subse-
quent eclamptic seizure are due to (i) uraemia, (2)
hydrcemia, 13) ammoniajmia, (4) reflex irritation, (5)
microbic influences, or (^6) to the influence upon the
system of some to.xic material, modern scientific in-
vestigation does not permit us to state. Most ob-
servers are agreed that the la.st mentioned approaches
the true explanation, and that the condition is one of
toxaemia, of auto-infection, of an accumulation in the
blood of some toxic material — biliary, urinary, fcetal, or
all three, but just what this material is has not up to
the present time been determined. It appears prob-
able, moreover, that the condition has not one but many
causes. Further, modern clinical research and study
would seem to prove that the pre-eclamptic state, or
what some have been pleased to term ''the toxaemia of
pregnancy," has certain well-marked symptoms and
signs to guide us to a diagnosis of this condition, and
that in the majority, if not in all instances, this state
extends over a period of days, if not weeks or months.
The limits of the present paper do not pemiit us to
enlarge further upon the clinical picture of this pre-
eclamptic condition, other than to state that it resem-
bles closely the clinical picture seen in slow or rapid
poisoning by some mineral or narcotic poison, and that
the condition is always accompanied by failure of the
eliminative organs to do their duty, notably on the
part of the kidneys. If these premises are correct, then
of the two treatments of eclampsia, the preventive and
the curative, the former is by far the most important,
especially .so when we come to find that in the major-
ity, if not in all instances, the eclamptic seizure is a
preventable accident.
(a) The Preventive Treatment. — What symptom
or sign, or what combination of symptoms or signs,
have we then, that will enable us to recognize this
pre-eclamptic state, in order that we may be warned
in time to pre->jent the subsequent eclamptic convul-
sions ?
The symptoms of the state preceding an eclamptic
attack include a rapid pulse, accompanied usually by
high arterial tension, loss of appetite, gastric and in-
testinal disturbances, headache, lassitude mental and
physical, a gradual or rapid diminution of all the e.v-
cretions, both liquid and solid — in a word, what one
' Read before the New York .\cademy of Medicine, at a special
meeting, November 27, 1896.
would expect to observe from the introduction or re-
tention in the blood of some toxic material.
Aside from the direct examination of the blood
itself, the condition of the urinary secretion offers us
the most convenient physical sign or clinical index of
this pre-eclamptic state. The amount of urine passed
in twenty-four hours is not always a reliable guide of
kidney failure. Albuminuria, as is well known, may
be absent before, during, and even after an eclamptic
seizure. The amount of urea excreted is a far better
guide, as has been shown by Bouchard, of Paris, in the
non-pregnant condition, and recently by Dr. E. P.
Davis, of Philadelphia, in pregnancy; for the latter
found that when urea fell to 1.5 per cent., stimulation
of the excreting processes resulted in distinctly favor-
able results, in all cases in which toxic symptoms were
previously present. It is not to be inferred from this
that urea causes the convulsions, for large quantities
of urea may be injected into rabbits without producing
toxic symptoms. Indeed, Bouchard found that bile
had nine times the toxic power of urea. It is gener-
ally accepted that the diminution in the amount of the
urea e.xcreted indicates kidney inadequacy, but it is
not always a reliable guide. There are other sub-
stances in the urine with as great or greater poisonous
qualities. Urea may be found in sufficient quantity
and an eclamptic attack occur. Bouchard determined
the toxicity of the urine by injections of the same into
the circulation of rabbits. His experiments show that
normal healthy urine is toxic in the proportion of a
certain unit per kilo by weight of the rabbit. In kid-
ney insufficiencv, when some poison or poisons are re-
tained in the circulation, the toxic properties of the
urine diminish, and it requires more of the urine to
the kilo by weight of the rabbit to produce toxic symp-
toms in the animal. This gives us a delicate test for
determining kidney inadequacy in doubtful cases.
Bouchard's experiments further show that in renal in-
sufficiency the poisons retained in the patient's blood
arise from :
1. Food, especially nitrogenous food, as muscle,
and food containing the salts of potassium.
2. Bile.
3. Putrefaction in the intestines, and absorption of
its products.
4. Toxic materials constantly being produced by
the metabolism of all the cells of the body.
To this last we add the metabolism of the fcetal
tissues, as this greatly increases the toxic material in
the mother's blood, for, clinically, we are familiar
with the fact that when the fcetus dies in iitcro, or is
delivered in the case of a living child, the eclamptic
seizures usually cease.
Again, Winckel's obser\ation that in twin and trip-
let pregnancies there is a greater predisposition to
eclampsia has been verified by others. Moreover, the
tendency to eclampsia becomes greater proportionately
with the advance of gestation and the consequent in-
crease of ftetal metabolism.
Further, we know that the maternal mortality dimin-
ishes progressively from the ante-partum to the post-
partum states; namely, that it is greatest when eclamp-
sia sets in during pregnancy, is less during labor, and
lowest of all when the attack occurs for the first time
9'4
MEDICAL RECORD.
[December 26, 1896
after the birth of the child. Thus, the mortality dur-
ing eight years at the Boston Lying-in Hospital, as has
been shown by Green,' was: Ante-partum eclampsia,
maternal mortality, 46 per cent.; foetal mortality, 69
]3er cent. Intra-partum eclampsia, maternal mo-talit)-,
25 percent.; fottal mortalit}-, 25 per cent. I ost-par-
tum eclampsia, maternal mortality, 7 per cent.
Our present knowledge of the causation of puerperal
eclampsia, meagre though it be, furnishes us, if not
with the key to the successful preventive treatment of
the condition, still with a working hypothesis, name-
Iv, the early recognition of the pre-eclamptic state.
'I'o accomplish tliis, something more than a perfunc-
tory monthly or bimonthly examination of the urine
for the presence of albumin is called for, since non-
albuminuric eclampsia occurs in from nine to si.xteen
per cent, of cases, and it would appear to be quite as
fatal, if not more so than an eclampsia accompanied
by albuminuria. Something more is demanded than
the late recognition of renal insufficiency, as it shows
itself in a marked diminution in the quantity of urine,
specific gravity of the same, and amount of urea e.\-
creted.
When we shall accustom oursehes to watch our
cases of pregnancy, not only for the physical signs of
])ronounced renal inadequacy as an inde.x of an ap-
proaching eclamptic attack, but also for the general
symptoms of the overcharging of the blood with to.xic
material — as high arterial tension, headache, gastric
disturbances, physical and mental lassitude, and fur-
ther for failure of the bowels, li\er, skin, and lungs
properly to perform their functions, and intelligently
treat the same, then, and then only shall we have done
our whole duty by our patient, and done all in our
power to correct the pre-eclamptic condition and avei t
an impending eclampsia.
We would formulate our line of treatment of this
preeclamptic state somewhat in the following manner:
1. Reduce the amount of nitrogenous food to a min-
imum.
2. Limit the production and absorption of to.xic
materials in the intestines and tissues of the body, and
assist in their elimination by improving the action of
(i) the bowels, (2) the kidneys, (3) the liver, (4) the
skin, and (5) the lungs.
3. If necessary, remoNC the source of f(eta! metal)-
olism and of peripheral irritation in the uterus by
the emptying of that organ.
Our first indication, the reduction of the amount of
nitrogenous food to a minimum, can best be fulfilled
in an exclusive milk diet, to which, as the symptoms
subside or disappear, can be added fish and white
meats. We have found it not only safer, .but less try-
ing to the patient, to commence with an absolute milk
diet, than to compromise and afterward be compelled
to cut off all but the milk. For our second indication
— that of elimination — we must first secure an abun-
dant supply of pure air and water. This may be as-
sisted by moderate exercise or light calisthenics or
massage, in certain instances. For the bowels we ad-
vocate daily doses of colocynth and aloes at bedtime,
followed by a saline in the morning. For the liver
an occasional dose of calomel and soda at bedtime,
followed in the morning by one of the stronger sulphur
waters, as Rubinat, Villacabras, or Birmenstorf. In-
creased diuresis is secured by maximum doses of
glonoin. The action of the skin is encouraged by en-
casing the body in wool or fiannel underclothing, by
massage, by the warm imtii. hot bath, hot pack, or hot-
air bath, according to the urgency of the case.
We are accustomed in instances of eliminative in-
sufficiency to give at bedtime twice weekly, or more
' Green : " Puerperal Eclanipsi.T. Experience of the Hoston
T.ying-in Hospilal in the Last Eight Years," American Journal
of Obstetrics, iSq3, x.wiii.. 18-44.
frequently if necessary, a tablet composed of calomel,
digitalis, and squill, each one grain, and muriate of
pilocarpine, one-twentieth of a grain. This is followed
in the morning by a full dose of \'illacabras water.
We have found a decided diaphoretic-diuretic action
follow the administration of such a combination, with
the additional prompt action upon the liver and intes-
tines as well. So of our five eliminative processes
four are stimulated to more energetic action by its use.
Because jaborandi has been practically abandoned
as a diaphoretic in the presence of an eclamptic at-
tack, we know of no good reason contraindicating its
use in this, the pre-eclamptic state, in the absence of
pronounced cardiac disease, and we advocate its use
for its diaphoretic and diuretic actions.
Finally, when exercise cannot be taken and an
abundant supply of fresh air is wanting, oxygen in-
halations will prove of service. Some preparation of
iron will also be called for, as the tincture of the
chloride, or Basham's mixture.
This, then, is the general hygienic and medicinal
treatment of the pre-eclamptic state. No hard and
fast rule can be laid down. Every case must be
treated on its merits. In one a restricted diet and
mild stimulation of the renal and intestinal functions
is sufficient, and the patient may be allowed to be
about and even exercise in the open air, her skin being
protected 4rom sudden changes by being incased in
wool or flannel. Other more pronounced cases of
eliminative insufficiency must be kept absolutely quiet
in bed upon an exclusive milk diet, and the stimula-
tion of all tiie eliminative organs must be resorted to,
to remove the symptoms of impending eclampsia.
But it must be kept e\ er before us that tiie hygienic
and medicinal treatment is only of secondary impor-
tance to the milk diet, and that the latter is the foun-
dation of the preventive treatment of puerperal
eclampsia. Given a case in which, in spite of an ex-
clusive milk diet and the vigorous stimulation of the
five excretory outlets already mentioned, the symptoms
and signs of tiie pre-eclamjHic condition continue or
at any time become urgent, the indication is to induce
artificially abortion or premature labor.
We cannot understand the position of those author-
ities (notably of the British school of midwifery) who
advise against inducing labor in the presence of ur-
gent symptoms of the pre-eclamptic state.
The arguments that l)y tl-.e methods usually in vogue
induced labor increases reflex excitability and precipi-
tates convulsicjus; that by the same methods, because
of the time necessary to remove the barrier of the cer-
vix, the patient's fate is sealed before the delivery is
effected; and, moreover, tiiat the onset of labor in-
creases the danger to the patient, are good ones and
must demand our attention.
In answer, we would state that our methods of ter-
minating the pregnancy need not increase reflex exci-
tability, and if perchance they do, the excitability is
readily controlled for the time necessary to accomplish
our ends: that the time necessary is, in most cases,
verv short: and, linally, that to-day the onset of labor
and the termination of pregnancy may be practically
brought about at one and the same time, and we have
no prolonged or tedious labor to react unfavorably
upon the patient.
The objection raised by Byers at the last (second)
International Congress of Obstetrics and Gynecology,
iield at Geneva, in September, 1896, that induced
labor, because of the necessarj- manipulation, increases
the risk of sepsis, will not deter us from performing
the operation wiien we know we are surgically clean.
Charles, of the Liege Maternity, r^eported, at the last
International Congress of Obstetrics and Gynecology,
in favor of induced labor, when treatment fails or
the svmptoms become urgent in the pre-eclamptic
December 26, 1896]
MEDICAL RECORD.
915
state. His statistical table shows that ever\- mother
recovered and seventy-live per cent, of the children
were saved.
We believe in a rapid manual dilatation of the os
in these cases, but only after the cervical canal is in a
condition favorable for its safe performance. More-
over, we would insist upon a complete dilatation of
the OS before delivery is undertaken.
(V') The Curative Treatment. — In the presence of
an eclamptic attack we face a desperate condition.
The latest statistics from various parts of the worki
still place the maternal mortality at from twenty-five
to thirty-five per cent. .As long as the pathology of
eclampsia remains obscure there can be no rational
curative treatment of the condition. Our experience
does not permit of our recommending any single treat-
ment. Many subjects recover, no matter what the
treatment, many die in spite of treatment, and others
do well without any treatment at all. No single treat-
ment can be recommended; each case must be man-
aged according to the indications present. Our ex-
perience has taught us that not a single but a combined
treatment promises best for saving the lives of mother
and child in the event of an eclamptic seizure. We
would offer for this combined treatment three indi-
cations, as follows:
/. Control the convulsions.
II. Empty the uterus under deep anksthesia, by some
method that is rapid and that ivill cause as little injury
to the patient as possible.
III. Eliminate the poison or poisons ivhich we pre-
sume cause the cou-'ulsions.
Although we have named these indications in the
order of their importance, still we often carry them all
out at one and the same time. In another class of
cases we fulfil the first and third, and wait for a suit-
able moment to carry out the second. The third in-
dication— elimination — should really go hand in hand
with the first two and be put into action at one and
the same time with them.
(/.) Control the convulsions. There is to-day a
wide range of opinion regarding the relative value of
the various medicinal means employed to control
eclamptic convulsions. That eclamptic attacks must
be controlled, that the danger to mother and child is
in direct proportion to the number of convulsions oc-
curring before the emptying of the uterus, most ob-
servers are agreed. The four medicinal means most
certain and safe as antieclamptics are chloroform,
morphine (hypodermatically), veratrum viride, and
chloral hydrate, the latter alone or combined with so-
dium bromide. It would appear from the Transactions
of the last International Congress of Obstetrics and
Gynecology that of these drugs morphine is most fre-
quently relied upon.
We cannot altogether subscribe to the teachings of
the Rotunda Hospital, that morphine and chloral when
given in eclapmsia " act just like the poison which
causes the eclampsia and increase the tendency to
death;" still we believe we are too prone to resort to
the purely symptomatic treatment with narcotics and
anjesthetics, forgetting the more important eliminative
treatment. At the Rotunda chloroform is now given
only when operative interference is required. For
the convulsions at this hospital morphine would seem
to have given much better results than chloroform for
years past. Our preference is for chloroform, vera-
trum viride, and chloral, in the order named. Until
three years ago we used morphine freely in eclampsia,
but since have abandoned its use almost entirely, as
we believe it prolongs the post-eclamptic stupor and
increases the tendency to death during coma by inter-
fering with the eliminative processes.
Second only to chloroform in value is veratrum
viride. Provided the pulse be strong as well as rapid.
it is the most certain means at our command for tem-
porarily and even permanently controlling the convul-
sions. When the pulse is weak we rely upon mor-
phine hypodermatically, chloroform by inhalation,
and chloral by rectum, with stimulation if necessary.
As a temporary measure in ante-partum and intra-par-
tum and even as a curative means in post-partum
eclampsia, veratrum viride will, we believe, accom-
plish all that has been claimed for it.
(i) Veratrum viride reduces the pulse rate, and con-
vulsions are practically unknown with a pulse rate of
60 or under; (2) it reduces the temperature; (3) it
relaxes and renders more yielding the rigidity of the
cervical rings; (4) it causes prompt diaphoresis and
(5) diuresis, so that it aids not only in the fulfilment
of our first indication, the control of the convulsions,
but in the third, the elimination of an unknown poison
as well. Our practice has been to rely upon chloro-
form, veratrum viride, and morphine or chloral as
temporary measures, and the prompt emptying of the
uterus permanently to control the convulsions.
(//.) Empty the uterus under deep ainesthesia by some
method that is rapid and that ivill cause as little iu/itrv
to the woman as possible.
Those who follow the teachings of Charpentier, of
France, and Winckel, of Germany, namely, that the
uterus in eclampsia should be left alone, except after
full dilatation of the os, as the irritation of inducing
labor or artificially dilating a cervix precipitates con-
vulsive attacks, will, we believe, see many cases lost
that could by prompt and intelligent measures be
saved. It would appear from careful observation that
the danger is practically over in some ninety per cent,
of cases the moment the uterus is emptied, if accom-
plished early in the attack. Not that by this means
the convulsions always cease, but they become less
dangerous, and the case becomes one of post-partum
eclampsia, in which the mortality, as we have stated,
is only seven per cent.
Although one can scarcely find an authority to-day.
as shown by the reports of the last international con-
gress, who absolutely rejects local interference in the
presence of ante-partum or intra-partum eclampsia, still
authorities dift'er widely as to the extent to which such
interference shall be carried out. Charpentier, in
1892, as the result of an exhaustive analysis of four
hundred and fifty-four cases of eclampsia, and again
in the present year (1896) as the result of further
observation, practically arrives at the same conclu-
sions, namely :
1. That labor should be waited for and terminated
naturally whenever possible.
2. That induced labor should be reserved for ex-
ceptional cases in w liich medical treatment has entirely
failed.
3. That interference should be delayed until the
cer\'ix is dilated or dilatable, so as to avoid danger to
the mother; that in eclampsia Caesarean section, man-
ual dilatation of the cervix, and especially deep inci-
sions of the cervix are absolutely unjustifiable.
Charpentier, in this statistical analysis of the differ-
ent methods of treating eclampsia and of the method
known as Diihrssen's deep incisions of the cervix,
arraigns the latter in very forcible language, char-
acterizing the operation as brutal and unjustifiable.
He places himself in "resolute opposition to forced
labor, . . . and even to induced labor, which he re-
serves for exceptional cases where medical treatment
fails." He rejects absolutely forced labor by deep
incisions of the cervix. From his analysis of the 454
cases, which included all known methods of treatment
of eclampsia, he lias constructed the following table:
Mortality from spontaneous labor, 13.93 per cent.;
from artificial labor, 29.13 per cent. ; from Cesarean
section, 36.26 per cent.: from forced labor, 40.7^ j5er
9i6
MEDICAL RECORD.
[December 26, 1896
cent. The infant mortality in the 454 cases was jG.^,
or 36.12 per cent. Charpentier concludes that the best
treatment in eclampsia is to wait until labor begins,
and let it alone unless absolutely necessarj- to inter-
fere. In the mean time he administers chloroform and
bleeds if the patient be robust.
On the other hand, it would appear from the liter-
ature of the last five years and from the reports of the
last international congress (Geneva, September. 1896)
that the weight of medical opinion is in favor of empty-
ing the uterus in as short a time as possible in in-
-stances of eclampsia, whether the attack occurs before
or during labor, altliough there is a wide range of
opinion as to the means to be employed. In the sec-
ond stage of labor, after dilatation has been secured,
all authorities are agreed that the immediate empty-
ing of the uterus is indicated and is to be performed
promptly: the indication under such circumstances
is readily carried out without additional danger to
mother or child. In pregnancy and the first stage of
labor the undilated cervix is the barrier to immediate
delivery, and it is here that obstetricians differ so
widely as to the best method of procedure. An ex-
pectant or palliative treatment means almost certain
loss of the child, and something like one-third of the
mothers are lost. On the other hand, the child is
saved and the mother is practically safe, as far as the
eclampsia is concerned, if the uterus is immediately
•emptied by appropriate surgical means.
During pregnancy and the early part of labor four
procedures are offered for rapidly emptying the uterus,
viz. :
1. Cesarean section.
2. Mechanical dilatation of the cervix (various
methods).
3. Deep incisions which at once completelv remove
the barrier of the cervix.
4. Combined mechanical dilatation and deep cer\'i-
cal incision.
The first method, Ca'sarean section, for the relief of
eclampsia still carries with it a high mortality (36.26
per cent, according to Charpentier's figures) ; more-
over, there are many objections to its employment, as
the uterine atony and hemorrhage, the irritation of the
uterine and abdominal scars and of the curative peri-
tonitis about the uterine sutures, all of which are to
be avoided as exciting causes of subsequent eclamptic
seizures.
The second method, the mechanical dilatation of
carry it out, and certain conditions of the cervix, even
in this lime, refuse to yield to manual dilatation or
result in lacerations into the lower uterine segment.
The third method of delivery, b)' deep cervical inci-
sion, offers us a surgical means for emptying the uterus
in. OS.
Fig. 1. — Cervix in Latter Part of Gestation or at Beginning of Labor. Va>;in.tl
and supiava>r>nal portions of cer\-ix unchaaged. :■.. Cuff of vagina ; cx.cs.,
external os and infravaginal portion of the ce^^■ix ; f.^y., cer\*ico-vaKinal
junction ; J.r'.f., supravaginal portion of cen'ix ; /'/.()j., internal os; Lti.s.
lower uterine segment.
the cervix and the immediate extraction of the foetus,
appears to be the popular method of the day. Prop-
erly performed the method is safe and efficient. Be-
fore dilatation is well advanced, however, from forty
minutes to an hour and a half is necessarv safelv to
I II. OS.
ex. OS.
Fig, 2. — Lower Uterine Segment During Labor, t-. , Cuff of vagina ; f.x.as.^
external os. infravaginal portion of cervix has disappeared ; c.v.J.. cervico-
\-aginal junction ; j.r'.t., sujiravaginal cervix, small portion only remaining ;
///. C.V. , internal os : l.u.s.^ lower uterine segment.
in from fi\e to ten minutes, provided the supravaginal
portion of the cenix has disappeared or is made to
disappear by appropriate means. The fourth or com-
bined method is a combination of the second and third
methods, and is applicable to cases in which the supra-
vaginal portion of the cervix is still present and rapid
emptying of the uterus is demanded. Here mechani-
cal dilatation of the os until the internal os has been
caused to disappear is made use of, and the dilatation
then in an instant completed by the incisions. The
third method and its modification, the fourth, are com-
paratively new, and we have few statistics as to the
results of the operation. We believe a rapid manual
dilatation of the os and subsequent extraction of the
foetus will fulfil the indications in most cases, but
unless this can be intelligently carried out, with a due
appreciation of the mechani.sm of dilatation, especially
in primipar.t, a purely expectant treatment will give
better results. Unfortunately puerperal eclampsia is
four times more frequent in primiparre than in multi-
para;, although, on the other hand, the mortality is
greater in the latter.
The cer\'ix uteri is composed of constricting and
dilating muscle, and, while it is true that the first con-
vulsions usually induce labor, still the resulting as-
phyxia exerts a marked constricting action upon the
body of the uterus and cervix, which is especially
marked at the internal ring of the os. Therefore, any
method of rapid manual dilatation of the os that is
undertaken before the internal os has been made,
partially at least, to disappear is attended with great
danger of uterine rupture (Figs, i, 2). This is es-
pecially true in primipara-, in whom the supravaginal
portion of the cervix obtains late in pregnancy and
even up to the beginning of labor (Fig. 1). We
believe a warning should be .sounded against the care-
less undertaking of rapid manual dilatations of the os,
particularly in eclampsia. Uterine rupture and death
have, we know, been the outcome. Moreover, undue
shock has resulted from the dragging of a fcttus
through an imperfectly dilated os, to say nothing of
the loss of the child.
In placenta prajvia the hemorrhage and the result-
ing an.x-mia of the lower uterine segment and cer\'ix
render these parts more readily dilatable. In eclamp-
sia the reverse obtains, as we have already hinted.
Hence it is that in eclampsia in instances in which
the internal ring of the os has been drawn up into the
body of the uterus (Figs. 2, 3), and the external ring
December 26, 1896]
MEDICAL RECORD.
917
remains rigid and tense, particularly in primipaia-,
and there is urgent need of rapidly terminating the
labor, we prefer four clean incisions extending from
tlie edge of the os to the utero-vaginal junction, in
in. OS.
i.V.OS.
Fig. 3. — Lower Uterine Segment During Labor. Os uteri in progress of dila-
tation. Supravaginal and infravaginal portions of the cervix have disap-
peared. Os admits one tin>;er. :■., Cuff of vagina : ^.t-.(7j-., external os ;
W.T'.y. , utero-vaginal junction ; /.«.j. , lower uterine segment.
order to save the patient from the greater dangers of
rapid manual dilatation.
In the second place, we believe a warning is not
out of place against the premature extraction of the
fcEtus before full dilatation has been secured and the
external ring of the os paralyzed. Premature extrac-
tion, under such circumstances, we know has resulted
in many unnecessary and dangerous lacerations of the
lower uterine segment, and an increase of the mortal-
ity for the child and mother.
(///.) EliiHiihttion of the poison or poisons 7i.'lii<h H'c
presume cause the convulsions.
For the elimination of the toxic materials from the
blood and tissues we have nothing new to offer. We
believe it essential, however, to rely not upon one but
upon all the eliminative organs of the body, and,
moreover, that the fulfilment of this third indication
in the treatment of eclampsia should go hand in hand
with the first two already mentioned. To tliis end we
secure catharsis as early and as promptly as possible
by the administration of croton oil, compound jalap
powder, or calomel, followed by salines and high ene-
mata of sulphate of magnesium. In the coma or post-
eclamptic stupor of the condition, we have relied
mainly upon the repeated administration of concen-
trated solutions of sulphate of magnesium or Villa-
cabras water, by means of a long rectal tube high up
in the descending colon. The hypodermatic adminis-
tration of magnesium sulphate we have found too
slow and uncertain to be of any use. Diuresis we
obtain by dry or wet cups over the kidneys, followed
by hot fomentations. The value of glonoin as a diu-
retic and antieclamptic, the latter by reducing the
arterial tension, we believe, cannot be overestimated.
.Second only in value to glonoin we consider ^era-
trum viride. We give it at this time for the same
reasons and looking for the same results as when we
administer it in tiie pre-eclamptic condition. Dia-
phoresis we encourage by means of the hot-air bath or
the hot pack, our preference being for the former.
Pilocarpine as a diaphoretic in the presence of an
eclamptic attack we utterly reji^ct, because of tiie dan-
ger of (edema of the lungs and glottis which it may
produce. We have seen these conditions follow-
promptly upon its administration. The drawing off
of large quantities of toxic liquids in the form of
blood or serum, by means of venesection, catharsis,
diaphoresis, diuresis, followed by the replacement of
the same, by intravenous, stomachic, rectal, or hypoder-
matic means, causing a washing or disintoxication of
the blood and tissues, as it were, has thus far proved
of doubtful value. In instances of collapse, however,
with the small compressible pulse, the introduction
into tlie blood of a normal saline solution is of the
same value here as in collapse under other circum-
stances. As a general stimulant, to assist in the elim-
ination from the lungs and to prolong life in the
post-eclaraptic stupor or coma, we have found the free
administration of oxygen of the greatest value. Fur-
ther, alcohol will often be needed as a stimulant dur-
ing and after an eclamptic attack, and strj-chnine in
the post-partum state and in the face of threatened
collapse — although for physiological reasons it would
seem to be contraindicated — has served us well.
Finally, although no one has been or is a firmer
believer than the writer in the efficacy of a prompt
removal of foetal metabolism and of irritation for not
only the control but the cure of the eclamptic con-
dition, still we beg to enter a protest, first against
the careless use of the term accouchement Jorce as ap-
plied to the rapid, scientific, and intelligent empty-
ing of the uterus; and, secondly, to the easy confi-
dence with which this accouchement force has been
recommended as the best if not the only means at our
command for the control of eclamptic seizures, with-
out attaching sufficient importance to the condition of
the cer\-ical barrier. By accouchement foi ci\ we under-
stand to-day three operations, namely, (i) the com-
plete instrumental or manual dilatation of the cervical
canal, followed by {2) either combined or direct ver-
sion, or the application of the forceps, and (3) the
immediate extraction of the child.
The accouchement force of the older writers upon
obstetrics was often quite another and more serious
operation, for the condition of the cer\ical canal was
frequentlv lost sight of, and it too frequently meant
(i) the plunging of the hand or the application of the
forceps through a cervical canal imperfectly dilated.
Fio. 4.— Bimanual Dilatation of the Parturient Os. Os two-tbirds dtlaced.
Kntirc cfTacemcnt of the internal €*. Compare Fig. 5. (From a photo-
graph.)
and (2) the immediate extraction of the fcetus through
this constricted os. That the latter definition of the
term still obtains, seems proven by the frequency of
accidents in the extraction of the foetus that are con-
9i8
MEDICAL RECORD.
[December 26, 1896
stantlv being brought to our notice. Our maternity
hospitals are repeatedly in receipt of ambulance or
emergency cases due to the neglect on the part of the
operator to fulfil the first condition of the operation,
namely, complete dilatation. Within the past few
days, while preparing this very portion of the paper,
the writer was summoned by telephone to remove from
the uterine cavity a foetal head decapitated by traction
upon the trunk, in the presence of an imperfectly
dilated os. The retained head resulted in post-partum
hemorrhage, and the additional shock of its subse-
quent extraction. It is no uncommon event for emer-
gency cases to be brought to our hospitals with a
podalic version or extraction partially completed be-
cause of the operations being attempted in the pres-
ence of a partially dilated os (Figs. 4, 5); moreover,
for uterine rupture to occur, clue to the same cause.
In Fig. 5 we have represented the outcome of a
premature extraction through an imperfectly dilated
OS. With such a complication — a rigid, imperfectly
dilated external os, grasping the fcetus tightly under
Fic. s. — Dangers of a Rapid Breech Extraction through an Imperfectly Di-
lated Os. External os not fully dilated or paralyzed. Traction on the
legs results in extension of the head and both arms.
the armpits — the loosening of the arms, the dragging
of these, and subsequently the head through the os
will take considerable time, and not only forfeit the
child's life but subject the lower uterine segment to
dangerous if not fatal rupture. Our plea in these
cases is not alone for complete dilatation or disappear-
ance of the external ring, as seen in Fig. 6, but fur-
ther, for a paralysis of the ring as we see it performed
in Fig. 7, so that the dangers of the extraction, whether
by forceps or version, may be reduced to a minimum
for both mother and child.
The limits of the present paper forbid our entering
upon the arguments for or again.st any particular vari-
ety of rapid manual or instrumental dilatation of the
parturient os, further than to state that our preference
is for a rapid bimanual method, as shown in the
illustrations, since we have given this method an
abundant trial over a period of several years, and it
has proved most satisfactory.
The bimanual method is to be preferred to other
digital and instrumental methods, because (i) the
membranes are preserved throughout the operation or
until full dilatation is obtained: (2) there is no in-
terference with the original presentation and position ;
(3) the sense of touch of the operator's fingers is un-
impaired; (4) there is no constriction of the opera-
tor's hands; (5) the amount of force exerted upon the
/.//.
Fit-;. 6. — Lower Uterine Segment at Completion of First Stage of l.abor. Os
uteri completely dilated, r.. Cuff of vagina ; ^.r.«. , border of external os,
scarcely perceptible ; «.?-._/'., utcro \-a^'inal junction.
external ring can be better estimated, and hence there
is less likelihood of lacerations occurring; (6) in pla-
centa prarvia there is less preliminary separation of
the placenta by this method than by any other; (7)
by no method with which we are acquainted, can not
only complete dilatation but complete paralysis of the
parturient os be so quickly and safely obtained
(Figs. 4, 7).
Again, we beg lea\e to protest against the undertak-
ing of a rapid manual dilatation of the os (namely,
the entire dilatation completed wiliiin an hour) before
the cervix has become, at least slightly, relaxed by
uterine action and is already somewhat yielding. A
rigid cervix, in the condition as we see it in Fig. i,
should, we believe, receive a preliminary treatment, a
cervical dilator of gauze or hydrostatic bag, that will
set up some uterine action and render the rings of the
OS yielding enough to make a ra]nd dilatation a safe
Fig, 7.— Bimanual Dilatation of the Parturient f)s. The os is fully dilated
and is being stretched and paralyzed, to prevent subsequent accidents to the
after-coming head during the extraction of the ftetiis. Comjiare Fig. 6.
( Prom a photograph.)
operation. In the presence of even a minimum amount
of uterine action, or with a softening, yielding, and re-
laxing OS, although the anatomical conditions may
December 26, 1896]
MEDICAL RECORD.
919
obtain as in Fig. i, we may still undertake the rapid
manual dilatation and produce complete paralysis of
the cervix within an hour, as seen in Fig. 7. Far bet-
ter a purely expectant treatment, as regards emptying
the uterus, tharr the attempt rapidly to overcome a
rigid OS by manual methods, the supravaginal portion
of the cervi.x being present. We have known complete
uterine rupture to result from such an undertaking, the
maternal intestines prolapsing between the fingers of
the operator. Fortunately for the eclamptic woman,
the frequency of the attack increases proportionately
with the progress of gestation, and, we may add, with
the increase of fcetal metabolism. Hence, the attack
is more frequent in tlie latter part of pregnancy and
in labor, when we can more readily and safely apply
our surgical principle of treatment, namely, an early
and rapid evacuation of the uterus.
Unfortunately, the attack is four times more fre-
quent in primipara; tlian in multipara;, and in the
former the presence of the supravaginal portion of
the cervix late in pregnancy and of an unyielding and
unrelaxed os compel us to make use of preliminary
and temporizing means befo'-e we can safely perform
a rapid dilatation of the os and subsequent extraction
of the foetus. It is in such cases, a--i at such a
critical time, when we are waiting for the measures
preparatory to a rapid dilatation and emptving of tlie
uterus to act, and to give us at least a yielding and
relaxed cervical canal, if not a partial disappearance
of the internal os, that we have found veratrum viride
most valuable and life-saving, by reason of the vari-
ous actions of the drug already mentioned.
50 East Thirty-Fourth Street, New York,
Xovember 27, 1896.
THE TREATMENT OF I3IPHTHERIA: AN
INQUIRY INTO MODERN METHODS EM-
PLOYED AT BERLIN IN THE SUMMER OF
1896.'
By LOUIS FISCHER, M.D.,
ATTENDI.S'G physician to the children's department of the GERMAN
POLIKLINIC, TO THE MESSIAH HOME FOR CHILDREN, TO THE WEST SIDE
GERMAN DISPENSARY, ETC.
It was my good fortune to have the opportunity of
carefully observing the treatment of diphtheria at
Berlin last summer, through the courtesy of Professor
Baginsky. Indeed, I was rather anxious to see what
changes, if any, had been made since orrhotherapy
was generally introduced, and to compare the results
with what I saw in the summer of 1894. To one
inexperienced with the brilliant results of antitoxin
treatment, it would have been a surprise to see the
majority of patients when they were admitted to the
diphtheria pavilion, and then to note the changes in
these patients in the following two or three days. For
what on one day would ordinarily be considered a \ery
malignant case and one in which a grave prognosis
could be given, would frequently be so transformed by
the treatment pursued that the day following one
would almost be willing to guarantee a good progno-
sis.
Professor Baginsky pointed with great pride to
this pavilion, and showed me mild cases and con-
valescent cases. Among the number I saw two cases
in which tracheotomy had been performed for ur-
gent laryngeal dvspnci-a after an ineffectual intuba-
tion. His rule had been, after a proper clinical diag-
nosis aided by a bacteriological culture had been
made, to remove the patient from the quarantine to
the diphtheria pavilion, and inject about one thou-
sand, or at times fifteen hundred or even two thou-
' Read before the section on p.xdiatrics of the New York
Academy of .Medicine, Hecember 10, 1S9&.
sand units of antitoxin. If a concentrated antitoxin
of five or ten cubic centimetres contained this number,
he preferred it rather than to inject larger quantities
of the remedy. If stenosis existed, the patient was
quickly intubated, the .American (O'Dwyer) method
being used; if, however, stenosis persisted and no
great relief was afforded in a given time, then and
then only was tracheotomy performed; so the cases
which I saw were of the worst type.
Whoever has had a large experience in the treat-
ment of mild diphtheria in children will agree with
me that a certain class of patients will recover if iron
is used locally or internally, bichloride internally,
or Loeffler's solution locally; or, in some instance.s,
even with gargling with a strong salt-water solution.
In these children, however, we have a strong constitu-
tion and the disease is distinctly localized, and with
them any form of treatment will succeed, be it hot
poultices or ice externally. We frequently iiave a
small patch of pseudo-membrane on a tonsil or
in the pharynx, in which a bacteriological exami-
nation will show Klebs-LoeflRer bacilli, and the dis-
ease disappears in two or three days— I might say
by itself, or really without any special treatment.
Frequently there is hardly any fever, no swelling of
the submaxillarv glands — nothing save pain on swal-
lowing, and possibly the child may complain of being
tired. In my experience these children recover with
any form of mild local antiseptic treatment, if we pay
great care to hygienic and dietetic treatment, using
possibly nasal irrigation and isolation. Indeed, this
latter is about the only thing that needs careful atten-
tion, for just because these children feel comparatively
comfortable their parents neglect them and permit them
to roam about, and then we have a great source of mis-
chief, dissemination of tlie Klebs-Loefifler bacilli and
resulting infection.
I wish, however, to take up your time this even-
ing with the consideration of malignant diphtheria.
There are three possibly fatal forms, viz. -.
1. Laryngeal diphtheria.
2. Nasal diphtheria.
3. Septic diphtheria, which results from prolonged
absorption of toxic elements, generated in either the
laryngeal, nasal, or e\ en tonsillar type of the disease.
Any form of diphtheria can in time develop septic
.symptoms, so that in this type we are really called upon
to deal with a diphtheritic septicaemia rather than with
an ordinary form of diphtheria.
Diphtheritic Croup. — Baginsky maintains that la-
ryngeal croup is always a secondary lesion, and is the
result of the e.xtension of the diphtheritic process
from the nose, velum palatinum, and tonsils.
Yiewing it from a practical standpoint, we are sum-
moned, let us say, to a case of urgent dyspnaa. in
which laryngeal stenosis due to diphtheritic depo>its
exists. The voice is hoarse, accompanied by a ring-
ing cough and prolonged inspiration and expiration ;
the respiration is becoming slower and slower: the
auxiliary muscles of respiration are brought into
play, and the thora.x appears to be considerably en-
larged. Still, it is impossible to give the lungs
enough air. The intercostal s])aces, the jugulum, and
scrobiculus cordis at the lower portion of the sternum
are deeply drawn in with each respiratory act. ']"he
accessory muscles of resjjiration brought into play are
in the neck and thorax — the scaleni, omohyoid, pec-
toralis, serrati, and sterno-cleido-mastoid muscles.
The child appears livid and cyanotic, and is usually
covered with a cold, clammy perspiration. If a piece
of membrane is coughed out, there may be a tempo-
rary relief of these urgent symptoms, but it rarely
lasts more than a few hours. Then the symptoms usu-
ally reappear, and are more severe than before. Un-
less mechanical relief — /.c, intubation — is rapidly af-
920
MEDICAL RECORD.
[December 26, 1896
forded, carbonic-acid poisoning will set in, and our
patient will die of asphyxia.
Nasal Diphtheria. — Diphtheritic rhinitis is fre-
quently ushcicd in by a simple catarrhal rhinitis, in
which there is an excess of mucus or muco-purulent
secretion. The secretion is of a yellowish or grayish
color, and can be removed by syringing the nose or
with a small forceps. At times bleeding follows this
method ; the mucous membrane of the nose appears of
a deep reddish hue and is intensely congested. If
we examine the membrane we find that it appears
under the micoscope to be made up of fibrin, in which
round cells are embedded, and the bacteriological cul-
ture rarely fails to give either Klebs-Loeffler bacilli
or streptococci, or both together. At times diphthe-
ritic rhinitis occurs secondarily to the pharyngeal
process, and as a result of the extension of this in-
flammatory condition through the choanas narium or
the posterior nares.
The symptoms of occlusion of the nasal passages
by these exudations, be they pseudomembranous or
otherwise, the excoriations at the entrance to the air
passages (alai nasi), the stinking breath (fittor ex
ore), the snoring and open-mouth breathing — all point
to interference with natural breathing and obstruction
in the nasal passages.
It is, therefore, a good plan, knowing as we do that
almost all cases of membranous rhinitis contain
Klebs-Loeffler bacilli and that they are infectious, to
isolate. This would be especially called for in a
given case of rhinitis in a family in which a case of
diphtheria had already existed, and wherein we might
have reason to believe that the simple rhinitis was the
result of a new infection and the first symptom of a
diphtheritic process. The constitutional symptoms of
all fonns of diphtheria are alike. The patient has
fever, appears somnolent, usually has enlarged sub-
maxillary glands, manifests anorexia, appears intensely
anamic, at times has excessive perspiration, and shows
general evidence of a severe illness; if old enough,
children complain of intense headaches.
It is not the purpose of this paper to inquire into the
physiological effects of antitoxin, or into the manner
in which it produces its effects, nor do I care to tire
you with the results of its effect on the blood in par-
ticular; but I desire to remind you that, knowing as
we do that antitoxin has no direct effect on the Klebs-
Loeffler bacilli, the bacilli can be demonstrated days
after an injection of antitoxin has been given, at the
site of infection or where the diphtheria was first seen.
This [)oint must not be lost siglit of in the treatment,
and particularly it must be borne in mind in tiie ques-
tion of isolation.
Toxins. — The classification of toxins" by Sidney
Martin is worth rejxiating. Martin states that there
are two kinds of toxins: i, that produced in the diph-
theritic membrane: 2, that produced in the tissues of
the body. The poison of the membrane causes the
local as well as the constitutional symptoms of diph-
theria, and here antitoxin is most eftectual, for it has
a specific effect and can control the clinical manifes-
tations which are peculiar to the toxin of diphtheria.
If large quantities of this so-called membrane toxin
are allowed to enter the sj-stem through neglected or
delayed treatment, these toxins transform the albu-
minoid bodies of the tissues and cause tissue poisons
or tissue toxins. Martin finds that these tissue toxins
can be classified into: 1, those that belong to digested
proteids; 2, those that are not proteid substances.
The first is an albumose: the second is an organic
acid. Albumoses have a specific action on the human
organism; when present in small quantity they pro-
duce fever, and if allowed to act for any length of
time on the human organism they produce paralysis.
In very large quantity they produce great exhaustion,
and also fatty degeneration of the heart and kidneys.
It is in these cases that antitoxin at times fails, owing
to the presence of poisons other than those peculiar
to the membrane toxins, and which are by-products
produced by degenerative changes in the tissues.
That the so-called mixed infections, Klebs-LoefHer
bacilli and streptococcus cases, cannot all be cured
by injecting antitoxin and antistreptococcic serum,
has been repeatedly shown. Monti believes that we
shall have to produce artificial mixed infections in
animals, infections which shall combine the toxins of
Klebs-Loeffler bacilli and of streptococci, and thus
probably yield a modified serum.
Kmmerich gave the name of immune proteids to the
hypothetic bodies formed from body albumin, or,
rather, from transformed cells in the human organism,
during the transformation or action which follows
when specific antitoxin is introduced and reaches the
human Antikbrper or antibodies of the blood.
If the body becomes gradually habituated to alcohol,
no antialcoholin is formed: if to morphine, then when
morpliinc is introduced, no antiniorphinin is formed;
and still a certain toleration of tiiese poisons is and
can be produced by virtue of the living cells, so that
heroic or othenvise toxic doses can be taken without
killing the individual.
Serum Statistics. — In the fifth annual report of the
Emperor and Kmpress Frederick Children's Hospital,
from January i, 1895, to January i, 1896, we find among
the detailed reports that the greatest success of the year
comes from the diphtheria wards since the introduction
of the serum treatment. The number of new cases ad-
mitted was 538, as against 583 in tiie preceding year
— probably because serum treatment was more exten-
sively used in private practice by physicians. Mor-
tality from diphtheria, first year, 36.56 per cent.; sec-
ond year, 35.57 per cent.: third year, 41.78 per cent.
Average, 37.63 per cent.
In 1894, the first year antitoxin was used, the mor-
tality fell to 27.8 per cent., including cases wherein
other forms of treatment were used; in cases wherein
serum treatment alone was used, the mortality sank
to 16.6 per cent. In 1895 the mortality fell to 11.2
per cent. The number of diphtheria cases examined
in the polyclinic was 574, of which 516 were admitted
to the diphtheria pavilion: 460 children were treated
with immunizing doses of antitoxin, of whom 18 con-
tracted dipiitheria rather late, and of a very mild type.
Not one single death occurred among the latter.
Prof. C Fraenkel, in a paper read before the Ger-
man Hygienic Society at Kiel on .September 11, 1896,
gave the following statistics: Froiii 1875 until 1886,
in all twelve years, there were 539,901 deaths from
diphtheria in Prussia, or about 45.000 yearly, or 165
to every 100,000 .souls. In 1892 there were 55,746,
which is 1 18 to every 100,000 souls. In 1893 there
were 75,322, which is 158 to every 100,000 souls. In
1892 there were 320 deaths in every 100,000 cases
of intestinal disorder, 259 deaths from tuberculosis,
and next follows diphtheria; but, if we exclude the
nursing period or the first year of infancy, and also the
years from fifteen to sixty, in which most deaths occur
from tuberculosis, then we find that diphtheria causes
98 per cent, of the deaths from all causes beginning
with the second and ending with the fifteenth year.
.\ccording to a report in the JVh'iier vuuUzitiische
]]'oc/u-nsi/iri/t, 2,039, September 19, 1896, 1,103 P^"
tients were injected, of whom 970 were cured, 133
died, or 12.5 per cent. In 68 cases death occurred
during the first twenty-four hours: deducting these,
there were 1,035 ca,ses, with 68 deaths, or 5.3 per
cent, mortality. The same journal reports that all
children treated without serum died, whereas all
treated with serum — 16 in all— recovered. Of these
16. 3 had laryngeal diphtheria.
December 26, 1S96]
MEDICAL RECORD.
92 T
The IVii'iur klinischc Wochciiscliiijt, 1896, Nu. ij,
reports a series of 229 cases treated by l!luiiieiifeld,
with 20 deaths — a mortality of 8.7 per cent.; 60 cases
were of the severest character, with huyngeal involve-
ment. During the same period, 48 cases treated with-
out antito.xin gave 1 1 deaths, or 23 per cent.
Dr. Ladanyi' says: "' Diphtheria exists continuous!)-
with us in Kurope since 1870. It is never extinct ;
now and tlien only mild forms are seen, and at the
same time the most malignant;"' so that he l)elie\'es
we can exclude the "genus epidemicus.''
We must consider what formerly existed when the
disease was treated without serum. I'nder former
methods of treatment the course of a mild case of
diphtheria without complications showed at the end
of the first week, usually at the beginning of the sec-
ond week, a fall in the temperature and the throat
cleared — this in treatment without serum.
If we inject serum, wliat follows?
In from twenty-four to thirty-six hours, sometimes
twenty-four to forty-eight hours later, we have a dis-
tinct line of tlemarcation ; rarely do we see a second
formation of pseudo-membrane; the temperature falls.
The disease is virtually arrested in from twenty-four
to forty-eight hours.
The septic cases, those in wiiicii, in spite of anti-
toxin injection, anuria and otiier nephritic symp-
toms appear, were known long before antitoxin was
discovered, and might be the result of the sexerer ac-
tivity of the toxins in the system-.-aflecting already
weakened organs. .So, for example, feeble children —
who prior to infection were ana;mic, or tuberculous,
or scrofulous, or rachitic, with previous organic dis-
ease, or those infected during a convalescence from
measles or other disease — are more prone to develop
laryngeal stenosis, gangrene, etc., than children pre-
viously healthy. We must throw aside all theoretical,
statistical, and .bacteriological ideas, and be guided
wholly by empiric experience and obser\ation. The
serum causes, dc facto, a beneficial influence on the
diphtheritic process, and modifies it to the benefit of
the patient; and this and this only is a factor which
can explain the lower mortality.
The cause of the decreased number of cases can and
should be looked for in the number of prophylactic
injections given to those probably exposed to diph-
theria, and the consequent smothering of the sparks of
the disease and resulting innnunity.
Virneisel (,'ity Hospital at Coblent/." reports 158
cases of diphtheria. Of 150 of these treated with anti-
toxin, 131 were cured — 87.3 percent — and 19 died —
12.7 per cent. The mortality was zero for those in-
jected on the first day, 31.6 per cent, for those injected
on the third day, 68.4 per cent, for those injected after
the third day of illness. .Six of these patients were
moriljund at the time of treatment.
Kossel reports in Paris, during 1886, 1,524 deaths
from diphtheria. In 1895, 411 deaths^ one-third of
the former death rate.
Lenharts'-" had 137 cases; mortality, 12.4 percent.,
and 3 relapses.
Konig and Mexter' injected an infant, five days
old, with 150 units. The child reco\ered witiiout any
unpleasant after-effects.
St. Joseph's Children's Hospil.il in Vienna:' 138
males, 129 females, in all 267, treated for diphtheria
and croup. Discharged cured, 188; improved, 2;
died, 61; mortality, 22.84 per cent. Deducting 19
children brought in in a moribund condition, a mor-
tality of 15.73 per cent, would result. Seventy-four
' Wien. med. Presse, No. 38, iSt/i.
''Munuli. nied. Wochenschrift, No. if), iSgC.
'I'entt.ilbl. fUr Kinderheilkunde, No. i, 1896.
'' Zeitschrift f. pract. ,Aer/te, No. i, 1S96.
'Fifty-fourth .Annual Report for year iSgj.
cases required tracheotomy or intubation, some secon-
dary tracheotomy. Of these 74 subjects, 35 were dis-
charged cured and 39 died. The year previous to the
serum therapy, the mortality was 50.5 per cent. The
mortality in 1895 was, therefore, 27.7 per cent, less
than in 1894.
Kinder-Abtheilung des Spitales der allgemeinen
Toliklinik in Wien:' In all 108 cases were injected
— 73 fibrinous, 25 phlegmonous, 10 gangrenous; 27 pa-
tients died; 4 moribund were not injected; mortality,
25 per cent.
Paser,-' City Hospital of L'lleNeld by Christiania,
from January till November, 1895, had 392 cases of
diphtheria. Bacillus cultures were obtained in each.
In 140 mild cases not injected there were no deaths:
2 12 very malignant cases injected gave a mortality of
21, or 9.9 per cent, liefore the serum period, in 883
cases coming under treatment on the first and second
day, the mortality was 153, or 17.3 per cent.; in 713
cases admitted from tiie fourth to the seventh day of
illness, 224, or 30 per cent.; in 418 cases admitted
from the fifth to the sixth day of illness, 128, or 30
per cent. Sixty-nine patients had stenosis of the
larynx; of these 41 were operated upon. In 40 in-
tubations or tracheotomies secondarily there died 10
per cent. Before serum therapy the mortality in ope-
rated cases was 78.4 per cent. The epidemic during
the serum period was a serious one.
Professor Monti gives a series of 72 cases. Of
these 29 had laryngeal symptoms, with 6 deaths, or 8
per cent." He gives large doses, or from 2,000 to
5,000 antitoxin units.
Vadova' reports 240 cases of prophylactic injec-
tions resulting very favorably.
Abba'' reports a series of cases, with a mortality of
4 per cent. ; cured, 96 per cent.
Dr. Ramelle uses injections of serum per rectum,
having cleansed the parts pre\iously. My own ex-
perience is decidedly against the use of antitoxin per
rectum, for in each case it produced no effect what-
soever.
Ewing James, in an article on " Leucocytosis in
Serum Therapy,'" states that one-half hour after an
injection of serum the white corpuscles increase quite
rapidly in number. Those increased are chiefly mo-
nonuclear cells. Polynuclear cells stain easily with
gentian violet after serum injection. If, however, this
latter reaction of staining does not occur, then tlie
prognosis is very bad.
In our country John S, Hillings' has also studied
tills leucocytosis, and found the condition to be simi-
lar to that seen in scarlet fever and pneumonia, the
increase noted by iiis investigation being in the
polynuclear forms.
The literature of fa\orable antitoxin reports is so
overwhelmingly large, that I hope to be pardoned if
I do not quote all. In our country Louis Fischer, H.
Biggs, A. Campbell \\'hite, Paul Gibier, and, later,
A. Caille, and J-'.dwin Ro.senthal, of Philadelphia,
are worthy of notice. A. Seibert and F. Schwyzer'
report a series of experiments to prove the toxicity or
non-toxicity of antitoxin. The authors found, i.st, that
antitoxin was innocuous: 2d, that cari)olic acid con-
tained therein as a preservative was non-toxic; and
3d, that there was great danger of injecting air.
.Vdamkiewics" experimented on guinea-pigs with
carbolic acid, air, etc. His conclusions are that air
can be injected into a vein and taken up by the veins
' Third Annual Report for 1895.
'.\li. med. Zeit., No. 16, 1896.
^Arehiv flir Kinderheilkunde. vol. x.\l., 1896.
"t'.a/. dcgli Osped., 1S96. p. S, 77.
'Turin Riforma Medica, 1896, p. 590.
' .Mfdiiai. Rf.cord, .\pril 21;, 1896.
'N. Y. .Med. Journ., May.
Wien. med. Presse, May ,d.
922
MEDICAL RECORD.
[December 26, 1896
if injected slowly, and that it will be eliminated with-
out having done harm. Thus, 10 c.c. produced no ill
etlects when injected slowly, whereas 2 c.c. injected
forcibly and at one operation proved instantly fatal.
He believes the virulence increases with the force
u.sed.
In our country great credit is certainly due Dr.
Biggs for his activity in generalizing the antito.xin
treatment after it was introduced. While I have used
large quantities of Schering's serum, and while I am
willing to stand by every- word that I have published
in regard to its efficacy, I have recently used domestic
antito.Kin and was pleased with its effects.
The American Pediatric Society's collective report
for 1896 contains 3,384 cases, of which 1,256 were
lar)-ngeal, or 37.5 per cent. Operations were done in
565 cases, as follows: intubation in 533 cases, with a
mortality of 25.9 per cent.; secondary tracheotomy in
9 cases, with 7 deaths; tracheotomy alone in 32 cases,
with 12 deaths, or a mortality of 37.4 per cent.
Rosenthal, of Philadelphia, is quoted with iS opera-
tions and 16 recoveries.
Booker, of Baltimore, had 17 operations and 17 re-
coveries.
O'Dw^er says: "In my last 100 cases, 70 without
serum, the mortality was 73 per cent.; in my last 30,
witii serum, the mortalit)' was ^^.^ jjer cent."
The report of the American Pediatric Society is cer-
tainly incomiilete, for I sent a record of fifty cases,
most if not all of which were seen in consultation in
this city with some very eminent gentlemen, and these
have been omitted. In a paper read by me before the
German Society of this city in April, 1895,' my mor-
tality in a series of 225 cases injected was stated as
equivalent to 15^, per cent. Since that time 100 care-
fully recorded cases, mostly in private practice, still
give me a mortality of 7 per cent. These, however,
were septic and moribund cases.
The report of tiie London J.aiiat special commis-
sion, published July 18, 1S96, is worth reading.
A large number of specimens of antitoxin, from
Schering's laboratory, from ISehring's, and from Bur-
roughs & Wellcome's in England, also some from
French laboratories, were tested to determine the real
merits of the various brands, and the German speci-
mens were found the best of all.
.\s there are various forms of diphtheria so must
th.ere be different methods of treating them, and we
accordingly have, first, a treatment for mild forms, in
which I believe no antito.xin is required, and in which
the disease is localized and there is no apparent gen-
eral systemic infection. In such cases we can confine
ourselves to local treatment.
Local Treatment of Mild Forms. — \Ve know that
tearing oft' pseudo-membrane is always followed by
bad results; so also is cauterization of necrotic mem-
branes, whether by acids, by Paquelin cautery, or
otherwise, and that these heroic measures are usually
rewarded by a spreading of the disease, /.<•.. an in-
crease in the pseudo-membranes. Baginsky warns
against this method of treatment; so also have Jacobi
and many other authorities. Loeffler, however, rec-
ommends that his mixture of alcohol {60), toluol
(36), and liquor ferri sesquichloridi (4) be applied
locally at the site of infection. .After going into all
manner of local applications, Baginsky returns to sub-
limate, which he still uses for local antisepsis and
cleansing. For the cleansing of the nose and throat.
Professor Baginsky uses a lukewarm table-salt solu-
tion (0.5 to I per cent.). This is to be used with
care, owing to the risk of entering the Eustachian
tube and producing disagreeable otitis media. The
only precaution I take is not to exert too great hydro-
static pressure during irrigation; I usually tilt the tip
' N. V. Medical Kkcoru, .\pril 0, 1395.
of the syringe toward the centre of the nose. It is in
this class of cases that bichloride of mercury in one-
half-per-cent. solution, applied hourly on cotton, can
be used to advantage; or tincture of chloride of iron
may be applied on cotton hourly, besides stimulating
the body w ith tonics, fresh air, and concentrated food.
Should, however, any complications arise, then the
disease must be treated on general principles. Great
stress should be laid on the necessity for immediate
burning in the fire of all swabs used.
Serum Treatment of Malignant Forms. — The
moment we see that we are dealing with a general
infection, with fever, enlarged cervical glands — in
fact, that the whole system participates, then no time
should be lost. Antitoxin should be at once injected.
Children up to two years of age, with pseudo-mem-
branes in the pharynx, who have not yet assumed a
necrotic tendency and who do not show laryngeal ste-
nosis, should receive 500 antitoxin units; but if any
laryngeal stenosis exists, or if necrosis in the phar-
ynx exists, then from 1,000 to 4,000 units mu.st be in-
jected at once. In children in whom the di.sease has
already existed a long time, and in whom there are
enlarged lymphatic glands, hoarseness, and laryngeal
stenosis, 2,000 antitoxin units should be injected at
the commencement of the treatment and the result
carefully noted. If no improvement is visible in
twenty-four hours, it is wise to follow the first injec-
tion by a second one, of either 1,000 or 2,000 units.
In older children it is wise, in veiy malignant cases,
to commence treatment by injecting 3.000 antitoxin
units. The symptoms of improvement which should
guide us as to the necessity of repeating the injection
of antitoxin are a rapid decline of the fever, throwing
off of the false membrane, or an apparent loosening of
this otherwise firmly adherent pseudo-membrane, with
general constitutional improvement and limitation of
the pseudo-membranous patches.
Baginsky states that although he has seen urticaria,
erythema, and at times intiammation of joints follow-
ing injection, the patients all improved in time. .Al-
buminura, heart lesions, and nephritis he does not
consider the results of antitoxin injections when they
occur during orrhotherapy, for he says these compli-
cations existed long before antitoxin was known.
Besides the injections of antitoxin, active local
treatment is required, and Baginsky believes an ice
collar should be apijlied and small pills of ice or ice
cream taken internally whene\er possible, i.e., if the
child is old enough. The internal medication con-
sists chiefly of cinchona and iron, or the ethereal tinc-
ture of iron, in conjunction with a streng^thening diet.
.As a local application the following may be used
with a brush everv hour or two:
K Animoni.c sulfo-ichthyolic.
llydrajj. biclil. corros. ,
.Aqux- <lest. ,
10.0
o. I
loo.o
For infiltrated cervical glands, mercurial inunctions
or an ichthyol-lanoline salve, 10 to 20 per cent., sev-
eral times a day, are of decided ad\antage in some
cases.
Treatment of Septic Forms. — Having given the
required amount of antitoxin, which in some cases is
as much as 3,000 or 4,000 antitoxin units at the first
injection,' we must attend to local treatment as given
above and watch for cardiac adynamia, which mani-
fests itself by feeble pulse, muffled heart sounds, and
' In diphtheritic larjngeal stenosis, when septic symptoms
exist and when a large quantity of antito.xin is required, it is ad-
visable to inject as small a quantity as possible, highly concen-
trated. For this purpose potent and extrapotent antitoxin
have recently been made, each cubic centimetre containing yy>
and 400 antitoxin units respectively, so that 5 c.c. would be in
the last instance equal to 2,O0(i a. u. and 10 c.c. would be equal
to 4,000 a. u.
December 26, 1896]
MEDICAL RECORD.
92.
arliythmic cardiac action. If we are called upon to
treat this condition, then tincture of strophanthus, one
drop for each year of age, may be given three times a
day or oftener; digitalis, Squibb's Huid extract, cau-
tiously used in one-drop doses, is advantageous. It
should be remembered, however, that the use of digi-
talis must not be prolonged, for it disturbs the stom-
ach, and also that its action is cumulative. It is in
this condition that wine, champagne, or whiskey is so
urgently called for, and as much as half a pint of
whiskey may be given daily, preferably by gi\ing milk
and whiskey; or eggs and wine or eggs and brandy
may be used instead. We must also think of the
value of caffeine, camphor bv hypodermic injection,
nitroglycerin, and mustard baths when indicated.
O.vygen is a most valuable adjunct in this condi-
tion, especially so if dyspnaa due to a complicating
pneunHsnia exists, and even when no pneumonia ex-
isted I have seen great benefit following its use. Such
valuable remedies should not be entrusted to inexpe-
rienced parents or to persons not familiar with their
use, and therefore it is always wise to have a trained
nurse in charge of these cases. Whether we give oxv-
gen by the mouth or the nose is immaterial, providing
we give it; I certainly prefer to have it administered
through the nose than to have a struggling child bite
and break the glass mouthpiece through a parent's ig-
norance in forcing the glass tube between its teeth,
as recently I saw done while entering a room in a
case in which I was called in consultation.
Method of Using Antitoxin. — As illustrating my
method of using the antitoxin, permit me to cite
the following cases:
Samuel Roberts, two years and nine months old,
193 Myrtle A\-enue, Brooklyn, was seen by Dr. Bie-
nenstock at 2 :3o a.m., September ist. The child had a
croupy cough, and the throat showed yellowish depos-
its on the pharynx and tonsils, so that the clinical di-
agnosis of diphtheria and laryngeal croup was made.
The child was placed on caffeine and benzoate of so-
dium, which seemed to reduce the temperature, but at
8 A.M. the stenosis of the larynx was so increased that
I was called in consultation. I saw the child on the
morning of September 2d, and met Dr. O'Connell, of
Brooklyn, besides Dr. Bienenstock. After consulta-
tion we decided that the main point was to give me-
chanical relief for the stenosis, and I intubated about
noon. Besides putting an ice collar around the child's
neck and leaving the mouth alone, we agreed to use
rectal feeding. No antitoxin was given at this first
consultation. We left the tube in situ for about six
days. The temperature Jiaving gone down to almost
normal and the child being in a fair condition,
the stenosis having entirely disappeared, we decided
to extubate. I extubated on September 6th, at 9 130
A..\i., waited a short time, and found no audible steno-
sis. We still ordered cold to the neck and continued
the expectant plan of treatment. When I got to New
York, about an hour later, I was summoned as ur-
gently as possible to reintubate. Meanwhile, Dr. S.
P. Truax, of Brooklyn, had been called, besides also
the attending physician. Dr. Bienenstock, and the
child received a little warm sweet oil in its mouth to
relieve the collapsed condition. .At i p.m. I reintu-
bated, when the stenosis at once disappeared and the
child's condition again impro\ed. It was then that on
talking over the treatment with the attending physi-
cian I decided to use antitoxin. I injected 5 c.c. of
Aronson's double antitoxin, of the strength of 1,000
units, in a careful aseptic manner in the interscapular
region. Besides rectal feeding, using concentrated
meat and egg emulsion plus some stimulation of
brandy, we decided to leave the mouth alone. It was
the rule to order a saline enema of the ordinary warm
salt solution to cleanse the rectum of any accumulated
fKCal matter prior to each nutrient enema. On Sep-
tember 14th I extubated; the temperature remained
normal, and on September 20th the attending physi-
cian informed me that the child had been taken into
the park, that the \oice had returned, that there had
been very little emaciation, and that the urine was
normal. The patient was discharged as cured.
A child, M , about five years of age, was seen
by me in consultation with Dr. Martin Goldberger, of
this city, on Tuesday, October 13th. I found that the
child, according to the attending physician, had been
ill two or three days. When he first saw the case he
diagnosed diphtheria and, recognizing it to be malig-
nant, gave an injection of i,ooo units of antitoxin.
The child did not improve enough to satisfy the doc-
tor, and he found on careful examination that he was
dealing with a septic type of the disease. Large
membranes filled the alai nasi; the temperature was
102.4^ F. ; pulse, iio; respiration rapid; general ap-
pearance good. The child was a mouth-breather, evi-
dently from the presence of adenoids. A very dis-
tressing labored breathing with dyspnoea was notice-
able, and to all appearances the child vas suffocating.
On holding the nose tightly shut with my fingers, the
breathing by mouth appeared easier, and it was evi-
dent that the noise during respiration was due to the
obstruction of the current of air by pseudo-membranes
in the nose and naso-pharynx. The examination of
the throat revealed enormous hypertrophied tonsils.
There were loss of appetite, slight constipation, no
vomiting, some thirst, and intense headache. On
considering all points in this case, besides the somno-
lent condition, I decided to inject a large quantity of
antitoxin and gave 2,000 units of Aronson's. The
temperature at my first visit was 102.4° F., and gradu-
ally crept up to 105° F. on the second day. The tem-
perature was always taken in the rectum. Both Dr.
Ooldberger and myself suspected pneumonia, but a
careful physical examination of both lungs proved
negative. Remembering, however, the possibility of a
pneumonia centralis, we cautiously used stimulants,
ordered the expectant plan of treatment, and gave oxy-
gen. In this case it required from thirty-six to forty-
eight hours for the temperature to fall, and then it fell
by lysis, i.e., gradually. The swelling of the submax-
illary glands was not very marked. The mechanical
treatment of forcing a permanganate-of-potassium
douche, I to 1,000, through the nose was rewarded by
bringing away large masses of tenacious membrane,
and it was ordered several times a day. In this child
the constant drowsiness and sleeping, the large pseudo-
membranes in the pharynx and tonsils, and rhinitis,
besides no food being taken, made the prognosis very
grave. The treatment was followed up by careful
stimulation and nutrition. The patient was dis-
charged cured fi\e or six days after my first visit. The
urine was examined several times and showed nothing
abnormal, save the usual manifestations of slight albu-
minuria, which subsided without further treatment.
A little earache developed about ten days after the
treatment was first commenced, which we attributed
to possible entrance of fluid from the nose through the
Eustachian tube during the mechanical irrigation.
Dr. Goldberger informed me that the child had com-
pletely recovered and was again out of doors.
In a paper read before the Medical Society of
I'ennsylvania, May 21, 1896, Edwin Rosenthal, of
Philadelphia, gave a series of interesting reports of
reduced period of intubation consequent upon the
senmi treatment of laryngeal diphtheria. His con-
clusions are: i. The duration of intubation varies.
Some cases were extubated after one-half hour: others
after forty-eight hours; but his average was one hun-
dred and twenty hours. European observers — Bokai,
V^on Ranke, Heubner, and American observers —
924
MEDICAL RECORD.
[December 26, 1896
O'Dwyer, Fischer, Rosenthal, all agree as to the con-
siderable saving in the length of time the tube is re-
quired now with the use of serum, as compared with
the time that was formerly required. 2. The operation
of tracheotomy is avoided, and intubation, when used
in conjunction with antitoxin, may be considered to
effect a cure even in long-continued cases (five days
and over). 'I'he use of serum has placed intubation
on a definite basis by : (^f) lowering the mortality ; (/')
shortening the period of intubation; (i) avoiding the
major operation of tracheotomy.
Dr. Jacobi, speaking of antito.x.in, says: " Xor is
there a practitioner but has at present the right or
rather the duty to give it a place among his most reli-
able remedies. If present e.xperience is confirmed by
many more similar facts, it will be entitled to be
claimed as a specific, though it have not the power to
cure every case of diphtheria, any more than quinine
cures every case of malaria, or mercury of .syphilis.
Paralysis is no less frequent in antitoxin cases than
it was formerly; it may be that many cases which sur-
\ ive with antitoxin and develop paralysis would not
ha\e lived to become paralyzed under a less satisfac-
tory treatment. At all events, there are but few left
who maltreat both the child and the throat by the
former cruel methods of local ap|)lications and cauter-
ization." He quotes Haginsky, Fischer, and others.
Dr. .A. Campbell White, while physician at the
AN'illard Parker Hospital, made some very interesting
experiments, in which he tried to find the most useful
antiseptic to be used in local irrigation, and speaks
highly of the salt-water .solution. He says : "• \\e have
found no antiseptic solution which has so materially
shortened the duration of the diphtheritic membrane
or the necessarv jjeriod of isolation of the patient."
His interesting report is contained in the New York
health department bulletin No. i. This I can fully
endorse, as a result of careful personal observation.
After-Treatment. I!y this I mean that following
antitoxin the matters to be especially considered are:
1. Supporting diet. 2. Careful cardiac tonics. 3.
Stimulants only when called for. 4. Nasal irrigation.
5. Local antisepsis, rarely called for. 6. Attention
to bowels and urine. 7. Treatment of complications
as required. 8. Strictest attention to hygienic meas-
ures, insuring fresh air, bathing when required, abso-
lute cleanliness as to clothes and linen. 9. Immedi-
ate disinfection, or, preferably, the total destruction
by burning or steaming of everything used in contact
with the patient, especially swabs, etc. 10. Isolation
until all bacilli have disappeared, blood-serum cul-
ture to determine this point. II. If it is a hmngeal
case, then my plan is to feed per rectum whene\er
possible, especially when nurses are handy, by means
of peptonized foods, such as milk and eggs, axoiding
stimulants per rectum.
I regard strychnine as a most valuable adjunct in the
cardiac feebleness, and I believe it will increase the
muscular tone of the heart better than any other drug.
Feeding in Diphtheria. — I male quite a distinc-
tion in feeding with ami feeding without intubation.
My success is greatest and my complications are fewest
when I have tho.se children that are intubated fed per
rectum and [ler rectum only. The so-called Schluck-
pneumonia is in most instances really only a mechan-
ical pneumonia, due to fluids entering the tracliea and
alveoli through the tube while />/ s/'/u during intuba-
tion, and the question of leaving the tube in the lar-
ynx is to-day not to be considered as formerly or in
the pre-antitoxin days. I rarely find it necessarj- to
leave tne tube in the larynx more than from three to
five days, and during this time we can safely use the
rectum for absorption. It is important to remember
that the rectum merely absorbs and does not digest.
Hence we must peptonize foods. On the other hand.
if we are not dealing with an intubated case, we can
safely feed per mouth. I use concentrated foods,
some of which are beef, veal, and chicken broths,
chicken jelly, clam or oyster soup, expressed beef-
steak juice, yolk of egg with milk and brandy or
whiskey if indicated. I feed every two or three hours,
using small quantities, one, two, or three ounces at a
time.
Nasal feeding: In obstinate children we frequently
have great difficulty in feeding |3er mouth, and rather
than exhaust a child by using force, and knowing that
we must sustain life, it is frequently advisable to feed
through the nose in the following manner: Lay the
child riat on its back, and have the nurse hold its arms
and head: pass a small rubber catheter well lubricated
(I use glycerin for this purpose) into the nose, and by
pushing it we can easily enter the pharynx, cesopha-
gus, and stomach. I attach a glass funnel to » piece
of rubber tubing, such as we ordinarily use for lavage,
and, having entered the stomach, allow the peptonized
milk, which has previously been prepared and put into
the funnel, slowly to enter the stomach. Nasal feed-
ing 1 have used onlv when the rectum showed irrita-
tion from rectal feeding, giving symptoms of tenesmus,
etc., and when I wished to give the parts rest. It is
distinctly understood that I do not advise nasal feed-
ing in na.sal diphtheria.
If a cathartic is called for, I give either calomel or,
if the child is old enough, a few tablespoonfuls of
liquor of citrate of magnesium or a few spoonfuls
of Villacabras water. Locally, ice-cold cloths or an
ice collar are exceedingly valuable. I do not use
sprays or gargles of any kind, as a thorough nasal ir-
rigation sufiices to gargle the vault of the pharynx.
While describing medicinal treatment and orrho-
therapy, it is. I believe, pro|)er to mention mechanical
treatment: but this is most urgently called for in la-
ryngeal stenosis, and it is hardly in the province of
this paper to give the details of intubation, the uses of
which are so well understood by most of us.
187 Second .\vENfE.
NOTES ON APPENDICITIS."
By KOBEUT T. MORRIS. M.D..
NEW YORW.
Frequency of Occurence of Appendicitis. — In order
to make an estim.ite of the number of appendicitis
cases that develop annually in the I'nited States, I
wrote to several general practitioners who are in the
habit of diagnosticating appendicitis, and asked them
to report upon the new cases that had come to them in
one year, between the dates of July i, 1895, and July
I, 1896. Eight physicians have answered my query,
and the average number of cases for each one during
that period was four. In order to make an estimate
of the number of appendicitis jiatients who die under
medical treatment, I analyzed the findings in one hun-
dred consecutive operative cases of my own, and found
that the death rate in that particular series would Jiave
been about twenty-eight per cent, eventually, but not
necessarily in the fir.st or second or tenth attack. 'J'he
estimate was based upon these findings:
Kslimatcd Deaths
100 Consecutive Operative .Appendicitis Cases. under
.Medical Treatment.
7 cases of tuberculosis and cancer 5
I case of stran'iulation of bowel by appendix ad-
hesion band I
3S abscess cases 15
S cases with hard incarcerated concretions 2
12 cases of occluding stricture dams 5
34 cases in common interval stages or in acute stages
before advent of pus o
' A paper read at the meeting of the New Vork County Medi-
cal Society, November 23, i8g6.
December 26, 1896]
MEDICAL RECORD.
925
This estimate, I presume, is low enough to please
the most conservative.
[ncidentally, it may be interesting to know that the
surgical death rate in this series of one hundred cases
was two per cent, A fair criticism will be made that
only the worst cases get to the surgeon. To this I an-
swer that the list contains practically all of the cases
of any sort of severity that occurred in the practice of
some physicians of my acquaintance, and consequently
an average medical death rate of twenty-five per cent,
would be low enough, remembering always that this
refers to eventual death rate, and not to the rate in
first, second, or tentli attacks.
According to Polk's " Medical and Surgical Report-
er of the United States for 1896," there are rather
more than 103,000 physicians in tiiis country. In-
stead of allowing four new cases of appendicitis annu-
ally for each one, let us put the number at two, which
gives 206,000 new cases of appendicitis annually in
the practice of physicians in the United States.
Twenty- five per cent, death rate for causes given in
my stated analysis would show 51,500 deaths from
appendicitis annually, at an estimate which is proba-
blv too low. It is my plan to obtain statistics from
a much larger number of physicians, but it is neces-
sary for me to know personally that the physicians to
whom application is made are in the habit of recog-
nizing the cases. For instance, one physician of my
acquaintance who has a deservedly large practice be-
cause of his fine general qualifications, is reported to
say that he has never seen a case of appendicitis. I
have operated upon two cases of appendicitis which
had been under his treatment in previous attacks, and
I know of two other cases that terminated fatally under
his treatment, which had been diagnosticated as appen-
dicitis by other physicians. He is certainly not one of
the men from whom I can obtain statistics, although he
is the sort of man whom the best class of people de-
pend upon for trustworthy information in regard to the
subject. With a stubbornness which has won for him
success in overcoming obstacles in life, he maintains
that appendicitis is a fad, and his cases of that disease
do not appear as such in the vital statistics reports.
Etiology. — Appendicitis begins at an infection
atrium. The infection atrium is produced in the nui-
cosa or in the serosa of the appendix. An infection
atrium is apparently produced in the mucosa of the
appendix by traumatism inflicted by the right psoas
muscle commonly, by traumatism inflicted by a con-
cretion frequentlv, by traumatism inflicted i>v entozoa
occasionally.
An infection atrium is also produced in the mucosa
of the appendix by bacterial inflammation of any sort
which injures the protecting epithelial layer.
An infection atrium is produced in the serosa of the
appendix when destructive inflammation extends from
the serosa of some neighboring structure to the serosa
of the appendix.
When an infection atrium lias allowed the entrance
of bacteria or toxins or both into the tissues of the ap-
pendix, the results are in character similar to the re-
sults of similar invasion of the colon, but they are
different in degree. The reasons why they are ditTer-
ent in degree are not more than two or three, but these
are of determining importance.
First reason: The narrow outer tube of the appen-
dix will not allow the lymphoid layer and the connec-
tive tissues of the inner tube to swell quickly and
freely, and the inner tube is therefore subjected to
compression an.Tcmia within the confining outer tube.
Compression' ana-niia so disaliles the compressed tis-
sues that they readily fall a prey to l)acteria.
Second reason : The blood supply of the appendix
is principally from a .solitary terminal artery.
Branches of this arterr are occluded bv infectire in-
flammation. Bacteria attack tissues which are de-
prived of their blood supply when arterial branches
of the solitary appendix artery are occluded by endar-
teritis.
The two reasons above given do not apply to the
colon, and that explains why the colon so often es-
capes the common destructive inflammation to which
the appendix is subjected.
In appendicitis it is not necessary to have " anything
in the appendix" excepting bacteria, for that is all
that we have in the bowel in cholera infantum. The
biggest thing that ever gets into the bowel is the colon
bacillus, when that bacillus is favored by conditions
for its development at the expense of structures which
cannot defend themselves. The reasons why the ap-
pendix is a target for the colon bacillus are the ones
tliat I have given. We see why it cannot defend itself
as the colon does.
The principal reason why appendicitis occurs less
frequently in women than in men seems to have been
explained by Robinson, of Chicago, who has shown
that the appendix in women much more frequentlv
hangs over into the pelvis, out of the way of psoas
traumatism.
Diagnosis. — The diagnosis of appendicitis is made
principally by expert palpation, and secondarily from
the testimony of the subjective symptoms and vital
signs. The most important thing to bear in mind in
this connection is the fact that the temperature of the
patient is a matter of no consequence as giving any
clue to the condition of the appendix.
Palpation. — Some physicians say that they cannot
palpate a normal appendix; other physicians fear that
no one can do it. Gynecologists, who are in tlie habit
of palpating ureters and Fallopian tubes, find it an
easy matter to palpate normal appendices after they
have adopted a correct method of procedure. Some
surgeons palpate most of their interval appendices in
the presence of an audience, and state their findings
before operating. It is all a question of acquired skill
and method.
In attempting to palpate the appendix in an acute
progressive case, we have to deal with a board belly so
rigid that deep palpation is diflicult and dangerous;
but when board belly makes palpation difficult pal-
pation is unnecessary, because we already have testi-
mony enough. Board belly is the principal differen-
tial sign between acute appendicitis and salpingitis.
Pathology. — When a physician is uncertain wheth-
er he sh.ill turn an appendicitis case o\er to the sur-
geon or over to the bacteria, he must be informed
upon the relative dangers from the two entities, and
the question is decided upon the known pathology of
appendicitis and the known qualifications of the sur-
geons in any locality. The physician cannot avoid
making a study of these two real factors in the prob-
lem, becau.se it is absolutely a question of life or death
for some of his patients — perhaps for a member of his
own family.
The pathology of appendicitis which 1 ofl'ered to
the profession at Washington in 1893 has been pretty
generally accepted, or corroborated since that time, in
this country and in Europe. It is all contained in my
book upon the subject, so I shall this evening simply
give object lessons in the known pathology, by pa.ss-
ing about a series of type specimens illustrating the
various stages of appendicitis, from early infection to
rhexisand complete gangrene, and from early infection
to complete connective-tissue replacement of all struc-
tures of the apiXMidix excepting its peritoneum — an
ending reached by tlie largest proportion of all appen-
dicitis cases after passing through the dangers of
acute infection. There is no occasion for the dis-
play of any speculative philosophy or any personal
feeling in discussions upon the subject of appendi-
926
MEDICAL RECORD.
[December 26, 1896
ciiis. It is all a question of knowing the pathology
or not knowing it.
Catarrhal Appendicitis Tlieie is no specimen of
catarrhal appendicitis in the group, because I have
not as yet operated upon any case in that stage.
There is no doubt that catarrh of the mucosa occurs
in the incipiency of infective appendicitis, and it
must occur simultaneously with catarrh of the colon
and cKCum ; but apparently it causes no symptoms
which would lead me to make a diagnosis of appen-
dicitis. When we have symptoms of appendicitis
sufficient to lead me to advise operation, the case has
passed beyond tlie catarrhal stage. If any one can
make up his mind that it is right to ojxjrate in the ca-
tarrhal stage in any given case, and if he will present
me with the specimen, 1 shall be very thankful for it,
as such a specimen is very much needed for the com-
pletion of my series. The diagnosis of catarrhal ap-
pendicitis is constantly being made by physicians who
have not obtained a series of specimens. Those of
us who are in the habit of getting the specimens find
that the cases diagnosticated at the bedside as catar-
rhal appendicitis are cases w ith big or little concre-
tions, cases with walled-in sloughs and perforations,
cases with big or little ragged ulcerations of the inner
tube, cases with stricture dams and empyema and tu-
berculosis. These are the things that we find when we
really look to see what is the matter with the appendix.
The term "catarrhal appendicitis" is a narcotic
term, which dances before the eyes of consultants and
pleases them. We must use persistent effort to eradi-
cate it from the consulting-room. It is almost as \i-
cious a narcotic term as "malaria'' in post-partum
infection cases, and both terms leave a black train of
deaths in their wake. They are more deadly in their
effects than the narcotic word " e.xhaustion," which
is made to take the jjlace of the painful word ".septi-
ca;mia" in descriptions of fatal cases following ope-
ration. The word "exhaustion" painlessly shifts the
responsibility from the live surgeon to the dead ji.i-
tient, and does little damage excepting to morals.
Medical Treatment. — The cases of acute infective
appendicitis with big or little concretions, with
walled-in sloughs and perforations, with big or little
ragged ulcerations, with .stricture dams closing off
mucous cavities, may all subside one or many times
under various kinds of medical treatment. The ice
pack and catharsis are effective with some physicians.
Morjihine treatment and locking the bowels are effec-
tive with other pliysicians. Patients often die under
any form of medical treatment in the first attack, or
in the second attack, or in the tenth attack. Patients
who do not die under any sort of medical treatment
often lose much valuable time in bed. No one can
foretell which patient will recover, which one will
spend much or little time in bed, which one will die.
That is always determined afterward. When we lose
a bright boy wiiose ca.se did not pre.sent " symptoms
calling for an operation," we say: "There! that was
a case for operation!" The diagnosis of the nature
of any case of appendicitis is made afterward. The
reason why no one can foretell the outcome in any case
of appendicitis is because tiie abdominal wall is
opaque.
Surgical Treatment. — The surgical death rate of
two per cent, in the series of one hundred consecutive
cases quoted this evening, could evidently have been
avoided if the two cases could have had oix/ration at
a time which I would have chosen : but circumstances
prevented, and so these two men were buried. If cir-
cumstances had prevented all of the one hundred cases
from having operation, about twenty-eight of the pa-
tients would have been buried for reasons perfectly
clear and evident, as shown by the findings at opera-
tion.
Immediate Operation. — In view of the fact that no
one can describe the appearance of an infected appen-
dix until he has looked at it, in \ iew of the fact that
each hour of progress in an advancing case allows
wider infection of structures, in view of the fact that
each subsequent attack leaves the patient a little far-
ther away from safe and easy operation — I long ago
stated the rule that we should isolate an infected ap-
pendix as soon as an accurate diagnosis could be
made, provided that the case was in skilled hands
and that the case was otherwise within surgical limi-
tations. I was promptly misquoted. (Ipponents who
were not quite familiar with the significance of the
word " rule," made it appear that I was not wise
enough to bend to justifiable exceptions. If a patient
has diabetes or a dilated heart or sclerotic arteries, I
see to it that a consultation is called, and I listen well
to the opinions of physicians if they possess the judi-
cial temperament and if they really know something
about genuine surgeiy. I was widely misquoted on
the subject of removal of "slightly infected or normal
appendices." This began as good-natured banter on
the part of friends, and ended as malignant quotation
by men who found that they could make use of it.
The idea of removing normal ajjpendices I have al-
ways opposed in speaking and in writing. 'i"he rea-
son for my opposition is because a perforating wound
of the bowel is made by removing a normal appendix.
The danger is small in skilled hands, and yet it is
enough to forbid us from subjecting a patient to that
risk until acute infective appendicitis makes the mat-
ter one of comparative dangers for the patient. .Any
one who has been led into believing that I have at
anytime advocated any other idea, is not familiar with
the plane on which my surgical work is conducted.
.\s to "slightly infected appendices." they are not
sent to me. I have no patients of my own. There is
no need for discussing the question.
The Nearest Surgeon.— .Some physicians who have
lately come to believe in tlie rule that cases of true
infective ap|x-ndicitis should have the infected appen-
dix isolated, say tliat they send their cases to the near-
est surgeon. The nearest doctor, or' the nearest law-
yer, or the nearest broker, or the nearest engineer are
all lotteries. Some surgeons not previously famous
have become famous through their residts in appendi-
citis work. Other surgeons who had deservedly
acquired a fine reputation, have suddenly sent it to
smash on appendicitis cases, and some of them have
told me that they were discouraged and that they did
not want to operate upon another case. The nearest
surgeon, then, is not sure to make surgical treatment
any safer than medical treatment in appendicitis.
Ambitious and successful surgeons from the smaller
towns have sometimes gone to some great city to see a
celebrated general surgeon do appendicitis work, and
iiave returned to their homes with methods which
blasted their reputations and stopped all operating for
appendicitis in their vicinity. On the other hand, a
Hartford surgeon, at the last meeting of the .American
.Medical .Association, reported on a series of one hun-
dred consecutive appendicitis operations of his own,
showing a mortality rate of two per cent.
Mistakes in Diagnosis. — Surgeons of proper ex-
perience do not make mistakes in diagnosticating
appendicitis more often than they make mistakes in
diagnosticating fractured bones.
The Short Incision In order to avoid scar mar-
ring and to reduce the liability to post-operative ven-
tral hernia. I gradually shortened the length of the
abdominal incision to one and one-h.alf inches for
most of the cases without abscess. This idea, care-
lessly repeated by surgeons who would not willingly do
me a harm, was made to assume different forms.
Some said that it was a hard-and-fast rule. Others
Uecember 26, 1896]
MEDICAL RECORD.
927
thought that the nielhod was to be applied in pus
cases. Others thought that 1 wished to have begin-
ners do that sort of work. The rule is this : Every
surgeon should work through as small an incision as
he can use safely and well for the patient's best inter-
ests. If the surgeon feels that he needs an incision
ten inches long, Ity all means let him use that inci-
sion. The blunt-dissection or "gridiron" nielhod of
entering the abdominal cavity, I feared would require
too large an incision ; but that was a preconceixed
notion. Dr. McBurney, in his admirable contribution
to the subject in Dennis' "Surgery," says that in
proper cases the incision through the deeper layers of
the abdominal wall need not be more than two inches
in length; and since reading that opinion I have em-
ployed the blunt-dissection method in nearly all of
my interval cases with adhesions, making the incision
one and one-half inches long through all structures of
the abdominal wall.
Abscess Cases. — In cases of appendicitis with al^-
scess, I have made it a rule to break up adhesions in
a search for multiple abscesses and for the infected
appendi.v, exposing the free peritoneal cavity without
hesitation. Our resources to-day allow us to do that
•very safely indeed, but one must not attempt it unless
he has confidence in his resources. Arguments pro
and con before the medical societies are farcical. It
is all a matter of individual art. Certain details of
treatment in abscess cases have passed out of the
realm of individual art and belong to science. I will
refer briefly to two points.
Gauze Packing — When we accidentally leave a
gauze sponge in a patient's abdominal cavity and close
the incision, the patient is likely to develop ileus.
When we put gauze packing into a patient's abdominal
cavity, leave one end protruding, and term it a drain-
age device, this patient is also likely to develop ileus,
because as a layman he does not know the fine distinc-
tion in nomenclature between "accident" and "drain-
age device.'
Iodoform Gauze. — When an operator has employed
iodoform gauze in the abdominal cavity, he sometimes
asks me to see the case a day or two later, and a con-
versation something like this follows: '"I wanted to
have you see the case, because the patient does not
seem to be doing well. His temperature is only a lit-
tle elevated, his tongue is pretty clean, but his pulse
is altogether too rapid and he seems to wander a little
in mind. The case was not a bad one at all, but the
patient is not doing well." In reply I say: "Take
out your iodoform gauze instantly. Remove iodoform
from the wound with sterilized oil. Examine the
urine for free iodine." A few days later we again
jneet. The doctor says: "By George! you were right
about that iodoform poisoning, and I remember now
that I lost a boy with similar symptoms a year ago.
But why does Dr. X ■ not lose cases from iodoform
poisoning? I learned the method from liim."
In fighting for reform against some of our earlier
errors in apijendicitis work — late operation, counter-
incisions, large incisions, inaccurate suturing, gauze
packing, incomplete work, ligation of the appendix
like an artery — I seemed to be working again.st the
consensus of opinion in surgical circles; but now that
the contest is about over, many surgeons inform me
that they were working along the same lines, but so
quietly that their popularity was not endangered.
I have not allowed anv consideration for popularitv,
any influence of friends, or any attacks of antagonists
to interfere with my work. I saw patients dying, and
patients developing post-operative ventral hernias,
and patients subjected to two or three operations — and
that was stimulation enough to carry on reform work.
The atmosphere has been pretty thick with smoke at
times, and at one meeting of the surgical section of
the Academy of Medicine the section got itself into
the curious predicament of putting the stamp of dis-
approval upon methods which had given the best sta-
tistics at that time. One of the most eminent sur-
geons, whom we would all like to revere, so far forgot
his dignity as to call into question the integrity of m\-
statistics, instead of leaving that sort of thing to a
class of men who could do it without injury to the
academy. The s]5irit of scientific investigation was
not abroad that night, and the meeting was dominated
by quite ordinary molixes. The profession at large
understood.
Medical Statistics.- At the present time we are
much in need of medical statistics of appendicitis.
None have been given to us in a scientific way.
There have been a number of reports of treatment of
series of single attacks, some very favorable and some
very unfavorable, ^^'hat we need is a report upon one
hundred consecutive cases of appendicitis treated
medically for a period of two years, with full notes on
recurrent attacks, loss-of-time rate, interval palpation
findings, interval complications, deaths, and post-
mortem findings. The time that I have set is very
short, but enough things happen to the average appen-
dicitis case in two years to make an instructive re-
port. The statistics must come from men who make
the diagnoses accurately, and who make skilful palpa-
tion of appendices in the intervals between attacks.
Physicians who take the patient's ;jtatenient of the case
without making careful painstaking examination,
must not place their cases in the report, because there
is a marked tendency on the part of patients who fear
operation to say to their physicians that they feel
perfectly well whenever a twinge of pain attracts their
attention to the seat of the old trouble. The statistics
for such a series as I propose cannot be collected in
the cities where skilled surgical services are at hand,
because we alreadv know that the medical death rate
from such unavoidable factors as concretions, stricture
dams closing off mucous cavitie.s, abscess, and tuber-
culosis, is so much larger than the surgical death rate
that the medical treatment of one hundred cases car-
ried to a finish would be experimentation of the most
heartless kind. The statistics must be collected by
some association of physicians who are so situated
that one hundred of their appendicitis patients cannot
have the benefits of the difference in a surgical death
rate of two per cent, and a medical death rate of
twenty-five per cent.
Vaginal Secretions. — Kronig, in about two hun-
dred examinations, found that the vagina in pregnant
women, aside from the gonococcus and the thru.sh
fungus, contained no pathogenic micro-organisms.
The streptococcus was not found in a single case.
Moreover, Kronig found after inoculating the vagina
with pure cultures of streptococcus, staphlyococcus,
and bacillus pyocyaneus that none of these micro-
organisms could be discovcj-ed after eleven to twenty
hours. Kronig attributes the germicidal powers of the
vagina, which were demonstrated by these observa-
tions, to the outward Mow of the vaginal secretions, and
not to any special microbe having its normal habitat
in the vagina. .According to this obser\er, acid, neu-
tral, and alkaline secretions all ha\e germicidal jiower.
Further, Kronig found that if an hour after the infec-
tion of the vagina an antiseptic douche of lysol were
administered, not only were the infecting micro-orga-
nisms not destroyed by the douche, but also that it
took the vaginal secretions from nineteen to thirty-six
hours to destroy microbes that without the douche
would disappear in eleven to twenty hours. — Dciitsi-lie
miuliaiilsihf Wochcnschrift, October 24, 1894. p. 819.
928
MEDICAL RECORD.
[December 26, 1896
^'rocjress of ijElcdicaX Science.
Successful Graft of the Spinal Cord of a Rabbit
in the Median Nerve of a Man. — Kobson {British
Mritical Journal, October 31, 1896, p. 1,312) has re-
ported the case of a gardener, twenty-nine years of
age, who sustained a deep incision on the lower
and inner part of the right upper arm, with division
of the brachial artery, by falling on a scythe. The
artery was ligated and the two ends of a divided nerve
sutured. The wound healed slowly by granulation,
but finally closed, leaving the muscles of the wrist
and hand supplied by the ulnar and median nerves
paralyzed, wliile those supplied by the musculo-spiral
retained their motility. Sensibility was lost in the
same distribution and also in that of the internal cu-
taneous nerve. .\n operation was undertaken, an in-
cision being made along the line of the cicatrix and
]5rolonged some distance upward and downward, and
supplemented by a transverse incision about an inch
above the elbow. The lower end of the upper seg-
ment of the ulnar nerve, which was bulbous, was con-
nected by fibrous tissue with the upper end of the
lower segment. A small nerve was found at the upper
part of the wound, which proved to be the internal
cutaneous. The lower end of the same nerve was
found subsequently and united to the upper with a cat-
gut suture. .A.fter considerable search the bulljous
lower end of the upper segment of the median ner\e
was discovered at about the middle of the upper arm,
concealed by the belly of the biceps; and the upper
end of the lower segment, expanded and sending rami-
fications into the cicatrix, was found subsequently ju^t
above the bend of the elbow. The fibrous tissue be-
tween the ends of tlie ulnar nerve was excised and the
two healthy portions were united by grafting strands
of the sciatic nerve of a rabbit so as to fill up the gap
and establish continuity. It was not possible to bring
the divided ends of the median nerve closer together
than two and a half inches. In the absence of more
suitable tissue the spinal cord of a rabbit just killed
was used as a graft to connect the ends of the median
nerve, the inserted cord lying loose and quite free
from tension when finally placed in position. Fine
catgut sutures were used throughout. The edges of the
wound were brought togetlier, tiie usual dressings ap-
plied, and the arm was fixed upon a rectangular splint.
Union took place by first intention, with a total ab-
sence of fever and pain. Kleven days after the oper-
ation the patient could feel the scratch of a pin on
the flexor aspect of the first phalanx of the thumb, as
well as at the root of the index finger. "He could tell
wlien the hairs on the back of the first phalanges of
the ring and little fingers were touched, but could
not feel the scratch of a \>\w in that situation. .Seven
days later sensation had returned over the whole of
the palmar surface of the thumb and the proximate
phalanx of the index finger. .After a further inter-
val of sixteen days sensation seemed to be creep-
ing slowly along the first finger and to be present
over the w-hole of the palmar area supplied by the
median nerve and extending down as far as the
web of the fingers and a short distance along the
middle finger. The muscles presented evidences of
gradual development and the general nutrition of the
hand improved. Slight power of grasp and some
power o£ fiexion of the wrist returned, with slight
power of adduction of the thumb and flexion of the
fingers. Sensation was present all over the thumb and
index finger and in the second finger up to the first
phalanx on the palmar aspect, also in the third finger,
though less distinct. In the course of several weeks
more sharp shooting pains began to be felt in the dis-
tribution of the ulnar nerve and the flexors of the fore-
arm began to react to galvanism. Improvement thus
continued, when the patient was lost to observation,
and then was not seen again until after the lapse of
six years. The man had continued the use of galva-
nism for a time and did not resume his work until more
than a year after his accident. During the subsequent
five years he had not missed a day's employment, at-
tending to all of his duties, from wheeling a well-
laden barrow to using a scythe. On examination the
right arm was found scarcely smaller than the left and
power had returned to all of the muscles except the
abductor of the thumb. Sensibility also had been re-
stored and the electric reactions were normal except
in the muscle named.
The Diagnostic and Prognostic Value of Angina
in Variola.— Dr. Chassy {IJ IiuUpcndaiuc MedicaU,
October 7, 1896, p. 328) says that angina in variola al-
ways manifests itself at the same time as the cutaneous
eruption (ordinarily at the end of the third day). It
is often evident before the cutaneous eruption. Like
it, the elements pass through the same phases, ma-
cules, papules, vesicles, and pustules. Peri-amygda-
loid and submaxillar}' oedema are frequently observed
in the confluent forms. It is a benign adema, which
may be confounded with parotiditis. Angina of vari-
ola presents little gravity if uncomplicated. It does
not leave cicatrices after healing. Its coincident ap-
pearance with cutaneous eruption is an element of dif-
ferential diagnosis that is highly important. Slight
iiemorrhage, at an early stage, in the papules of the
palatine vault (resembling tobacco seeds), announces
the early, hemorrhagic, deadly form. The presence of
streptococcus pyogenes appears to be an aggravating
element in prognosis. Angina of variola is of great
importance from a hygienic standpoint. It assures an
early diagnosis, even in varioloid and in concealed
forms. It proclaims and controls the intermittent out-
breaks following in the course of the contagious dis-
ease. The treatment should be antiseptic — gargles
and naso-pharyngeal washes with lukewarm boric-acid
solution.
Infantile Scorbutus. — Dr. A. L. Vernhes {L' Jndi-
pcndiiihY AJciliuilc, October 7, 1896) writes as follows:
This malady, studied by many authors, results from
the influence of insufficient nourishment or of over-
feeding. It is often complicated with rachitis, and its
principal symptoms consist in hemorrhagic manifesta-
tions, which give it a marked analogy to scorbutus.
Of the true nature of this disease but little is known:
it is, however, generally attributed to defective nutri-
tion followed by inanition. It often follows gastro-
intestinal affections or infectious diseases, such as
scarlatina, whooping-cough, etc. This leads us to
suppose that infection plays a role as the occasional
cause of this affection.
Remarks on the Topography of Zona. Dr. Don-
gradi ( /.' Jtidepe/idiiiur Mediid/f, Oclohcr 7, 1896) writes
that most cases of zona called primary or essential
have a spinal origin. The disagreement which exists
as to the topography of the eruption and the distribu-
tion of cutaneous nerves; the concordance of the to-
pography of this eruption with that of .sensitive trou-
bles of mediillary origin; the possible coexistence of
spinal anaesthesia with the eruptions; the character of
the pains, which are vague and diffuse; the habitual
absence of neuralgic points: the existence, sometimes
verified, of symmetrical pains and of spinal hypera:s-
thesia; some instances of motor troubles associated
with the zona — con.stitute the arguments in favor of
the medullary theory. The infectious theory of I,an-
douzy is easily reconcilable with the spinal origin of
zona.
December 26, 1896]
MEDICAL RECORD.
929
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 43, 45, & 47 East Tenth Street.
New York, December 26, 1896.
THE SURGICAL TREATMENT OF GASTRIC
PERFORATION AND HEMORRHAGE.
The most certain, withal the most radical, method of
preventing the disastrous consequences always likely
to follow perforation of or hemorrhage from the stom-
ach or intestines consists in direct exposure of the
seat of lesion and suture of the opening or ligature of
the bleeding vessel. It goes without saying that such
measures may not always be necessary, but the deci-
sion in the individual case must depend upon the con-
ditions present and the special indications to be met.
Whenever doubt exists as to the course of action to
be pursued, the principle will be a safe one to follow
that the risks and dangers of operative interference
are in general less than those of e.xpectancy. The
validity of this proposition has been amply demon-
strated throughout the whole range of modern surgery.
As illustrations w-e need but point out the control of
intracranial hemorrhage by trephining and the appli-
cation of a ligature to the bleeding vessel or the pack-
ing of the wound; the excision of tlie vermiform
appendix in the event of suppurative, ulcerative, or
perforative appendicitis; the performance of cceliot-
omy for the relief of perforation or the control of
hemorrhage in case of typhoid fever or gastric ulcera-
tion.
The difficulties under the several conditions named
are always considerable, often apparently insurmount-
able and sometimes really so, but the results in every
way justify the surgical procedure. In the event of
perforation of the stomach, operation may be under-
taken at once and should not be interfered with by
any ordinary counterindication. Single or occasional
hemorrhage in a case of gastric ulceration may be left
to the usual therapeutic measures, but persistent, fre-
quently repeated, or copious haematemesis, sufficient to
portend a fatal issue, may be looked upon as an indi-
cation for abdominal section and exploration, together
with such additional procedures as the conditions pres-
ent in the given case may seem to justify.
A not inconsiderable number of operations have
already been performed in cases of gastric ulceration,
as a rule on account of the occurrence of perforation,
but in at least one for the control of hemorrhage. In
a very fair proportion the results were entirely suc-
cessful. One of the earliest of the successful cases
has been reported by Barling. ' Following symptoms
of peritonitis due to perforation of an ulcer of the
stomach, a swelling appeared in the left hypociion-
drium, which proved to be an abscess behind the stom-
ach. Upon evacuation of this accumulation and the
provision of drainage recovery ensued. Two other
cases previously operated on by Barling terminated
fatally. In one the site of perforation could not be
discovered at the operation, although a perforating
ulcer of the stomach was found after death. In the
second case an ulcer was found and sutured, but after
death a second area of ulceration, almost perforated,
was found in a diflerent situation. A successful re-
sult has also been reported by Gilford,' who excised
the margins of a perforated gastric ulcer and approxi-
mated the edges with sutures. Atherton' has reported
one case in which death followed the evacuation
through a small incision in the epigastrium of about
two quarts of sour greenish fluid from the peritoneal
cavity and the introduction of a drainage tube; and a
second case in which recovery followed exposure of
the perforation after cceliotomy and suture of the
margins. An exceedingly interesting group of cases
of perforation of the stomach consequent upon ulcera-
tion was reported at a meeting of the Clinical Society
of London' during last year. Dunn reported one case
in which suture of the perforation w-as followed by
recovery, and a second in which perforation was not
found at the operation, while a large area of gastric
ulceration was found after death. Silcock related a
case in w-hich a perforation was successfully sutured,
but death took place in consequence of septicamia
due to a purulent accumulation about the stomach,
liver, and spleen. In a second case, in which a per-
foration was found in the midst of adhesions between
the stomach and the liver, recovery followed the in-
troduction of a drainage tube and closure of the
wound. Lees reported one case in which the contents
of a subphrenic abscess were evacuated through a
trocar and several days later fatal hemorrhage took
place; a second case, which terminated fatally, al-
though operation was done within forty hours after
rupture and the perforation was closed by suture ; and
a third case in which one perforation was sutured and
death resulted from perforation of a second ulcer.
Cheyne reported a case in which the perforation was
found limited by adhesions; the wound was left open
for a week, but two days later the patient died, and on
post-mortem examination a large abscess was found
above and behind the stomach. White related a case
terminating fatally, in which operation failed to dis-
close the existence of ulceration and there was little
evidence of peritonitis. In a second case temporary
relief was afforded by washing out the stomach, but
death occurred suddenly and post-mortem examina-
tion disclosed the presence of perforating gastric ulcer
firmly adherent to the under surface of the liver.
Bradford reported two cases, one of which was suc-
cessfully operated upon, the other terminating fatally
' Birmingham Medical Review, vol. xxxiv.. No. iSi. p. 129.
'Lancet, No. 3,692, p. 1,369.
'.Mfjucm. Rf.cord, No. 1,261, p. 2.
* British Medical Journal, No. 3,742. p. 1.252.
930
MEDICAL RECORD.
[December 26, 1896
some time after the evacuation of a considerable
amount of fluid from the peritoneal cavity. Finally,
in a case of gastric ulceration attended with copious
ha?matemesis, Kiister' performed coeliotomy for the
purpose of controlling the hemorrhage and preventing
secondary contraction. After exposure of the ulcer in
the stomach the thermo-cautery was applied. The pa-
tient recovered satisfactorily from the operation and
gained in weight and strength, and the hemorrhage
did not recur. In the most recent contribution to the
literature of this important subject, Hirsch ' reports a
case in which, although ha;matemesis was frequent and
copious, ulceration of the stomach could not be found
on surgical exploration; and a second case in which,
on account of the profound degree of anaemia present
and in view of the previous experience, an operation
was not undertaken. Death ensuing in the latter,
post-mortem examination disclosed the presence of
a smairulcer on the anterior wall of the stomach near
the pylorus, with the erosion of a large vessel. In
view, therefore, of all of the circumstances, and guided
by the experience that has already been gained, the
conclusion seems justified that operative interference
is indicated in cases of gastric ulceration when, not-
withstanding regulation of the diet and enforcement
of rest, haematemesis occurs with such frequency and
in such a degree as to endanger life.
THE CLOSE OF VOLUME FIFTY.
The completion of the fiftieth volume of the Medical
Record, in the present issue, is in some respects a
matter for congratulation in connection with the fact
that during all the period covered from its first publi-
cation until the present it has been under the same edi-
torial management. Through all the continuous labors
of the past thirty years the lives of editor and pub-
lislier have been spared to make this statement possi-
ble. \Mien passing retrospection is thus invited, it
is some comfort to believe the efforts to make this pub-
lication what it now is have not been altogether vain.
Probably no medical journal started under more un-
fortunate prognostications than did the Medical Rec-
ord. The leading medical men in this city at that time,
while they cordially endorsed the project, were almost
unanimous in their predictions that no medical jour-
nal could succeed, pecuniarily or otherwise, as none
had yet done so, and that ultimate failure, mucli as it
might be regretted, was a foregone conclusion. Still,
by the very few who thought otherwise it was deter-
mined to take the chances of reversing the well-estab-
lished rule. At this distance of time it is perhaps
reasonably safe to conclude that the victory rightly
belongs to such as can do and dare. It may not be
uninteresting in this connection to say that the origi-
nal policy of the journal has been consistently carried
out in every particular. It has been a rare privilege,
granted to few if any, to have worked so long and so
continuously in one direction, and to have watched the
encouraging progress of the journal during all these
' .Archiv fi'ir klinische Chirurgie, B. xlviii., H. 4, p. 7S7.
* Berliner klinische Wochenschrift, September 21, 1S96, p. S47.
years, as shown by its growth from the smallest begin-
nings to the present realization of the most extrava-
gant expectations. In this consummation what changes
have taken place! How many theories have risen and
fallen, how many advocates of them are heard no
more, how many, alas! who started in the early career
of the Medical Record have pas.sed away! Com-
paratively few are now living who can rejoice with us
in having placed the first volume on their shelf and in
adding one to another until a jubilee number has been
reached. To such as may recollect those earlier times
we tender the kindly greeting which passes between
old tried friends; to the new ones, many and unseen,
we still strive to be close and true. Fifty volumes
done — the Medical Record landmark for a fresh
start — with greetings of even better times to come
and more work to do.
BODY SNATCHING.
How frequently one is led to reflect upon the simila:
ity of events as they occur and are chronicled in the
journals of the two English-speaking countries sepa-
rated by the Atlantic. Coincidently one reads of the
disappearance of a body from the New^ York Morgue
and of the wrong body being taken by mistake from
the Queen's Hospital in London. The body of an
unknown woman who has died in one of our hospitals
is identified by a man as that of his mother-in-law ;
the insurance money is collected and spent in a fu-
neral, while the real mother-in-law, in actual life, is
engaged in the arduous duties of laundry work. Al-
most upon the same day an undertaker rushes into the
dead-house of an English institution and carries away
and buries one body, when he should have been in less
haste and secured the one in which the friends were
more interested.
It is a fact well known to many physicians that cer-
tain undertakers are affected with precipitation. Some
of them have it in a severe form. It was only the
other day that a well-known surgeon had the following
disagreeable experience: Death liad occurred in a
most rare and scientifically interesting form. Per-
mission to perform an autopsy had been granted.
Upon reaching the house with one or two invited con-
freres, the surgeon found that an undertaker had re-
moved the body, the friends thinking the physician had
ordered it. Going to the undertaker's establishment,
tlie gentlemen were surprised to find the object of their
search embalmed and on the ice, the process having
destroyed all possibility of scientific research in the
case. Six hours had elapsed from the time of death.
Let us suppose these gentlemen had paid their last
visit, not to dissect the patient in the interests of sci-
ence, but to determine whether the patient were in a
state of real death or pseudo-death, what chance would
the undertaker have left them or the patient?
Friends, and especially physicians, are to blame tor
the worse than barbarous manner in which the dead
and supposed dead are hurried away by undertakers
to beds of ice which preclude any possibility of re-
vival from states of suspended animation. William
December 26, 1896]
MEDICAL RECORD.
931
Tebb and Edward VoUum have just written a work on
" Premature Burial and How it may be Prevented."
We do not know what arguments these authors advance,
but the subject has received attention often enough in
times past to make us ashamed of the manner in which
in most civilized countries patients are treated just
after they are thought to have expired.
A CRUEL DECEIT.
We have of late derived much pleasure from the con-
templation of sundry portraits of robust and handsome
healers with which, in contrast to their word pictures
of loathsome disease, some of our esteemed contempo-
raries adorn their pages. We see in one the round
and rosy features of Sir Dyce Duckworth; in another
the intellectual but somewhat austere countenance of
Mr. Jonathan Hutchinson meets our admiring gaze;
while a host of lesser lights, our own and Europe's,
twinkle out and illumine this firmament of western
journalism. We are grateful for this exhibition of
manly beauty, but with the gratitude which is a lively
anticipation of favors yet to come we make bold to
ask that these portraits be correctly labelled. In one
of our most esteemed of contemporaries there was re-
cently a charming picture, labelled " Osier on Angina
Pectoris;'" but it was neither. It was pretty, but it
resembled Dr. Osier no more than it did angina. M'e
are glad that our old friend can claim neither one.
And now w^e are in a most distressing state of incerti-
tude, for we are sure of the identity of hardly one of
these collected portraits which made up our galler}-.
We may perhaps have been engraving upon our heart
the features of some unhung train robber, deluded by
an unprincipled editor into the belief that they were
those of Virchow, of Kitasato, or of N. Senn. The
thought is intolerable, and until we have the assurance
that the label editor has had a change of heart or
really knows the celebrities of medicine, our portrait
gallery shall be closed to our visitors.
X-RAYS AND SIGHTLESS EYES.
In our editorial columns of a previous issue we de-
precatep the idea of holding out to the blind any strong
hope of their being made to see by the .v-rays. We have
always had the greatest confidence in Mr. Edison's
wondrous powers and magic-like achievements, but in
the present case we did not feel that he was justified
in calling forth hopes which could, in most instances
at least, if not in all, result only in disappointment.
In a recent number of the Electrical Jicricw, Nikola
Tesla found little ground for any claims of making the
blind see. The rays have not been demonstrated to be
transverse vibrations, and at best refraction would be
necessary to project a sufficiently small image upon
the retina. .As it now is, only a shadow of a very
small object can be so projected.
Dr. Thomas More Madden, of Dublin, has recently
had conferred upon him the honorary degree of master
of obstetrics by the Royal University of Ireland.
Bcius of the cl^cch.
Board of Education and Sanitary School Inspect-
ors.— An appropriation of $47,500 has been granted
the board of education to pay medical inspectors for
each school district of this city. The health board
will appoint one hundred and fifty physicians at §30
per month for the ten school months of the year.
This is a move in the right direction, since most chil-
dren's diseases of an infectious nature are largely
spread through school intercourse. It is to be hoped
that careful examination of the scalp will form part
of the inspectors' duties and that the spread of favus,
ringworm, and pediculosis will thus be materially
lessened.
Epidemics in Various Places Small-pox is re-
ported to be raging with exceptional severity in the
principal sea towns of Japan. At Kobe two hundred
cases and several deaths have been reported. Yoko-
hama has declared a quarantine against Kobe, and
the board of health of San Francisco has declared
both Yokohama and Kobe infected and has established
quarantine against all Japanese ports. Colon, on the
Isthmus of Panama, is now declared to be free from
small-pox, which has been epidemic there for some
time. Yellow fever is reported to be slightly less at
Havana and other Cuban ports, although the disease
is constantly supplied with new material to work upon
in the persons of the raw Spanish recruits. In Port
au Prince, Hayti, the yellow-fever epidemic shows no
signs of abatement. Dr. Terres is reported as saying
that ihe present epidemic is the worst outbreak he has
ever seen during his long residence on the island.
Every unprotected foreigner who has landed at Port
au Prince during the past six weeks has been stricken
with the disease. The reports from Bombay concern-
ing the plague are disquieting. The official statistics
show that, up to the middle of December, there had
been r,s5i cases known to the authorities, and 1,094
deaths. All who can get away are fleeing in terror
from the city. Calcutta has become alarmed and re-
cently appointed a sanitarj' board to make a survey of
the city. The report of this board is far from reassur-
ing. It says that the city area is terribly overcrowded,
several wards having a population of more than one
hundred thousand per square mile, one of them rising
to nearly one hundred and forty-five thousand. Houses
which should accommodate fifty persons only, if ordi-
nary precautions regarding health were obser\-ed. con-
tain five times that number, while the bastis, which are
collections of mud huts, are densely packed. The en-
vironment of filth in which the residents of these huts
live is described in terms which make it plain that if
the plague or typhus fever should obtain a footing it
would be alriost impossible to stamp it out. In
houses, too, which are outside these basiis, insanitary
conditions exist which invite outbreaks of epidemic
disease. The government has warned the municipal
authorities of their neglect of duty and urged upon
them the necessity of sanitary reforms in view of the
imminent danger of an invasion by the plague.
932
MEDICAL RECORD.
[December 26, 1896
Fined for Grave Robbery Two Dartmouth med-
ical students were recently arrested for grave robbery.
They pleaded guilty to the charge, and were heavily
fined.
Diphtheria has been prevailing in epidemic form
in several places in Northern New York. In Ogdens-
burg, out of seventy-three cases treated with antitoxin
only two resulted fatally.
Bellevue Hospital Medical College.— Dr. T. M.
Rotch, of Boston, lectured before the students of
Bellevue Hospital Medical College, by invitation, De-
cember 15th. The subject of the lecture was diiTer-
ential diagnosis in the eruptive diseases of children,
with especial reference to scarlet fever and its com-
plications. The lecture was illustrated with colored
lantern slides.
Too Much Study. — Charles Winlander, twenty-six
years of age, a student at the Bellevue Medical Col-
lege, committed suicide on December 14th. He was
formerly a student at the Rush Medical College of
Chicago and came to New York from Mount Carmel,
111., some months ago to pursue his medical studies,
bringing with him his wife, to whom he had been
married but eight months. It is said that too close
application to his studies affected his brain. He had
complained of severe headaches for some time.
M. Roux Decorated by the German Emperor —
Emperor William has conferred a decoration on M.
Roux, for his discoveries in relation to the antitoxin
of diphtheria, and, contrary to the precedent in the
matter of German decorations, M. Roux has accepted
the honor. It was said last year that the German
emperor had sounded Pasteur as to his acceptance of
the German Order of Merit, and that he refused to
accept the honor, declaring that he could never forget
1870.
Against Street Music. — The Brooklyn board of
aldermen recently adopted by a vote of eighteen to
six a resolution prohibiting the operations of itinerant
bands in that city and restricting the use of hand
organs to certain hours. A similar resolution passed
about two years ago was vetoed by the then mayor,
who apparently approved of street noises.
Objections to Canadian Nurses. — The question
was raised some time ago as to whether the Canadian
trained nurses who come to this country to work in
hospitals do so in violation of the law. At that time
it was held that they could not be interfered with, as
they were semiprofessional persons. Now the secre-
tary of the treasury has ruled that these nurses can be
deported, and it is said that the new ruling will be
carried out at once, and five Canadian nurses employed
in a sanatorium in this State are to be deported ac-
cordingly.
The Practical School of Medical Specialties is
the title of a post-graduate school recently opened in
Madrid. The specialties there taught are obstetrics,
gynecology, paediatrics, surgery-, nervous diseases, oph-
thalmology, otology, rhinology, laryngology, and dis-
eases of the liver.
A Subscription to pay the heavy expense (about
^^1,000^ incurred by Dr. CuUingworth in defending
the suit brought against him by Miss Beatty, has been
begun in England. Considerably more than half the
needed amount, namely 561 guineas, has already been
subscribed.
Tribulations of Russian Students. — The police
of Moscow recently arrested forty of the students at
the university, in whose rooms they found a number
of letters and papers alleged to be of a treasonable
nature.
The Post-Graduate Hospital. — The twelfth annual
report of this institution shows that 1,895 house pa-
tients were treated during the last year. Of these 729
were babies, and 1,166 children and adults; 20,084
patients were treated in the dispensary, to which more
than 75,000 visits were made. Seventy-five thousand
visits, if paid for at an average of only twenty-five
cents each, would bring in $18,750 to be distributed
among the struggling young physicians of this city.
The directors make an appeal for funds to establish
free beds in the hospital, and they state that at this
moment there are not half enough free beds for the
worthy poor in the hospitals of the city of New York.
Faith-Cure Fanatics Struggling with Diphtheria.
— An epidemic of diphtheria is prevailing in Hopeton,
Oklahoma, and it is reported that the faith-cure peo-
ple, who compose the majority of the community,
persist, in spite of quarantine orders, in holding public
meetings at the houses where the disease exists, and
physicians sent out by the authorities have been com-
pelled to use force in order to examine the sick. In
one instance a twelve-year-old boy was carried through
the worst stage by a physician and volunteer nurse
and was apparently on his way to recovery, but when
the physician left to attend others the father refused
to give the medicines or follow any of the instructions,
and the boy died, the family and friends sitting around
and praying, but doing nothing to relieve his suffer-
ing. Six or eight others have been allowed to die in
the same way.
Making the Punishment Fit the Crime — .\ Mon-
treal school teacher recently discovered some tobacco
which had been brought in by one of the boys, and by
way of punishment he made an infusion of it and ad-
ministered it to several of the scholars. The school
commissioners very justly reprimanded the fool, who
may consider himself lucky that none of the boys was
fatally poisoned by him.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. Changes in the medical
corps of the United States navy for the week ending
December 19, 1896. December 14th. — Surgeon L. B.
Baldwin detached from the Neivark and ordered to the
Furitaji. Passed .Assistant Surgeon S. G. Evans de-
tached from the Piiita on reporting of his relief and
ordered to the naval hospital. New York. Passed
Assistant Surgeon G. Rothganger detached from the
Patterson, December 25th, and ordered to the Pinta,
per steamer of December 29th.
December 26, 1896]
MEDICAL RECORD.
933
The Death Rate of Johannesburg. South Africa,
is thirty-two per thousand.
The Body of Sir Benjamin Ward Richardson
was, in accordance with hi.s express wish, cremated
at Woking.
Stealing Drugs from Doctors. — In the inquest in
a case of suicide by cocaine of a woman in London, it
was learned that she had stolen tlie drug, to tlie amount
of fifty grains, from a drawer in the house of iier med-
ical attendant.
The Rinderpest It is reported that Dr. Edington,
the official bacteriologist of Cape 'I'own, has discov-
ered the bacillus of the rinderpest, thus anticipating
Koch, who is on the way to the Cape to study the dis-
ease.
The Moscow Medical Congress. — The following
is a revised list of the officers of the Twelfth Interna-
tional Medical Congress, to be held in Moscow on
August 19 to 26, 1897 : The president of the commit-
tee of organization will be Prof. N. W. Sklifassowski ;
the vice-president of the committee of organization
will be Prof. J. F. Klein (president of the executive
committee); and the secretary-general w.ll be Prof.
W. K. Roth.
Montreal and Moscow. — The Mctlical Press does
not look for a large attendance of English physi-
cians at Moscow. Speaking of the proposal to amend
the by-laws of the British Medical Association so that
Americans may take part in the meeting next sum-
mer, it says that " it is stated that to amend the by-
law for the forthcoming meeting at Montreal would
lay the association open to the charge of attempting to
promote a reunion rival to that of the international
medical congress at Moscow. But we cannot think
that this can rightly be deemed to be the case. The
congress at Moscow is not likely to suffer from any-
thing which may transpire at Montreal, and chiefly for
the reason that the two meetings will be patronized by
practitioners drawn from entirely different parts of the
world."
A Lunatic on Lunacy. — A curious occurrence took
place recently in Professor Krafft-Ebing's clinic,
where a patient, at his own request, was allowed by
the professor to deliver a lecture in his place, in order
to demonstrate the peculiarity of his mental state.
The patient is a highly-educated man, of exceptional
intellectual endowments, but for many years he has
been the subject of so-called '' circular"' insanity.
The recurrence of the disease prevents his pursuing
for any length of time any occupation in which his
natural abilities and acquired accomplishments would
in happier circumstances have enabled him to gain
distinction. In the maniacal phase of his illness he
shows an astonishing wealth of ideas, and with his
manifold knowledge and his readiness of expression
(he has lately been a writer) becomes witty and even
brilliant in his language. Thus, in the lecture he de-
livered, on the mental condition of the maniac in
periodical attacks of madness, he puzzled his auditory
by the brilliant and exact form of his speech, and on
a layperson or a junior student might even have made
the impression that his statements were correct and
his conclusions logically drawn, thougii, in fact, they
were all non.sense. He spoke for nearly an hour, hold-
ing the attention of his audience the whole time. His
look and bearing, which are those of a scholar, helped
to keep up the illusion. — British Aiedical Journal.
The Bubonic Plague is spreading rapidly in Bom-
bay. On iJecember 8th there were thirty-nine deaths
from the disease, and fifty- five new cases were discov-
ered and reported.
The Medical Department of the British Army is
reported by its director-general to be short sixty men.
If England became involved in a serious war, the com-
batant officers would soon come to a realizing sense
of their dependence upon the medical staff.
The Persecution of Dr. Cullingworth The nurse
Beatty, who recently lost the suit which she brought
against Dr. Cullingworth because he removed both of
her ovaries, has just served notice of motion for a
new trial of the case.
A Quick Diagnosis. — At a surgical clinic a few
days ago, before a class in the Harvard Medical
School, a patient was shown who had a wound on the
thigh caused by the bite of a rat. The instructor, hav-
ing asked the class for a diagnosis of the case, one
of the students replied promptly, " Rodent ulcer." —
British Medical and Surgical Journal.
Schnapps and Beer. — By a decision of the Hes-
sian court, it is considered much better to eat bread
than to drink schnapps before consuming large quan-
tities of beer. A restaurant keeper had applied for a
liquor license, on the ground that the health of his
customers necessitated a good drink before starting
in on their daily consumption of beer. After examin-
ing experts, the court said liread would do.
Ethicomania. — The Melbourne correspondent of the
Medical Brcss, after describing one of the many broils
of Dr. Leith Napier, the hired man from London in
charge of one department of the Adelaide Hospital,
adds: "The danger of meddling with such matters
was, I need hardly remind you, pointedly illustrated in
the recent report of the meeting at Carlisle, and it is at
least curious that the gentleman whose case cost the
British Medical Association £1,300 was the founder
of an ethical society, and in that capacity he figured
as an expert in removing or in discovering motes in
people's eyes. This is precisely our experience here.
Those who are the loudest in preaching the duty of
ethics are just the men whose names you will find
constantly occurring in the newspapers under all
sorts of pretexts. It is the old business in the panto-
mime— 'Here we are again! ' The question then pre-
sents itself: Are medical journals the proper media
in which such matters should be dealt with.' Is it
the legitimate function of a medical journalist to hunt
up infractions of what we are assured are ethical rules?
It is devoutly to be wished that the experience gained
in this wretched .Adelaide strike will serve as an an-
titoxin in the oermanent cure of this ethicomania."
934
MEDICAL RECORD.
[December 26, 1896
Afraid of Growing Old — A man in Batavia, N. V.,
recently connmitted suicide on his ninety-seventh
birthday.
Dr. M. 0. Terry, of Utica, has been appointed sur-
geon-general on the staff of Governor Black. Dr.
Terry is a member of the homoeopathic school. He
held the same position on the staff of Governor Mor-
ton.
Influenza has reappeared in London. The cases
are of the usual type, with sudden onset, grave prostra-
tion, and high fever, with specially marked gastric
disturbance.
A Legacy of a Body Refused.— Dr. Caroline PJ.
Winslovv, who died recently in Washington, left a will
bequeathing her body to Howard University to be dis-
sected by women medical students in the interest of
science. After that she desired that her skeleton be
mounted and presented to the Minor Normal School
of the district. The university declined to accept the
body, and it was cremated.
Dr. William A. Macy, medical superintendent at
the Manhattan State Hospital, has been appointed su-
perintendent of the Willard State Hospital, to take tlie
place made vacant by the transfer of Superintendent
Mabon to be superintendent of the St. Lawrence State
Hospital. The vacancy in the Manhattan State Hos-
pital occasioned by Dr. Macy's promotion will be
filled from the civil-service eligible list of candidates
for hospital superintendent.
A Wasteful Measure — A statute was passed last
year, requiring the city of New York to furnish a suit
of clothes to each insane patient sent by it to the State
hospitals. Mr. Croft, commissioner of charities, has
requested the board of estimate and apportionment to
prepare an amendment to this statute, which shall per-
mit the city to use the clothes more than once. He
made an investigation in the Manhattan State Hospi-
tal on Ward's Lsland, to find out what became of the
clothes furnished to the patients by the city, and
found that the clothes were worn by the insane only
during their passage from the city to the island, and
that they accumulated so fast that it was necessary to
burn great quantities of them every month. He said
that the clothes cost the city $i6,ooo last year, and
$25,000 would be necessary for the same purpose this
year.
Unauthorized Use of a Physician's Name A
drug company of this city recently distributed a pam-
phlet in England, containing laudatory testimonials
of one of its preparations. One of these testimonials
purported to be from Dr. \V. B. Ransom, of Notting-
ham. As the gentleman mentioned had written no
such testimonial, he broT5ght suit against the company
to restrain it from this unauthorized use of his name.
The suit has been settled in Dr. Ransom's favor, and
the offending company has published an apology, say-
ing: "Although we received the testimonial in ques-
tion on a post card purporting to come from Dr. Ran-
som, we now find that the same was not sent by him
or by his authority, and that he has never used the
said drug or given any testimonial concerning it. We
therefore publish this statement, and desire to express
our sincere regret to Dr. Ransom for having misguid-
edly made use of his name in this connection and for
the inconvenience and annoyance caused him thereby,
and we have submitted to an injunction restraining us
from further publishing or making use of Dr. Ran-
som's name in connection witli this remedv."
The Northern Medical Association of Philadel-
phia celebrated on December sth the fiftieth anniver-
sary of its organization, by a dinner held at the Hotel
Walton, which was attended by some fifty participants.
Water Filtration for Philadelphia. — The city
councils of Philadelphia have passed a loan bill for
$3,000,000 for the construction of a filtration plant or
of filtration plants in connection with the several pump-
ing-stations embraced in the water supply of the city.
Dinner to Mr. Potter.- On December Sth a dinner
was tendered Mr. William Potter, the recently elected
president of the board of trustees by the Alumni As-
sociation of Jefferson Medical College. Dr. A. K.
Minich presided and responses were made by Mr.
Potter, ex-Justice S. Gustine Thompson. Dr. S. M'eir
Mitchell, and others.
Sir Benjamin Ward Richardson was one of the
most remarkable men in the profession. Though
never one of its leaders in the ordinary sense, he was
to a large section of the public its most prominent rep-
resentative. By his brethren he was held in consider-
able respect in spite of certain intellectual perversi-
ties, or rather eccentricities, which prevented his
taking the rank in wJiich his originality of mind and
the quality of his earlier work would otherwise have
placed him. His discoveries would have brought
fame and fortune to half-a-dozen ''eminent physi-
cians," yet Richardson himself could hardly be called J
an eminent physician. In the same way his writings
were in many ways excellent, and served a useful pur-
pose in diffusing a knowledge of the laws of health
among the people; yet, particularly in his later years,
they were pervaded by an element of "crankiness"
which greatly detracted from their \alue. Richardson
was intended by nature for a philosopher; owing to
some flaw in the material or some botching in the
workmanship, he turned out a faddist— though a fad-
dist of genius. In his later years he was left behind
in the onward rush of scientific progress; and his cry-
ing in the' wilderness where he was left was not always
edifying. A striking illustration of the way in which
he allowed his enthusiasm to mislead his judgment is
afforded by the circumstances of his own death. It
is but a few months since he told an interviewer that
no man who obeyed the laws of health ought to die
under the age of a hundred. Vet he himself, after a
life devoted to the worship of hygiene, has just been
laid in the grave before he had reached the more an-
cient limit of three score and ten. He was a good
man and wanted only some trifling readjustment in
the disposition of his brain cells to have been a great
one.— 77/tf Pmctitioncr, December, 1896.
December 26, 1896]
MEDICAL RECORD.
935
Bug in the Ear.— A daily-newspaper report tells
of a wonderful '" operation" for the removal of a bug
in the ear, with complete restoration of hearing. Dr.
Burnett in a recent article {Fraititioncr) upon foreign
bodies in the ear says much damage may be done by
groping after foreign substances, especially when there
is none present. No one but a specialist, he thinks,
should ever attempt instrumental extraction. If a liv-
ing insect has entered the ear, a few drops of sweet oil
will smother it and it may then be syringed out with
warm water. Syringing will also usually remove ob-
jects introduced by children. No hurry is demanded.
Delay is better than rough handling. Death has oc-
curred from unskilful endeavors. If larva; of flies are
present, as sometimes happens in the tropics, a drop
or two of chloroform or ether will destroy them.
Neuro-Psychic Medicine.— Z^^ Medccine Modcrne
announces that Dr. Tsikonki, professor of psychiatry
in the University of Kieff, will publish a new review,
devoted to " neuro-psychic medicine." This will be
the fifth journal in the Russian language which con-
fines itself to nervous and mental affections.
Pathological Society of Philadelphia. — At a stated
meeting of the Pathological Society of Philadelphia,
on December loth, Dr. T. J. Kalteyer presented a
horseshoe kidney with its suprarenal body occupying
the right side, and the left suprarenal in its normal
situation. He also exhibited a long attenuated cae-
cum of infantile type, from the body of a woman, sev-
enty-four years old; the appendix also was unusually
long. Dr. F. A. Packard presented a specimen of
aneurism of the aorta, which had eroded one of the
dorsal vertebrae and had ruptured into the left pleural
cavity. The patient had been free from symptoms of
this condition, and was walking about when he fell
and soon died. Dr. Packard showed also a bicuspid
pulmonary valve and an abnormally lobulated liver,
together with the intestines and mesenteric glands
from a case of typhoid fever. Dr. S. Solis-Cohen
exhibited multiple abscesses of the liver and ulcera-
tion of the colon from a case of dysentery; and also
a perforating tuberculous ulcer of the small intestine.
Dr. J. P. Arnold exhibited contracted kidneys from a
young man free from arterial changes. The morbid
condition, in the absence of other appreciable cause,
was attributed to a fundamental tendency to inter-
stitial fibrous deposit or a congenital hyperplastic
condition. Dr. H. W. Cattell demonstrated a simple,
speedy, and efficacious method of preparing frozen
sections by means of a spray of methyl and ethyl
chlorides. Dr. Joseph Sailer presented a brain exhib-
iting numerous sclerotic areas, from a case of epi-
lepsy and idiocy with sarcoma of the kidney. The
formations in the brain were supposed to be neoplastic
and probably sarcomatous, though they may have been
merely hyperplastic and indurated. Dr. Alfred Sten-
gel presented two diminutive stomachs from cases of
pernicious anaemia, and referred to a tiiird stomach, in
size intermediate between these two, from a case in
which pernicious anaemia was not present. He exhib-
ited al.so diffuse and almost universal spindle-cell
sarcoma of the thyroid gland; primary sarcoma of
the gall bladder, with extension to the liver; carci-
noma of the rectum in a case terminating fatally
from purulent peritonitis; malignant endocarditis,
with a myocardial abscess; appendicitis with peri-
typhlitis.
Philadelphia Hospital. — At a meeting of the
bureau of charities and correction on December 8th,
the entire medical staff of the Philadelphia Hospital
was re-elected. Dr. John B. Shober was elected to
fill the vacancy in the obstetric department caused by
tlie resignation of Dr. R. P. Hamill.
Ehrlich's Test for Typhoid Fever. — Dr. Charles
L. Greene writes that he has received several inqui-
ries as to where the solutions for making Ehrlich's
test in typhoid fever may be obtained. In answer to
them he would say that any competent pharmacist can
put up the solutions after the formula" given.
Emergency Ration for the Army. — The war de-
partment, after several years' experimenting, has es-
tablished an emergency ration for troops operating for
short periods under circumstances which require them
to depend upon supplies carried upon their persons.
It will consist of bacon, 10 ounces, hard bread, 16
ounces; pea meal, 4 ounces, or an equivalent in ap-
proved material for making soup; coffee, roasted and
ground, 2 ounces; or tea, 0.5 ounce, saccharin, 4
grains; salt, 0.64 ounce; pepper, 0.04 ounce; tobac-
co, 0.5 ounce. The secretary of war directs that this
emergency ration be resorted to only on occasions
arising in active operations, when the use of the regu-
larly established ration may be impracticable; that
although its nutritive qualities permit its use on half
allowance, it will not be so used except in cases of
overruling necessity, and never for a longer period
than ten days, and that not more than five days'
emergency rations be carried on the person at one time.
Philadelphia County Medical Society. — At a stated
meeting of the Philadelphia County Medical Society,
on December 9th, Dr. Edward Martin described the
ambulant treatment of fractures of the legs by means
of plaster casts extending from just below the knee to
below the sole of the foot, and exhibited the method
of application, together with a number of patients who
had been thus treated. Dr. Martin has employed this
method of treatment in about thirty cases thus far, and,
while the results cannot be said to be better, they have
been no worse than those secured by other methods.
The especial advantage of the treatment is that the
patient is permitted to be up and about for the greater
part of the time that firm union is taking place at the
site of fracture. Dr. Thomas J. Mays read a paper
entitled "The Local Application of Cold in Acute
Pneumonia (Final Collective Report)." His statistics
included nearly tiiree hundred cases, with a mortality
of less than four per cent. The cold may be applied
in various ways — by means of ice bags, of ice througli
towels or flannel, of snow, of cloths wrung out of ice
water, etc. It was thought that the cold had not only
a favorable intluence upon the fever and the tempera-
ture, but also a directly beneficial effect upon the mor-
bid process in the chest.
936
MEDICAL RECORD.
[December 26, 1896
©orrjcspondcnce.
OUR LONDON LETTER.
(From our Special Correspondent.)
MEDICAL COUNCIL^VOTING PLUMPING — WRITIXG TO
THE TIMES — DEPUTATION TO THE GOVERNMENT — MR.
ANDERSON — ILLNESS OF MR. MILLER — DOES CANCER
EVER DISAPPEAR? URIC-ACID DIATHESIS — MR. BAN-
CROFT'S READING DR. CULLINGWORTH'S COSTS.
London, December 4, 1896.
Voting for the medical council has been going on
all the week and no papers will be received after to-
morrow. It is generally considered strange that the
council should have met a few days before the elec-
tion. Some say that this was because no change could
possibly affect its decisions. On some points this is
true; but when, as has happened, a majority of one or
two has occurred, this explanation fails. Some go so
far as to assert that the time was chosen expressly to
prevent the influence of the profession from penetrat-
ing the council chamber.
The result of the election will not be declared for
some time.
The council prolonged its session over the Monday
and Tuesday of this week, and was called upon to con-
sider an electioneering card of one set of candidates.
This was signed by Prof. Victor Horsley, and stated
that " plumping is not permitted," the object evidently
being to induce electors to vote for the three candi-
dates of whose committee he is chairman. Mr. Riv-
ington, who is running alone, called the attention of
the council to this erroneous statement. There are
three vacancies and the electors may vote for one or
two or three candidates. If he initial only one name
it is counted as one vote for that candidate, and so far
favors him over any other two. Tliis is plumping.
Mr. Horsley says it is only one form of plumping and
that another is what he aimed at, viz., recording three
votes for one candidate. Even if this interpretation
be admitted, his logic is sadly at fault; for it amounts
to saying one form is inadmissible, therefore all forms
are. The council declined to intervene and left the
candidates to settle their several proceedings. Mr.
Horsley wrote to The Titiics a defence of his use of
the word, but was of course promptly answered. I do
not think the appeal to T/ie Times will commend this
move to his professional brethren, and every one I have
spoken to on the subject disapproves the proceeding
and disagrees with his interpretation of the word
plumping. I regret the introduction of electioneering
tactics into this appeal to the profession to choose
representatives.
The council resolved to ask the president of the
local government board to receive a deputation on
the subject of the irregular registration of deaths, which
is too prevalent and constitutes a public danger.
There was a full debate on Monday on the multipli-
city of examinations and the subject must again de-
mand attention, having been referred back to the
examination committee.
The question of assisting Mr. Anderson in defend-
ing his rights came up, but the council did not see its
way to devote any of its funds to this purpose. Penal
cases and dental business received considerable at-
tention.
On Tuesday, the last day of the meeting, Mr. Mil-
ler, the clerk, was seized with paralysis, and arrange-
ments were made to give him leave of absence and to
provide for the work of counting the voting-papers
and completing the election. The retiring members
were complimented on their services.
Does cancer sometimes disappear, and if so under
what conditions? The question is not perhaps un-
deserving of consideration. On I-'riday, the 27th ult.,
Mr. Pearce Gould showed at the Clinical Society meet-
ing a woman, aged forty-three years, who was admitted
to the cancer ward of the Middlesex. Hospital in Janu-
ary, 1892, for a painful lump in the left mamma. There
was a history of a blow several years previously. In
1888 she noticed a lump, which grew till 1890, when
the amputation had been performed. In 1892 a lump
in the left axilla was removed. In February, 1S94,
lumps in the scar of the first operation appeared and
also one above the right breast. All were removed, but
in December small lumps came round the scar, and
difficulty of breathing was felt. In March, 1896, there
were great dyspnoea and cough with expectoration,
which once or twice was tinged with blood. Death
was daily expected. There w'ere a number of hard
tubercles near the scar, just such as are seen in sec-
ondary recurrences in the skin, and masses of enlarged
glands in the left axilla and o\er the clavicle. Tliere
was a large growth, apparently bony, an inch below
the left trochanter, and further deposits. She was
thought to be in the last stage of malignant disease.
Nevertheless in June the lumps, except one tiny
nodule, had all gone and the dyspnoea had disap-
peared, as well as the growth on the femur. The
history of this case is just that of mammary scirrhus
up to the unexpected change for the better. This his-
tory was confirmed by Dr. Collins, and microscopists
had reported specimens to be typical. Mr. Powlby
said he had no doubt the case was cancer which had
spontaneously disappeared, and mentioned a case he
had seen which is now apparently undergoing the same
process, having subsided to the extent of nine-tenths.
Mr. Golding Bird reported a case of sarcoma of the
testicle operated on three )'ears ago with recurrence
but subsequent subsidence, the patient being now quite
well. Mr. Makins -said he had met with more than
one case of sarcomatous growths wliich had spontane-
ously disappeared.
Uric acid has long held its place as one of the most
troublesome substances to both patients and doctors.
No one has of late studied it more diligently than Dr.
Haig. He has written and said so much upon it that
some have spoken of his " craze" about it. A friend
of mine once said he would never come to an end of
his suggestions, was in fact interminable and there-
fore insupportable. If you suppose that Dr. Haig finds
the uric-acid diathesis at every turn, you are greatly
mistaken. At the Medical Society meeting last week
he denied that any such diathesis exists. 'I'he excess
of this acid which often exists in our bodies is intro-
duced with the food. He cannot deny that some is
normally present and this amount he puts at one to
thirty-three of urea, which ^^ill not produce symptoms,
but as soon as that proportion is exceeded we may
expect them. The regulation of the diet should be
the natural treatment, but the exclusion of everything
that may increase the formation of the noxious acid
requires a more rigid restriction tlian is easily toler-
ated. Then even under the most careful effort symp-
toms which Dr. Haig would certainly attribute to uric
acid are apt to appear, suggesting to me that, if his
views can be substantiated, some modification of nor-
mal metamorphosis may produce in excess that which
is always present to some extent. In the discussion
on Dr. Haig's paper Dr. Fortescue Fox recalled the
fact that children always have a large amount of the
acid, even on the plainest diet, and held that we should
distinguish between acid dependent on diet and that
due to a tendency to excessive formation. Dr. Vaughan
Harley enlarged this argument by the statement that
while all children pass more than adults in proportion
to body weight, the amount decreases as the age in-
creases. He asked if any evidence could be produced
December 26, 1896]
MEDICAL RP:C0RD.
937
that a heallliyold man passed more than a \oiiiig one.
He referred also to leucocythamiia, in wliich the amount
is quadrupled : also to malignant liver disease, in which
excess is an important indication. Dr. Ewart held by
the prevalent view that acid is formed in the body, the
quantity not being constant for all persons, and in the
gouty there being excess. Dr. Freyer asked how, on
this hypothesis, we could explain the prevalence of
stone, etc., in India and among the tribes living on
pulses. These and some other difficulties in the wav
of his hypothesis will no doubt occupy Dr. Haig's
attention.
The cancer ward of the Middlese.x Hospital has
benefited to the extent of ^^300 from Mr. Bancroft's
reading of a '"Christmas Carol" on behalf of this
charity.
A subscription has been started to reimburse Dr.
Cullingworth the heavy costs incurred in his defence
against the action of the nurse, which the jury declared
ought never to have been brought. Nevertheless. I
hear he is threatened with further litigation. The
appearance of Sir S. Wells in the action is generally
regretted. I would suggest that he might hand his
fees to the defence fund.
OUR CANADIAN LETTER.
(From our Regular Correspondent.)
THE Kt.MALE BICYCLISTS IN CANADA — DEATHS OF
PHYSICIANS FROM SEPTIC/EMIA BRITISH MEDICAL
ASSOCIATION MEETING — MEDICAL SCHOOLS.
Canadian readers of the Medical Record (and they
are many) were somewhat amazed to notice in a recent
issue an editorial on ''Immorality in Canada." The
startling statement had been made in an advertising
venture, which, to the disgust of every one, presumes to
style itself a medical journal, that cycling, instead of
adding to the health and the beauty and the charm of
women in Canada, was indulged in as '" a means of
gratifying unholy and bestial desire." The Medical
Record did well to say that it hesitated to believe
such a report. Probably the slanderous anicle would
not have been read by half a dozen had not attention
been thus directed to the calumny on Canadian wo-
men. The source from which the slander emanated
would deter any Canadian journal from noticing it.
The conclusion arrived at by the Medical Record
that our women are "victims of a contemptible slan-
der" is correct. Canada has reason to be proud of
her robust daughters, and to them cycling has proved
a healthful and benign exercise. To Canadians it is
both a surprise and a shock that any one would pub-
lish such an infamous libel as that to which the Med-
ical RKt:i)Rii has justly called attention.
Another well-known Canadian practitioner died
recently in Toronto from septicemia contracted in the
discharge of duty. Two weeks before his death Dr.
R. J. Hastings, in endeavoring to assist a nurse to ad-
minister medicine to a sick child, had his finger bit-
ten. For four days no notice was taken of the injury,
but on the fifth symptoms of blood poisoning were
apparent. While every method was resorted to to
avert a fatal termination, all elTorts proved unavailing.
Three well-known members of the profession in Can-
ada have lost their lives within a year from some
such slight injury afterward terminating in septicae-
mia. Dr. Hastings was a much-respected, faithful, and
energetic worker, and his untimely death under such
peculiarly sad circumstances is more than generally
regretted. Death has also removed two other widely
known Canadian medical men lately, in the persons
of Dr. Ridley, of Hamillow, Dr. D. Bergin, M.P., of
Cornwall, and the Hon. Dr. Ferguson, of Niagara.
Already considerable interest is taken in the foith-
coming meeting of the liritish Medical Association at
Montreal. The profession in that city is now well
organized, and while it is intended that the meeting of
the association shall not be regarded as a local event,
but rather as a welcome from the members of the med-
ical profession throughout the whole dominion, the
success of the gathering will in some important par-
ticulars depend upon the energy and zeal of the medi-
cal men in Montreal. No one doubts their willingness
and ability, and consequently none doubts the success
of the meeting. The executive committee which has
been appointed embraces the presidents of the Do-
minion and Provincial medical associations, and the
attendance is likely to be the largest in the history of
medical gatherings in Canada. The members of the
Piritish Medical Association who shall cross the Atlan-
tic, many of them for the first time, will receive a cor-
dial welcome from the whole Canadian profession.
The executive will experience some delicacy in urging
medical men from the United States to attend the
meeting, as such an appeal might be misconstrued by
those desirous of promoting the success of the Inter-
national Aledical Congress at Moscow. There is
positively no desire to promote a rival international
meeting. The British Medical Association meeting is
an annual event, and, it having been decided that the
ne.xt one shall be held in Canada, there should be no
suggestion of any intention to detract from the greater
meeting at Moscow. Unfortunately, so Canadians
consider, none but British subjects can gain member-
ship in the dissociation, but, as at every meeting there
is always a number of guests present, the leading
American authorities in the different departments of
medicine w-ill doubtless be invited to be present at
Montreal. Many Canadian members will regard the
forthcoming meeting as an excellent opportunity for
reciprocating in some measure the kind and courteous
treatment they have always received when they have
had the privilege of being present at any of the great
medical gatherings in the United States. The date
of the meeting will be the last week in August.
The attendance of students at the different Canadian
medical colleges indicates that the five years' course
is not likely to prevent many from entering the medi-
cal profession in Canada. In addition to attending
college for five years, six months in each year, it is
now imperative that each student sliall take one sum-
mer session. In some quarters there is a feeling that
four sessions of eight months would be productive of
better results, but is it most unlikely that any change
will be made, now that both colleges and students have
adapted themselves to tlie change. The matriculation
examination which must be passed by everyone before
commencing the college course in medicine has grad-
ually been made more exacting, until the present stand-
ard renders a complete liberal education necessary for
every matriculant.
The large towns in Canada are gradually recogniz-
ing the necessity of having hospitals, and the number
of such institutions which have been erected in the
smaller towns during recent years is a pleasing evi-
dence of the appreciation of the public, and a recog-
nition of the fact that in a properly equipped hospital
at home fully as good results may be obtained as by
resorting to the larger cities. There is also pleasing
evidence that in Canada there is a growing recognition
that money expended in equipping these institutions
with every facility for asepticism and antisepticism in
the practice of medicine and surgery is likely to yield
results beyond computation by the ordinary rules of
every-day commerce.
The Best Work done by physicians is never paid
for and can never be paid for.
938
MEDICAL RECORD.
[December 26, 1896
ABDOMINAL SECTION STATISTICS.
To IHK KuiruKOK THK MeDICAL ReCOKL>.
Sir: In the Medical Record for December 12, 1896,
Dr. Savidge compares certain hospital statistics of ab-
dominal-section cases, and then quotes some statistics
of Pean, Jacobs, and of mine, giving in the context
the idea that such statistics mean selected cases and
refusal of operation in desperate cases. This idea
must be corrected in its reference to my appendicitis
satistics. I have operated upon every recognized case
of acute appendicitis that has come into my hands,
with one exception. That was a case with advanced
complicating disease of the iieart and arteries, which
I saw in consultation with Dr. Judson C. Smith last
year. Dr. Smith thought that the patient could not
bear the anaesthetic and I accepted his judgment.
Some of my patients were pulseless and moribund.
In some cases pus ran over both sides of the table
when the abdomen was opened. Some patients had
general septic or suppurative peritonitis. Sometimes
I found patients dead when we arrived at their homes.
The only cases that I have refused to operate upon
were mild acute cases, in which there was doubt about
the diagnosis, or mild chronic cases, in which it did
not seem wise to operate at just tiie time when the cases
were examined. My series of one hundred consecu-
tive unselected appendicitis operations with a mortal-
ity rate of two per cent., quoted by Dr. Savidge, was
published for the single purpose of establishing the
importance of certain principles in treatment. The
character of the cases making up the lifct can be de-
termined by any one who will step into a lil)rary and
ask for the second edition of my book on the subject.
I do not know how many cases of appendicitis I ha\e
operated upon. Their histories are all recorded in
full in a special book at my office, and any responsible
member of the profession is at liberty to come in and
count them if he wants to. It is not a matter of in-
terest to me, this score of numbers, but the principles
involved in the treatment are of consequence. Dr.
M. M. Johnson, of Hartford, at the last meeting of
the American Medical Association reported on a sim-
ilar series of one hundred consecutive appendicitis
operations of his own with a mortality rate of two per
cent. The principles which he employed are ones
which would give a very small death rate in unselected
cases. Robert J'. Morris, M.D.
49 Wes'i Thirty-Ninth Strekt, Ne\v York,
December 12, 1806.
HYPNOTISM, AND WHAT IT SIGNIFIES.
To THE Editor of the Medical Record. '
Sir: Probably if you selected ten men to-day from
vour acquaintance, choosing only those who were a
little better read, a little better educated than tlie rest,
and asked these ten severally pointblank what the
word hypnotism meant, they would answer without the
slightest hesitation : " A certain sleep state of the in-
dividual, caused by, or induced by, suggestion from
within or from without, in which state the individual
is unconscious of his actions and becomes an autom-
aton." They might add, if they had ever taken the
trouble to peruse modern English literature upon the
subject, that hypnotism tended to weaken the will of
the subject, and, if persisted in, would indubitably re-
sult in insanity or crime.
It is perfectly amazing that such an impression of
a simple, natural, and universally applied therapeutic
agent should have become so firmly established in
men's minds, and be so difficult to uproot. But argu-
ment is of no avail against popular prejudice, and the
p-ople will probably continue for another century to
regard the word "hypnotism'' with dislike, if not with
horror. It is unfortunately true that for one person
who will take the trouble to investigate the plienomena
of effect, there are fifty who do not trace the effect
back to the cause at all, but are content with an as-
sumption of fact as a basic truth. Within the past
three months, however, it has become very clear to
me that physicians in the West are not only willing
but anxious thoroughly to sift the question for rr
against the employment of hypnotic suggestion as an
honorable ally in therapeutics, and from the tenor of a
recent article which appeared in these pages upon the
subject of mental therapeutics I gather that the ten-
dency in the l^ast also is to investigate. It has always
struck me as very curious, in looking over works upon
this science written by medical men, that they invari-
ably make mention of the fact, either in their prefaces
or elsewhere, that they are pleased to note the change
of attitude on the part of the profession toward this
science of hypnotism; that whereas forty years ago it
was publicly ridiculed and denounced, to-day phy-
sicians everywhere recognize it as a valuable auxiliary
in medicine. This is all very pleasant and gratify-
ing, laut I doubt if hypnotism has won its way to the
toleration, much less to the favor, of the profession.
I believe the chief obstacle to its popularity is the
erroneous impression which is abroad in the land that
a jserson is not hypnotized unless he is either sound
asleep or in a somnambulistic condition. James
Braid performed all his experiments upon somnambu-
lists. Dr. Charcot knew only three stages of hvjjiiosis,
and produced them only in acti\e .sonniambulists.
Dr. Ksdaile, the English surgeon, induced a state of
coma in his Hindoo patients which carried with it a
complete anaesthesia, and may be classed as one of the
]>rofound stages. The " professor" who gives public
entertainments works his vulgar effects by means of
subjects in the somnambulistic condition, and the
whole trend of thought upon this science is to exalt
the more profound stage of hypnosis as .something to
be aimed at, and entirely to neglect the greater value
of the lighter stages. I am not alone in thinking that
the exhibitions of hypnotism as presented by the pub-
lic professor should be put a stop to, but as an evil
onlv needs a little legal severity to insure its popular-
ity, I would suggest that a better way to attain the end
desired would lie to remove the element of mystery at
present surrounding the subject, and show the people
that there was really nothing very extraordinary in the
performances which so delighted them. Once remove
the general belief that these subjects are compelled to
do certain foolish feats against their will, and the
entertainment would lose its flavor and the " profes-
sor" his patronage. The general public does not read
books upon hypnotism, but it does go to see the "pro-
fessor," and from him it gets the idea that hypno-
tism is a power, a force, which few can exercise, and
which converts an entirely w ide-awake individual into
an irresponsible somnambulist. Most physicians (not
all, by any means) know now that no one can be hyp-
notized against his will, but ver)- few would admit the
truth of the contention that a state of light hypnosis
is of greater therapeutic advantage in the relief of
nervous ailments and functional derangements than
the condition of somnambuli.sm : in other words, that
it is better for the patient to be merely passixe and
drowsy, becatise the fact that he does not upon sug-
gestion go into a condition of somnambulism, in which
sense delusions are instantly accepted, siiows that he
is not of such an imaginative nature as the one who
does, and also shows that when he thoroughly under-
sands the significance of his treatment he will be less
likely to relapse, because less likely to yield to the
adverse suggestions of others, or to his own doubting
auto-suggestion. This fact has been well illustrated
at the Chicago School of Psycholog}'. Active som-
December 26, 1S96]
mi:i)I(:ai. rfxord.
939
nambulisls are of two classes — the very weak and the
very strong. The latter are rare, indeed, but you will
occasionally find a man who has such perfect com-
mand of himself that he can permit himself to accept
sense delusions as real in a self-induced state of hyp-
nosis. The great mass of mankind, however, is not
somnambulistic, but if put in a state of light sleep, or
in a drowsy restfulness, most men could be greatly bene-
fited by suggestive treatment. So simple a thing is this
hypnotic influence that the mother who rocks the cradle
of her baby at night hypnotizes the child. She sug-
gests sleep, and her monotonous singing has the same
effect as the monotonous suggestions of the operator
that "the eyelids are getting heavy," a "feeling of
sleep is coming over you," etc. But at this point
most operators stop; and if they cannot induce sleep
in a patient, with evidences of catalepsy to follow,
they give up. .\s a matter of fact, hypnosis is merely
a state of exalted receptivity of the brain, due to close
attention to one thing for a certain length of time, and
does not depend upon sleep for its existence, but may
be accompanied by sleep. Hence the foolishness of
giving up suggestive treatment merely because the
patient does not slumber will be very apparent. It is
enough for the physician's purpose if his patient keeps
his eyes shut for ten or fifteen minutes, and listens
attentively to the suggestions given him. The cure of
any complaint is due to the force gathered from the
repetition of such suggestions upon the patient's mind.
If not to-day, then to-morrow; if not to-morrow, then
the next day. Persist in the treatment, remembering
that the gradual cure in which you have the assistance
of the patient's reason and auto-suggestion is the per-
manent cure. Sidney Flower.
Chicago. December 12, iSu6.
ANGINA PECTORIS (STENOCARDIA).
I'o THE Editor ok the Medical Recoki*.
Sir: May I ask you to correct some errors and omis-
sions in the report upon my paper on the above sub-
ject, on page 866, of December 12th. I am made to
say : "■ Even microscopically we could not always recog-
nize changes in the heart at post-mortem." I said:
■■ Macroscopically we failed even at the post-mortem,
and only the microscopic investigation, in many cases,
furnished evidence of change in the coronary arteries."
Under the heading of " treatment," I am made to say :
" The potent factors were to unload the congestion of
the liver and spleen by calomel and salines, and
strengthen the heart by saline baths and exercises,
etc." I tried to call attention to the fact that the blind
use of peripheral dilator drugs, such as nitroglycerin,
nitrites, etc., did little good so long as the internal
viscera remained congested and could fill up the
peripheral vessels immediately the above drugs had
ceased to act. It seemed to me like a game of tlie
veil-known story " Box and Cox"' between the loaded
viscera and the loaded peripheral vessels.
The proper treatment is to unload the congestion of
the internal viscera by calomel and salines, and then
to resort to the peripheral dilator drugs, such as nitro-
glycerin, etc. Immediately your congestion is relieved
internally and peripherally, you maintain the equilib-
rium by using cardiac stimulants, sparteine, strophan-
thus, digitalis, etc., and general tonics.
Now with the aid of the saline baths and exercises
after the Schott method, we can secure results which
act to relieve the superficial or peripheral conges-
tion, coincidently directly stimulate the heart muscle,
and improve the entire tissue metamorphosis. It was
to the sequence of the treatment that I attached the
greatest importance.
H. Xewio.s- Heinema.v, M.D.
IS IT POSSIBLE?
Til the Kli roi; ok -ihe Meuicai. Rkcokd.
Sir: Will some one of your many readers inform n\e
through the Medical Record's columns whether im-
pregnation within twenty-four hours of childbirth is a
possibility? A fellow-practitioner has just related to
me an instance in which a German woman married to
an lalian bore a second child eight months after the
first, or two living children, at what seemed to be full
term, within a period of seventeen months. Upon inves-
tigating the occurrence, my informant w as led to believe
from statements made that impregnation had taken
place upon the very night of the first delivery. There
is an old proverb believed in France — if nowhere else
--that r Allcmand Halianisc est Ic diahle mcanic. If the
report as above detailed is true, then a new proverb
should be made to fit the Italian (Germanized by hyme-
neal bonds. The latter portion of the proverb can
stand as it is.
I. N. Vestigaior.
ITtXedical Items.
Contagious Diseases — Weekly Statement Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending December 12, 1896:
Tuberculosis
Typhoid fever
Scarlet fever
Cerebro-spinal meningitis,
Measles
Diphtheria
Small-pox
Deaths.
99
3
7
3
6
33 ■
Patent-Medicine Making Exclusive of those con-
nected with the advertising department, a numerous
branch, and the stockholders in such of the concerns
as are incorporated, ten thousand men are engaged in
the patent-medicine manufactories of the United
States, receiving collectively more than $4,000,000 a
year in salaries and wages. There are eight hundred
and fifty such manufactories, ranging in importance
from those which flood the American and the foreign
market with proprietary medicines, as they are tech-
nically called, down to the small laboratories or bot-
anist shops, in which some particular herb or root is,
in a grudging and primitive manner, supplied to such
])ersons as may have heard of its eflicacy. The par-
tiality of Americans for patent medicines is well
known, and doctors — who don't usually agree — agree
in declaring that the true reason of the extensive use
I if such medicines in the I'nited States is to be found
in the fact that dyspepsia is a general ailment, and
that persons suffering from dyspepsia are prone to be-
lieve that they ha\e some other ailment. Thus they
become patent-medicine patrons under conditions that
recall the memorable remark of Col. Mulberry Sellers,
the sanguine speculator, who. in describing the bene-
fits of the "Oriental F.ye Water," the sale of which he
believed would enrich him, declared that the more of
it peojDle used, the more of it they would need, and
hence the sale once started would constantly increase.
Many of the patent medicines sold, if not, indeed, a
majority of them, do not come under this description,
for they are merely compounds, in pleasant form and
in palatable shape, of drugs and medicine.5 in constant
use by physicians, and found efficacious in what is
called general practice. Though it didn't use to, .New
940 MEDICAL
York City now stands at the head of the cities of tlie
United States in the manufacture of patent medicines,
with eighty-five factories, giving employment to one
thousand persons at aggregate wages in excess of
$700,000 a year. Philadelphia comes second, St.
Louis third. New Haven fourth, and Lowell fifth. In
proportion to its population Lowell is the American
city which is most deeply interested in patent-medi-
cine manufacture. After Lowell comes Chicago, a
poor sixth. It is a somewhat peculiar circumstance
that though enormous quantities of patent medicines
are sold in the South, and the ingredients for their
manufacture come very largely from that section, few-
patent medicines are made in the South, though New
Orleans and Atlanta do a little in this line. The city
of Baltimore seemed likely a few years ago to attain
prominence in the manufacture of patent medicine,
ijut recently it has fallen back on the list, while the
city of Boston has been pushing steadily ahead.
Providence is another New England cit>' which is
largely represented in the manufacture of patent med-
icines. In New York State two other cities so repre-
sented are Buffalo and Rochester. In the West, out-
side of Chicago, St. Louis, and Cincinnati, the city
which does the largest business in patent medicines is
Grand Rapids, Mich., and Peoria does a little in this
line, but not very much. The exportation of Ameri-
can patent medicine is increasing, but the manufac-
twrers continue nevertheless to appeal, with the greatest
confidence, to the home market. — The Si/n.
More than One-Third of the people of this country
live in cities and more than half the doctors are there
too.
Himself to Blame.- If the Paris physician finds
himself with a decreased patronage he has only him-
self to blame for constantly advocating hygienic meas-
ures, supporting Pasteur laboratories, and the like.
"The Sanitarian" gives the following mortality
figures :
Deaths Caused by 1885-1889. 1800-1895.
Small-pox 1 .271 655
Scarlet-fever 1,225 94f>
Measles ^f>7i 5.:92
Diphtheria 8,383 7.588
Typhoid fever 5.9°? 3.493
Surgical Cleanliness and Surgical Handicraft.—
We know that nowadays our practice is based on sound
principles. If care and cleanliness be exercised, no
region of the body can be violated by the surgeon's
knife; no limit can be placed to the possibilities of
eradicating or ameliorating disease. The prevention
of death is the aim of our science; and it is the glory
of modern surgery that it has advanced in this direc-
tion beyond the dreams of even the most sanguine
prophets of a past generation. We know that no
wound made deliberately in healthy tissues ought to
suppurate. If it does so, the defect lies in the sur-
geon's hands — literally and not figuratively; and at
his door must be laid the graver charge of surgical
disaster. " Godliness is next to cleanliness" — in other
words, the most important factor in surgical success,
when dealing with the life or limb of your patients, is
— cleanliness. Syme long ago expressed a grave truth
in forcible language when he observed that " a probe
in the hands of a careless surgeon was as dangerous
as a loaded pistol in the paw of a monkey;'" and we
might say conversely that tiie paw of a monkey would
be a source of less danger in a wound than the dirty
hands and instruments we unfortunately still some-
times see employed. The surgeon who neglects know-
ingly the precautions imposed by scientific investiga-
tion as regards cleanliness is as blameworthy as the
fool who smokes a cigar in a powder magazine. No
RFX'ORD.
[December 26, 1896
sophistry or special pleading can free him from blame
if the appalling catastrophe of death is the result of
his ignorant carelessness or culpable neglect of essen-
tial principles. Therefore, above all things, let your
iiands be clean. It will be part of our effort here to
so instill into your minds the principles of wound
treatment that fatal results will be, humanly speaking,
impossible; and to endeavor that the gospel of surgi-
cal cleanliness will become before you leave these
walls an ingrained part of your being — an instinct
that time can neither impair nor destroy. "Cleanli-
ness is Godliness;" and, to put it on no higher basis,
for your own sakes remember that, according to Scrip-
ture, " Godliness is great gain.'" — Dr. R. Glasgow
Paiteson, IVic Dublin Journal of Mnliuil Sriencr,
November, 1896, p. 435.
Herpes Gestationis. — Drs. Fournier and Cannet (I.a
Matccine Moderne, March 14, 1896) presented a pa-
tient, aged thirty years, affected with herpes. She
was attacked in the course of an eighth pregnancy.
The eruption showed itself in the second month of
pregnancy, being, as is usual, polymorphous. Of the
seven previous pregnancies, the first four progressed
without cutaneous manifestations. In the course of
the fifth, sixth, and seventh pregnancies the affection
showed itself with variable intensity. Actual obser-
\ation shows the fourth relapse of this disease.
Apples. — A Brooklyn physician translates the fol-
lowing from a German writer: "The apple is such a
common fruit that few persons are familiar with its
remarkably efficacious medicinal properties. Every-
body ougiit to know that the very best thing he can
do is to eat apples just before going to bed. The
apple is excL-lIent brain food, because it has more phos-
phoric acid, in an easily digestible shape, than any
other fruit known. It e.xcites the action of the liver,
promotes sound and healthy sleep, and thoroughly
disinfects the mouth. It also agglutinates the surplus
acids of the stomach, helps the kidney secretions, and
prevents calculus growth, while it obviates indigestion
and is one of the best preventives of diseases of the
throat. Next to lemon and orange, it is also the best
antidote for the thirst and craving of persons addicted
to the alcohol and ojiium habit."
Irregularity in Delivery Due to Short Umbilical
Cord. — Dr. (iuido Bell {Indiana Medical Journal, No-
vember, 1896) gives the following rhumd : A short
umbilical cord may be the cause of delayed or of has-
tened labor during any stage of birth, but delayed
labor is more frequent in the second stage, and has-
tened labor often at the beginning. The symptoms
of brevity are: i. Secondary or dragging pains. 2.
Localized tenderness of the womb,
retreating head.
An elasticallv
Spermatorrhoea is a frequent symptom in neuras-
thenia. Most frequently it depends upon a peculiar
hereditary irritability of the cerebrospinal axis.
When occurring during the act of micturition, it may
come on independently of any pathological seminal
loss, and may have as an occasional cause a blennor-
rhagic urethritis. Occurring during defecation, as it
frequently does, an occasional cause may be and prob-
ably frequently is the simultaneous contraction of the
seminal vesicles and the rectum, aided by pressure of
the abdominal muscles. Since impotence often ac-
companies this form as well as that which is prodro-
mic of tabes, the latter condition must be looked for.
It is rare for neurasthenic spermatorrhoea to reach an
advanced degree. Usually the symptoms improve un-
der proper treatment. — Goldspiegki., Thhe de Paris,
1896, No. 526.
INDEX
Abdomen, best method of closing, after
laparotomy, 455; contusions of the,
532: fissure of the, 725; gunshot
wounds of the, 16, 901; obscure lesions
within the. 3S8.
Abdominal cavity, drainage of the, 2S3.
Abdominal disease, deceptive similarity of
signs and symptoms of, 524; in chil-
dren, rectal examination in the diag-
nosis of, 305.
Abdominal section, need of, in diagnosis,
7S2; on a new-born infant, 912; pre-
vention of hernia after. 799; statistics
of. 938.
Abdominal surgery, cleansing and cleanli-
ness in, SS3 ; report of cases in. 338.
Abortion, curettage as a means of inducing,
630; indications for the induction of,
16; induced, and perforation of the
uterus without peritonitis, 246; treat-
ment of, 175, 650.
Abrahams, R., rheumatismus neonatorum,
547.
Abscess, how to open an. 319; retropharyn-
geal, 629; subphrenic, 391; treatment
of acute, 513, 646; treatment of tuber-
culous. 647.
Accident insurance policies, the law con-
cerning, 377.
Acetanilid, 250.
Achiliodynia, 52.
Acne, treatment of, 306.
Acrocyanosis. 457.
Acromegaly, 779.
-Addison's disease, congenital absence of
the suprarenal capsules in, 422,
Adenitis, cervical tuberculous, removal of
glands without visible scar, 155.
Adulteration, report of the British commit-
tee on, 35S.
Aeroporotomy, an impossible word, 18.
Aged, diseases of the, a specialt}', 610.
Ager, Louis C, narcotine in malaria, 174.
Agnew, W. P., notice of book by, 203.
Aiken, S. C, as a winter resort, 654.
Air passages, bacteriology of the, 36.
Alabama, health resorts of, 655.
Albuminuria, physiological, 612; prognosis
of, 423; treatment of some forms of,
by renipuncture, 661.
Albuquerque, N. M., as a winter resort, 65S.
Alcohol, a physician's right to withhold,
3S1.
Alcoholism, 393; ammonia in, 451; in
France, 763; in relation to insanity,
592; in relation to suicide, 569.
Alexander. I,. S., snake bile for snake
bite, 355.
Alexander, Samuel, radical treatment of
prostatic enlargement by prostatotomy,
841.
Alexander's operation, new method of fas-
tening the round ligament in, 534.
.\lienists and Neurologists, French Con-
gress of, 457.
Alimentation, subcutaneous. 612.
Allbutt, Thomas Clifford, notice of book
edited by, 491.
Allen, Chas. W., what shall we do with
the leper? 695.
Allen, F. H., cyck'pia, 249.
Allen, Hull, death of, 3S0.
Allingham, William and Herbert, notice
of book by. 165.
Allis, Oscar H., notice of book by, 383.
Alopecia, treatment of, 31.
Aluminium, non-toxic properties of, 717.
Amenorrhoea. remedy for, 502.
American Association of Obstetricians and
Gynecologists, 525.
American Dermatological Society. 492.
American I.aryngological Association, 93.
American Medico- Psychological Associ-
ation. 244.
American Microscopical Society. 308.
American Neurological Association. 59.
American Orthopedic .Association, 21.
.American Public Health .Association, 497.
Amniotic sac. supplementary, with fibroid
of the uterus, 351 ; time to rupture the,
912.
Amputations. 319; irritable stump after,6(X).
.\myl nitrite, poisoning by, S16.
.Anrvmia, discussion on, 273: in cardiac
disease. 852. SO5; pernicious, 134; per-
nicious, the blood in, 745; pernicious,
treatment of. 713; primary pernicious,
348; rachitic. 350; splenic. 69.
-Anaesthesia by chloroform, 630: during
sleep, .S39; jubilee of. O35; local. 174,
175, 249; oxygen in, 419, 431; paraly-
sis following, 424, 558; the discoverers
of, 76S.
Anaesthetics, antiquity of. 68; deaths from.
174; ether and o.xygen as, 373.
.\nastomosis, intestinal, 6S. 209, 313, 469.
797, S29; uretero ureteral, 872.
Anatomy an explanatory science, 766.
Andre, Orrin C, safety attachment for
thermometers, 143.
.\neurism, dissecting, 170: multiple miliary,
of the left anterior cerebral artery. 345;
subclavian. 429: thoracic, .x-rays in
the dmgnosis of, 793.
Angina pectoris, ? sympathetic neurosis.
447: nature of, 6S0; of Bright's dis-
ease. 424.
Anglo-American Continental Medical So-
ciety. 336.
Animal diseases and animal food, report of
the committee on, of the American
Public Health Association, 49S.
Animals, ideative faculties and self-con-
sciousness in the lower. 42.
Antimony terchloride in epithelioma of the
face, 50.
.Antisepsis and asepsis in genera! practice. 59
Antitoxin of diphtheria. 25. 58, 462. 596: a
possible effect of, 390; cause of sudden
death after the use of, 712; isolation of
the, 641; phenomena consecutive to
the use of, 421 ; poisoning by, 460; re-
port of the .American Pediatric Society
on, I, 17; second coliective investiga-
tion of the American Pediatric Society
on, 574; use of, in .\ustria, 596; use
of, in Berlin, iSi, 919.
Antitoxins, the therapeutic action of, 533.
Antivenin. 687.
Antivivisection extremism, 54; legislation,
127: legislation, protest against, 560.
Antrum, empyema of the, 42S.
Anus, artificial, transperitoneal treatment
of, 731; common diseases of the, 521.
Aorta, double, 170; rupture of the, 171;
spontaneous rupture of the, 794.
.Apex catarrh simulating nasal trouble, 206.
.Aphasia, motor, 606; uricmic, 44S.
-Appendicitis. 304: and peritx-phlitis, S56;
as it affects life insurance risks. 253;
chronic. 566; comment on Dr. Morris'
paper on, 910; complicating pregnancy,
461, 831; controversy concerning, 215.
358. 466, 569. 729; following family
lines. 3S7; hydrogen dioxide and saline
solution in operations for, 211; latent,
metastatic abscess from, 637; masked.
315, 380; notes on, 924; perforative,
followed by general fecal peritonitis.
63S; resemblance of acute catarrhal
salpingitis to. 735: secondary operation
for extensive adhesions, T32: surgical
treatment of, 311; treatment of. 904:
types of. S(i9; when to operate, 508, 534.
.\ppendix. a pin in the. 134; empyema of
the. 672; measurements of the, 104:
surgical rest for the, 105: use and dis-
ease of the. 598.
.Apples, medicinal properties of, 940.
.Appointments, unfairness in. 786.
Arizona, health resorts of, 658.
Arkansas, health resorts of, 657.
Army, British, medical service in the. 102,
503. 524. 729.
Arteries, catheterism of. 828; closing
wounds of, by suture, 68, 629.
Arthritis deformans, 562.
Arthritism. diabetic, dosage of alimentation
in, 423.
Artman, Milton E.. death of, 634.
Ascaris lumbricoides, 250.
Ascites, differential diagnosis of, 92S.
Aseptic surgical technique, 903,
Ashe\-i!le, X. C, as a winter resort, 653.
Ashmead, Albert .S. , a proposed congress
of leprologists, 466, 764; beriberi twelve
thousand feet above the sea level, 177.
Asthma, classifications of, 650; formula
for, 463; spasmodic, 249.
Atlanta, Ga.. as a winter resort, 654.
-Atheroma, relation of. tosj-philis, 16.
-Auditory hallucinations, 457.
-Augusta, Ga., as a winter resort, 654.
-Auscultation, improved instrument for, 103.
Auscultatory percussion, 56S.
-Austin. Tex., as a winter resort. 657.
Auto-intoxication of gastrointestinal ori-
gin. 57-
-Ayers, Edward -A., symphyseotomy, 368.
B
Babcock, Warren L., a contribution to the
study of acute delirium, with special
reference to its bacteriology, 156.
Hacterial products, 2S3.
Bacteriology, hygiene, and medicine, 755.
Bacteriuria, 22S.
Baginsky, -Adolf, notice of book by. 201;
the antitoxin treatment of diphtheria
in the Kaiser and Kaiserin Friedrich
Children's Hospital in Berlin, and Dr.
Winters' observations thereon. i3i.
Bailey, Pearce. the effect of early optic
atrophy upon the course of locomotor
ataxia, 710-
Baker, Morrant, death of, 645.
Balderdash, definition of, 465-
Baldwin, J- F., a loud heart murmur. 272.
Ball. -A. Brayton. how specimens of urine
may be sent to India for diagnosis. 695.
Balsam of Peru in castor oil as a dressing,
759-
Barnes, W illis. notice of book by, 130.
Barton, Joshua I.indley. diseases of the
trachea, bronchi, and lungs treated by
intratracheal injection. 151.
Bartow, Fla., as a winter resort, 655.
Baruch, Herman B..thephonendoscope.624.
Bashore. Har\ey B., disinfection of the
hands during labor, 207.
Bassini's operation. 57.
Baths, diagnostic value of thermal, 696.
Battle of the clubs. 212.
Bauer. Joseph, death of. 19.
Bay St. Louis. Miss., as a winter resort, 656.
Beal, F. E., strychnine in uterine inertia,
427-
Beaumont. Cal., as a winter resort. 659.
Beck. Carl, a case of hermaphrodism, 135,
694.
Becker, Tracy C. notice of book by. 129.
Bell, Robert, notice of book by, 203.
Bell, Victor C. notice of book by. 165.
Beriberi in Dublin. 763: twelve thousand
feet above sea level. 177.
Berlin, cost of medical education in, 344;
letters from, 2S5, 56S.
Bernacki, Charles, death of, 452.
Bertrand, Leon, a new fluorescent sub-
stance. 86-
Bicvcle. alleged injurious effect of. om
women. 6S1; a physician on the, 557;
for scoliosis. 615; fright, 270; in first
aid to the injured, 55S; sanitary aspect
of, 501.
Bicyclists, advice to, 288.
Biloxi, Miss., as a winter resort, 656.
Bismuth naphtholate, 304.
Bladder, female, cystoscope in the diagno-
sis and treatment of diseases of the,
S35; female, palliative treatment of
cancer of the, 603; removal of calculi
942
INDEX.
[December 26, 1896
from the, S02: rupture of the, 5i3,
759 ; tuberculosis of the, treated by
direct medication, 753.
Bleything, George D., uses of the stomach,
' 145-
Blindness, prevention of, 499.
Blood, diagnosis of tuberculosis from the
morphology of the. 325, 796; diagnos-
tic value of examination of the. 433;
in general paralysis, 4(18; in pernicious
ansemia, 745; in tuberculosis of the
bones, 340; in yellow fever, 793;
preparation of, for microscopical ex-
amination, 2S6, 3S5, 544, 6gf.
Blood-vessels, lesions of the, 16S; suture of
large, injured in operation, 531.
Body snatching, 930.
Boerne, Tex., as a winter resort, 65S.
Boisliniere, L. Ch., notice of book by. 131.
Bond. A. K., diseases of the aged as a
specialty. 610.
Bones, fragility of the, in the insane, 162.
Book Nuiiles:
Anatomie des Menschen, Ilandatlas der,
von W. His, 203.
Anatomy, comparative, text-book of, by
Arnold Lang, 3S4.
Anatomy, descriptive and surgical, by
Henry Gray, 648.
Anatomy, manual of, by I.S.Haynes,3S2.
Anatomy, l^luain's elements of, 202.
Abdominal surgery and other subjects,
clinical lectures on, by Charles T.
Parke s, 130.
Angines couenneuses non-diphtheriques,
par Dr. Dufand, 384.
Autopometria militaire, 202.
Appendicitis, treatise on, by J. B.
Deaver, 202.
Bacteria, pathogenic, text-book of, by
Joseph McFarland, 131.
Bacteriology, text-book of, by George
M. Sternberg, 131,
Blind leaders of the blind, by J. R.
Cocke, 3S3.
Boston City Hospital, medical and sur-
gical reports, 202.
Braithwaite's Retrospect of Medicine, 3S4.
Chemistry, short course of experiment
in general, by Charles R. Sanger. 490.
Children, how to feed, by I,. E, Hogan,
3S4.
Chirurgie ccrebrale, traite de, par A.
Broca et P. Maubrac, 129.
Consumption, its nature, cause, and pre-
vention, by Edward Playter, 165.
Dame Fortune Smiled, by Willis Barnes,
I JO.
Deaf-mutism, by J. K. Love. 130.
Diagnosis, manual of clinical, by C. E.
Simon, 727.
Dictionary, a vest-pocket medical, by
.\lbert H. Buck, 491.
Dictionary, the student's medical, by G.
M. Gould, 201.
Diets for infants and children, by Louis
Starr, ]66.
Dispensatorv formularv, the national,
165.
Electricite, traiteraent des maladies des
femmes par, par L. R. Regnier, 383.
Electricity in electro-therapeutics, by E.L
Housten and A. E. Kennelly, 165.
Electricity, medical and surgical uses of,
by .\. D. Rockwell. 491.
Ethical codes, the three, 202.
Eye, methodical examination of the, by
William Lang, 165.
Fear, by .-Xngelo Mosso, 3S4.
Fievre typhoide, la scrotherapie de la,
par M. Funck, 165.
Formulaire et aide-memoire, par F.
Roux, 3S4.
Formulary of unofficial preparations,
national, 203.
Fundus oculi, by W. Adams Frost, 382.
Germinal selection, bv .August Weisman,
3S4.
Hahnemann's defense of the organon of
r.itional medicine, translated by R.
E. Dudgeon, 3S3.
Head and neck, anatomy of the human,
by Dr. Schmidt, 202.
Hemorrhoids and other non-malignant
rectal diseases, by W. P. .\gnew,203.
Book Xoiices:
Hip, difficulties in the reduction of dislo-
cationsof the, by Oscar H. Allis,3S3.
Histological laboratory, directions for
work in the, by G. C. Huber, 129,
Hospitals and charities, by H. C. Bui-
dett, 202.
Humane Society of the Commonwealth
of Massachusetts, report of, 64S,
Inebriety, non-heredity of, by L. E.
Keeley, 3S3.
Infancy and childhood, treatise on the
medical and surgical diseases of,
by J. L. Smith. 165.
Jurisprudence, medical, and toxicology,
manual of, by H. C. Chapman, 130.
Jurisprudence, medical, forensic medi-
cine and toxicology, by A. R. Wit-
thaus and Tracy C. Becker, vol. iii.,
129.
Kinderkrankheiten, Lehrbuch der, von
A. Baginsky, 201.
Le Fort, Leon, cruvres de, publices par
Felix Lejars. 16O.
Leprosy, handbook on, by S. P. Impey,
3S4.
Medicine, a system of, edited by T. C.
AUbutt, 491.
Medicine, practice of, by W. < '. Goodno,
131-
Midwifery, manual of, by W. E. Fother-
gill, 490-
Militar-Sanitatswesens, Veroffentlichun-
gen aus dem Gebiete der, 3S4.
-Minor surgery and bandaging, by H. R.
Wharton, 727.
Modern Greek mastery, by Thomas I..
Stedman, 901.
Mouth and teeth, popular essays on the
care of the, by V. C. Bell, 165.
Multum in parvo reference and dose book,
by C. Henri Leonard, 490.
Nervous system in women, functional dis-
orders of, by r. J. McGillicuddy,90i.
Nose and throat, text-book of diseases of
the, by F. H. Bosworth, 727.
.Nurses, elementary anatomy and surgery
for, by W. .M'c.V. Eccles. 3S3.
Nurses, text-book for training-schools
for, by P. iM. Wise, 64S,
Nursing, practical points in, by Emily
A, M, Stoney, 490.
Obstetric accidents, emergencies, and
operations, by L. Ch. Boisliniere.
131-
Obstetrics, manual of, by W, A. N.
Dorland. 727.
Operations-Cursus an der Leichc. anlei-
tender Vorlesungen fiir den, von H.
Rochs, 3S3.
Pan-.American .Medical Congress, trans-
actions of the first, 383.
I'athological anatomy and histology,
handbook of, by Francis Delafield
and T. M. Prudden, 901,
Pathology and pathological anatomy,
text-book of, by Richard Thoma,
1 30.
Pharmacology and therapeutics, manual
of, by W. Murrell. 727.
Philadelphia Hospital reports, edited by
G. E. de Schweinitz, 202.
Phthisis treatment of, by Arthur Kan-
some, 166.
Physics for students of medicine, by .Al-
fred Daniell, 202.
Presbyterian Hospital of New York, re-
port of the, 490.
Proceedings of the .American Psycho-
logical .Association for 1895, 202.
Railway Surgeons, Report of the Ameri-
can Academy of, 490.
Rectum, anus, and contiguous structures,
diagnosis and treatment of diseases
of, by S. G. Gant, 3S2.
Rectum, diseases of the, by W. and H.
Allingham. 165.
Rheumatism, its nature, its pathology,
and its successful treatment, byT. J.
Maclagan, 64S.
Schutzpocken Impfung. die Pathologie
der, von L. Flirst, 3S4.
Science progress, 129.
Sickness and health, edited by J. W.
Roosevelt, 20^.
Book Notices:
Skin, atlas of diseases of the, by H. Rad-
cliffe Crocker, 131, 490.
Skin diseases and syphilitic affections, a
pictorial atlas of, by E. Besnier and
others, edited by J. J. Pringle. 16";,
64S.
.Skin diseases, ready reference handbook
of, by G. 'I". Jackson 64S.
Skin, histcpathology of diseases of the,
by P. (;. Unna. 201.
Statistica sanitaria dell' armata italiana,
202.
Sterility, by Robert Bell. 203.
Stomach, its disorders and how to cure
them, by J. H. Kellogg, 201.
Surgery, a system of, edited by Frederic
S. Dennis, 490.
Syphilis, die Heilung der, von C. Wester-
field, 384.
Syphilis in the middle ages and in
modern times, by V. Buret, 130.
rherapie, Encyklopadie der, von O. Lie-
breich, 3S3.
Trained nurses' directory, edited by M.
Louise l.ongeway, iCO.
Transactions of the .American .Associa-
tion of Obstetricians and Gynecol-
ogists, 203.
Transactions of the American Surgical
Association, 165.
Transactions of the Medical Society of
the State of New York, 203,
Transactions of the New York State
Medical Association for the year
1895, 165.
Transactions of the Southern Surgical
and Gynecological .Association. 202.
Ironc, affections chirurgicales du, par
D. Polaillon. 3S4.
Twentieth Century Practice, edited by
Thos, L. Stedman, 382.
Whittaker's anatomical model, by Dr.
.Schmidt, 202.
Booth, Carlos C, a case of collapse from
excessive vomiting successfully treated
by intravenous infusion of saline solu-
tion, 462.
Booth, J, Arthur, oedema in Graves' disease,
45. 65.
Borosalicylic cream, 502.
Bosworth, Francke Huntington, notice of
book by, 727.
Bottome, V. A., secondary hemorrhage fol-
lowing tonsillotomy. 316.
Bowman lecture, 140.
Bowden Lithia Springs, Ga. , 654.
Boyer, .Arthur Irving, malignant diphtheria
treated bv antitoxin — rapid recover).
4^2.
Boyd, Robert, neuralgia of the penis, 208.
Boyd, Robert M., death of, 236.
Brain, abscess of the. 563; associated cen-
tres of the. 569; concussion o( the. 630;
cortical embolus (red softening! of the.
148; ectal relations of the right and
left parietal and paroccipital fissures.
61; hemorrhage in surgery of the, 279:
prognosis of hemorrhage of. 571; sur-
gery of the, 68; syphilitic disease of
the, 464, 834; tumors of the. 167, 571.
Hreast, abscess of the, 143; amputation of.
for cancer, 447; cancer of, 311, 429;
care of the, in lactation, 4S0; preven-
tive treatment of inflamed, 556; radical
operation for cancer of, 637; tumors of.
571. ?94.
Bremer, Ludwig, the knife for coccygo-
dynia a failure, 154.
Brettauer, Joseph, chronicendometritis,553.
Bright's disease, diet in, 6S0; pilocarpine
in, 690.
British army, injustice to medical officers
in the, 102, 503, 524, 729.
British Association for the Advancement of
Science, 539, 567.
British Medical Association, 234, 238, 273
2S4, 309, 320.
Broca, A., notice of book by, 129.
Bromides, unusual effects of. 765.
Bronchi, local treatment of affections of
the. 151, 430.
Bronchiolectasis. multiple, 83S,
Bronchitis, acute capillary, o.xygen in the
treatment of. 479; diffuse, in children.
December 26, 1896]
INDEX.
94:
4S3; fonnulEB for, 139; of the aged,
remedy for, 463; treatment of simple
acute, lot.
Bronchocele, unilateral, with myxa'dema,
565.
Bronchopneumonia, hot baths in, 650; in
children, remedy for, 502.
Brothers, Samuel, hypnotism and sugges-
tion, with a case of spasmodic stricture
of the '.esophagus, 293.
Browder, James D., death of, 54.
Brown, Charles DaCosta. death of, 127.
Bruce, Alexander, notice of translation by,
130.
Brunswick, Ga. , as a winter resort. O54.
Bryan, .^lonzo, arrest of small-pox in the
vesicular stage, S3.
Bubo, treatment of, by iodoform, 13S, 781);
venereal, 712: venereal, etiology and
treatment of, Soi.
Buchanan, .\le.xander, death of, 3S0.
Buck-, Albert H., notice of book by, 491,
Burchard, Thomas H., death of, 752;
resolutions on the death of, S23.
Burdett, Henry C. notice of book by, 202.
Buret. F. , notice of book by, 130.
Burns from hot-water bottles. 594: ichthyol
for, lofi; "I," line favorite for, 502;
of the second degree, application for,
174; picric acid in, 307: potassium
nitrate in, 591; turpentine in the treat-
ment of, 353.
Bursitis, a case of, 51.
Burt, Frank 1... uterine tibroid and preg-
nancy, 564.
Bush, \V. D., malarial h.-ematuria or hem-
orrhagic fever, 209.
C
Cadwallader. K., poisoning by amyl nitrite,
S26.
Cjesarian section, post-mortem, with de-
livery of a living child, 245: suture of
the uterus ;■.'. total extirpation, 429;
vaginal S20.
Calculi, biliary, obstruction of the common
duct by, 602.
California, health resorts of, 659.
Calomel, danger of combining with antipy-
rin, 689; dispensing, with sugar of
milk, 303; hypodermic injections of,
518.
Canada, alleged immorality in, 681, 803;
letter from, 937.
Cancer and tuberculosis, association of , 345;
contagion of. S39; disappearance of,
936; of the breast, 311, 429: of the
tongue, 836; of the uterus, diagnosis
of, 393: of the uterus, palliative treat-
ment of, 74S; of the uterus treated by
the toxins of erysipelas and bacillus
prodigiosus, 746: Roentgen rays for,
307; rules for operation in. 174: treat-
ment of, 428.
Cannabis indica, aqueous extract of, 650;
poisoning by, 280, 519.
Carbolic acid, vinegar as an antidote to, 462.
Carbonic acid, exhalation of. 144.
Carstens, J. II.. the need of abdominal
section in certain cases to aid the
general practitioner to diagnose ob-
scure abdominal affections, 7S2.
Cartilages, displaced semilunar, massage
movements and bandaging in the treat-
ment of, 819.
Cartwright, S. S.. strangulated hernia in
an aged subject. 390.
Castration for enlarged prostate, 11; of
criminals, 37S.
Catalepsy lasting over thirteen years, 837:
thyroid treatment of, 244.
Catarrh, treatment of chronic, of the nose,
throat, and ear in children, 537.
Catarrhal diseases of children, value of car-
bolic acid in some. 371.
Catgut, sterilization of, 67, 207, 232.
Cauterization, submucous linear, 534.
Centenarians. 252.
Cerebellum, tumor of the, i6a, 34S.
Cerebritis, rapidly fatal, resembling cere-
brospinal meningitis, 63.
Cerebrospinal fever, adhesions of the mem-
branes following, 427; the micro-or-
ganism of, 103.
Cerebrospinal lluid, diagnostic value of, 423.
Cervix knife for denuding in trachelorrha-
phy, 178.
Chalkley, Charles I-I., death of, 523.
Chapin, Henry Dwight, the sphere of the
physician and the hospital, 733.
Chapman, Henry C, notice of book by, 130.
Chapped skin, application for, 392.
Chamberlin, K. Crosby, a possible effect
of antitoxin, 390.
Chambers. Thomas, death of. S3S.
Chancellor. James Edgar, death of. 452.
Chancre of the hand. 760; phagedenic soft,
treatment of. 138.
Chancroid, treatment of. 463.
Charcoal, uses of, 4S4, 714.
Charities, commissioners of. and the public
hospitals. 414.
Charleston. S. C., as a winter resort. 653.
Charlotte, N. C, as a winter resort, 653.
Chattanooga. Tenn., as a winter resort. 656.
Cheatham, William, pyrozone and dilute
hydrochl^ic acid in suppurating in-
flammations of the middle ear. 3SS.
Cheyne-Stokes respiration, tremor com-
bined with. 423.
Chicago, impure water in, 4S8.
Chilblains, treatment of, 139.
Childbirth, constipation after, producing
symptoms of puerperal infection, 247;
relative advantages of forceps and ver-
sion in moderately contracted pelvis,
279; partial convulsions prior to de-
livery, 429; with unruptured mem-
branes, 137.
Childhood, prevention of diseases and mor-
tality in, 431.
Children, insanity in, 431; mortality of, 501.
Chilgren. G. A., clinical history and post-
mortem appearance of a case of cortical
embolus, 14S.
Chili, hospital management in, 6S5.
China, .Vmerican physicians honored in, 56.
Chloroform, Kiinig-Maas' method of resus-
citation from apparent death by, 250;
narcosis from, 59; t's. ether, 42S.
Chlorosis, marriage not contraindicated by,
712; sulphur in, 502.
Choate, George C. S. , death of, 19.
Cholagogues, S19.
Cholelithiasis, 29, 871.
Cholera in South Russia, 862.
Cholmeley, William, death of. 141.
Chorea, 412, 484; arsenic in, 450; electrical,
50; rheumatic causation of, 244.
Cigarettes, arsenic in, 127.
Citronella, .Ma., as a winter resoit, 655.
Clark, I,. Pierce, occupation neurosis or
ironer's cramp, 642; thyroid in epilepsy,
58S.
Clavicle, massage in fracture of the, Soo.
Clayton, Harry, death of, 91.
Cleft palate, time to operate upon, 68.
Cleveland Medical Society and the .\meri-
can Medical .Association, 716.
Close of volume fifty, 930.
Clubfoot, 2S3: muscles of the leg in, 568:
treatment of, 25.
Coagulation, pathogenesis of intravascular,
422.
Cocaine, an;esthesia by. S40; in surgery,
396; poisoning by, 854.
Cocainism. Magnan's sign in chronic. 712.
Coccygodynia, the knife a failure for, 154.
Cochran, Jerome, obituary of. 272.
Cocke, I. R., notice of book by, 3S3.
Codes, revision of. 633.
Cod-liver oil. creamy emulsion of, 391.
Cold, influence of, upon a diseased heart. So.
Cold bathing during menstruation, 356.
Coleman, Fiobert. glass double-current irri-
gating tubes, 519.
Colic, asafci'tida in, 765; renal, treatment
of pain in, 590.
Collapse from excessive vomiting success-
fully treated by intravenous infusion of
saline solution, 462.
College of Physicians of Philadelphia, 19,
559, 680, 715. 824.
Colles' fracture, 373. 572: immunity, 2S2.
Colorado, warning reputation of, 71.
Colpotomy, anterior, 783.
Columbia. S. C, as a winter resort, 653.
Comedones, ointment for, 502.
Conception, prevention of, 359.
Congar, Stephen, death of, 452.
Conjunctivitis granular, application for,
391; purulent. 57.
Consciousness, double, 237.
Constipation a cause of disease in women,
650: chronic, 44S; treatment of, 638,
791; unconsciousness from, 680; water
for, 1 38.
Consumption, are sanatoriums for, a danger
to the neighborhood? 4S2.
Contagious diseases of the lower animals,
relation of. to those of the human
family, 133; origin and spread of, 629;
weekly statement, 72, 108, 143, 17S,
216, 251, 2SS, 323, 359, 395, 431, 468,
504, 574, 612. 651, 696, 732. 766, S03,
S39, 876, 939.
(opeman, Dean, death of, 610.
I -opper arsenite, 304.
Copper salts in canned vegetables. 711.
Lord, disseminated sclerosis of the, 556;
lesions of ihe cells of the, consecutive
to nerve section and anamia, 45S;
lesions of the, produced by microbic
toxins, 457; penetrating wounds of the.
59°-
Cordier. A. II.. report of cases in abdomi-
nal and pelvic surgery. 33S.
Corish, John L., ether and oxygen as anaes-
thetics, 373: oxygen in the treatment
of acute capillary bronchitis, 479.
Cork of a tablet bottle, how to draw the, 517.
Cornea, treatment of opacities of the. 801.
Corning, J. Leonard, use of congealed oils
to prevent the reunion of nerves after
their subcutaneous division, 809.
Corns, application for, 250.
Corpus Christi, Tex., asa winter resort, 658.
Corrigan's pulse, 412.
Cortelyou, Lawrence B.. death of, 200.
Coryza, acute, 249.
Cough, bromoform in, 688, 6S9; remedy
for, 356; tonsillar, 124.
Council, general medical, of Great Britain,
464, 905, 936.
Co.xalgia, resection of the hip for. 176.
Coxitis, tuberculous, diseases simulating,
.556-
Craig, Cherles L"., recent advances in our
knowledge concerning the malarial
organism, 664.
Craig Colony for epileptics, 686, 767.
Cranial vault, fractures of the, 36.
Craniotomy on the dead child, 2S.
Creolin. toxic action of, 102.
Cretinism, treatment of. 563.
Crico-ar)tenoid joint, perichondritis of the,
99.'
Criminals, castration of, 378.
Criminology, report of the committee of the
New York .State Medical Association
on, 599.
Crocker. H. Radcliff, notice of book by,
I3i.4'^)0.
Croup, laryngeal, treatment of, 137; mem-
branous, after-treatment of tracheot-
omy cases of, 42S.
Cruel deceit, a, 931.
Crying babies, cure of. 79S.
Cuba, butchery of the sick and wounded
in, 593; epidemic disease in, 451; sur-
gical corps of the army of, 574.
Cumberland County (N. L) Medical Soci-
ety, 686.
Cullingworth. I)r, , suit against, 875.
Curettage of the uterus. 430: indications
for, 368.
Cyanosis, congenital, 563.
Cyclopia, 249.
Cystitis in women. 630.
Cystoscopic work, residual water in, 756.
Cystotomy, suprapubic, S29.
1)
Daniell, Alfred, notice of book by, 202.
Darnall, William PJdgar. a complicated case
of poisoning by bichloride of mercuryv
719.
Darr, Hiram Henry, death of, 823.
944
INDEX.
[December 26, 1896
David Lewis trust, hospitals benefiting by
the, Sol.
Davis, Henry G., death of, S6o.
Davis, Theo. G., congenital occlusion of
the urethra. 354.
Davis, Wesley, antiseptic treatment of
typhoid fever, 183.
Dead, transportation and disposal of the,4ij9.
Deaf, music for the, 540.
Deafness, thyroid extract in, 6Sg; word, 244.
JJeath. a sign of, 359.
Death scenes in fiction, 89.
Deaver, John B., notice of.book by, 202.
Deceit, a cruel, 931.
Deciduoma malignum, S7.
Dcclat, Dr., death of, S9S.
Deformity, ultimate etiology of, 23.
Degenerate, extinction of the, 7S5.
Delalield, Francis, notice of book by, 901.
Delaware State Medical Society, 133.
Delirium, acute, bacteriology of, 156; of
persecution of double form, 459; tre-
mens, cold baths in, 52, 520.
Delivery at full term, two cases of, follow-
ing cul-de-sac operations, 136.
Dementia, paretic, a form, of mental
disease resembling 65.
Jjeming, X. .M., as a winter resort, 658.
Dengue, 49S.
Denison, Charles, morphology of the blood
in tuberculosis, 395; the microscopical
proof of a curative process in tubercu-
losis, or the reaction to tuberculin
evidenced by blood changes hitherto
unrecognized, 330.
Dennis, Frederic S. , notice of book edited
by, 490.
Dental Association, meeting of the British,
3')4-
J)erraatitis herpetiformis, relation of, to
erythema multiforme and to pemphi-
gus, 496; iodoform, 496.
Dermatology, international congress of,
320; the higher aims of, 706.
De Schweinitz, George E., notice of book
by, 202.
Despres, Ormand, death of, 308.
Dessau, .S. Henrv. the value of carbolic acid
in some catarrhal diseases of children,
371-
J)evelopment, mixed premature and im-
mature, S02.
Diabetes mellitus, dermatoses in, 495; elec-
tricity in, 200; pathogeny of, 590;
prescription for, 392; renal, 285; the
forms of, 855.
Diagnosis, relationship of, to future surgi-
cal progress, 534.
Diarrhoea, chronic, 419: chronic, treat-
ment of, 0S9; infantile. 13S. 435, 463,
585; infectious, in infants, 435; remedy
for, 356; summer, of children. 13S.
Digestion, relation of diseases of the nose
and throat to, 97.
Diller. Theodore, primary muscular dys-
trophy in two brothers. 670.
Dillon, John Dale, death of, 200.
Diphtheria, acute disseminated sclerosis
with neuritis in the sequence of, 233;
acute multiple neuritis following, 353:
antitoxin of, see Atifitoxin of diph-
l/i(iia; bacilli of^ and mixed infec-
tion, 639; bacteriological examination
of one thousand suspected cases of
124: bromides as a cure in, 603; citric
acid in, 6S9; diminished mortality
from, in Paris, 56S; immunizing power
of normal horse serum, 421; manage-
ment of suspected cases of, 660; of the
nasopharynx, 618; of the penis, 829;
prevention of, 500; treatmentof, in Ber-
lin, 919 ; treatment of pharyngeal, 688.
Diplococcus lanceolatus, pathogenicity of
the, 343.
Diploma mills and State protection, 125.
Disinfection of the hands, 301.
Dispensaries, prosperity of the, 559.
Dispensary abuse, 89, 767; in England,
212, 6S7.
Dog-tail sutures, 175.
Dorland, W. A. Newman, notice of book
by, 727-
Douglas, Beaman, primary carcinoma of
the inferior turbinated body, 210.
Down, Langdon. death of, 645.
Drainage tube, method of retaining the,
600.
Drake, E. L., recurrent scarlatina, 790.
Drescher, August, notes from the labora-
tory and dispensing counter, 303.
Dressings, best material for, 2S3; surgical,
indications for the removal of, 646.
Drew, C. A., some thoughts on disordered
memory and kindred conditions, O74
Dropsy, causation of, 74S.
Drug habit, 575.
Drumhead, permanent artificial perforation
of the, Sog.
Duboisine sulphate as a means of combat-
ing refusal of food in general paralysis,
459-
Dudgeon, R. E., notice of translation by,
3S3.
Dufand, D., notice 01 book by, 3S4.
Dunant, Henry, the founder of the Red
Cross, 2S8.
Dunn, James H., appendicitis — to operate
or not to operate, 508, 534.
Dunwody, !• A., horse serum in consump-
tion, 51.
Duodenum, stenosis of, sinmlating pyloric
stenosis, 424.
Dwight, Thomas, methods of estimjiting
the height from parts of the skeleton —
a correction, 141.
Dysmenorrhcea, 412; caffeine in, 792; dis-
cussion on, 276; treatment of, 139,
6S9.
Dyspepsia, dieting in, 550: remedy for,
392, 463, 502; sodium bicarbonate in,
650.
Dysphonia spastica, intermittent, 98.
Dystocia due to disparity between size of
head and circumference of shoulders,
351 ; in Mexico, 795.
Dystrophy, primary muscular, in two
brothers, 670.
Ear, acute and chronic purulent inflamma-
tion of the middle, 317; chronic sup-
puration of the middle, 67: eczema of
the external auditory canal, loi; hay-
seed sprouted in the, S20: importance
of an understanding of diseases of the,
by all practitioners, 1S7; movable, in
man, 570; plastic operation on the, 758;
purulent disease of the middle, the
ophthalmoscope as an aid to the diag-
nosis of cerebral disease in. 225; puru-
lent inflammation of the middle, pyro-
zone and dilute hydrochloric acid in,
388; relation of affections of the upper
air passages 10 diseases of the. 601;
so-called supernumerary, too; removal
of foreign bodies from the, 463; treat-
ment of chronic catarrh of, in children,
537-
F^arache, remedy for, 463.
Harle, Samuel T., some new instruments
for the treatment of rectal diseases, 215.
Eating, rules for, (129.
Fkcles, \V. McAdam. notice of book by, 3S3.
Echinococcus cyst, sterile, 33S.
Eclampsia, puerperal, treatment of, 456,
765. 913; recent investigations con-
cerning, 604.
Eczema, dry. with pruritus. 249: effect of
diet and alcohol upon, 493: of the
breast and nipple, treatment of, 649.
Eddy, Mary Pierson, a woman physician in
Turkey in Asia, 911.
Edgar. J. Clifton, treatment of puerperal
eclampsia, 913.
Edinburgh, students of. S37.
Elbow-joint, prognosis of injuries of the,
Soi; treatment of old dislocations of,
425-
Electro-diagnosis and electrotherapeutics
simplified, 533.
Elliott, Hiram, insanity of pubescence, 73.
Ellis, John, death of, Sf)0.
Ellsworth. Pinckney Webster, death of, S23.
El Paso, Tex., as a winter resort, 658.
Embolus, cortical, of the brain, 14S.
Emergency ration, 360, 935.
Empyema, the surgery of, 438.
Encephalitis, acute non-suppurative hemor.
rhagic, 60.
Endarteritis obliterans, 422.
Endocarditis, infectious, 443; potassium
iodide in, 138; rheumatic, arrest of,
412; ulcerative, 170.
Endometritis, chronic, 553; senile, 551;
treatment of, 602.
Enteritis, 44S.
Enuresis in children, causes of, 464; varie-
ties of, 72.
Epididymitis, 175: formula for, 31.
Epilepsy, 393; causes of reflex, 571; collat-
eral theory of, 66; colony treatment of,
404. 6S6, 767; legislation regarding, 27;
medical and surgical treatment of, 419;
nitroglycerin in, 791; panial, in acro-
megaly, 457; pathology of, 64; remedy
for, 403, 502; surgical treatment of
focal, 64. 731; thyroid in, 588; trional
in, 16.
Epileptics, colonies for, 404; Craig Colony
for, 0S6, 767; home cure of, 26; mar-
riage of, 680.
Epispadias, operation for, 67.
Epistaxis in heart disease, 563; treatment
of, 689.
Epithelioma of the face, terchloride of anti-
mony in, 50: resorcin for, 174.
Erdtmann. Paul W., a cas*- of oxalic-acid
poisoning, 461.
Ergot, action of, 13S; Rheinstadter's mix-
ture, 393.
Erichsen, Sir John F>ic, death of, 488, 567.
Erysipelas, application for, 392; in infants,
447; toxins of. 557.
Erythromelalgia, SiS.
Eshner, Augustus A., a case of electrical
chorea, 50.
Ether and o.xygen as ancesthetics, 373; vi.
chloroform, 42S.
Ethics in Paris, 803; medical, a proposed
international congress of, igg.
Ethmoid disease, pathological anatomy of,
97-
Eucaine, a new local anxsthetic, 164.
Eureka Springs, Ark., as a winter resort,
657.
Evans, D. W., how to draw the cork of a
tablet bottle, 517.
Examinations, medical, in England, 33.
Excoriations in children, ointment for, 138.
Exophthalmic goitre, oedema in, 45, 65.
Extension, ambulatory, in surgery, 30.
Eye. contamination of liquid medicines for
the, 7S3; effects of extrinsic poisons on
the, 636; foreign bodies in the interior
of the. 2S1; new morphological ele-
ment in the cones of the retina, 725;
relation of diseases of the, to general
diseases, 636; subconjunctival injection
in the treatment of certain diseases of
the, 536; treatment of corneal opaci-
ties, 801.
Eyesight of school children in London,
251.
Farrington, Edward S., resolutions on
the death of, 595.
Fat necrosis, abdominal, pathogenesis of,
54; starvation, nutritional changes re-
sulting from, 3SO.
Favell, William Fisher, death of, 838.
Favus of the nail. 423.
Feeding, irregular Sunday, penalty of, 449.
Fees, medical, and mulli-millionaires, 821.
Feet, sweating of the, 392; sweating of the,
lotion for, 502.
Ferguson, E. D., a class of fatal cases pre-
sumably due to intestinal ptomains,
620.
Fernandina, Fla., as a winter re-sort, 65;.
F'essenden, C. S. D., death of, 163.
Fever, a relapsing, 641: aseptic surgical,
S95; autumnal, in the southern Atlan-
tic States, 826; continued, S33; treat-
ment of, 464.
Field, Jacob T., death of, 823.
Fifield, Wm. C. B., death of, 416.
Fingers, clubbing of the, 874; lacerated
wounds of, 286.
Finger tip, union of a severed, 51S.
December 26, 1896]
INDEX.
945
Fiiiley. Mary Jordan, adhesions of the
meninges following cerebrospinal (ever,
427.
First aid, methods of instruction in. 332.
Fischer, l.ouis. the treatment of diphtheria
in Berlin, gig.
Fischlovvitz, (',. G. , poisoning by cannabis
indica, 2S0.
Fisher, \V. A., foreign bodies in the in-
terior of the eye, 2S1.
Fishhook removed from an infant's throat
by digital manipulation, 460.
Fistute, faecal, treatment of, 586, 600.
F'istula in ano, 375; dermoid cysts a cause
of, 2g; reasons for unsuccessful treat-
ment of, 175; treatment of, 647.
Flagg. Cora H., rudimentary organs, 364.
P'lat foot, 22, 25.
Flatulence, treatment of. S40.
Fleming. Andrew, death of, 30S.
Fleming, Luke, malarial h,tmaturia, 426.
Flies, means of driving away, 55.
F'looding, death after, 3g6.
Florida, health resorts of, 654.
Flower, Sidney, hypnotism and what it
signifies, Q3S.
Floyd, C. S., death of. S60.
Fluorescent substance, a new, Sfi.
Foal.er, Surgeon-Major, death of. go6.
Fontanelle, clinical significance of the
child's, 536.
Foot, anterior transverse arch of the, 22.
Forceps, indications for use of the, Sg3.
F'oreign bodies swallowed by children, 731.
Forker, F. L. . plastic operation for deform-
ity of the nose caused by syphilis, 719.
Formaldehyde, disinfection by. S03.
Formalin as a preservative, i()2, S3S; in
septic wounds. 759 ; uses of, 347.
Fort Myers, Fla.. as a winter resort, 655.
Fort Worth, Tex., as a winter resort, 657.
Fossa navicularis. treatment of follicular
abscess of, 6go.
F'othergill, W. E., notice of book by, 490.
Fowler, George R., empyema of the vermi-
form appendix, 672.
Fractures, prognosis of, 69; treatment of
compound, 571.
Fragilitas ossium, S75.
France, foreign medical students and prac-
titioners in, 34. 70.
Frank, J., a new contrivance for intestinal
end-to-end anastomosis, 469.
Frankenburger, J. M., a monstrosity, 514.
Fraser, Patrick, death of, 906.
F'reeman, Walter J., diphtheria of the
nasopharyn.x, 6i3.
French Medical Congress, third, 420.
Freudenthal. W.. a nasal bag. 72.
Frisbie. W. L., death of. 452.
Frost, W. Adams, notice of book by. 3S2.
Frost-bite, application for, igfi.
Frothingham, Richard, the importance of
an understanding of middle-ear disease
by all practitioners. 1S7.
Frye, Maud f., estimation of the number
of bacteria in milk. 442.
Funck, M., notice of boolt by, 165.
Funis, treatment of the 412.
Furraan, F. S., arrest of small-pox in its
vesicular stage. 354.
Furman, Guido, death of. S60.
Furneaux, William S., notice of book by, 202.
Furst, L., notice of book by, 384.
Gage. W. v., need of caution in the use of
the Roentgen rays, 307; union of a
severed finger tip, 518.
Gainesville, Fla., as a winter resort, 655.
Gallant, A. Ernest, dystocia due to dis-
parity between the size of the head
and the circumference of the shoulders
of the fretus. ^$1.
Gall bladder, surgery of the, 512.
Gall stones, treatment of. 13S.
Galveston, Tex., as a winter- resort, 65S.
Gant, S. G., notice of book by, 382.
Clarbage, disposal of, 498.
Garden City, Kan., as a winter resort, 657.
Gardner, If. M., report of a case of bur-
sitis, 51.
Gargling, v. Troltsch's method, 13S.
Gasserian ganglion, removal of the, 533;
surgery of the, 2S.
(Jastralgia, remedy for, 139.
Gastric acidity, nature and treatment of, 834.
Gastric perforation and hemorrhage, sur-
gical treatment of, g2g.
Gastro-enterostomy for cancer of the py-
lorus, S74.
Gastro-intestinal tract, some inflammatory
diseases of the. 533. ,
Gastro-jejunostomy with the Murphy but-
ton, 338.
Gates, II. A., rupture of the urethra, 565.
Gauze dressings, 572; preparation of, 252.
Geiser. Mary L., poisoning by cannabis in-
dica, 5lg.
Gelsemium as an adjuvant to belladonna or
opium, 6go.
Georgia, health resorts of, 654.
Gerhard, Kmanuel F. , death of, 271.
Germs and serums, 103, 177.
Gestation, ectopic, 195; prolonged, 502.
Gibbs, Theron Z., death of, gi.
Giles, J. Edward, a folding ophthalmom-
eter, 141.
Gillette, Willard, hydatidiform mole, ij.
Gilliam, D. Tod. a new trachelorrhaphy
knife, 6g(i.
Gladmon, Edwin, a case of infectious en-
docarditis, 443.
Glasgow, pathological institute in, 72S.
Gleet, absence of gonococci in; 730; injec-
tion for, Soo,
Cilossitis. a case of, 172.
Glycosuria, regulatory, loS.
Goelet, Augusiin H., a cervix knife for
denuding in trachelorrhaphy. 17S; im-
proved trachelorrhaph)', 13: senile en-
dometritis and vaginitis. 551; what is
the best operative procedure for retro-
deviation of the uterus? 302.
Goitre, thyroid extract for, 6S9; exophthal-
mic, surgical treatment of. 198; exoph-
thalmic, symptoms of incipient, 855.
Golden. William W.. mountain fever, 910.
Goldenburg, Hermann, bacteriuria, 22S.
Gold, combinations of, 46.
Gonococcus, biology of the, 887.
Gonorrhtea. alumnol for, 30; citrate of sil-
ver for, 791; in children, 757; injec-
tion for, 356; in women, 740, 757:
marriage of men who have had, 912;
protection of the innocent from, 501;
protection of the internal organs in;
573; purulent ophthalmia in, 107;
treatment of. (18, 71; use of injections
in, 319-
Goodno, William C, notice of book by, 131.
Gordon, Bernard, gonorrhoea in women,
740. 757.
Gould, G. M., notice of dictionary by, 201.
Gould, Orissa \V., induced abortion, per-
foration of the uterus without peri-
tonitis, 246.
Gouley, J. W. S., prostatic enlargement,
577,"599-
Gout, acute, 412; formula for, 391; guaia-
cum in. 32; local treatment of, 520;
preventive treatment of, 650.
(Jrafts. epidemic, persistence of pigmenta-
tion in, 31.
Graham, James, death of, 78S.
Grant Hey, J. A. S., death of, 236.
Grass in the ear, 820.
Graves' disease, see F.xophlhalmic goitre.
Graveyard soil, 576.
(Jray, Henry, notice of book by, 64S.
Greek, the proper pronunciation of, 597.
Green Cross Society, 164, 6S7.
Greene, Charles Lyman, recent aids in the
differential diagnosis of typhoid fever,
697; the serum test of Widal and the
possibility of its application without
microscopic examination, 805.
Greene, J. H., does the appendix demand
surgical rest? 104.
Griffin. K. Harrison, two cases of an en-
larged ascending pharyngeal artery
situated on the posterior wall of the
pharynx, 247.
Grove, Sir W. R., death of. 200.
Guaiacol. external employnvent of, 502.
Guaiacum. therapeutic value of, 32.
Guild of St. Luke, 72S.
Guite'ras, Ramon, treatment of stricture of
the male urethra, 699.
Guleke, Hermann F., death of, 271.
Gunshot wounds, accidental, 40S; of the ab-
dominal viscera, 16: of the pharynx. 97.
Gutmann, Edward, death of, i(')3.
Guy's Hospital, subscriptions for, 34.
Gynecology and Obstetrics, Second Inter-
national Congress of, 453, 504.
Gynecology, principles and progress of, 530.
H
Hadra, B. F., rupture of the pancreas, 77.
Ila^matemesis from rupture of a gastric
varix. 761 ; remedy for, 502,
Ha'maturia, malarial, 209, 319, 356, 426,
540.
Hemoptysis, effect of high altitude upon,
359; treatment of, 6go.
Haines, John 11, death of, 30S.
Hair, bacteriology of the, 629; physiology
and function of, 143.
Hair cups, pitting about the, in certain ner-
vous disorders of central origin, 62.
Hall, A. L. , a medico-legal consideration of
some of the general features, signs,
and symptoms of the simple traumatic
neuroses, 436; treatment of laryngeal
croup, 137.
Hall, J. N., accidental gunshot wounds,
408: threecasesof phthisis pulmonalis
following scald of the chest, 248.
Halton, Frederick J., the appendicitis con-
troversy. 56g.
Hammond, La., as a winter resort. 656.
Hand, clinical significance of the, 679; lac-
erated wounds of the, 572.
Hanot, Professor, death of, 764.
Harley, George, death of, 682, 763.
Harrison, Reginald, observations on vesi-
cal stone and prostatic troubles, 877;
treatment of some forms of albumi-
nuria by renipnncture, 661.
Hartford Medical Sociely, fiftieth anniver-
sary of the, 6S4.
Ilarveian oration, 72S.
Harvey, Thomas W. , posture in labor, 677.
Haslam, George, fracture of the base of
the skull, of both superior maxilk-e, of
the nasal bones, of the inferior maxil-
la, and of the hyoid bone; recovery.
3go; subphrenic abscess, 391 : two new
needle holders. 651.
Hastings, Dr. R. J., death of, 937.
Hatchett, B., laparo-splenectomy. 426.
Hauptniann, J. H, a case of Raynaud's
disciise, 459.
Hawaii, medical practice in, 307.
Hawthorn, a heart tonic, 685.
Hay fever, formula for, 139; remedies for,
392.
Haynes, Irving S., notice of book by, 382.
Hays, Harry C, foreign bodies in the
male urethra, 517.
Hayward, William, death of, 752.
Head, injuries of the, necessity of close
inspection of, 28.
Heaidache from eye strain, 393; treatment of,
649, 893 ; treatment of sick, 249, 68g.
Health department of New York City,
scope of the work of. 63g.
Health Protective Association, Ladies', 521.
Health resorts in the United States, 7Sf>;
winter, 633, 652.
Heart, a loud murmur of the, 272; a tonic
for the, 685; action of taurocholate
of sodium on the, 393: ananiia in dis-
ease of the, S52, SO5: anatomy of the
blood supply of the, 666; calomel in
disease of the, 791; congenita! narrow-
ing of the mitral orifices as a cause of
dwarfed lives and irritable, 679; con-
genital stenosis of the pulmonary
valves, 562; diseases of the, in central
Delaware, 134; disturbance of the.
from gastric irritation, 691; failure of
the, in phthisis, 463; fatty tumor of
right auricle complicating pneumonia,
355; functional murmurs of the, 865;
healed wound of the, 7S4; influence of
eold upon a diseased. 80; lesions of
the, 16S; physical and Schott treat-
946
INDEX.
[December 26, 1896
mem of disease of the, 721, S47, 939 ;
physical signs other than murmur in
valvular disease of the, 535; remedy for
valvular disease of the, 7gS; rupture
of the. i6g; starving in disease of the,
108; treatment of failure of the, 242;
treatment of fatty, 689.
Heat, mortality from, 235.
Hegeraan, Thomas B,, a fishhook removed
from an infant's throat by digital ex-
amination. 460.
Heiman, Henry, biology of the gonococccus,
S87.
Heineman, H. Newton, experiences with
the physical and Schott treatment of
chronic heart disease, 721, 847, 939.
Hemiplegia, hysterical, 422.
Hemorrhage, prevention of operative, 800.
Hemorrhoids, treatment of, 31, 447.
Henderson, A. H , inflammation of the sub-
lingual glands, 3S7.
Hendersonville, N. C, as a winter resort,
653-
Heredity, and crime, 74S; crossed, 457.
Hermaphrodism, a case of, 135, 214, 694,
724: pseudo-, 796.
Hernia after abdominal section, prevention
of, 7gg: congenital irreducible um-
bilical, 425, 514; irreducible, compli-
cated by inflamed appendi.x in the sac,
758; radical cure of femoral, 807; re-
lation between external, and gastro-
intestinal disorder, 785; resection of
the intestine in, S33; strangulated,
249: strangulated, failure to diagnose,
771; strangulated, in an aged subject,
3go: strangulated, in a child two
months old, successfully operated upon,
7go; treatment of, 572: treatment of
crural, by an inguinal operation, 646;
tuberculous. 820.
Herpes, counter-irritation in the treatment
of, 446; genital, powder for, 392; zos-
ter, 791.
I lerpetic nerve disturbance, 642.
Hertzog, William F., death of, 308,
Hiccough, autotraction of the tongue in,
448.
Hickory, N. C. as a winter resort, (153.
Hildenbrand, Louis W., death of, 708.
Hillis, Thomas J. , technique of intubation
of the larynx in children, 773.
Hip disease, 2S3; abscess of, 59; cause
of the limp in, 23; diagnosis of, 572;
iodoform injections for, 30; other dis-
eases simulating, 556; treatment of,
647.
Hip-joint, amputation at the, for sarcoma,
63S: congenital dislocation of the,
Hoffa-Lorenz operation for, 361; dis-
locations of the, 16, 730; osteosarcoma
of the, 24; spontaneous dislocation of
the, 2t.
His, Wilhelm, notice of book Ijy, 203.
Hodgen, Harry, death of, 416.
Hogan, Louise E,, how to feed children,
384.
Holden, Ward A,, the visual disturbances
clue to nervous diseases, 626, 636.
Hollenback, Henry, death of, 752.
Hollowbush, J. K.. two contributions to
the surgery of the gall bladder, 512.
Holly Springs, Miss., as a winter resort,
656.
Holmes, A. -M., the diagnosis of tubercu-
losis from the morphology of the blood,
325-
Hope Hospitalin Langholm, -Scotland, 597.
Hopkins. John L., death of, 416.
Horses, crimson-clover balls in, 575.
Hospital and physician, sphere of the, 733.
Hospital corps of the U. S. army, new
uniform for, 524.
Hospital Reform Association in London,
716, 762.
Hospitals, public, the commissioners of
public charities and, 414.
Hotels, deaths in European, 682.
Hot rooms and catching cold, 633.
Hot Springs. Ark., as a winter resort, 657.
Houston, Edwin J., notice of book by, 165.
Houston. Tex., as a winter resort, 658.
Huber, G. Carl, notice of book by, 129.
Humphrey, Sir George Murray, death of,
596, 609.
Hunterian Museum, exhibits in the, 176.
Hunter, John, immorality in Canada. S03.
Hunter's Point stench and the State Board
of Health, 270.
Huntsville, Ala., as a winter resort. 655.
Hutchinson, Kan., as a winter resort, O57.
Huxley lecture, the first, 044.
Hydatids of the back, 75S; of the liver,
treatment of, 7gg; results of, 712.
Hydramnios and some of its complications,
231.
Hydrogen peroxide in diseases of the nose,
throat, and ear, ig5.
Hydrology, climatology, and geology, in-
ternational congress of, 634.
Hydronephrosis, 8ig.
Hydrophobia, two cases of, 38g.
Hygiene and medicine, 755.
Hymen, double, 803.
Hyperidrosis, formula for, 139.
Hypnotism and suggestion, 293, 938.
Hysterectomy, 68; in the presence of active
inflammation, 528: vaginal, 762, 817.
S56; vaginal, electrode for severing
ligatures in, 132.
Hysteria, trophic changes in the teeth in,
422.
Hystero-epilepsy. 26.
Hystero-paludism, 424.
Ichthyol eruptions of the skin, 555; varnish,
502.
Idiots, deformity of the hard palate in, 245.
Ileus, dynamic, 529: treatment of, 630.
Illinois State Medical Society, 25.
Immorality in Canada, 6S1, 803.
Immunization, surgical, 419, 894.
Impetigo contagiosa universalis, 497.
Impey, S. P., notice of book by, 3S4.
Impregnation, effects of lactation on, 412;
when possible, 2S0.
Income tax on physicians, 56.
Incompatibilities of new remedies, 340.
Indiana Health Hoard rules. 897.
Indigestion, functional. 30: intestinal, 417;
nerve disturbance from, 66.
Indio, Cal., as a winter resort, 659.
Inebriates, female, new scheme for the
treatment of. 431.
Inebriety, medical treatinent of, 601.
Infancy, management of disease in, 576;
prevention of diseases and mortality in,
431-
Infant feeding, 139. 463.
Infants, care of premature, 396.
Infection, and symmetry, 422; by pets, 630;
mixed, 42S.
Infectious diseases, etiology and classifica-
tion of, 720; prevention of, 417.
Injury, slight results of a severe, 427.
Innominate artery, ligation of the, 196.
Inquests, evidence at, 567.
" Ills " and "outs." 751.
Insane, commitment of the. 45S; fragilitas
ossium in the, 162; relation of visceral
disorders to the delusions of the, 530;
state care of the, 245.
Insanity, disorders of the muscular system
in. 217, 24;: following gynecological
operations. 647; in children, 431; in
women, some causes of. 530: of pubes-
cence. 73; prognosis and duration of
attacks of, 62; relation of alcohol to,
592; senile. 50;. 539: studies of the
blood in thyroid feeding in, 2S9; the
new law on, and commitment of pa-
tients, 60S.
Insect bites, treatment of, 765.
Insomnia of neurasthenia, remedy for, 393.
Instruments, an alloy for, 756; sterilization
of, 643, 647.
International Medical Congress in Moscow,
128, 594, 6S2. 764, 7S8.
Intestinal anastomosis, 68, 209, 313. 4&9
797. S29.
Intestinal fermentation, 612.
Intestinal obstruction, lateral anastomosis
with the Murphy button introduced
through the vagina, 209: post-opera-
tive. 7?'?.
Intestinal strangulation and engorgement,
lesions of, 424.
Intestine, congenital occlusion of the, 725:
hemorrhage from the. 323; innervation
of the. 324; preservation of specimen^
of the, 34S; resection of nearly eleven
feet of the small, 855.
Intubation of the larynx in children, tech-
nique of, 773; in the adult for acute
laryngeal stenosis, 95; modifications of
the tube, gog.
Intussusception, 315; ileo-colic, 347.
Iodides, other than of potassium, in syph-
ilis, 250.
lodism, prevention of, 356,
Iodoform, dermatitis from, 496.
Irene, Sister Mary, death of, 271; resolu-
tions on the death of, 488.
Iron peptonate, elixir of, 688.
Ironer's cramp. 642.
Irrigating tubes, glass double-current, 519.
Irwell, Lawrence, the contagiousness of
pulmonary phthisis, 838.
Irwin, S. Nelson, strangulated hernia in a
child two months old, with operation
and reco\'ery, 700.
Ischuria, non-obstructive, 120.
Itching and the itch, 822.
J
Tackson, George Thomas, notice 01 book
by, 648.
Jackson. Miss., as a winter resort, 656.
Jacksonville, Fla., as a winter resort, 655.
James. Walter B. , notice of book edited
by, 490.
Jameson, Dr., illness of, 900.
Janus, a new international journal, 3S1.
Jaw, curious deformity of the, S74.
Jenner centenary in Berlin, 108; in Chili,
4S7; in Japan, 128; in Russia, 41;.
Johnson, Sir (jeorge, death of, 32.
Joints and spine, suppuration in disease of
the. and its relation to tuberculous
meningitis. 22; dry heat in the treat-
ment of disease of, 23; floating bodies
in. 175.
Kales. J. W. , childbirth with unruptured
membranes. 137.
Kansas, health resorts of, 657.
Keeley. Leslie E.. notice of book by. 383.
Keene, C. I),, death of. SgS.
Keiller, William, hermaphrodism (?), 214.
Kekule, Friedrich .-Vugust, death of. 127.
Kellogg, J. H.. notice of book by, 201.
Kellogg, Theodore H,. the disorders in the
muscular system in insanity, 217, 245.
Kendell, H. E., septic peritonitis, opera-
tion, recovery, 20S.
Kenefick, Thomas A., apoplectic form of
Meniere's disease, 122.
Kennedy, James C, the appendicitis con-
trovers) — an unfair criticism, 729.
Kennelly, A. E., notice of book by, 165.
Kerrville, Tex., as a winter resort, 658.
Kidder, Augustus S,, death of, 54.
Kidney, absence of the left. 718; acute in-
flammation of the, from oxalic-acid
poisoning, 124: congenital absence of,
556; cystic, 204; malposition of the,
204: movable, 2S3, 527, 532, 855I
nephrectomy for ruptured. 762, 893;
rupture of the, 519: sacculated, 532;
surgery of the, 603, 731; tumors of
the, 204; wounds of the, 483.
Kilbourne. H. S,, an emergency, obstetri-
cal and epistolary (inversio uteri), 247.
Kiliani, Otto G, T., the bicycle for scolio-
sis, 615.
Kittredge, C. M., death of, 308.
Knapp, Mark I., a director for the stomach
tube, 322.
Knee, treatment of tuberculous disea'^e of
the, 23, 637.
Kneipp cranks. 4S6.
Knopf, S. A, , are sanatoriums for consump-
tives a danger to the neighborhood?
482.
December 26, 1S96]
INDEX.
947
Knoxville, Tenn., as a winter resort. 656.
Koles, Henry M., report of a case of recur-
rent basilar meningitis, with recovery,
515-
Koller, Carl, two cases of a rare fatal
disease of infancy with symmetrical
changes in the macula lutea, 266.
Krause method of skin transplantation, 53S,
792.
Kuttarasome body, 725.
I^bio-ylosso-iaryngeal paralysis of cerebral
origin. 424.
Labor, abnormal pains of, 13, 123: chloro-
form in, 5g2; disinfection of the hands
during, 207; local anLvsthesia in, 464;
management of, 360; management of
after-pains, S12; posture in. 677; rise
in temperature after, 606; spontaneous
rupture of the uterus during, 529; time
of rupturing the amniotic sac in, 4S4;
urination after, 41; uterine fibroids ob-
structing, 5S.
Laboratory and dispensing counter, notes
from the, 303.
Lacing, tight, 322.
Lactation, care of the breast in, 4S6; effects
of, on menstruation and impregnation.
412.
La Kayette. La., as a winter resort, 656.
Lake Charles, La., as a winter resort, 657.
Lakeland, Fla. , as a winter resort, 655.
Lambert, Adelaide, catarrhal salpingitis,
911.
Lang, .\rnold, notice of book by, 3S4.
I.ang, William, notice of book by, 165.
Langerhans case, report on the, 91.
Laparo-splenectomy. 426.
Laparotomy, an exceptional. ;fj6 ; best
method of closing the abdomen after,
455-
Laryngitis, treatment of simple acute, loi;
unusual manifestations of so-called
catarrhal, 99.
Laryn.x, diagnosis in disease of the. 393 ;
intubation of, in the adult, 95 ; intuba-
tioi' of, modifications of tube for, 909;
irritation of the. 4S3; operations on the,
794 ; papilloma of the, in a child — re-
peated intubation — death, 513; pho-
tography of the, 94. CS3; technique of
intubation of, in children, 773; treat-
ment of malignant disease of the, 95,
646: unusual growth in the, 9S.
Las Cruces. N. M., as a winter resort, 65S.
Las Vegas. N. .M., as a winter resort, 658.
Lead, wholesale poisoning by. 272.
Legislation, international sanitary, 755;
medical, in Illinois, 27; medical, in New
York. 17S.
Lehigh Valley (Fa.) Medical .\ssociation,
23;; Lehigh Valley Railway Surgeons,
.\ssociation of. 561.
l.ejars, Feli.v. notice of book edited by, i6f).
Leloir, H., death of, <)0.
Lens, a new spectacle, 107.
Leonard, C. Henri, notice of book by, 490.
Leper, what shall we do with the? O95.
Leprologists, proposed congress of, 46b,
594. "'^'4. Sfii. S99.
Leprosy, bichloride injections in. 307 ; an-
titoxin of. 559. 826 : in America. 756 ;
in New York, 6S1, 693; in Russia,
S24; tubercular, 132.
Letters from Berlin, 103, 2S;, 56S ; from
Canada, 937; from London, 32. 69, 102,
140,176, 211. 251, 284, 320, 357, 394,
464, 503, 540, 567, 609, 728, 761, 801,
^37. S74, 905. 936; from Paris. 70, 567,
S36, 906.
Leucocytes in tuberculosis, 123.
Leucocytosis, influence of large saline in-
jections upon, 449.
' eucorrhfta, chronic, 319; formula for, 31.
i.eviseur, Fred. J., skin diseases occuring
in connection with gastro intestinal
disturbances, 84.
Lewis, F. Park, anew spectacle lens, 107.
Lichen, thyroid extract for. 699.
Liebreich. Oscar, notice of book edited by,
383-
Life, duration of. among physicians, 468.
Light cures. 144.
Lindlev, Walter, acute uterine inversion,
352.
Lips, peculiar affection of the mucous mem-
brane of the, 493.
Little Rock, Ark., as a winter resort, 657.
Liver, abscess of the, 31, 68,314; acute yel-
low atrophy of the, 827; cirrhosisof the,
S8 ; early enlargement of the, 563 ;
primary cancer of the, 346 ; treatment
of hydatids of the, 799.
Liverpool, pay of police surgeons in, 660.
Livezey. .Abraham, death of, 3S0.
Llano. Tex., as a winter resort, 658.
Locomotor ata.xia. effect of early optic
atrophy upon the course of. 710 ; trunk
anaesthesia in. 532.
Lofton, Lucien, a new stone searcher, 142.
Logan, Sir T. G.. death of, 69.
l^ohrstorfer, F , laryngeal papilloma in a
child — repeated intubation — death, 5 1 3.
London, letters from. 32,69, 102, 140, 176,
211, 251, 2S4, 320, 357, 394, 4')4. 503;
540, 567, 6og, 72S, 761, 801,837, S74,
905 , 936 ; opening of the medical schools
in. 609.
Longevity, and labor, 575; signs of, 714.
Longeway, M. Louise, notice of book by,
166.
Loomis Sanatorium for Consumptives, 6S7.
Lorand, .\rnold, influence of cold on a dis-
eased heart. So.
Lord. John Prentiss, a portable sterilizer
and dressing-retainer. 2S6.
Los .\ngeles, Cal.. as a winter resort, 659.
Louisiana, health resorts of, 656.
Love, James Kerr, notice of book by, 130.
Lunch wagons, spread of disease by, 876.
Lungs, cantharidal blisters in acute affec-
tions of the. 794; diseases of, intra-
tracheal injections in, 151: local treat-
ment of affections of the, 430; surgery
of the, 67.
Lupus, camphorated naphthol in, 591 ; thy-
roid in, 137.
Lupus erythematosus, treatment of, 690.
Luther. Calista V., herpes zoster, 791.
Lymphangitis, periphlebitic, 11.
M
Mac.Artney, \V. N., discriminating treat-
ment of appendicitis, 358; the treat-
ment of pneumonia. 397.
Mc.^dam, Alexander H., death of, 416.
McCassy. J. H.. otitis mediapurulenta.317.
McClanahan, H. M., infantile scorbutus,
477-
McClurg, John Russell, death of, 715.
McConnel, H. 8., elimination, antisepsis,
and starvation in the treatment of ty-
phoid fever, 46.
McCosh, .\ndrew J., notice of book edited
by, 490-
McCreery, Forbes K.. a case of symphyse-
otomy, 246.
McCresson, Thomas R., death of, 452.
MacEvitt, rupture of the uterus. 159.
McFarland, Joseph, notice of book by, 131.
McGillicuddy, T. J., notice of book by, 901.
McGivern. John H.. death of, 163.
McGuire, J. C, eruptions of the skin pro-
duced by the local application of ich-
thyol, 555.
Mclnnis, H. L.. turpentine in the treat-
ment of burns. 353.
McKay, A. F., winter health resorts, 652.
McKee. K. S., congenital inferior incisors,
570.
McLaury, William Muir, death of, 380;
resolutions on the death of, 6Sj.
McNair, Robert H . , slight results of a se-
vere injury-. 427.
Maclagan, T. J., notice of book by, 64S.
Macroglossia, muscular, 447.
Macula lutea, a rare fatal disease of in-
fancy with symmetrical changes in, 266.
Madeira, typhoid fever in, 635.
Magical remedies, 766.
Malakine in rheumatism, 727.
Malaria, discussion on, 133; facts of prac-
tical utility in relation to, S26; narco-
tine in, 174; propagation of. by mos-
quitoes. 35; recent advances in our
knowledge of the organism of, 664.
Malarial ascites, pathology and clinical va-
rieties of, 423; ha-maturia, 209. 319,
356, 426, 540.
Malignant tumors, inoperable, treatment
of, by Coley's toxins, 196.
Maubrac, P., notice of book by, 129.
Marietta, (ia.. as a winter resort, 654.
Markey, Surgeon-. Major General, death of,
906.
Marriages, consanguineous. 360.
Martin. .Alfred J., death of, S9S.
Martin. E. 11.. malarial hamaturia, 540.
Martin, George W.. death of, 6S2.
Martin. James Cooper, obituary of, 768.
Mastitis, prevention of, 556.
Mastoid operation, indications for. in acute
suppurative otitis media. ?oo.
Masturbation and spermatorrhcea, 501.
Maternity Hospital of Puebla, statistics of
the, 829.
Matlack. William H.. death of, 127.
Mattison, J. U., diagnosis of morphine dis-
ease, 268.
Maxillary sinusitis, purulent, 97.
.Measles, murder by, 102; relief of the cu-
taneous irritation of, 463; sequel* of,
649; treatment of, with the blood se-
rum of convalescentf, 269.
Meckel's diverticulum. Peyer's patch in, 347.
.Mecray. P. M., some notes on the bacteri-
ology of mumps, 440.
Mediastinum, sarcoma of the anterior, 48.
Medical and Chirurgical Faculty of Mary-
land, 833.
Medical Defence Union, 212.
Medical profession and the public, mutual
relations of. 27.
Medical schools in Great Britain, opening
addresses at the, 644.
Medical Society of the County of New
York, 537, 693, S67; address of the
president, S67; election of officers, 683.
Medical Society of Delaware. 133.
Medical Society of New Jersey. 20, 57.
Medical Society of the State of Virginia. 417.
Medicine, agitation to discourage the study
of. in France, 837.
Medico-Chirurgical Society, dinner of the,
762.
Melancholia cured by craniectomy and
removal of a brain cyst, 457.
Membranous sore throat, varieties of. 393.
Memory, disordered, and kindred condi-
tions, 674.
Memphis, Tenn.. as a winter resort. 656.
Meniere's disease, apoplectic form of, 122;
treatment of. 197.
Meninges, adhesions of, following cerebro-
spinal fever, 427.
Meningism and mental confusion. 422.
Meningitis, acute exudative, 345: recurrent
basilar, 515; tuberculous, 284.
Meningococcus, 103.
Menopause, oophorin tablets for the, 103.
Menorrhagia in virgins, 731.
Menses, retention of, in atresia, 530.
Menstruation, cold bathing during, 356;
effects of lactation on, 412.
Mental complications following surgical
operations, S71; therapeutics, 631.
Mercury bichloride, complicated case of
poisoning by. 719.
Merriman, J. J., death of, 540.
-Merritt, Frank D., a case of unilateral
bronchocele with myxcedema, 565.
Mescal buttons. 258.
.Metatarsalgia, 29.
.Metric system, objection to the. 567.
Metropolitan asylums board of London, 540.
Metrorrhagia, potassium iodide in passive,
796.
Mettler, L. Harrison, syphilitic disease of
the spine, 475.
.Mexico, medical education in, 753; Pan-
.■\merican Medical Congress in, 750,
753. 793. 826; sanitary legislation in,
499; two health resorts in, 659,
Miasmatic fevers of the State of Sonora,
Mexico, 499.
Microbes, are they necessary to human
life? S16.
Microscope, practical use of the, 245.
948
INDEX.
[December 26, 1896
Migraine, causes of. 464: clinical equiva-
lent of, 459; formuLc for. 392.
Milk, boiled, digestibility of, 732; estima-
tion of the number of bacteria in, 442;
exhibition of, 763; infectiousness of,
493; sulticiency of, after birth, 395; to
dry up the secretion of, 792.
Miller, li. F., germs and serums, 177.
Miller, J. Estill, masked appendicitis, 315.
Millet, George B., death of, 567.
Milligan, J. D., a simple means of throat
examination, 765.
Milliken, Samuel K., tendon grafting and
muscle transplantation for deformities
following infantile paralysis, 771.
Milne, Charles, death of, 488.
Mississippi, health resorts of, 656.
Mississippi Valley Medical Association,
532.
Mitchell, Henry Hooper, death of, 523.
Mobile, .-Ma., as a winter resort, 655.
Mole, fleshy, 278; hydatidiform, 15, 797.
Monell, Joseph Augustus, death of, 271.
Monstrosity, a, 514.
Monterey, Mexico, as a winter resort, 659.
Moore, James E., an exceptional lapa-
rotomy, 566.
Moore, Sir William James, death of, 523,
540.
Morgan, Francis I'., mescal buttons, 25S.
Morphine disease, diagnosis of the, 26S.
Morphiiea, symmetrical, 494.
Morris. Robert T., abdomical section
statistics, 938; notes on appendicitis,
S69. 924; the appendicitis controversy,
467-
Morton, William J., the j.--ray and some of
its applications in medicine, 9.
Moscow congress, 6S2, 754, 7SS: Hebrew
physicians at the, 128, 594.
Moser, W., two cases of hydrophobia, 3S9.
Mosquitoes as carriers of the malarial
germ, 35.
Mosso, Angelo, notice of book by. 3S4.
Mount Airy, Ga., as a winter resort, 654.
Mountain fever, 910.
Mouth, antiseptic wash for the. 650; pecu-
liar affection of the mucous membrane
of the, 493.
Mulford, Sylvanus S., death of, 380.
Mumps, the bacteriology of, 440.
Munile, I'aul F., hermaphrodism (?), 214.
Munro, Surgeon-General William, death
of, 802.
Murdock, James H., death of, 6S2 ; resolu-
tions on the death of, 751.
Murray. II. G., a relapsing fever, f)4i.
Murreil, William, notice of book by, 727.
Muscular atrophy, progressive. 562 ; atro-
phy, progressive, of sudden onset, 62;
pains, liniment for, 356.
Music and noisy nuisance. 858.
Music for the deaf. 540.
Mycosis fungoides and sarcomatosis cutis,
494-
Mydriatic action of pseudo-jusijuianiine,
649.
Myelocythajmia, diphtheritic. 23().
Myers, P. P., constipation after childbirth
producing symptoms of puerperal in-
fection, 247.
Myocarditis, a case of fatal traumatic, 171.
Myomalacia of the heart, Hnj.
Myrtle, extract of, in skin diseases, 650.
Myxoderiuia, 820.
Myxcedema. thyroid treatment of, 423, O13;
with unilateral bronchocele, 565.
N
Naevus unius lateris, 557.
Nammack, Charles E., the Woodbridge
treatment of typhoid fever. 7.S9.
Nammack, William H., dislocation of the
fourth cervical vertebra— reduction —
recovery, 15.
Narcotine in malaria, 174.
Nasal bag. 72.
Nashville. Tenn., as a winter resort, 656.
Nasopharyngeal fibrous tumors, 96.
Nasopharynx, diphtheria of the, (uS.
Navy, needs of the medical service of the,
857.
Needle holders, two new, 651.
Neoplasms, favorite sites of, 5C9; inheri-
tance of, 522.
Nephralgia, splitting the capsule for relief
of, 872.
Nephrectomy, fatal secondary hemorrhage
following, 833; for ruptured kidney,
762,893; indications for, 572,799.
Nephritis, acute, from oxalic-acid poison-
ing, 124; management of pregnancy
with, 340.
Nephrorrhaphy, the limits of, 527.
Nephrotomy, 339.
Nerves, operations for injuries of, in the
upper extremity, 535; section of, use
of congealed oils to prevent reunion
after, 809; successful grafting of, in
man, 927.
Nervine tonic and sedative, 464.
Nervous disease, relation of toxic agents in
the production of, 722; visual disturb-
ances due to, 626, 036.
Nettle rash, lotion for, 502.
Neuralgia, 250; formula for, 650; inter-
costal, ichthyol in, 648; of the periph-
eral nerves, 604; osmic aci<i in, 792.
Neurasthenia,, association of, with general
paralysis, 459; diagnosisand treatment
of, 30.
Neuritis, acute multiple, following diph-
theria, 353; forms of, 679; multiple,
engrafted upon a nervous diathesis,
424; syphilitic, 25,0.
Neuron, functions of the. 59; theory of the,
244-
Neuronymy, report of a committee on,
66.
Neuroses, traumatic, medico-legal features
of, 436.
New Jersey, Order of Military Surgeons of ,
104.
New Mexico, health resorts of, 658.
New Orleans as a winter resort, 656.
Newton, Richard ('., the treatment of
typhoid fever, 90S.
New York Academy of Medicine, 539, 636,
720. S3 1, 863 ; Section on (Jeneral
Medicine, 865; Section on (;eneral
Surgery, 637, 75S ; Section on Genito-
urinary Surgery, 760; Section on Neu-
rology, 722; Section on Obstetrics and
Gynecology, 756 ; .Section on Pediat-
rics, 562.
New York County Medical Association,
690, 831.
New York Obstetrical Society, officers of.
7"5-
New York Pathological .Society, 166, 204,
345. 3S5. 639. 724-
New York State .Medical Association,
593.
New York State, mortalily in. S23.
New Zealand, anti-tuberculosis legislation
in, 6S5.
Nicaise. Edouard, death of, 416.
Nichols, I. 11.. note on the effervescence of
urine with nitroso-nitric acid, 781).
Night, psychic influence of, 24J.
Night shelters, 3211.
Night sweats, 391. 688.
Night terrors, 234.
Nipple, Paget's disease of the, 492.
Nitroglycerin, uses of. 573.
Nomenclature of diseases. 20. 498.
Nordau on Xordau's methods of work, 76S.
North Carolina, health resorts of, 652.
Northrup, William I' , wandering phlebi-
tis (periphlebitic lymphangitis), 11.
Nose, apex catarrh simulating disease of
the. 206 ; etiology and treatment of
deviations of the septum, 93; micro-
organisms in the health}', 431; plastic
operation for deformity of, caused by
syphilis, 719; ])olypus of the. in an
infant four weeks old, 718; primary-
carcinoma of the inferior turbinated
body, 210; red. treatment of, 4S4;
sarcoma of the nasal chambers and
accessory sinuses, loi; spindle-celled
sarcoma of the, 96; teeth in the, gS;
treatment of chronic catarrh of, in
children, 537.
Notitlcation of di.sease. 320.
Nymphomania, treatment of, 729.
Nystagmus by suggestion. 458.
O
Obstetrical complications, 134: praclice,^
cleanliness in, 28; practice, disinfec-
tants in, 649.
Occupation neurosis or ironer's cramp. 642.
Ochsner, A. J., notice of book edited by,
130.
Odor a symptom of disease. 360.
O'Uwyer, J., the intubation tube and its-
modifications, 909.
Ohmann-Dumesnil, A. H., notice of trans-
lation by. 130.
Old age, endometritis and vaginitis in, 551 ;
insanity in, 505, 539.
Operation, management of cases after, 14S.
Ophthalmia, gonorrhcxal, ulcerations in,
250; neonatorum, plea for preventive
measures of, 604; purulent, 319.
Ophthalmometer, a folding, 141.
Opium commission, criticism of the report
of the, 214.
Orchidectomy, bilateral, and suprapubic
cystotomy followed by acute mania
and death, I 73.
Organs, rudimentary. 3iM-
Orlando, I'la., as a winter resort, 655.
Orrhothcrapy, 420, 422, 756; at the Nur-
sery and Child's Hospital, S14.
Osteomyelitis and immunizing experiments,
483; diagnosis of, 175; treatment of,
569; tuberculous, iodoform-glycerin
in, 22.
Osteotomy, femoral, for the correction of
hip deformity in adnlts, 24.
O'Sullivan, George 11., death of, 558.
Otitis media purulenta. 317; indications-
for mastoid operation in, 800.
Otorrhcca, treatment of, 600.
Ovarian extract at the menopause, 103:
medication, 423; tumors, treatment of
small, 799.
Ovaries, abscess of the, 428; degeneration
of the, 34S; mixed tumors of the, 52(1,
removal of the, for insanity and epi-
lepsy in women, 530,
Ovariotomy, double, during pregnancy,
followed by the birth of twins at term.
643; double, followed by pregnancy,
643-
Overton, Frank, two cases of tapewonii,
641.
O.xalic aciil, poisoning by, 461.
O.xygen, and ether as anajsthetics, 373; in
an;vsthesia, 419. 431; in surgery, 311;
in the treatment of suppurating sur-
faces, 491; use of, in chloroform nar-
cosis, 537.
Oysters, typhoid fever spread by, 645.
Pachydermatosis ressmbling tubercular
leprosy, 496.
Padded room, death in a, 540.
Paget's disease of the nipple, 492.
Pain, woman's inferior sensitiveness to,
856.
Pajot, Professor, death of, 271.
Palate, cleft, new operation for, 532; epi-
thelioma of the velum cured by injec-
tions of caustic potash, loi.
Palmer, |ohn O., local application of ter-
chloride of antimony in epithelioma of
the face. ^o.
Palmer, W. W., death of, 682.
l'an-.\merican .Medical Congress, the sec-
ond, 750, 753, 793, 826.
I'ancreas, primary cancer of the head of
the, 346; rupture of the, 77.
Pancreatitis, acute, 573.
Papillomatous tumors, multiple. 496.
Paralysis agitans. remedies for, 649, 68q.
Paralysis following an.-vsthesia, 556; of
toxic origin, 413; spastic, treatment
of, 647; spasmodic, 457.
Paresis, general, of the insane, and hered-
itary syphilis, S13; early symptoms
of, S34: in sisters, 245; the blood in,
46S. ■
Paris, letters from, 70, 567, 836, 906; low
death-rate in, 567; medical measures
during the Tsar's visit to, 64;.
December 26, 1S96]
INDEX.
949
I'arker, Edward Hazeu, obituary of, S25.
Parkes, Charles T. . notice of book by, 1 30.
Parsons, Ralph Lyman, practical points
regarding the senile insanities, with
special reference to prophylaxis and
management. 505, 539.
Pasteur celebration at Alais, 6S5; Institute,
attack upon the. 70.
Pass Christian, Miss., as a winter resort,
656.
Patella, fracture of the, 319; subcutaneous
wiring of the, 590.
Patent medicine making, 939.
Pathological Society of London, jubilee of
the, 72S.
Pathological Society of New York, lOO,
204. 345. 3S5, 639, 724.
Pathological Society of Philadelphia, 55,
92. 261, 416. 489, 561, 086, S6i, 935.
Patients, self-prescribing. 342.
Peet, Edward \V., treatment of acute ab-
scesses, 513.
Pellotine. a new hypnotic. 106, OS4.
Pelvic abscess. 28; disease, cause of, 524;
suppuration, surgical treatment of,
453; surgery, report of cases in, 33S.
Pelvis, ambulant treatment of certain
forms of disease in the, 796; method
of e.\amining the contents of, without
exploratory laparotomy, 37; uterine
drainage in inflammation of, 901.
Penis, a ring encircling the, 766; diph-
theria of the, S29; neuralgia of the,
20S.
Pensacola, Fla. , as a winter resort, 655.
Pental, administration of, 375.
Percussion, auscultatory, 568.
Pericarditis, S74; treatment of suppurative,
S94.
Pericardium, adherent, 356.
Perineum, central laceration of the, 316;
preservation of the, 175.
Periscope, compound achromatic, 107.
I'eritoncum, effect of adhesions of, upon
the digestive tract, 777; endothelium
of the free surface of the, log; wounds
of the, 573, 799.
Peritonitis, septic, operation for. 208; sep-
tic, treatment of, 175; traumatic, ;iS;
tuberculous, effect of laparotomy upon,
520.
Perkins, ('■. W., a neat spherical gauze
sponge. 216.
Perry, Middleton L. , some studies of the
blood in thyroid feeding in insanity,
2S9.
Pertussis, see W hoopi iig-cough.
Peterson, Frederick, colonies for epileptics,
404.
Petroleum, report of the committee on, 465.
Pets, infection by, 630.
Pharmaceutical conference at Liverpool,
251.
Pharyngeal abscess, retro-. 224; artery,
enlarged ascending, situated on the
posterior wall of the pharynx. 247;
tonsil, atrophy of, about puberty, 834.
Pharyngitis, chronic, treatment of, 689.
Philadelphia County Medical .Society, 19,
91, 416, 489, 597, 686, 717, S24, S61,
935-
Philadelphia, medical profession in, loS;
vital statistics of, 416, 597, 715, 752,
S60; water supply of, 596.
Phillips, Lincoln, germs and serums, 103.
Phimosis, reflex troubles from, 160.
Phlebitis, rheumatic, 422; treatment of,
569; wandering, u.
Phcenix, .\riz., as a winter resort, O59.
Phonendoscope, the, 624.
Photomicrography, 347.
Physician and hospital, sphere of the, 733;
and pharmacists, relations of, 57; of
the near future, 858; relation of the,
to society, 767.
I'ifTard, Henry G. , preparation of blood
for microscopical examination, 544,
695.
Pilcher, James E., methods of instruction
in first aid, 332.
Piper, William A., death of, 91.
Pitney, Jonathan Key, death of, 271.
Plague, the bubonic, 592; in India, S40,
899.
Playter, Edward, notice of book by, 165.
Pleura, etiology of serous effusions in the,
680.
Pleurisy, auscultatory signs in, 423; with
effusion, 748.
Pneumonia, etiology of lobular, S19; com-
plicated with fatty tumor of the right
auricle, 355; hydrotherapy in, S63; in
infants, treatment of, 520; relapse in,
484; treatment of, 282, 307, 397, 473,
S63.
Pneumonotomy, 123.
Pocket instruments, necessary, 484.
Poison ivy, antidotes to, 431.
Polaillon. Dr. . notice of book by, 3S4.
Polymyositis acuta. 138.
Pons, hemorrhage in the. venesection in,
232.
Pooley, Thomas R.. the ophthalmoscope
•IS an aid to the diagnosis of cerebral
disease in purulent affections of the
middle ear, 225.
Poor-law medical officers in Ireland, S37.
Population of the earth. O9O.
Porro's operation, 529.
Potsdamer, Joseph B. , sarcoma of the an-
terior mediastinum, 4S.
Pott's disease, 318; treatment of, 25; treat-
ment of abscess in high dorsal caries, 22.
Poultry, tapeworms of, 37S.
Powell, (i. IL. death of, from a wasp-
sting on the tongue, 567.
Practitioners' Society of New York, 132.
Pratt, P'rank P., a bad habit of some smok-
ers, 105.
Pregnancy, appendicitis complicating, 461,
831; complicated with uterine fibroids,
504, 873; complicating operations on
the uterus and its appendages. 511;
diagnosticated by the urine, 7S4, dou-
ble ovariotomy during, followed by
the birth of twins at term, 643; ectopic,
396, 836; ectopic, treatment of, 795;
following double ovariotomy, 643;
management of, 6S8; vomiting of, 412,
649: with nephritis, management of,
340.
Prentiss, D. W. , mescal buttons, 258.
Prescription, an old-time shotgun, iSo;
ownership of the, 344.
Preston, S. P., a case of chronic appendi-
citis, 566.
Prettyman. J. S. , tuberculosis and bacter-
iophobia, 611.
Prince, John A. , intestinal obstruction, lat-
eral anastomosis with the Murphy but-
ton introduced through the vagina, 209.
Princeton laboratory, bacteriological work
at the, 58.
Pringle, J. J., notice of book edited by,
165, 64'8.
I'ritchard, Donald B. , strengthening and
sterilization of catgut, 207.
Prize, award of the Graefegold medal, 6S7;
the Alvarenga, of the College of Physi-
cians of Philadelphia, 595.
Professional secrecy in France, 64G.
f-'rofeta's immunity, 283.
Prognosis of disease, 240; temperature an
element in, 605.
Proprietary medicines, covert puffing of,
S97.
Prostate gland, castration for hypertrophy
of the, II, 175; hypertrophy of the,
520, 577, 599; prostatectomy for hyper-
trophy of the, 84 1 ; relation of the tes-
ticle to the, 862: surgical treatment of
hypertrophy of, 309; thyroid in hyper-
trophy of the, 250.
Prostatism, radical cure of, 82S.
Prudden. T. Mitchell, notice of book by,
901.
Prurigo, 4S7.
Pruritus, treatment of, 17, 589; treatment
of anal, 688; treatment of vulvar, 393,
502; vulvie in America, 687.
Pryor, W. R. , method of examining the
pelvic contents which renders explora-
tory laparotomy unnecessary, 37.
Psoriasis, effect of diet and alcohol upon,
493; treatment of, 138, 139.
Psychological Congress in Munich, ;68.
Psvchoneural factor in clinical medicine.
532-
Pterygium, operative treatment of, 53b.
I'tomains, intestinal, fatal cases probably
due to, 620.
Public Health congress at Glasgow, 251.
Puericulture, 645.
Puerperal aclampsia, treatment of, 456,
763, 913; hemorrhage, 277; pulmonary
thrombosis, 304; self-infection, 799;
^.epticamia, 396, 797; septic.x-mia,
treatment of, 2S4, 530.
Punta Gorda, Fla. , as a winter resort, 655.
Purgative, a hypodermic, 463.
Pusey, Henry K., death of, 416.
Pyelitis, chronic, relief of pain in, 502;
chronic, treatment of, 31, 689; in in-
fancy, 731.
Pylorus, surgical treatment of obstruction
of the, 534.
Pyonephrosis, 339.
Pyosalpinx. treatment of, 646.
1 'yosepticsmic puerperal exanthem simulat-
ing hemorrhagic variola, 591.
Pyrantin, a new antipyretic, 6S3.
Quacks, prosecution of. in England, 766.
Quadriceps extensor, rupture of the, 284.
i,)uarantine. abolition of, in Great Britain,
451-
Queen's nurses' reception, 140.
(Quinine, contraindications of , 35; mixture,
392.
R
Rabbits and reform, 377.
Rabies, newspaper, 66; preventive inocu-
lations in Vienna, igi.
Rachitic paralysis, a case of, 791.
Rachitis, anremia in, 350; phosphorus for,
391 ; spontaneous straightening of
curves in, 174.
Rafferty, T. N., the surgery of empyema,
43S.
Railway car sanitation, 497.
Raleigh. N. C, as a winter resort, 653.
Ralfe, Dr., death of, 176.
Ramsdell, Edwin D. , obituary of, 20.
Rankin, Francis IL, death of, 752; reso-
lutions on the death of, 824.
Ransome, .-Vrthur, notice of book by, 166.
Ration, an emergency, 360.
Raymond, James Harvey, congenital irre-
ducible umbilical hernia — double ute-
rus, 514; congenital irreducible um-
bilical hernia. 425.
Raynaud's disease, 459 ; cerebral complica-
tions of, 60.
Reason, the dawn of, 222.
Rectum, alimentation by the, 393; extirpa-
tion of the, by the Kraske method, 520;
hemorrhage from the, 323; instruments
for the treatment of diseases of the,
215; treatment of prolapse of the, by
torsion, Soo.
Reed. B. Harvey, notice of book edited by,
490.
Regnier, L. R. , notice of book by, 3S3.
Relapsing fever, a, 641.
Renipuncture for albuminuria, 661.
Respiration, new method of artificial, S19.
Respiratory passages, warm baths in the
treatment of affections of the, 424.
Retropharyngeal abscess. 629.
" Revista de Ciencias Medicas," cessation
of publication of, 200.
Reynolds, Sir J. Russell, death of, 32.
Rheumatism, methyl salicylate in. 423, 765;
of the new-born, 547; ointment for the
joints in. 6S9; treatment of acute artic-
ular, 593.
Rhinitis, atrophic, 94.
Rhinopharyngitis, chronic, 2S4.
Ribs, fracture of. in old age, 874.
Richardson. .Sir Benj.-imin Ward, death of,
788, 906, 934.
Ring. Frank Witman, death of, 127;
resolutions on the death of, ■'^25.
Ringnell. C. J., measurements of the ap-
pendix, 104.
950
INDEX.
[December 26, 1896
Ringworm, treatment of, in institutions,
690.
Riverside, Cal., as a winter resort, 659.
Roberts, A. Sidney, death of, 308.
Roberts, Sir William, attacl< upon, for de-
fendingf opium, 213.
Robinson, A. R. , the higher aims of der-
matology, 706.
Robinson, Byron, effect of peritonitic ad-
hesions on the digestive tract, 777; the
endothelium of the free surface of the
peritoneum, log.
Robinson, Daniel S. , a case of supplemen-
tary amniotic sac with fibroid tumor of
the uterus, 351.
Robinson, William G. , treatment of acute
abscesses, 646.
Robinson, William J-. the Moscow Inter-
national Medical Congress, 764.
Rochs, H., notice of book by, 383.
Rockwell, A. D., notice of book by, 491.
Rodent ulcer of the forearm, S38.
Roentgen rays, a new fluorescent substance
for use with, 86; caution in the use of,
307; Li Hung Chang's bullet found by
the, 20; practical use of, in surgery,
600; some of the applications of, in
medicine, 9, 103, 423, 793.
Rome, Ga. , as a winter resort, 654.
Roosevelt, J. West, notice of book by, 203.
Rosacea, hypertrophic, resembling tuber-
cular leprosy, 496.
Rosenberg, L. , a case of antitoxin poison-
ing, 460.
Rosenwasser, Louis, a case of rachitic
paralysis, 791.
Rosewater, Charles, care of the breast in
lactation, 480.
Roux, Ferdinand, notice of book by, 3S4.
Royal College of Surgeons in Ireland, S37.
Rudimentary organs, 364.
Rudinger, Nicholas, death of, 416.
Rupp, Adolph, report of a case of nasal
polypus in a female infant four weeks
old, 718.
Russia, politics and medicine in, 6S2.
Ryfkogel, H. A. L., formalin as a preser
vative, 192.
S
St. .Andrew's University and Dundee Col-
lege, 102.
St. Augustine, Fla. . as a winter resort,
655.
St. Luke's Hospital, annual report of,
862; censure of, 488.
St. Petersburg, Fla., as a winter resort, 655.
Sackville, John C, death of, 4SS.
Sacrum, tumor of the, S75.
Salisbury, N. C, as a winter resort, 653.
Salpctriere, school of the, 906.
Salpingitis, catarrhal, 911; pathology and
treatment of suppurative, 535; resem-
blance of acute catarrhal, to appen-
dicitis, 735.
Saltillo, Me.xico, as a winter resort, 660.
San .Vntonio, Te.\. , as a winter resort, 657.
Sanatoriums for consumption, are they a
danger to the neighborhood? 482.
Sanford, Leonard J., death of, 89S.
Sanger, Charles R. , notice of book by, 490.
Sanitary Institute, Congress of the, in Lon-
don, 503.
Sanitary legislation, 499, 755; science, le-
lation of the physician to, 58.
Santa Fe, N. M., as a winter resort, 658.
Santway, F. L. , collapse from excessive
vo.niting, 570.
Sarcoma, blastomycetes of, 332.
Sarcomatosis cutis and mycosis fungoides,
494-
Sass, Louis, F. , death of, 78S.
Savannah, Ua. , as a winter resort, 654.
Savidge, Eugene Coleman, a comment on
Dr. Morris' paper on appendicitis.
910; the judging of comparative results
in the surgical arena. 875; the Second
International Congress of Gynecology
and Obstetrics, 504.
Saxl, fosef, a case of rupture of the uterus.
641.
Scabies, treatment of, 438.
.Scaremosquito. 696.
Scarlatina, recurrent, 790.
Schadle, J. E., new snares for post-nasal
and intra-nasal surgical operations, 142.
Scheppegrell, W. , use of peroxide of hydro-
gen in diseases of the nose, throat,
and ear, ig;.
Schmidt, Dr. , notice of book by, 202.
School children, experiments upon, in Chi-
cago, 685.
Schoolhouses, municipal responsibility for
healthy, 498.
Schools, contagion in, 85S; health inspec-
tors for, S62.
Schuylkill County (Pa.) Medical Society,
560, 787.
Sciatica, 375.
Science and medicine, 485.
.Sclerosis, acute disseminated, and neuritis
in the sequence of diphtheria, 233;
disseminated spinal, 556; treatment
of, 21.
Scoliosis, the bicycle for, 615.
Scorbutus, infantile, 86, 477, 928.
Scorching, dangers of, 612.
Seasickness, management of, 139, 502, 875.
.Seger, C. E. , death of, SgS.
Semeleder, F. , local treatment of affections
of the trachea, bronchi, and lungs,
430; movable ears in man, 570.
Seminal vesiculitis, 630.
Senile dementia and toxicity of the urine.
459; insanity. 505, 539.
.Sepsis, cryptogenetic, 31.
Septicemia, puerperal, 278, 797; puerperal,
treatment of, 284.
Serpent bite, vaccine against, 684, 687.
Serotherapy, see Orrhotkerapy and Anti-
toxin.
Serre-fine, a living. 360.
Sexton, Samuel, obituary of, 92; resolu-
tions on the death of, 859,
Sexual hygiene, 143.
Shelley, Henry A., impregnation, when is
it possible ? 280.
Shock, treatment of, 573.
Shrewsbury, W. J., specialism, 105.
.Sigmoid flexure, resection of dilated, 762.
.Silkworm-gut sutures, buried, 572.
.Silly season, a spectacle for the, 163.
Silver City, N. ^I. , as a winter resort, 658.
Simon, Charles E., notice of book by, 727.
Simpler life, a plea for a, 341.
Singultus, autotraction of the tongue in, 44S.
.Sinus, healing of a suprapubic, without op-
eration, 760.
Skeel, Frank D. . skiascopic rack, 143.
Skeleton, method of estimating the height,
from parts of the — a correction, 141.
Skiagraphy, advances in, 49.
Skiascopic rack. 143.
.Skin, diseases of, in connection with gas-
tro-intestinal disorders, 84; eruptions
of, produced by ichthyol, 555; Krause
method of transplantation of, 538,
792; pathological and clinical classifi-
cation of diseases of the, 492; some
of the influences of .r, solar, and elec-
tric rays on the, 895; tuberculosis of
the, treated by nosophen, 63S.
Skinner, W. W., the cure of seasickness,
875.
Skull, fracture of the base of, with re-
covery, 390; operation in simple frac-
ture of the, 175; trephining in injuries
of the, 448.
Skunk, the secretion of the. 854.
Sleep, anaesthesia during, S39.
.Sloan, W. Harper, congenital absence of
the uterus. Fallopian tubes, and ova-
ries, 248.
Slobbering of infants. 359.
.Small, Sidney I., central laceration of the
perineum, 316.
Small-pox, arrest of. in the vesicular stage,
83, 354; epidemic of, at Gloucester,
102 : hemorrhagic, pyosepticajmic puer-
peral exanthem simulating. 591: sig-
nificance of the angina in, 92S.
Smith, .Andrew H.. anajmia in cardiac dis-
ease. 852, 865.
Smith, Curran C death of, 271.
Smith, Elsworth. death of. 380.
Smith, Harriet W., death of, 683.
Smith. J. H . , absence of the left kidney, 7 1 8-
Smith, J. Lewis, notice of book by, 165.
Smith, I,. B., fracture of the base of the
skull, of both superior maxilla;, of the
nasal bones, of the inferior maxilla,
and of the hyoid bone; recovery, 390;.
subphrenic abscess, 391.
Smith, Wm. T.. does appendicitis foUow-
family lines ? 3S7.
Smokers, a bad habit of some, 10;.
Smoking and intellectual labor, 307.
Snake bite, snake bile for, 3J5.
•Snares for post-nasal and intra-nasal surgi-
cal operations, 142.
Sour Lake. Tex., as a winter rescrt, 658.
.South Carolina, health resorts of, 653.
.Southern Surgical and Gynecological Asso-
ciation, S70, 901.
Specialism, 105.
Speech, automatic. 459.
Speir, Robert Fleet, death of, 271.
Spermatorrhoea and masturbation, 501 ; in
neurasthenia, 940.
Spine, lateral curvature of. the treatment
of, 21; syphilitic disease of the, 47J.
Spinal cord, changes in the, after amputa-
tion of the extremities, 203; explana-
tion of true heterotopia of the, 166.
Spleen, the malarial, 424.
Splenic anemia, 69.
Sponge, a spherical gauze, 216.
Sprague, George P., diagnostic value of
blood examinations, 433.
Spruill, Jos. L., pneumonia complicated
with fatty tumor in the right auricle,
355-
Sputum, tuberculous, examination of, 640.
Stage fright, remedy for, 592.
Starr, Louis, notice of book by, 166.
Steams. Henry S., a case of post-mortem
Ccesarian section with delivery of a
living child, 245.
Stedman. Thomas L., notice of book by,
goi ; notice of book edited by, 382.
Stein. Alexander W., some forms of non-
obstructive i.schuria, 120.
Stenocardia, treatment of, 866.
Sterilizer, portable, 286.
Sternberg, (leorge M., notice of book by,
131-
Stevens, E. B., death of, 127.
Steyer, Charles, death of, 91.
Stillborn, meaning of the term. 49S.
.Stinson, J. Coplin, the radical cure of
femoral hernia, S07.
Stomach, cancer of the, 347; clinical valut
of hyperacidity of, 424; dilatation of,
simulating ascites, 63g; foreign bodie!*
in the, 767; hyper."cidity of, with con-
stipation, 392; intestine, and rectum,
hemorrhage from the, 323; phosphatic
calculus in the, 423; ulcer of the, 319,
359. 39*'; ulcer of, analgesic remedy
for, 356; uses of the, 145.
Stomach tube, a director for the, 322.
Stomatitis in small children. 392.
Stoner, .\. P., a study of hydramnios and
some of its complications, 231.
.Stone, R. M., report of a case of malignant
uterine tumor treated by the toxins of
erysipelas and bacillus prodigiosus, 746.
.Stone searcher, a new, 142.
Stoney, Emily .\. ^L . notice of book by,49o.
Stools, bloody, causes of, 660.
Straight, Howard S. , a case of apex catarrli
simulating nasal trouble, 206.
Stricture, linear electrolysis in, 797; treat-
ment of, 6gg, 760.
Strjchnine, chronic poisoning by, 132; irt
uterine inertia, 427.
Students, association of, in Paris, 764.
Studley, F. C, congenital transposition of
the viscera, 643.
Styes, treatment of. 251.
Subcutaneous alimentation, 612.
Submersion, continuous. 428.
Subperitoneal tissue, surgery of the. 314.
Subphrenic abscess, 310, 391.
.Substitution, the sin of, 161.
.Suicide among Russian physicians, 51;;
relation of. to alcohol, 569.
Sunday penalty of irregular feeding, 449.
Suprarenal capsules, congenital absence of,
in Addison's disease, 422.
December 26, 1S96]
INDEX.
951
Surgeon, legal responsibilities of the opera-
ting, 821.
Surgery of the twentieth century, evolution
of the, 831; preventive, 241.
Surgical arena, comparative results in the,
875; cleanliness, 940; operations, re-
sults and methods of, 31)5.
Surgical treatment of gastric perforation
and hemorrhage, 929.
Sutton, K. Stansbury, double ovariotomy
followed by pregnancy; and double
ovariotomy during pregnane)' followed
by the birth of twins at term, 043;
pregnancy complicating operations on
the uterus and its appendages, 511.
Sweats, night, of phthsis, 391, 688.
Swift, Samuel, death of. 163.
Symonds, Brandreth, danger of filtering
urine with talc, 193.
Symphyseotomy, 246, 368, 629.
Syphilis, cerebral, 464, S34; Colles' im-
munity, 2S2; congenital and pathogno-
monic symptoms of, SiS; from an in-
surance point of view, iSo; hereditar)',
and general paresis of the insane, S13;
hydriodateof the iodate of quinine in,
688; in infants and young children,
301, 817; intra-uterine infection of, 749;
is inherited, contagious? 5S9; mercuri-
al injections in, 31; nasal sequela; of,
99; nervous diseases supposed to be
due to, the effect of antisyphilitic
treatment of, 61; nervous manifesta-
tions of, 81S; Profeta's immunity,
2S3; reinfection of, 424, 574; relation
of, to atheroma, 16; secondary, the
spermatic fluid in, 216; spinal, 250,
475; thyroid gland. 138, 6S9.
Syringomyelia, 108; limited to one posterior
horn in the cervical region, 62.
Tabasco, Mexico, public health in, 500.
Tait, Lawson, cleansing and cleanliness in
abdominal surgeons' operations, 883.
Tampa. Kla, , as a winter resort, 655.
Tapeworm, new treatment for, 1 38; of
poultry, 378; two cases of, 641.
Taurocholate of sodium as a cardiac
remedy, 393.
Taylor, Basil M., the treatment of pneu-
monia, 473.
Taylor, George H., death of, 89S.
Taylor, William Remsen, death of, 523 ;
resolutions on the death of, 59;.
Taylor, J. B. , death of. 54.
Teeth, congenital, 570, 803.
Temperature an element in prognosis, 605.
Tendon grafting and muscle transplanta-
tion for deformities following infantile
paralysis, 771.
Tenement houses in greater New York, 381.
Tennessee, health resorts of, 655.
Tetanin, the poison of, 371.
Tetanus, 340; antito.xin of, 640, 846; neo-
natorum, prevention of, 277.
Texas, health resorts of , 657.
Thalamus, tumor of the. 60.
Thermometers, safety attachment for, 143.
Thistle, W. B., theory of eliminative
treatment of typhoid fever, 541.
Thoma, Richard, notice of book by, 130.
Thomas, Allen M., orrhotherapy at the
Nursery and Child's Hospital, 814.
Tliomas, T. CJaillard, medical address at
the twenty-ninth anniversary of the
Woman's llospital in the State of New
York, 769.
Thomasville. Ga. , as a winter resort, 654.
Thompson, Levi II., death of, 6S3.
Thorax, tumors within the, 31.
Thought-weighing machine, 787.
Throat, a simple means of examination of
the, 765; treatment of chronic catarrh
of, in children. 537.
Thrombosis, puerperal puhnonary. 304.
Thyroid cartilage, incomplete fr.icturc of
the left cornu of the, 99.
Thyroid gland, iodine-containing substance
in the, 87; tuberculous disease of the
83S; tumors of the, 68; medication,
26, 421, 680; in myxedema, 613; in
lupus, 137; in syphilis, 138.
Thyroidin, 250.
Thyroproteid, 250.
Tibbals, F. B. , two cases of obscure intra-
abdominal lesions, 388.
Tinea favosa, 249.
Tobacco, diatribe against, 504.
Toenail, ingrown, mechanical treatment of,
24 : perchloride of iron for, 894.
Tomlinson, H. .\., clinical history and
post-mortem appearance of a case of
cortical embolus, 14S.
Toms, S. W. S., the appendicitis contro-
versy, 466.
Toner, Joseph M., death of, 200.
Tongue, cancer of the, 836; extirpation of
the, for epithelioma, 637; inflamma-
tion of the sublingual glands, 3S7.
Tonsil, etiology of peritonsillar abscess,
712: lingual, acute disease of the, 101.
Tonsillar cough, 124.
Tonsillitis, follicular, 356.
Tonsillotomy by cauter)- dissection, 534 ,
secondary hemorrhage following, 316.
Toothache, remedv for, 463.
Tooth extraction, to arrest bleeding after,
502.
Topo Chico Springs, Mexico, 659.
Torrens, Benjamin, two cases of delivery
at full term following cul-de-sac opera-
tions, 136.
Torticollis, due to adenoid vegetations, 25.
Tourniquet, precautions in using the, 428.
, Townsend, \\'illiam A\'arren, bilateral or-
chidectomy, suprapubic cystotomy,
followed bv acute mania and death,
173-
To.xasmia in gastro-intestinal disease, 568.
Trachea, bronchi, and lungs, local treat-
ment of affections of the, 430 ; diseases
of the, intratracheal injections in, 151.
Trachelorri aphy, improved, 13; knife for,
178. ()96.
Tracheotomy, 319.
Trachoma, prevalence of. 428.
Tractor, a novel, 31.
Trades, dangerous, report of committee on,
465-
Transfusion, infusion, and auto-infusion.
748.
Transversalis fascia at the internal inguinal
and femoral rings, 807.
Traumaticine, anew. 731.
Tremors, semeiology of. 458.
Trephine, when to, 319.
Trichocephalus dispar, 798.
Trimen, Henry, tieath of, 838.
Trional in epilepsy, 16; poisoning by, 250.
Tubercle bacilli, difference in virulence of
the, 422.
Tuberculosis, a factor in the elimination of
the unfit, 126; a hospital for, in Phila-
delphia, 452; and bacteriophobia, 611;
and cancer, association of, 345; bovine,
57; diagnosis of, from the moqjhology
of the blood, 325; discussion on, 274 ;
hcemology of, 796; in a hernial sac,
820 ; injections of guaiacol and iodo-
form in sterilized olive oil for, 679 ;
laryngeal, 98; latent and larval, 53;
morphology of the blood in, 395; me-
ningeal. 2S4 ; of the axilla, followed by
that of the hand, 25S ; of the bladder,
treated by direct medication, 758 ; of
the bones, the blood in, 340; of the
female generative organs, abdominal
section for, 531 ; of the knee, 794; of
the pharyngeal lymphoid tissue, 96 ;
of the tliyroid gland, 838; peritoneal,
effect of laparotomy upon, 520; pul-
monary, 249: pulmonary, cold air in,
791 ; pulmonary, contagiousness of,
838 ; pulmonary, following scald of
the chest, 24S ; pulmonary, gymnastics
in, 356 ; pulmonary, heart failure in,
463 ; pulmonary, management of, 393 ;
pulmonary, prevention of, 791 ; pul-
monary, reinfection in, 533 ; pulmo-
nary, sanatorium treatment of, 36;
pulmonary, simulation of, by certain
acute bronchial affections, 423 ; pul-
monary, strapping the chest in, 52 ;
restriction of the spread of, 30; re-
lation of diathesis trj local manifesta-
tions of, 903; the microscopical proof of
a curative process in, 330 ; the leuco-
cytes in, 123; treatment of, 26, 51,-
391, 420, OSo.
Tubo-ovarian cysts. 52O.
Tucson, Ariz., as a winter resort, 659.
Tumors, malignant, relation of trauma to,
Turbinated body, primary carcinoma oC
the inferior, 2icj.
Turkey in Asia, a woman physician in, yii.
Turner, \Vm. T., death of, 416.
Tympani membrana, permanent artificial
perforation of the, 809.
Typhoid fever, changes in the cord and
nerve roots in, 422; chills in, 463;
course of, 413; diagnosis of, 28, 421,
500, 632, 680, 697, 732, S05 ; from
ice cream, 3S0 ; intestinal perforation
in, 207 ; patholog)' and bacteriology of,
835 ; phenacetin in, 68S ; theory oi
eliminative treatment of, 541 ; treat-
ment of, 28, 46, 183, 463, 468, 6gt,
789, 8 1 8, 908.
Typho-malarial fever, 418, 856.
Typhus fever in Liverpool, 575 ; in Mexico,,
498; urology in, 424.
Tyrone, N. C, as a winter resort, 653.
Tyson, James, " give the full name, " 802.
U
Ulcers of the leg, treatment of, 31, 428.
Unna, P. G., notice of book by, 201,
Ura;mia, aphasia in, 44S.
Uretero-ureteral anastomosis, 872.
Ureters, catheterization of the, 19S.
Urethra, congenital occlusion of the, 354 ;:
foreign bodies in the male, 517; niel-
anosarcoma of the female, 531 ; of ai
child obstructed by a stone, 760; rup-
ture of the, 175, 565; treatment of
stricture of the, 699, 760.
Uric acid, the place of production of, 424;
diathesis, 286, 936.
Urination, non-obstructive difficulty of, 120,
I'rine, danger in filtering with talc, 193;
effervescence of, with nitroso-nitric
acid, 789 : examinations of the, 4S4 ;.
in yellow fever, 793; incontinence of,
l(\ 214; modern method of examining
the sediment of, S35 ; pregnancy diag-
nosticated by the, 784.
Uterus, cancer of the, 124, 2S3, 592, 801 v
cancer of the pregnant, vaginal hys-
terectomy for, 339 ; cancer of the,
treated by toxins of erysipelas and
bacillus prodigiosus, 746 ; diagnosis
of cancer of the, 393 ; dilatation of
the cervix at term or during labor, S93;
double, 514; curettage of the, 430;
electricity in new growths of the,
277; Fallopian tubes and ovaries,
congenital absence of, 24S ; fibroids of
the, complicated with pregnancy, 564,
795 ; fibroid tumor of, with supple-
mentary amniotic sac, 351 ; hamalo-
metra and pyometra, 279; hysterectomy
for fibroids of the, 277, 279; indica-
tions for ventral fixation of the, fii,
856; infantile, 757; inversion of the,
247, 352; leaving the in situ after
excision of the appendages, 52S ; opera-
tion for retrodeviation of the, 302;
operations on the, (luring pregnane)'.
511 ; palliative treatment of cancer of
the. 6"3, 748 ; photography of the in-
terior of the, 252 ; physiology of the
cervix. 679 ; results of the Apostoli
treatment of fibroids of the, 591 ;
retroversion of the, vaginal section
for, 29; rupture of the. 159, 641:
.septic disease of the parts surrounding
the. 528 ; spontaneous rupture of, dur-
ing labor at term, 529 ; str)chnine in
inertia of the. 427; surgical treatment
of retrodeviations of the, 454 ; treat-
ment of fibroids of the, 67, 175 ; treat-
ment of hemorrhage of the, 792,
95^
INDEX.
[December 26, 1896
\'accination, report of the Uriiish com-
mission on, 357, 394; results of, in
the German army, 766 ; vigorous en-
forcement of, 200.
Vaccine, 640 ; in liquid form, S59.
Vagina, bacteria in the, 573; irrigation of,
without wetting the clothes, 2SS.
Vaginal exploratory section, limits of, as
compared with abdominal, Soo; versus
abdominal section, 283, S70.
Vaginitis, blennorrhagic, nascent carbonic
acid in, 765; injection for, 139, 689;
senile, 551.
Vagino-fixation, Mackenrodt has not aban-
doned, 694.
Vagus neri'e, division and immediate suture
of the, 573.
Valentine, Kerd. C, gonorrhoea, 71.
Vandoren, S. H., treatment of pneumonia,
2S2.
Van Santvoord, R., a case of fatal trau-
matic myocarditis (?), 171.
Varicocele, 319; resection of the scrounn
for, 569.
Variola, orrhotherapy of, 422.
Varix, gastric, 761.
Veins, suture of, 629.
\'ena cava inferior, thrombosis of, 422.
^ enereal disease a sufficient cause for
divorce, 288.
Vertebra, dislocation of the fourth cervical,
15-
Vertebra?, caries of the, 429.
Vesiculitis, seminal, 630.
Vicksburg, Miss., as a winter resort, 656.
Victoria, medical practice in, 634.
Vienna, salaries of medical teachers in, 44.
Vineberg, Hiram N., acute catarrhal sal-
pingitis; its resemblance to appen-
dicitis, differential diagnosis; treat-
ment, 735; has Mackenrodt abandoned
vagino-fixation ? 694.
Vinke, H. II., acromegaly, 779.
Viscera, anatomical and clinical significance
of multiple interstitial inflammation of,
423; congenital transposition of the,
643.
Vision, hallucination of, 803.
Visual disturbances due to nervous diseases,
O26, 636.
\'ivisection, Lawson Tait against. 503.
Volume fifty, close of, 930.
\"olvulus ten days after an operation for
appendicitis, 132.
Vomiting, collapse from excessive, treated
by intravenous saline infusion, 462,
570; in appendicitis, treatment of, 792;
of pregnancy, 250, 412; of pregnancy,
cured by suggestion, O49.
Vulva, papilloma of the, 791.
Vulvo-vaginal catarrh, 572.
Vulvo-vaginitis, infectious, in children, 447.
W
Waco, Tex., as a winter resort, O57.
Waiss, A. S., congenital teeth, S03.
Walcher's position, 279.
Walker, Xorman. notice of translation by,
201.
Walsh, J. J., some notes on the bacteri-
ology of mumps, 440.
War dogs in the (German army, 12S.
Warden, Carl C, traumatic peritonitis and
rupture of the bladder, 51 8.
Waring, William, death of, 271.
Warts, removal of, 673; the cause of, 820.
Washburn, W., a case of glossitis, 172.
Washington City as a winter resort, (152.
Water supply of London, 211, 503, Soi;
poisoning by plumbo-solvent, 804; pol-
lution of, 500.
Water, uses of, 536.
Weaning of infants, 612.
Weil, M. M., death of, 163.
W'einholtz, Charles H., death of, 236.
Weir, James, Jr.. the dawn of reason, 222;
the ideative faculties and self-con-
sciousness in the lower animals, 42.
Weisman, August, notice of book by, 384.
WcUer, W. ^I., herpetic nerve distur-
bance, 642.
Welsh University, 140.
Welsh, W. J., treatment of old disloca-
tions of the elbow, 424.
Wesley M. Carpenter lecture before the
New Vork Academy of Medicine, 720.
Westerfield, C, notice of book by, 384.
Wharton. Henry K. . notice of book by, 727.
Whiteheads operation, objections to, 319.
Whitman, Royal, treatment of congenital
dislocation of the hip wHth especial
reference to the Hoffa-I.orenz opera-
tion, 361.
Whooping-cough, ozone in, 792 ; quinine in,
52, 792 ; remedy for, 356 ; the parasites
of, 162; treatment of, 765.
Wichita, Kan., as a winter resort, O57.
Wickcrsheimer, Mr., death of, 452.
Wife, doctor's, in a new role, 749.
Wiggin, Frederick Holme, treatment 1 f
fsecal fistula;, 5SO, 600.
Wilkes, William Henderson, obituary of,
308.
Wilkins, Theoda, counter-irritation in the
treatment of herpes, 446.
W ilkins. Theoda, death of, 452.
Williams, Edward H.. hereditary syphilis
and general paresis of the insane, 813.
W illiamson, l)r., death of, 200.
Wisconsin, a diploma mill in, 125.
Wise, P. .M., notice of book by, 648.
Witthaus, K. A., notice of book by, 129.
"Wizard " cure, 7S6.
Wolff, Emil, death of. S60.
W Oman and her diseases t'j. gynecology,
535;
^\'oman's Hospital, medical address at the
twenty-ninth anniversary, 769.
Women, examination of unmarried, 679 ;
in medical societies in England, 272.
W'ood, Albert, appendicitis as it affects
life insurance risks, 253.
Woodman, John, a case of myxcedema
treated by thyroid extract, (113.
Woodruff, William H.. death of, S60.
WooUey, Charles X., death, of 898.
Worms, intestinal, 392.
Worthington, J. C, death of, 30S.
Wounds, aseptic method of closing, with-
out suture. 783.
Wrist, compound comminuted fracture of
the, 905; tuberculosis of the, 24.
X
Xanthoma diabeticorum, 495.
Xeroform, a substitute for iodoform, 690.
A'-rays and sightless eyes, 921 ; see also
Vellow fever an obstacle to civilization, 755 ;
blood in, 793 ; in Cuba, 344 : in sugar,
684 ; prevention of the spread of, 499 ;
urine in, 793.
\'unia, .Xriz. , as a winter resort, 659.
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